(dif THEER ee a & TET a nus TOKS oyds)
Diphtheria and tetanus disease prevention:
Diphtheria and tetanus toxoids adsorbed for pediatric use (DT): Infants ≥6 weeks and children through 6 years of age: Active immunization against diphtheria and tetanus when pertussis vaccine is contraindicated
Tetanus and diphtheria toxoids adsorbed for adult use (Td) (Tenivac): Children ≥7 years, adolescents, and adults: Active immunization against diphtheria and tetanus; tetanus prophylaxis in wound management
The Advisory Committee on Immunization Practices (ACIP) recommends routine vaccination for the following:
- Children ≥7 years, adolescents, and adults should receive a booster dose of Td every 10 years; may substitute a single Td booster dose with Tdap (CDC/ACIP 60[1] 2011)
- Children 7 to 10 years, adolescents, adults, and elderly ( ≥65 years) patients who are wounded in bombings or similar mass casualty events who have penetrating injuries or nonintact skin exposure and who cannot confirm receipt of a tetanus booster within the previous 5 years, may also receive a single dose of Td; children ≥11 years and adults may also receive Td if Tdap is unavailable (CDC [Chapman, 2008])
Hypersensitivity to diphtheria, tetanus toxoid, or any component of the formulation
Primary immunization (Td): IM:
Manufacturer labeling (Tenivac): Patients previously not immunized should receive 2 primary doses of 0.5 mL each, given at an interval of 8 weeks; third (reinforcing) dose of 0.5 mL 6 to 8 months later
ACIP recommendations: Patients previously not immunized should receive 2 primary doses of 0.5 mL each, given at an interval of 4 weeks; third (reinforcing) dose of 0.5 mL 6 to 12 months later. Patients not completely immunized (<3 doses) should receive the remaining doses. For patients who have not received Tdap, a dose should be included as part of primary immunization (in place of one of the Td doses) (ACIP [Kim 2016]).
Booster immunization (Td): IM: 0.5 mL every 10 years (for routine booster in patients who have completed primary immunization series). The ACIP prefers Tdap for use in in some situations if no contraindications exist; refer to Diphtheria and Tetanus Toxoids and Acellular Pertussis Vaccine monograph for additional information.
Tetanus prophylaxis in wound management (CDC/ACIP [Broder 2006]): IM: Tetanus prophylaxis in patients with wounds should be based on if the wound is clean or contaminated, the immunization status of the patient. Wound management includes proper use of tetanus toxoid and/or tetanus immune globulin (TIG), wound cleaning, and (if required) surgical debridement and the proper use of antibiotics. Patients with an uncertain or incomplete tetanus immunization status should have additional follow up to ensure a series is completed. Patients with a history of Arthus reaction following a previous dose of a tetanus toxoid-containing vaccine should not receive a tetanus toxoid-containing vaccine until >10 years after the most recent dose even if they have a wound that is neither clean nor minor. See table.
Tetanus Prophylaxis in Wound ManagementHistory of Tetanus Immunization Doses
Clean, Minor Wounds
All Other Wounds1
Tetanus Toxoid2
TIG
Tetanus Toxoid2
TIG
1Such as, but not limited to, wounds contaminated with dirt, feces, soil, and saliva; puncture wounds; wounds from crushing, tears, burns, and frostbite.
2Tetanus toxoid in this chart refers to a tetanus toxoid-containing vaccine. For children ≤6 years of age, DTaP (DT, if pertussis vaccine contraindicated) is preferred to tetanus toxoid alone. For children ≥7 years, adolescents, and adults, Td preferred to tetanus toxoid alone; Tdap may be preferred if the patient has not previously been vaccinated with Tdap.
3Yes, if ≥10 years since last dose.
4Yes, if ≥5 years since last dose.
Abbreviations: DT = Diphtheria and Tetanus Toxoids (formulation for age ≤6 years); DTaP = Diphtheria and Tetanus Toxoids, and Acellular Pertussis (formulation for age ≤6 years; Daptacel, Infanrix); Td = Diphtheria and Tetanus Toxoids (formulation for age ≥7 years; Tenivac); TT= Tetanus toxoid (adsorbed [formulation for age ≥7 years]); Tdap = Diphtheria and Tetanus Toxoids, and Acellular Pertussis (Adacel or Boostrix [formulations for age ≥7 years]); TIG = Tetanus Immune Globulin
Uncertain or <3 doses
Yes
No
Yes
Yes
3 or more doses
No3
No
No4
No
Table has been converted to the following text.
Tetanus Prophylaxis in Wound Management
History of tetanus immunization: Uncertain or <3 doses
Clean, minor wounds: Administer a tetanus toxoid-containing vaccine.
Children ≤6 years of age: DTaP (DT, if pertussis vaccine contraindicated) is preferred to tetanus toxoid alone.
Children ≥7 years of age, Adolescents, and Adults: Td preferred to tetanus toxoid alone; Tdap may be preferred if the patient has not previously been vaccinated with Tdap.
Other wounds (such as, but not limited to, wounds contaminated with dirt, feces, soil, and saliva; puncture wounds; wounds from crushing, tears, burns, and frostbite): Administer a tetanus toxoid-containing vaccine and TIG.
Children ≤6 years of age: DTaP (DT, if pertussis vaccine contraindicated) is preferred to tetanus toxoid alone.
Children ≥7 years of age, Adolescents, and Adults: Td preferred to tetanus toxoid alone; Tdap may be preferred if the patient has not previously been vaccinated with Tdap.
History of tetanus immunization: Three or more doses
Clean, minor wounds: Administer a tetanus toxoid-containing vaccine if ≥10 years since last dose.
Children ≤6 years of age: DTaP (DT, if pertussis vaccine contraindicated) is preferred to tetanus toxoid alone.
Children ≥7 years of age, Adolescents, and Adults: Td preferred to tetanus toxoid alone; Tdap may be preferred if the patient has not previously been vaccinated with Tdap.
Other wounds (such as, but not limited to, wounds contaminated with dirt, feces, soil, and saliva; puncture wounds; wounds from crushing, tears, burns, and frostbite): Administer a tetanus toxoid-containing vaccine if ≥5 years since last dose.
Children ≤6 years of age: DTaP (DT, if pertussis vaccine contraindicated) is preferred to tetanus toxoid alone.
Children ≥7 years of age, Adolescents, and Adults: Td preferred to tetanus toxoid alone; Tdap may be preferred if the patient has not previously been vaccinated with Tdap.
Abbreviations: DT = Diphtheria and Tetanus Toxoids (formulation for age ≤6 years); DTaP = Diphtheria and Tetanus Toxoids, and Acellular Pertussis (formulation for age ≤6 years; Daptacel, Infanrix); Td = Diphtheria and Tetanus Toxoids (formulation for age ≥7 years; Tenivac); TT= Tetanus toxoid (adsorbed [formulation for age ≥7 years]); Tdap = Diphtheria and Tetanus Toxoids, and Acellular Pertussis (Adacel or Boostrix [formulations for age ≥7 years]); TIG = Tetanus Immune Globulin
Refer to adult dosing.
Primary immunization: IM:
Infants and Children 6 weeks to ≤6 years (DT): ACIP recommendations (Robinson 2016): Note: For use when a pertussis-containing vaccine is contraindicated: 0.5 mL per dose, total of 5 doses administered as follows:
Three doses, usually given at 2-, 4-, and 6 months of age; may be given as early as 6 weeks of age and repeated every 4 to 8 weeks
Fourth dose: Given at ~15 to 18 months of age, but at least 6 months after third dose. The fourth dose may be given as early as 12 months of age, but at least 6 months must have elapsed between the third dose and the fourth dose. The fourth dose does not need to be repeated if inadvertently administered at least 4 months after the third dose.
Fifth dose: Given at 4 to 6 years of age, prior to starting school or kindergarten; if the fourth dose is given at ≥4 years of age, the fifth dose may be omitted
For children who start primary immunization series ≥4 months of age, refer to current ACIP Catch-up Immunization Schedule"
Children ≥7 years and Adolescents (Td): Refer to adult dosing.
Booster immunization: IM: For routine booster in patients who have completed primary immunization series. The ACIP prefers Tdap for use in in some situations if no contraindications exist; refer to Diphtheria and Tetanus Toxoids and Acellular Pertussis Vaccine monograph for additional information.
Children 11 to 12 years (Td): 0.5 mL as a single dose. If not contraindicated, Tdap is the preferred agent for this dose and may be administered regardless of the interval since the last tetanus/diphtheria-containing vaccine. Subsequent routine doses are not recommended more often than every 10 years. Note: If Tdap is given as part of catch-up dosing at 7 to 10 years of age, the 11 to 12 year Tdap or TD booster should not be given. Regular Td booster immunizations should begin 10 years after the last dose of the primary series.
Tetanus prophylaxis in wound management:Children ≥7 years and Adolescents: Refer to adult dosing.
There are no dosage adjustments provided in the manufacturer 's labeling.
There are no dosage adjustments provided in the manufacturer 's labeling.
For IM administration only; not for IV or SubQ administration. Prior to use, shake suspension well. To prevent syncope related injuries,adolescents and adults should be vaccinated while seated or lying down (NCIRD/ACIP 2011). US law requires that the date of administration, the vaccine manufacturer, lot number of vaccine, and the administering persons name, title, and address be entered into the patient's permanent medical record.
Td: Administer in the deltoid muscle; do not inject in the gluteal area
DT: Administer in the anterolateral aspect of the thigh or the deltoid muscle; do not inject in the gluteal area
For patients at risk of hemorrhage following intramuscular injection, the vaccine should be administered intramuscularly if, in the opinion of the physician familiar with the patient's bleeding risk, the vaccine can be administered by this route with reasonable safety. If the patient receives antihemophilia or other similar therapy, intramuscular vaccination can be scheduled shortly after such therapy is administered. A fine needle (23 gauge or smaller) can be used for the vaccination and firm pressure applied to the site (without rubbing) for at least 2 minutes. The patient should be instructed concerning the risk of hematoma from the injection. Patients on anticoagulant therapy should be considered to have the same bleeding risks and treated as those with clotting factor disorders (NCIRD/ACIP 2011).
Store at 2 ‚ °C to 8 ‚ °C (35 ‚ °F to 46 ‚ °F). Do not freeze; discard if product has been frozen.
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Injection, suspension [Td, adult; preservative free]: Diphtheria 2 Lf units and tetanus 2 Lf units per 0.5 mL (0.5 mL)
Tenivac: Diphtheria 2 Lf units and tetanus 5 Lf units per 0.5 mL (0.5 mL) [contains aluminum, may contain natural rubber/natural latex in prefilled syringe]
Injection, suspension [DT, pediatric; preservative free]: Diphtheria 25 Lf units and tetanus 5 Lf units per 0.5 mL (0.5 mL)
Do not mix with other vaccines or injections. Separate needles and syringes should be used for each injection.
Belimumab: May diminish the therapeutic effect of Vaccines (Inactivated). Management: Patients should receive inactivated vaccines prior to initiation of belimumab therapy whenever possible, due to the risk for an impaired response to the vaccine during belimumab therapy. Consider therapy modification
Fingolimod: May diminish the therapeutic effect of Vaccines (Inactivated). Management: Vaccine efficacy may be reduced. Complete all age-appropriate vaccinations at least 2 weeks prior to starting fingolimod. If vaccinated during fingolimod therapy, revaccinate 2 to 3 months after fingolimod discontinuation. Consider therapy modification
Immunosuppressants: May diminish the therapeutic effect of Vaccines (Inactivated). Management: Vaccine efficacy may be reduced. Complete all age-appropriate vaccinations at least 2 weeks prior to starting an immunosuppressant. If vaccinated during immunosuppressant therapy, revaccinate at least 3 months after immunosuppressant discontinuation. Exceptions: Cytarabine (Liposomal). Consider therapy modification
Meningococcal Polysaccharide (Groups A / C / Y and W-135) Tetanus Toxoid Conjugate Vaccine: May diminish the therapeutic effect of Tetanus Toxoids Vaccines. Management: When possible, administer the meningococcal polysaccharide (groups A / C / Y and W-135) tetanus toxoid conjugate vaccine either together with or at least one month before a tetanus toxoids-containing vaccine. Consider therapy modification
Venetoclax: May diminish the therapeutic effect of Vaccines (Inactivated). Monitor therapy
Monitor for syncope for 15 minutes following administration (NCIRD/ACIP 2011). If seizure-like activity associated with syncope occurs, maintain patient in supine or Trendelenburg position to reestablish adequate cerebral perfusion.
All serious adverse reactions must be reported to the US Department of Health and Human Services (DHHS) Vaccine Adverse Event Reporting System (VAERS) 1-800-822-7967 or online at https://vaers.hhs.gov/esub/index. In Canada, adverse reactions may be reported to local provincial/territorial health agencies or to the Vaccine Safety Section at Public Health Agency of Canada (1-866-844-0018).
Percentages noted within 2 weeks following booster dose of Decavac in persons ≥11 years of age.
>10%:
Central nervous system: Headache (34% to 40%), fatigue (21% to 27%), body pain ( ≤19% to 30%), myasthenia ( ≤19% to 30%), chills (7% to 13%)
Gastrointestinal: Nausea (8% to 12%), diarrhea (10% to 11%)
Local: Pain at injection site (63% to 71%), erythema at injection site (20% to 22%), swelling at injection site (17% to 18%)
Neuromuscular & skeletal: Arthralgia ( ≤7% to 12%), joint swelling ( ≤7% to 12%)
1% to 10%:
Dermatologic: Skin rash (2%)
Gastrointestinal: Vomiting (2% to 3%)
Hematologic & oncologic: Adenopathy (4% to 5%)
Miscellaneous: Fever (1% to 3%)
<1% (Limited to important or life-threatening): Anaphylaxis, arthralgia, dizziness, hypersensitivity reaction (includes angioedema, skin rash, urticaria), injection site reaction (includes cellulitis, induration at injection site, injection site nodule, warm sensation at injection site), limb pain, lymphadenopathy, musculoskeletal stiffness, myalgia, pain, paresthesia, peripheral edema, seizure, syncope, weakness
Concerns related to adverse effects:
- Anaphylactoid/hypersensitivity reactions: Immediate treatment (including epinephrine 1 mg/mL) for anaphylactoid and/or hypersensitivity reactions should be available during vaccine use (NCIRD/ACIP 2011).
- Arthus-type hypersensitivity: Patients with a history of severe local reaction (Arthus-type) following a previous tetanus toxoid dose should not be given further routine or emergency doses of Td more frequently than every 10 years, even if using for wound management with wounds that are not clean or minor; these patients generally have high serum antitoxin levels (NCIRD/ACIP 2011).
- Syncope: Syncope has been reported with use of injectable vaccines and may result in serious secondary injury (eg, skull fracture, cerebral hemorrhage); typically reported in adolescent and young adults and within 15 minutes after vaccination. Procedures should be in place to avoid injuries from falling and to restore cerebral perfusion if syncope occurs (NCIRD/ACIP 2011).
Disease-related concerns:
- Acute illness: The decision to administer or delay vaccination because of current or recent febrile illness depends on the severity of symptoms and the etiology of the disease. Consider deferring administration in patients with moderate or severe acute illness (with or without fever); vaccination should not be delayed for patients with mild acute illness (with or without fever) (NCIRD/ACIP 2011).
- Bleeding disorders: Use with caution in patients with bleeding disorders (including thrombocytopenia) and patients on anticoagulant therapy; bleeding/hematoma may occur from IM administration; if the patient receives antihemophilia or other similar therapy, IM injection can be scheduled shortly after such therapy is administered (NCIRD/ACIP 2011).
- Guillain-Barre syndrome: Use with caution if Guillain-Barre syndrome occurred within 6 weeks of prior tetanus toxoid-containing vaccine.
Concurrent drug therapy issues:
- Vaccines: In order to maximize vaccination rates, the ACIP recommends simultaneous administration (ie, >1 vaccine on the same day at different anatomic sites) of all age-appropriate vaccines (live or inactivated) for which a person is eligible at a single clinic visit, unless contraindications exist. The use of combination vaccines is generally preferred over separate injections, taking into consideration provider assessment, patient preference, and adverse events. When using combination vaccines, the minimum age for administration is the oldest minimum age for any individual component; the minimum interval between dosing is the greatest minimum interval between any individual component. The ACIP prefers each dose of a specific vaccine in a series come from the same manufacturer when possible (NCIRD/ACIP 2011).
Special populations:
- Adults: Td should be administered to adults.
- Altered immunocompetence: Use with caution in severely immunocompromised patients (eg, patients receiving chemo/radiation therapy or other immunosuppressive therapy [including high-dose corticosteroids]); may have a reduced response to vaccination. In general, household and close contacts of persons with altered immunocompetence may receive all age appropriate vaccines (IDSA [Rubin 2014], NCIRD/ACIP 2011); inactivated vaccines should be administered ≥2 weeks prior to planned immunosuppression when feasible (IDSA [Rubin 2014]).
- Pediatric: Pediatric dosage form (DT) should only be used in patients 6 weeks to ≤6 years of age. Td should be administered to children ≥7 years of age. Apnea has occurred following intramuscular vaccine administration in premature infants; consider clinical status implications. In general, preterm infants should be vaccinated at the same chronological age as full-term infants (NCIRD/ACIP 2011).
Dosage form specific issues:
- DT confused with Td: Do not confuse pediatric diphtheria and tetanus (DT) with adult tetanus and diphtheria (Td).
- Latex: Some products may contain natural latex/natural rubber.
- Thimerosal: Some products may contain thimerosal.
Other warnings/precautions:
- Antipyretics: Antipyretics have not been shown to prevent febrile seizures. Antipyretics may be used to treat fever or discomfort following vaccination (NCIRD/ACIP 2011). One study reported that routine prophylactic administration of acetaminophen to prevent fever prior to vaccination decreased the immune response of some vaccines; the clinical significance of this reduction in immune response has not been established (Prymula 2009).
- Appropriate use: Use of this vaccine for specific medical and/or other indications (eg, immunocompromising conditions, hepatic or kidney disease, diabetes) is also addressed in the ACIP Recommended Adult Immunization Schedule (ACIP [Kim 2016]). Specific recommendations for vaccination in immunocompromised patients with asplenia, cancer, HIV infection, cerebrospinal fluid leaks, cochlear implants, hematopoietic stem cell transplant (prior to or after), sickle cell disease, solid organ transplant (prior to or after), or those receiving immunosuppressive therapy for chronic conditions as well as contacts of immunocompromised patients are available from the IDSA (Rubin 2014).
- Effective immunity: Vaccination may not result in effective immunity in all patients. Response depends upon multiple factors (eg, type of vaccine, age of patient) and may be improved by administering the vaccine at the recommended dose, route, and interval. Vaccines may not be effective if administered during periods of altered immune competence (NCIRD/ACIP 2011).
C
Reproduction studies have not been conducted. DT is not recommended for use in persons ≥7 years of age. Inactivated bacterial vaccines have not been shown to cause increased risks to the fetus (NCIRD/ACIP, 2011). The Advisory Committee on Immunization Practices (ACIP) recommends a single Tdap vaccination during each pregnancy; ideally between 27 and 36 weeks gestation. Pregnant women who are not immunized or are only partially immunized should complete the primary series with Td. Tetanus immune globulin and a tetanus toxoid containing vaccine are recommended by the ACIP as part of the standard wound management to prevent tetanus in pregnant women; the use of a tetanus-toxoid containing vaccine during pregnancy is recommended for wound management if ≥5 years have passed since the last Td vaccination (CDC/ACIP 2013).
Promotes active immunity to diphtheria and tetanus by inducing production of specific antibodies.
- Discuss specific use of vaccine and side effects with patient as it relates to treatment. (HCAHPS: During this hospital stay, were you given any medicine that you had not taken before? Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? How often did hospital staff describe possible side effects in a way you could understand?)
- Patient may experience headache, muscle weakness, loss of strength and energy, joint pain, abnormal crying (children), or lack of appetite (children). Have patient report immediately to prescriber confusion, severe dizziness, passing out, vision changes, seizures, burning or numbness feeling, abnormal movements, or severe injection site pain or irritation (HCAHPS).
- Educate patient about signs of a significant reaction (eg, wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat). Note: This is not a comprehensive list of all side effects. Patient should consult prescriber for additional questions.
Intended Use and Disclaimer: Should not be printed and given to patients. This information is intended to serve as a concise initial reference for healthcare professionals to use when discussing medications with a patient. You must ultimately rely on your own discretion, experience and judgment in diagnosing, treating and advising patients.