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Supplementary Statement of Contraindications to Receipt of Pertussis Vaccine

The following statement updates some of the previous recommendations regarding pertussis vaccine (1). The Immunization Practices Advisory Committee (ACIP) reviewed the available data concerning the risks of pertussis disease and pertussis vaccine to infants and children with personal or family histories of convulsions. Based on available evidence, the ACIP does not consider a family history of convulsion to be a contraindication to receipt of pertussis vaccine. However, a personal history of a prior convulsion should be evaluated before initiating or continuing immunization with vaccines containing a pertussis component (i.e., diphtheria and tetanus toxoids with pertussis vaccine (DTP)) (Table 1). DEFERRAL OF DTP FOR INFANTS AND CHILDREN WITH PERSONAL HISTORIES OF CONVULSION(S)

Although there are uncertainties in the reported studies, recent data suggest that infants and young children who have previously had convulsions (whether febrile or nonfebrile) are more likely to have seizures following pertussis vaccination than those without such histories (2). Available data do not indicate that seizures temporally associated with vaccine administration predispose to permanent brain damage or exacerbate existing conditions. The incidence of pertussis in most areas of the United States is presently quite low. Consequently, for infants and young children who have histories of seizures before initiation of DTP immunization or who develop seizures before the four-dose primary series is completed, initiating or continuing pertussis immunization should be deferred until it can be determined that there is not an evolving neurologic disorder present. If such disorders are found, the infants or children should be given diphtheria and tetanus toxoids (DT) instead of DTP. If DT is used, three doses at least 4 weeks apart, followed by a fourth dose 6-12 months later, are recommended for infants. For children 1 year of age or older, two doses of DT at least 4 weeks apart, followed by a third dose 6-12 months later, are recommended. RECOMMENDATIONS FOR BEGINNING OR CONTINUING DTP AFTER DEFERRAL

For infants and children whose DTP immunizations are deferred because of histories of convulsion(s), the decision whether to proceed with DTP immunization can usually be made within the next few months. For infants who have received fewer than three doses of DTP, such a decision in most instances should be made no later than at 1 year of age. Following individual assessment, it may be decided to proceed with DTP, because infants and young children with convulsive disorders also appear to be at higher risk of adverse outcomes if they contract pertussis disease. Further, if unimmunized infants attend day-care centers, special clinics, and residential-care settings where other children may be unimmunized or if they travel to or reside in areas where the disease is endemic, they may be at increased risk of exposure to pertussis.

For infants and children with stable neurologic conditions, including well-controlled seizures, the benefits of pertussis immunization outweigh the risks, and such children may be vaccinated. The occurrence of single seizures (temporally unassociated with DTP) in infants and young children, while necessitating evaluation, need not contraindicate DTP immunization, particularly if the seizures can be satisfactorily explained. An example might be a febrile seizure in the course of exanthem subitum in a 14-month-old child. As with all infants or children with one or more febrile seizures, consideration of continuous anticonvulsant prophylaxis may be warranted.

Parents should be fully informed of the benefits and risks of immunization with DTP. Parents of infants and children with histories of convulsions should particularly be made aware of the slightly increased chance of post-immunization seizures. A minimum of three doses of DTP given at intervals of at least 4 weeks is necessary to provide adequate protection against pertussis. A fourth dose 6-12 months later is also recommended. CONTRAINDICATIONS TO PERTUSSIS VACCINE

Hypersensitivity to vaccine components, presence of an evolving neurologic disorder, or a history of a severe reaction (usually within 48 hours) following a previous dose all remain definitive contraindications to the receipt of pertussis vaccine. Severe reactions include collapse or shock, persistent screaming episode, temperature 40.5 C (105 F) or greater, convulsion(s) with or without accompanying fever, severe alterations of consciousness, generalized and/or local neurologic signs, or systemic allergic reactions. Although hemolytic anemia and thrombocytopenic purpura have previously been considered contraindications by the ACIP, the evidence of a causal link between these conditions and pertussis vaccination is not sufficient to retain them as contraindications. OTHER IMMUNIZATIONS FOR INFANTS AND CHILDREN FOR WHOM PERTUSSIS VACCINE IS CONTRAINDICATED

Immunization with DT and/or oral polio vaccine is not known to be associated with an increased risk of convulsions. Therefore, a history of prior convulsions is not a contraindication to receipt of these toxoids and vaccine. In addition, a history of prior convulsion(s) is not a contraindication for measles-mumps-rubella (MMR) vaccine. Further details concerning DTP vaccine or DT toxoids can be found in the 1981 ACIP statement (1).

References

  1. ACIP. Diphtheria, tetanus, and pertussis: guidelines for vaccine prophylaxis and other preventive measures. MMWR 1981;30:392-6, 401-7.

  2. CDC. Adverse events following immunization. Surveillance Report No. 1, 1979-1982 (in press).

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