About Young Children with a Contraindication to Pertussis-Containing Vaccines

Key points

• CDC recommends a series of diphtheria, tetanus, and pertussis vaccine (DTaP) for children aged younger than 7 years.
• Use tetanus and diphtheria vaccine (Td) off-label for children aged <7 years who develop a contraindication to pertussis-containing vaccine.
• If Td is used, follow the same schedule that would be used for DTaP.
• Children who receive Td in place of DTaP may have sub-optimal protection against diphtheria.

Background

CDC recommends a series of DTaP for children aged <7 years. For children aged <7 years who develop a contraindication to pertussis-containing vaccines, CDC previously recommended DT instead of DTaP.

Vaccine availability

Sanofi Pasteur, historically the sole licensed DT manufacturer in the United States, discontinued the vaccine in late 2022. Currently, there’s no licensed DT available in the United States. The current Td supply is adequate. The anticipated increase in Td use is relatively small, considering the rarity of developing a contraindication to pertussis-containing vaccine.

What the data show

Rarity of contraindications

There’s only one contraindication specific to the pertussis component in DTaP: encephalopathy. Encephalopathy, within 7 days of vaccination, is a contraindication when it’s not attributable to another identifiable cause.

Experts don’t know the exact number of people who experience this adverse reaction, but data suggest it’s extremely rare.

A family history of a contraindication or reaction to pertussis-containing vaccines isn’t a contraindication for young children to receive DTaP.

Uncertain impact on diphtheria protection

Td contains a lower dose (approximately 1/12^th the amount) of diphtheria toxoid compared to DT. The impact of this lower dose on the protection provided against diphtheria in young children is uncertain. Available evidence suggests young children who receive Td in place of DTaP may have sub-optimal protection against diphtheria.^1-7

In the primary series for young children

No available data evaluate Td effectiveness against diphtheria when used as part of a primary series in young children.

As the booster dose for young children

Several studies have looked at low-dose, diphtheria toxoid-containing vaccines used for a booster dose in children aged <7 years. Available data demonstrated mixed findings regarding the level of protective diphtheria antibody generated.^2,3,4

In the primary series for older children and adults

Limited data are available on the use of Td for primary vaccination of older children and adults. Available data suggest that low-dose diphtheria toxoid-containing vaccines may not reliably generate a protective diphtheria response.^5,6,7

Guidance

First dose

CDC recommends young children receive DTaP as the first dose in the diphtheria, tetanus, and pertussis childhood vaccination series. CDC recommends this dose at 2 months of age.

Keep reading: Diphtheria, Tetanus, and Pertussis Vaccine Recommendations

Subsequent doses

CDC recommends continued use of DTaP unless a contraindication to pertussis-containing vaccines develops. For young children with a contraindication to pertussis-containing vaccines, vaccine providers may administer Td for all recommended remaining doses in place of DTaP.

Parent counseling

Counsel concerned parents about:

1. What is and isn’t a contraindication to pertussis-containing vaccines
2. How rare contraindications are to pertussis-containing vaccines
3. How their child may have less protection against diphtheria and no additional protection against pertussis if they receive Td instead of DTaP

Resources

• Diphtheria, tetanus, and pertussis vaccination: Information for healthcare professionals
• Immunization schedules
• Contraindications and Precautions
• Pertussis chapter of the Epidemiology and Prevention of Vaccine-preventable Diseases Textbook

Footnotes

1. Kahn F, Lepp T, Storsaeter J. Primary diphtheria immunisation of adolescents and adults with low‐dose vaccine, a survey of historic evidence from the literature. Acta Paediatrica. 2023; 112(2):242-245.
2. Ciofi degli Atti ML, Salmaso S, Cotter B, et al. Reactogenicity and immunogenicity of adult versus paediatric diphtheria and tetanus booster dose at 6 years of age. Vaccine. 2001;20(1–2):74–9.
3. Meyer CU, Habermehl P, Knuf M, et al. Immunogenicity and reactogenicity of acellular pertussis booster vaccines in children: Standard pediatric versus a reduced-antigen content formulation. Hum Vaccin. 2008;4(3):203–9.
4. Stojanov S, Liese JG, Bendjenana H, et al. Immunogenicity and safety of a trivalent tetanus, low dose diphtheria, inactivated poliomyelitis booster compared with a standard tetanus, low dose diphtheria booster at six to nine years of age. Pediatr Infect Dis J. 2000;19(6):516–21.
5. Myers MG, Beckman CW, Vosdingh RA, Hankins WA. Primary immunization with tetanus and diphtheria toxoids. JAMA. 1982;248(19):2478–80.
6. Larsen K, Ullberg-Olsson K, Ekwall E, Hederstedt B. The immunization of adults against diphtheria in Sweden. J Biol Stand. 1987;15(2):109–16.
7. Sutter RW, Hardy R, Kozlova A, et al. Immunogenicity of tetanus-diphtheria toxoids (Td) among Ukrainian adults: Implications for diphtheria control in the Newly Independent States of the Former Soviet Union. J Infect Dis. 2000;181(Supplement 1):S197–S202.