Diphtheria, tetanus, and pertussis immunization in children 7 through 18 years of age

INTRODUCTION — Diphtheria, tetanus, and pertussis immunization in children and adolescents 7 through 18 years of age will be discussed here. Diphtheria, tetanus, and pertussis immunization in children six weeks through six years of age and other childhood immunizations are discussed separately. (See "Diphtheria, tetanus, and pertussis immunization in children 6 weeks through 6 years of age" and "Standard immunizations for children and adolescents: Overview".)

ABBREVIATIONS USED IN THIS TOPIC REVIEW — Throughout this topic review, the following abbreviations will be used to refer to diphtheria toxoid-, tetanus toxoid-, and pertussis-containing vaccines for children and adolescents:

●Tdap – Tetanus and reduced diphtheria toxoids, and acellular pertussis

●Td – Tetanus toxoid and reduced diphtheria toxoids; also called adult Td, dT, and adult dT

●DTaP – Diphtheria and tetanus toxoids, and acellular pertussis

●DTwP – Diphtheria and tetanus toxoids, and whole-cell pertussis

●DT – Diphtheria and tetanus toxoids; also called pediatric DT

VACCINE FORMULATIONS — Diphtheria toxoid-, tetanus toxoid-, and/or pertussis-containing vaccines for children age 7 through 18 years include:

●Tdap – Tdap contains tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine. The pertussis antigens that are included vary depending upon the vaccine product (table 1). Two Tdap vaccines are available in the United States [1]:

•Boostrix, for use in individuals ≥10 years of age

•Adacel, for use in individuals 10 through 64 years of age

Tdap must be distinguished from DTaP, which is used in children <7 years. Tdap vaccines contain less diphtheria toxoid and pertussis antigens than DTaP vaccines [1]. Tdap also may contain less tetanus toxoid than DTaP (table 1). (See "Diphtheria, tetanus, and pertussis immunization in children 6 weeks through 6 years of age", section on 'Vaccine formulations'.)

●Td – Td contains tetanus toxoid and reduced diphtheria toxoid. It is available for individuals ≥7 years.

Td must be distinguished from DT, which is used in children <7 years who have contraindications to the pertussis component. Td contains lower doses of diphtheria toxoid and may contain lower doses of tetanus toxoid than DT (table 1).

●Monovalent tetanus toxoid – Monovalent tetanus toxoid (TT) vaccine is no longer available in the United States [1], but may be available in other countries.

●Diphtheria or tetanus toxoid in conjugate vaccines – Diphtheria toxoid, CRM₁₉₇ (a nontoxic variant of diphtheria toxin), and tetanus toxoid are used as protein conjugates in some childhood vaccines (eg, pneumococcal conjugate vaccine, Haemophilus influenzae type b vaccine, meningococcal conjugate vaccine) to enhance the immune response. When used as protein conjugates, these toxoids do not substitute for diphtheria or tetanus toxoid immunization [2,3]. However, as vaccine components, they may contribute to adverse reactions. (See 'Adverse reactions' below and 'Contraindications and precautions' below.)

INDICATIONS — Routine immunization against diphtheria, tetanus, and pertussis during childhood and adolescence provides protection against these diseases into adulthood, prevents neonatal tetanus, and prevents transmission of pertussis to young infants, who have the greatest risk of mortality. (See "Clinical manifestations, diagnosis, and treatment of diphtheria" and "Tetanus" and "Pertussis infection in infants and children: Clinical features and diagnosis".)

●Worldwide – The World Health Organization recommends that all children worldwide be immunized against diphtheria, tetanus, and pertussis [4-6]. The recommended schedule includes a booster dose of diphtheria toxoid- and tetanus toxoid-containing vaccine during adolescence. Booster doses of acellular pertussis vaccine during adolescence or maternal pertussis immunization are also suggested for adolescents in countries that have switched from whole-cell to acellular pertussis vaccines for the primary series [6]. (See 'Other countries' below.)

●United States – Indications for Tdap for children ≥7 years and adolescents in the United States include [1,3,7]:

•Children age 11 through 12 years (routine immunization)

•Adolescents age ≥13 years and unimmunized with Tdap (catch-up immunization)

•Pregnancy (a single dose of Tdap is recommended during each pregnancy; immunization in pregnancy is discussed separately (see "Immunizations during pregnancy", section on 'Tetanus, diphtheria, and pertussis vaccination')

•Unvaccinated or incompletely vaccinated against pertussis and:

-Anticipated close contact with an infant <12 months of age (eg, household member, out-of-home caregiver); if possible, Tdap should be given ≥2 weeks before contact with the infant.

-At increased risk of pertussis infection (eg, living in or travel to an area with a high rate of endemic pertussis or an outbreak of pertussis; school or workplace outbreak of pertussis; close direct contact with a person with pertussis [eg, family member, residential facility, school-related activity]). (See "Pertussis infection in infants and children: Treatment and prevention", section on 'Prevention'.)

-At increased risk of complications from pertussis infection (eg, neurologic, muscular, cardiac, airway, or pulmonary disorder).

Complete pertussis vaccination at age 7 years is defined by four or five doses of DTaP at appropriate minimum ages and intervals (table 2). (See "Diphtheria, tetanus, and pertussis immunization in children 6 weeks through 6 years of age", section on 'Routine immunization'.)

Indications for either Td or Tdap include [7]:

•Wound management (table 3) (see 'Wound management' below)

•Tetanus or diphtheria disease (see 'Natural diphtheria or tetanus infection' below and "Tetanus", section on 'Active immunization' and "Clinical manifestations, diagnosis, and treatment of diphtheria", section on 'Treatment')

•Unimmunized or incompletely immunized close contact of an individual with diphtheria or pertussis disease (see "Pertussis infection in infants and children: Treatment and prevention", section on 'Prevention' and "Clinical manifestations, diagnosis, and treatment of diphtheria")

The Advisory Committee on Immunization Practices in the United States provides no preferential recommendation for Td or Tdap, although Tdap is more expensive [7].

EFFICACY AND EFFECTIVENESS

Protection against disease

●Efficacy – The efficacy and effectiveness of diphtheria, tetanus, and pertussis immunization vary depending upon the definition used for efficacy (eg, antibody levels correlated with protection or protection from disease) and the number of doses received.

•Td – After a series of three appropriately spaced doses of Td vaccines, approximately 95 percent of adolescents and adults achieve levels of diphtheria antitoxin correlated with protection (>0.1 international unit of antitoxin/mL), and virtually all adolescents and adults achieve levels of tetanus antitoxin correlated with protection (>0.1 international unit of antitoxin/mL) [8,9].

The estimated efficacy of diphtheria toxoid in the prevention of diphtheria disease is 97 percent [8]. The clinical efficacy of tetanus toxoid has not been studied in vaccine trials [9].

•Tdap – In randomized controlled trials, virtually all adolescent and adult recipients of Tdap developed levels of tetanus and diphtheria antitoxin correlated with protection [1,10,11]. Booster response rates to these antigens were achieved in ≥90 percent.

In a randomized trial, the efficacy of Tdap in preventing laboratory-confirmed pertussis in adolescents and adults was 92 percent (95% CI 32-99 percent) [12]. (See "Pertussis infection in adolescents and adults: Treatment and prevention".)

●Effectiveness – Vaccine effectiveness is a measure of how well a vaccine works to protect against an infection when the vaccine is used in routine circumstances in the community.

The effectiveness of diphtheria, tetanus, and pertussis immunization is demonstrated by the decline of these diseases in the United States after the immunizations were added to the routine immunization schedule in the 1940s (figure 1A-C) [8,9,13,14]. Most cases of diphtheria and tetanus in the United States occur in inadequately immunized persons [8,9].

Duration of immunity — Levels of diphtheria and tetanus antitoxin diminish with time [15,16]. After completion of routine childhood and adolescent immunization, booster doses of Td are necessary every 10 years. (See 'United States' below.)

The effectiveness of Tdap in preventing pertussis appears to wane soon after receipt among adolescents who completed childhood vaccination with acellular pertussis vaccines (ie, the cohort born in the late 1990s) rather than a combination of acellular and whole cell vaccines (ie, those born before 1997) [17-23]. The Advisory Committee on Immunization Practices began recommending Tdap for adolescents in 2006 [24]. In pertussis outbreaks during 2005 and 2007, reported effectiveness of acellular pertussis vaccine in preventing laboratory-confirmed or probable pertussis among vaccinated adolescents ranged from 66 to 85 percent [25,26]. In more recent statewide outbreaks, Tdap provided similar modest protection during the first year after vaccination (effectiveness of 64 to 75 percent), but effectiveness quickly waned to approximately 10 percent by ≥4 years [27-29].

Despite waning immunity, vaccination continues to be the most effective strategy to reduce pertussis morbidity and mortality [17,30-33]. In another outbreak, children and adolescents who received any doses of acellular pertussis vaccine were less likely to have severe illness or require hospitalization than unvaccinated children, and children and adolescents fully vaccinated with acellular pertussis vaccine had more rapid resolution of coughing [30].

SCHEDULE

United States

Age 7 through 10 years — Children 7 through 10 years of age generally do not require immunization with diphtheria toxoid, tetanus toxoid, and pertussis-containing vaccines if they have completed DTaP immunization before age seven years (ie, four or five doses at appropriate minimum ages and intervals) (table 2).

The catch-up schedule for children age 7 through 10 years of age with incomplete diphtheria, tetanus, and/or pertussis immunization varies with vaccination history.

●Previously unvaccinated or unknown vaccination status – Children 7 through 10 years of age who have never been vaccinated against tetanus, diphtheria, or pertussis or whose vaccination status is unknown should receive a series of three tetanus- and diphtheria-containing vaccines (table 4).

The preferred schedule is a first dose of Tdap (if there are no contraindications to pertussis vaccine (table 5)) to provide protection against pertussis, followed by a second dose of either Td or Tdap ≥4 weeks later and a third dose of either Td or Tdap 6 to 12 months after the second (table 4) [7]. (See 'Contraindications and precautions' below and 'Choice of vaccine' below.)

●Incompletely vaccinated – Children age 7 through 10 years who are incompletely vaccinated against pertussis and who have no contraindications to pertussis vaccine (table 5) should receive at least one dose of Tdap in their catch-up series, preferably as the first dose, to provide protection against pertussis [7]. Additional doses of either Td or Tdap should be provided as necessary to complete the immunization series (table 4). (See 'Contraindications and precautions' below and 'Choice of vaccine' below.)

Children who receive Tdap at age 7 through 9 years as part of a catch-up series should receive another dose of Tdap at age 11 through 12 years [7]. A catch-up Tdap that is administered at age ≥10 years may count as the adolescent Tdap dose.

The Centers for Disease Control and Prevention has developed a "job aid" to provide guidance for catch-up of diphtheria, tetanus, and pertussis immunizations in children age 7 through 18 years of age.

Age 11 through 12 years — The adolescent booster dose of Tdap vaccine is routinely recommended at age 11 through 12 years [1]. Thereafter, booster doses of either Td or Tdap vaccine should be given every 10 years [7].

The adolescent Tdap booster is recommended for children age 11 through 12 years, even if they received Tdap at age 7 through 9 years as part of a catch-up series [7]. The adolescent Tdap booster is also recommended for children who received an inadvertent dose of Tdap or DTaP at age 7 through 9 years. (See 'Vaccine mix-up or unnecessary dose' below.)

Tdap may be given at any interval after the last tetanus toxoid- and diphtheria toxoid-containing vaccine [7]. However, the minimum intervals in the catch-up schedule should continue to be followed (table 4).

The Centers for Disease Control and Prevention has developed a "job aid" to provide guidance for catch-up of diphtheria, tetanus, and pertussis immunizations in children age 7 through 18 years of age.

Age 13 and older — Adolescents ≥13 years who have not received a dose of Tdap or whose Tdap status is unknown should receive a single dose of Tdap as soon as is feasible. There is no minimum interval between Td and Tdap [1]. If necessary, additional doses of either Td or Tdap should be provided to complete the series (table 4) [7].

Provision of Tdap is particularly important for adolescents who anticipate having close contact with an infant younger than 12 months [1]. (See "Pertussis infection in adolescents and adults: Treatment and prevention".)

The Centers for Disease Control and Prevention has developed a "job aid" to provide guidance for catch-up of diphtheria, tetanus, and pertussis immunizations in children age 7 through 18 years of age.

Other countries — Routine immunization schedules vary from country to country. Schedules for individual countries are available through the World Health Organization and the European Centre for Disease Prevention and Control.

ADMINISTRATION

Contraindications and precautions

●Contraindications — A contraindication is a condition that increases the risk of a serious adverse reaction [1]. Absolute contraindications to Tdap and Td include:

•Severe allergic reaction (eg, anaphylaxis) after a previous dose or to a vaccine component. (See "Allergic reactions to vaccines".)

-Referral to an allergist is warranted to evaluate allergy to tetanus toxoid and the possibility of desensitization to tetanus toxoid given the importance of tetanus immunization

-Information about latex in Tdap vaccines is available in the prescribing information, available from the US Food and Drug Administration

•For Tdap only, another absolute contraindication is encephalopathy (eg, coma, decreased level of consciousness, or prolonged seizures) within seven days of the administration of a previous dose of a pertussis-containing vaccine (eg, DTaP, DTwP, Tdap) without another identifiable cause.

-Administer Td rather than Tdap (see 'Vaccine formulations' above)

●Precautions — Precautions are conditions that may increase the risk for a serious reaction to immunization, cause diagnostic confusion, or compromise the ability of the vaccine to produce immunity [34]. Although immunization generally is deferred in children with precautions, decisions regarding administering diphtheria toxoid, tetanus toxoid, and pertussis-containing vaccines to children and adolescents with precautions should be individualized according the benefits and risks, and reassessed at subsequent immunization visits [1].

Precautions to immunization with Td or Tdap include [1]:

•Moderate or severe acute illness with or without fever; immunization should be administered upon recovery

•History of Arthus-type reaction after a previous dose of tetanus or diphtheria toxoid-containing vaccines (including quadrivalent meningococcal conjugate vaccine) (see 'Past cutaneous reactions involving skin necrosis (Arthus-type reaction)' below)

•Guillain-Barré syndrome (GBS) within six weeks after previous dose of tetanus toxoid-containing vaccine (see "Guillain-Barré syndrome in children: Epidemiology, clinical features, and diagnosis" and 'Adverse reactions' below)

•For Tdap only, another precaution is progressive or unstable neurologic disorder, uncontrolled seizures, or progressive encephalopathy until a treatment regimen has been established and the condition has stabilized

●Conditions that are neither contraindications nor precautions — The following conditions are neither contraindications nor precautions to Tdap vaccine (table 5) [1,34]:

•Fever ≥105°F (40.5°C) within 48 hours after DTaP or DTwP (not attributable to another cause)

•History of collapse or shock-like state (ie, hypotonic-hyporesponsive episode) within 48 hours after DTaP or DTwP

•History of seizure with or without fever within three days of DTaP or DTwP

•History of persistent inconsolable crying lasting >3 hours within 48 hours after receiving DTaP or DTwP

•History of extensive limb swelling after DTaP, DTwP, or Td that is not an Arthus-type reaction (see 'Past cutaneous reactions involving skin necrosis (Arthus-type reaction)' below)

•Stable or resolved neurologic disorder (eg, well-controlled seizures, developmental delay, cerebral palsy)

•History of brachial neuritis

•Breastfeeding an infant

•Immunosuppression

Choice of vaccine — The choice of vaccine varies with the age of the child or adolescent and history of Tdap immunization.

●Tdap preferred – Tdap 0.5 mL intramuscularly (IM) is preferred to Td [1,7]:

•For the routine adolescent booster dose at age 11 through 12 years of age

•For at least one dose of the catch-up series (ideally the first) in children age 7 through 10 years who are unimmunized or incompletely immunized against diphtheria, tetanus, and/or pertussis (table 4) [7] (see 'Age 7 through 10 years' above)

Although none of the pertussis-containing vaccines are licensed in the United States for children between 7 and 10 years of age, the Advisory Committee on Immunization Practices and American Academy of Pediatrics prefer off-label use of Tdap to DTaP because Tdap causes fewer adverse reactions [7,35,36].

•For at least one dose (preferably the first) of the catch-up series in a Tdap-naïve child ≥10 years of age (see 'Indications' above)

•For pregnant women during each pregnancy (see "Immunizations during pregnancy", section on 'Tetanus, diphtheria, and pertussis vaccination')

●Td preferred – Td 0.5 mL IM is preferred:

•For children ≥7 years and adolescents who have a contraindication to the pertussis component (table 5) (see 'Contraindications and precautions' above)

●No preference between Tdap and Td – Either Tdap 0.5 mL IM or Td 0.5 mL IM may be administered [7]:

•For the every 10-year tetanus and diphtheria toxoids booster

•For wound management in people who have received at least one dose of Tdap

•For multiple doses in the catch-up immunization schedule for individuals ≥7 years of age

Although it is uncertain whether receiving multiple doses of Tdap for the above indications affects pertussis transmission or control, the Advisory Committee on Immunization Practices permits either Tdap or Td for improved flexibility [7]. Both vaccines appear to be safe and immunogenic [37-39]; Tdap is more expensive.

Administration with other vaccines — Tdap or Td may be administered at the same visit as other recommended vaccines (eg, meningococcal conjugate vaccine, human papillomavirus, influenza) (figure 2) [1,40-45].

Adverse reactions — The safety of Tdap was confirmed in postmarketing surveillance of more than 13,000 adolescents [46]. There was no increased risk of medically attended neurologic, hematologic, or allergic reactions on days 0 to 29 after Tdap vaccination compared with days 30 to 59 after vaccination, nor was there an increased risk of new-onset chronic illness in recipients of Tdap compared with historical recipients of Td. In randomized trials in adult patients, subsequent doses of Tdap also appear to be safe when administered as part of a catch-up series [47] or as the 10-year booster [37,38].

Adverse reactions to the Tdap vaccine include:

●Local reactions – Mild local reactions (eg, pain, redness, swelling) may occur after immunization with Td or Tdap. In prelicensure studies, the rates of mild local reactions were similar for Td and Tdap [48]:

•Pain – Approximately 70 to 80 percent

•Erythema – Approximately 20 percent

•Swelling – Approximately 20 percent

Severe local reactions are less frequent (≤6 percent for either Td or Tdap).

●Systemic reactions – Systemic reactions also may occur after immunization with Td or Tdap [3,48]:

•Fever – 3 to 14 percent

•Headache – Approximately 40 percent

•Fatigue – Approximately 30 to 35 percent

Fever >102.2°F (39°C), severe headache, and severe fatigue occur in less than 4 percent.

●Syncope – Syncope following immunization appears to be more common among adolescents and young adults than other age groups [1,49-51]. Having the recipient sit or lie down for 15 minutes after vaccination may prevent syncopal episodes and secondary injuries. If syncope occurs, patients should be observed until symptoms resolve. (See "Standard immunizations for children and adolescents: Overview", section on 'Local and systemic reactions'.)

●Local reactions with skin hemorrhage and necrosis – Arthus-type reactions can occur after vaccines containing tetanus or diphtheria toxoid [1]. They typically occur 4 to 12 hours after vaccination and are characterized by severe pain, swelling, induration, edema, hemorrhage, and occasionally necrosis at the site of the injection. They generally resolve without sequelae. The history of the reaction should be reviewed to verify the signs and symptoms; consultation with an allergist or immunologist may be warranted. (See 'Contraindications and precautions' above and 'Past cutaneous reactions involving skin necrosis (Arthus-type reaction)' below.)

●Guillain-Barré syndrome – There have been rare case reports of GBS following tetanus toxoid-containing vaccines [1,52-54]. However, an association between GBS and tetanus vaccination has not been demonstrated during active surveillance [1,55]. (See "Guillain-Barré syndrome in adults: Pathogenesis, clinical features, and diagnosis", section on 'Vaccinations'.)

GBS also has been reported after meningococcal conjugate vaccine, which may contain diphtheria toxoid as a protein conjugate. The possible association between meningococcal conjugate vaccine and GBS is discussed separately. (See "Meningococcal vaccination in children and adults", section on 'Adverse events'.)

SPECIAL CIRCUMSTANCES

Wound management — When tetanus prophylaxis is necessary for wound management (table 3) in children ≥7 years of age, either Tdap or Td may be used [7]. (See "Tetanus" and 'Administration with other vaccines' above.)

Past cutaneous reactions involving skin necrosis (Arthus-type reaction) — Arthus-type reactions are characterized by painful swelling, erythema, hemorrhage, and sometimes superficial skin necrosis at the site of injection of booster vaccines [1]. They usually begin within a few hours of the injection and peak by 24 hours. The history of the reaction should be reviewed to verify the signs and symptoms; consultation with an allergist or immunologist may be warranted. (See 'Adverse reactions' above and "Drug hypersensitivity: Classification and clinical features", section on 'Arthus reaction'.)

For patients with a history of Arthus-type reaction after diphtheria or tetanus toxoid-containing vaccine, we agree with the Advisory Committee on Immunization Practices recommendation to defer tetanus toxoid-containing vaccine for a minimum of 10 years after the last dose of tetanus toxoid-containing vaccine [1].

Incomplete pertussis — Adolescents with incomplete pertussis immunization (ie, because there was a precaution to administration of pertussis vaccine during childhood) generally should receive Tdap for their adolescent booster dose [1]. Conditions that were considered precautions to DTaP in the past (but are no longer precautions) are neither contraindications nor precautions for Tdap (eg, history of hypotonic-hyporesponsive episode within 48 hours after DTaP or DTwP; history of persistent, inconsolable crying lasting >3 hours within 48 hours after DTaP or DTwP). (See 'Contraindications and precautions' above and "Diphtheria, tetanus, and pertussis immunization in children 6 weeks through 6 years of age", section on 'Adverse reactions'.)

Incomplete records — Serologic testing can be performed in children and adolescents who have an adequate history of immunization against diphtheria and tetanus but incomplete documentation [1]. If tetanus and diphtheria antitoxin concentrations are ≥0.1 international units/mL, previous immunization can be presumed and the adolescent booster dose of Tdap administered as indicated. (See 'United States' above.)

Natural diphtheria or tetanus infection — Natural infection with diphtheria or tetanus disease does not induce immunity. Individuals with diphtheria or tetanus disease should receive Td during their convalescence. (See "Clinical manifestations, diagnosis, and treatment of diphtheria", section on 'Follow-up' and "Tetanus", section on 'Active immunization'.)

Natural pertussis infection — Well-documented pertussis disease (eg, positive culture, positive polymerase chain reaction, or epidemiologic linkage to a culture-proven case) confers short-term immunity [1]. However, the duration of protection is unknown. Adolescents with a history of pertussis infection should receive Tdap according to the routine schedule [1].

Vaccine mix-up or unnecessary dose

●Children age 7 through 10 years

•DTaP instead of Tdap in catch-up schedule – Inadvertent administration of DTaP instead of Tdap as part of a catch-up series in a child age 7 through 9 years counts as the Tdap dose of the catch-up series. The child should receive the adolescent Tdap at age 11 through 12 years [7].

If the inadvertent administration of DTaP instead of Tdap as part of the catch-up series occurred in a child age ≥10 years, the DTaP counts as the adolescent Tdap dose (as well as the catch-up dose) [7].

•Unnecessary Tdap – Inadvertent administration of Tdap to a child age 7 through 9 years who was fully immunized with DTaP (table 2) does not count as the adolescent Tdap [7]. The child should receive the adolescent Tdap at age 11 through 12 years.

If the unnecessary dose of Tdap is administered to a child age ≥10 years, it counts as the adolescent Tdap dose [7].

•Unnecessary DTaP – Inadvertent administration of DTaP vaccine to a child age 7 through 9 years who was fully immunized with DTaP (table 2) does not count as the adolescent Tdap [1]. The child should receive the adolescent Tdap at age 11 through 12 years [7].

If the unnecessary dose of DTaP is administered to a child age ≥10 years, it counts as the adolescent Tdap dose [7].

●Children ≥11 years

•DTaP instead of Td or Tdap – Inadvertent administration of DTaP vaccine (rather than Td or Tdap) to a child 11 through 18 years of age counts as the Tdap dose. The child should receive either Td or Tdap 10 years after the inadvertent dose.

Vaccine administration errors should be reported to the Vaccine Adverse Event Reporting System (VAERS).

Pregnancy — Immunization during pregnancy is discussed separately. (See "Immunizations during pregnancy".)

RESOURCES — Resources related to immunization in children 7 through 18 years of age include:

●The Centers for Disease Control and Prevention

●The American Academy of Pediatrics

●Vaccine information statement for Td and Tdap

●Immunize.org

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Pertussis" and "Society guideline links: Immunizations in children and adolescents" and "Society guideline links: Diphtheria, tetanus, and pertussis vaccination".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or email these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient education" and the keyword[s] of interest.)

●Basics topics (see "Patient education: Whooping cough (The Basics)" and "Patient education: Tetanus (The Basics)" and "Patient education: Tdap vaccine (The Basics)" and "Patient education: Vaccines for children age 7 to 18 years (The Basics)")

●Beyond the Basics topics (see "Patient education: Why does my child need vaccines? (Beyond the Basics)" and "Patient education: Vaccines for children age 7 to 18 years (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Routine immunization against diphtheria, tetanus, and pertussis during childhood and adolescence provides protection against these diseases into adulthood, prevents neonatal tetanus, and prevents transmission of pertussis to young infants, who have the greatest risk of mortality. (See 'Efficacy and effectiveness' above.)

●We agree with the World Health Organization (WHO) recommendation for a booster dose of diphtheria toxoid and tetanus toxoid-containing vaccine for all adolescents. (See 'Indications' above.)

•Additional indications for diphtheria toxoid and tetanus toxoid-containing vaccines for children ≥7 years include:

-Wound management (table 3)

-Tetanus or diphtheria disease (even if fully immunized)

-Unimmunized or incompletely immunized close contact of an individual with diphtheria or pertussis disease

●Recommendations for an adolescent booster dose of acellular pertussis vaccine vary geographically. Recommendations and schedules for individual countries are available through the WHO and the European Centre for Disease Prevention and Control. (See 'Indications' above.)

●In the United States, Tdap 0.5 mL intramuscularly (IM) is routinely recommended at age 11 through 12 years of age. Thereafter, individuals should receive a booster dose of either Td 0.5 mL IM or Tdap 0.5 mL IM every 10 years. (See 'Age 11 through 12 years' above.)

●Additional target groups for Tdap in the United States include (see 'Indications' above and 'United States' above):

•Tdap-naïve adolescents age ≥13 years (catch-up immunization)

•Pregnant adolescents (a single dose during each pregnancy) (see "Immunizations during pregnancy", section on 'Tetanus, diphtheria, and pertussis vaccination')

•Unvaccinated or incompletely vaccinated children age 7 through 18 years, particularly if they anticipate close contact with an infant <12 months of age or are at increased risk of pertussis infection or complications of pertussis disease; Tdap should be used for at least one dose of the catch-up series (preferably the first dose) (table 4)

●Absolute contraindications, precautions, and conditions that are incorrectly perceived as contraindications to administration of Tdap and Td are listed in the table (table 5). (See 'Contraindications and precautions' above.)

●Mild local (pain, redness, swelling) and systemic (fever, headache, fatigue) reactions are the most common adverse events after Tdap or Td. More serious reactions include syncope and Arthus-type reactions. (See 'Adverse reactions' above.)