What are the recommendations for Tdap (tetanus, diphtheria, and pertussis) vaccine administration?

Tdap Vaccination Recommendations

All adults aged 19 years and older who have not previously received Tdap should receive a single dose of Tdap vaccine to replace one Td booster, regardless of the interval since their last tetanus-containing vaccine, followed by Td or Tdap boosters every 10 years thereafter. 1, 2

Routine Adult Vaccination Schedule

• Adults aged 19-64 years should receive one dose of Tdap if they have never received it, with no minimum interval required from their last Td dose. 1, 2
• After receiving Tdap, continue with either Td or Tdap boosters every 10 years for ongoing tetanus and diphtheria protection. 1, 2
• As of 2019, ACIP updated recommendations to allow either Td or Tdap for decennial boosters, whereas previously only Td was recommended after the initial Tdap dose. 1

Adolescent Vaccination

• Adolescents aged 11-18 years should receive a single dose of Tdap, preferably at age 11-12 years, instead of Td for booster immunization. 1
• Adolescents who previously received Td but not Tdap are encouraged to receive Tdap, with a preferred interval of at least 5 years between Td and Tdap, though shorter intervals are acceptable when pertussis risk is elevated. 1
• The dose is 0.5 mL administered intramuscularly, preferably into the deltoid muscle. 1

High-Priority Populations Requiring Tdap

Healthcare Personnel

• All healthcare workers in hospitals or ambulatory care settings with direct patient contact should receive Tdap as soon as feasible if not previously vaccinated, with intervals as short as 2 years from the last Td acceptable. 1, 2, 3

Close Contacts of Infants

• Adults who have or anticipate having close contact with infants younger than 12 months (including parents, grandparents, and caregivers) should receive Tdap, with intervals as short as 2 years from the last Td. 1, 2, 3
• This "cocooning" strategy protects vulnerable infants who cannot yet be vaccinated and are at highest risk for severe pertussis complications. 4, 5

Pregnant Women

• Pregnant women should receive Tdap during each pregnancy, regardless of prior Tdap history, with the recommended timing between 27-36 weeks of gestation. 1, 4
• To maximize maternal antibody response and passive transfer to the newborn, vaccination as early as possible within the 27-36 week window is recommended. 4
• Tdap may be safely administered at any time during pregnancy if needed for wound management or during pertussis outbreaks. 4
• Women who did not receive Tdap during pregnancy should receive it immediately postpartum before hospital discharge. 2

Elderly Adults (≥65 Years)

• Adults aged 65 years and older should receive a single dose of Tdap if they have not previously received it. 1, 2
• When feasible, Boostrix (approved for ages ≥10 years) should be used for adults ≥65 years instead of Adacel (approved for ages 10-64 years); however, either vaccine administered to persons ≥65 years is considered valid and immunogenic. 1, 2
• After Tdap, continue with Td or Tdap boosters every 10 years. 1, 2

Important Note: Although Tdap was not initially licensed for adults >65 years in 2006, ACIP updated recommendations in 2012 after reviewing safety and immunogenicity data demonstrating comparable safety profiles and robust immune responses in this age group. 1, 2

Wound Management Protocol

Clean, Minor Wounds

• No tetanus vaccination needed if last dose was within 10 years. 2, 6
• If >10 years since last dose, administer Tdap (if never received) or Td. 2, 6

Contaminated or Severe Wounds (Including Puncture Wounds)

• Tetanus vaccination needed if >5 years since last dose. 2, 6
• Administer Tdap if the person has not previously received Tdap; otherwise give Td. 1, 2, 6
• For persons with unknown or incomplete vaccination history, administer both tetanus vaccine and Tetanus Immune Globulin (TIG) 250 units IM in separate syringes at different anatomic sites. 6

Critical Pitfall: Puncture wounds (such as stepping on a nail) are considered tetanus-prone wounds because they create anaerobic conditions favorable for Clostridium tetani, triggering the 5-year rule rather than the 10-year rule. 6

Catch-Up Vaccination for Incomplete Series

Children Aged 7-10 Years

• Children aged 7-10 years who are not fully immunized against pertussis should receive a single dose of Tdap. 1
• If additional tetanus-diphtheria doses are needed, complete the catch-up schedule with Td at appropriate intervals. 1
• Children who received Tdap as part of catch-up at ages 7-10 years should still receive the routine adolescent Tdap booster at age 11-12 years. 1

Adults with Incomplete History

• For adults with incomplete or unknown vaccination history, administer a 3-dose series: one dose of Tdap (preferably first), followed by Td at least 4 weeks later, then a third dose of Td 6-12 months after the second. 1, 6
• As of 2019, either Td or Tdap may be used for multiple doses in the catch-up series. 1

Interval Considerations and Flexibility

• When Tdap is indicated for pertussis protection, it should be administered regardless of the interval since the last tetanus or diphtheria toxoid-containing vaccine. 1, 3
• ACIP concluded in 2010 that the benefits of protection against pertussis outweigh the potential risk for local reactions, even at short intervals. 1
• While longer intervals between Td and Tdap may decrease local reactions, there is no minimum interval required when Tdap is otherwise indicated. 1

Contraindications and Precautions

Absolute Contraindications

• History of serious allergic reaction (anaphylaxis) to any component of Tdap vaccine. 1, 3, 7
• History of encephalopathy within 7 days of administration of a pertussis-containing vaccine not attributable to another identifiable cause. 3

Precautions

• History of Arthus reaction following a previous tetanus or diphtheria toxoid-containing vaccine. 2, 6
• For persons with a history of Arthus reaction, defer Tdap/Td for at least 10 years after the previous dose. 2, 6

Critical Pitfall to Avoid: Do not administer tetanus boosters more frequently than every 10 years for routine immunization, as this can cause Arthus reactions—severe local hypersensitivity reactions characterized by pain, swelling, and induration developing 4-12 hours post-injection. 6

Administration Details

• Dose: 0.5 mL administered intramuscularly, preferably into the deltoid muscle. 1, 3
• For infants and children through age 2 years, the anterolateral thigh is the preferred site. 1, 7
• Tdap may be administered simultaneously with other vaccines at different anatomic sites using separate syringes. 1, 3
• If syncope occurs after vaccination (more common in adolescents and young adults), observe patients for 15-20 minutes until symptoms resolve. 1

Licensed Products and Interchangeability

• Two Tdap vaccines are licensed in the United States: Boostrix (GlaxoSmithKline) for persons aged ≥10 years, and Adacel (Sanofi Pasteur) for persons aged 10-64 years. 1
• Either Tdap product can be used interchangeably to complete vaccination series regardless of manufacturer of previous doses. 1

Repeat Dosing Considerations

• Tdap is licensed for single-dose use only; neither product is licensed for multiple administrations. 1, 3
• After receipt of Tdap, subsequent tetanus-diphtheria protection should be maintained with Td or Tdap boosters every 10 years. 1, 3
• Recent research demonstrates that a second dose of Tdap approximately 10 years after the first dose is safe, well-tolerated, and immunogenic, though this is not yet reflected in current licensure. 8

Safety Profile

• Pain at the injection site is the most common adverse event, occurring in approximately 75% of recipients, with severe pain in 4.6%. 3
• Most adverse events are mild to moderate in intensity and transient. 3, 9
• Serious vaccination-related adverse events are rare. 3, 9
• The safety profile in adults ≥65 years is comparable to younger adults, with no increase in local or generalized reactions. 2

Common Pitfalls to Avoid

• Do not use DTaP (pediatric formulation) in persons aged ≥7 years; use Tdap or Td instead. 1, 6
• If DTaP is inadvertently administered to a person aged ≥11 years, count this dose as the Tdap dose and do not administer an additional Tdap. 1
• Do not delay Tdap administration in adults who have never received it, regardless of when they last received Td. 2, 6
• Do not restart the vaccination series if doses are delayed; simply continue from where the patient left off. 6
• Do not combine or mix Tdap with any other vaccine through reconstitution. 7