Practice Guidelines

ACIP Recommends the Use of Tdap in Adults

SHERRI DAMLO

In 2005, a tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap; Adacel) was approved in the United States for use in adults and adolescents. The Advisory Committee on Immunization Practices (ACIP) now recommends the routine use of Tdap among adults 19 to 64 years of age who have not already received a dose of Tdap. The ACIP recommendations are intended to decrease pertussis-related morbidity among adults, to maintain the standard of care for tetanus and diphtheria prevention, and to reduce transmission of pertussis to infants and in health care settings.

Routine Vaccination

Patients 19 to 64 years of age who received their most recent dose of tetanus and diphtheria toxoid (Td) at least 10 years earlier should be given a single dose of Tdap for active booster vaccination against tetanus, diphtheria, and pertussis. If less than 10 years has passed since the previous dose of Td was administered, a single dose of Tdap is appropriate to protect patients against pertussis. This is especially true in patients at increased risk of pertussis or its complications; the benefit of a single dose of Tdap at an interval of less than 10 years will likely outweigh the risk of adverse reactions to the vaccine. In addition, an interval as short as two years between Td and Tdap is considered safe.

In patients who have not previously received Tdap and who need a vaccine containing tetanus toxoid as part of wound management care, Tdap is preferred to Td.

adults in contact with infants

Compared with adults, infants younger than 12 months are at a higher risk of hospitalization from pertussis-related complications, and they have a higher risk of death. Therefore, vaccinating adults who come into contact with these infants may reduce the risk of transmitting pertussis (see accompanying table).

To protect against pertussis, adults who have not previously received Tdap and who are in contact or anticipate contact with infants younger than 12 months should receive a single dose of Tdap at an interval of less than 10 years since their most recent Td vaccination. These adults should receive the Tdap vaccine at least two weeks before coming into contact with an infant. An interval as short as two years from the previous dose of Td is recommended to reduce the risk of systemic and local reactions after the vaccination, but shorter intervals may be used, if appropriate.

women who are pregnant or may become pregnant

Ideally, women should be vaccinated with Tdap before becoming pregnant. If this is not possible, they should receive a single dose of Tdap in the immediate postpartum period. It should be administered before the patient is discharged from the hospital or birthing center.

Reported Source of Pertussis Infection Among Infants < 12 Months of Age
Relation of source to infant	Number of persons (%)
Mother	84 (14)
Father	39 (6)
Grandparent	22 (4)
Sibling	52 (8)
Other	67 (11)
Unknown	352 (57)
Adapted from the Centers for Disease Control and Prevention. Preventing tetanus, diphtheria, and pertussis among adults: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep 2006;55(RR-17):5.

health care professionals

Health care professionals who deal directly with patients should receive a single dose of Tdap. An interval as short as two years from the previous dose of Td is recommended for administration of the Tdap vaccine in this population. Health care professionals without direct patient contact should be given a single dose of Tdap to replace the next scheduled Td vaccine at an interval of 10 years or less since the previous dose of Td.

Administering the Vaccine

A single dose of Tdap is 0.5 mL and is administered intramuscularly, preferably into the deltoid muscle. If another vaccine is indicated in addition to Tdap, the vaccines should be administered simultaneously but at separate anatomic sites and with different syringes.

Special Situations

settings with increased risk of pertussis

During outbreaks of pertussis or in communities with increased pertussis activity, health care professionals should consider administering Tdap to adults at intervals of less than 10 years since the most recent dose of Td or tetanus toxoid if the patient has not previously received Tdap.

history of pertussis

Adults with a history of pertussis should receive a single dose of Tdap. Administration of the vaccine to these patients presents no theoretical safety concern.

wound management

Adults receiving wound management care should be given a tetanus toxoid-containing vaccine and tetanus immune globulin to prevent tetanus. Tdap is preferred to Td if these patients were vaccinated at least five years earlier but have not received Tdap. However, if Tdap was previously administered, Td should be given if a vaccine containing tetanus toxoid is indicated for wound care.

unknown vaccination history

Adults with unknown vaccination histories or who were never vaccinated against tetanus, diphtheria, or pertussis should be given a series of three vaccinations that contain tetanus and diphtheria toxoids. The preferred dosing schedule is a single dose of Tdap, followed by a dose of Td at least four weeks later and another dose of Td six to 12 months later. Tdap also can substitute for any one of the doses of Td in the three-dose series.

incomplete vaccination history

Adults who received other incomplete vaccination series against tetanus and diphtheria should be vaccinated with Td, Tdap, or a combination of the two to complete the three-dose primary series of tetanus and diphtheria toxoid-containing vaccines. A single dose of Tdap can be used in the series.

adults 65 years and older

Tdap is not licensed for use in adults 65 years and older. A dose of Td every 10 years is recommended for protection against tetanus and diphtheria and as needed for wound management care.

Contraindications

Tdap is contraindicated in adults who have a history of serious allergic reaction to any component of the vaccine. They should be referred to an allergy subspecialist to determine whether they can safely receive tetanus toxoid vaccinations.

The vaccine is contraindicated in adults with a history of encephalopathy not attributed to an identifiable cause within seven days of administration of a vaccine containing pertussis components. Because the contraindication is only for the pertussis components, these patients should receive Td instead of Tdap.

Precautions

If a patient may be at risk of developing a serious adverse reaction to a vaccine, health care professionals should evaluate the benefits and risks of administering Tdap.

Tdap should be deferred in patients with moderate to severe acute illness, with or without fever, until the illness resolves. Tdap administration should also be deferred in patients with an unstable neurologic condition and those with a history of an Arthus reaction following a previous dose of a vaccine containing tetanus toxoid, diphtheria toxoid, or both.

Practice Guideline Briefs

CDC Releases Data on Deaths from Poisoning

Poisoning from prescription or illicit drugs is one of the leading causes of death from unintentional injury in the United States. The Centers for Disease Control and Prevention (CDC) analyzed data from 1999 to 2004 and found that the annual deaths from poisoning had increased 62.5 percent (age-adjusted rate), from 12,186 deaths in 1999 to 20,950 deaths in 2004.

The number of women who died from poisoning increased by 103 percent; this increase was twice that seen in men. Poisoning deaths increased 75.8 percent among white persons, 113.6 percent in those living in the South, and 13.3 percent in persons 15 to 24 years of age. Persons 35 to 54 years of age accounted for 59.6 percent of poisoning deaths in 2004.

These data suggest that additional educational measures are needed and that regulatory measures should be more aggressive. The CDC notes that the trends in this report are related primarily to overdoses of prescription opioid analgesics and secondarily to cocaine and prescription sedative overdoses; they do not appear, however, to be related to heroin, methamphetamine, or other illicit drug use.

SHERRI DAMLO

CDC Reports on MRSA Infections Among Patients on Dialysis

Staphylococcus aureus, a leading cause of bloodstream infections in the United States, has become increasingly resistant to first-line antimicrobial agents. Patients on dialysis are particularly susceptible to methicillin-resistant S. aureus (MRSA) infection.

Compared with the general population, in which MRSA infections occur in only 0.2 to 0.4 per 1,000 persons, patients on dialysis are at high risk of MRSA infection. The Centers for Disease Control and Prevention (CDC) estimates that invasive MRSA infections occurred in 45 out of 1,000 patients on dialysis in 2005; these results indicate a 100-fold higher risk of MRSA infection in these patients.

Patients on dialysis who are older than 50 years are at especially increased risk of infection. The CDC also found that men and blacks on dialysis are at increased risk; of the total number of patients on dialysis who had been infected with MRSA, 57 percent were men, and
56 percent were black.

Those patients on dialysis who have invasive devices or a catheter also are at increased risk; according to the CDC, in the event of infection, 90 percent of those patients required hospitalization, and the in-hospital mortality rate for MRSA was 17 percent. Although the risk of infection in patients with a catheter is high, the risk is intermediate for grafts and low for arteriovenous fistulas.

Physicians should use antimicrobials judiciously to reduce pathogens only after following published guidelines. This is particularly true of vancomycin, because cases of S. aureus resistance to this drug have been reported.

SHERRI DAMLO

AHA Releases Statement on the Use of COX-2 Inhibitors and NSAIDs

Physicians should consider the increased risks associated with the use of nonsteroidal anti-inflammatory drugs (NSAIDs), including cerebrovascular and cardiovascular events, according to new guidelines issued by the American Heart Association (AHA). Warning labels have been ordered and advisories on the increased risks of these events in patients who take NSAIDs have been issued to patients and physicians by several regulatory agencies.

Evidence further suggests that myocardial infarction, heart failure, hypertension, and stroke can occur at increased rates in patients who take cyclooxygenase-2 (COX-2) inhibitors. Persons with a history of cardiovascular disease and those at increased risk are more likely to experience these adverse effects.

For patients at increased risk of cardiovascular and cerebrovascular events, COX-2 inhibitors should be prescribed only if no alternative pain relief medications exist. If prescribed to patients at increased risk, COX-2 inhibitors should be given only at the lowest dosage and for the shortest duration necessary. The use of any COX inhibitor, including NSAIDs, for long periods should be considered only in consultation with a physician.

SHERRI DAMLO

Answers to This Issue's Clinical Quiz Q1. B Q2. C Q3. B Q4. D Q5. C Q6. A Q7. A Q8. B Q9. A, B, D Q10. A, C, D Q11. B, C, D Q12. C, D

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