Diphtheria vaccine

Edina Avdic, Pharm.D.
Pediatric Dosing Author: Lisa Hutchins, Pharm.D.

VACCINE TYPE

  • Types/abbreviations:
    • DT (tetanus + diphtheria toxoids)
    • Td (tetanus toxoid+ reduced-dose diphtheria toxoid)
    • DTaP (DT + acellular pertussis)
    • Tdap (Td + reduced-dose acellular pertussis)
  • Usual administrations:
    • DTaP and DT: are given to children < 7 years old
    • Tdap and Td: are given to older children and adults
    • For other combinations, see formulations

INDICATIONS

ACIP RECOMMENDATIONS

  • Children, primary series, birth to 18 years:
    • All children should receive 5 doses of DTaP
      • 1 dose at each of the following ages: 2, 4, 6, and 15-18 months and 4-6 years
    • All adolescents between the ages of 11 and 12 should receive a single dose of Tdap
    • Pregnant adolescents should get a Tdap during each pregnancy (preferably between the 27th and 36th week)
  • Catch-up immunization:
    • Children < 7 years, utilizing DTaP:
      • Doses 1-3 doses should be given 4 weeks apart
      • Dose 4 should be given at least 6 months after dose 3 and after the child is at least 15 months of age
      • Dose 5 should be given at least 6 months after dose 4 and between the ages of 4 and 6 years. If dose 4 was given after the child’s 4th birthday, dose 5 may be omitted
      • For more information see the ACIP immunization schedule
    • Children 7-9 years:
    • Children 10-18 years:
    • Inadvertent doses of DTaP vaccine, see ACIP immunization schedule
  • Adults (≥19 yrs):
    • Td booster every 10 years
    • All receive one single dose of Tdap
      • This can be administered regardless of the timing of the last Td administration
    • Women should get a Tdap during each pregnancy (preferably between the 27th and 36th week)
    • All health-care workers should receive Tdap independent of their previous Td dose

OTHER INFORMATION

  • Travelers: give booster (Td or Tdap, depending) if diphtheria acquisition risk high.

FORMS

brand name

preparation

manufacturer

route

form

dosage^

cost*

ADACELTetanus toxoid

Tetanus toxoid, reduced Diphtheria toxoid, and acellular pertussis vaccine adsorbed (Tdap)

Sanofi Pasteur

IM

vial, syringe

2-5-2.5/0.5 mL

$51.65

BOOSTRIX

Tetanus toxoid, reduced Diphtheria toxoid, and acellular pertussis vaccine adsorbed (Tdap)

GlaxoSmithKline

IM

vial, syringe

2.5-5-8/0.5 mL

$45.88

DAPTACEL

Diphtheria and tetanus toxoids, and acellular pertussis vaccine adsorbed (DTaP)

Sanofi Pasteur

IM

vial

15-5-10/0.5 mL

$67.29

Td (generic)

Diphtheria and Tetanus toxoids (Td)

Grifols USA LLC

IM

vial

2-2 LF/0.5 mL

$26.34

DT

Diphtheria and tetanus toxoids (DT)

Sanofi Pasteur

IM

vial

5-25/0.5 mL

$113

INFANRIX

Diphtheria and tetanus toxoids and acellular pertussis vaccine adsorbed (DTaP)

GlaxoSmithKline

IM

vial, syringe

25-10-25/0.5 mL

$26

KINRIX

Diphtheria and tetanus toxoids, and acellular Pertussis adsorbed and inactivated Poliovirus vaccine (DTaP-IPV)

GlaxoSmithKline

IM

vial, syringe

25-10-25/0.5 mL

$58.62

PEDIARIX

Diphtheria and Tetanus toxoids and acellular Pertussis adsorbed, Hepatitis B (recombinant) and inactivated Poliovirus vaccine (DTaP-HBV-IPV)

GlaxoSmithKline

IM

syringe

25-10-25/0.5 mL

$68.47

PENTACEL

Diphtheria and tetanus toxoids, and acellular Pertussis adsorbed, and inactivated Poliovirus vaccine, and Haemophilus b conjugate vaccine (DTaP-IPV-Hib)

Sanofi Pasteur

IM

KIT

15-20-5-10

$105

TENIVAC

Tetanus and diphtheria toxoids adsorbed (Td)

Sanofi Pasteur

IM

vial, syringe

2-5/0.5 mL

$70.8

QUADRACEL

Diphtheria and tetanus toxoids, and acellular Pertussis adsorbed and inactivated Poliovirus vaccine (DTaP-IPV)

Sanofi Pasteur

IM

vial

15-25-20/0.5 mL

N/A

*Prices represent cost per unit specified, are representative of "Average Wholesale Price" (AWP).
^Dosage is indicated in mg unless otherwise noted.

PATHOGEN DIRECTED PROTECTION

Corynebacterium diphtheriae, Diptheria

DOSE/ADMINISTRATION

Adult PRIMARY SERIES

  • ADACEL, BOOSTRIX (adult Tdap): one dose of 0.5 mL IM.
  • TENIVAC (adult Td): three doses of 0.5 mL IM.
    • Dose 1 and 2 should be separated by 1-2 months.
    • Dose 2 and 3 should be separated by 6-12 months.
    • A one-time dose of Tdap can be substituted for one of the doses in the series, preferably the first.

Adult BOOSTER

  • 0.5 mL Td booster every 10 years.
    • Tdap should replace Td for adults without a prior Tdap dose.
    • Tdap can be used if Td is unavailable for any q 10-year dose.
  • Pregnancy: give Tdap with every pregnancy (to help avoid pertussis in the infant).

Pediatric PRIMARY SERIES

  • INFANRIX or DAPTACEL (DTaP): 0.5 mL IM dose at each of the following ages: 2, 4, 6, and 15-18 months and 4-6 years for 5 total doses
  • DT, when pertussis vaccine contraindicated: starting at 6 weeks administer three doses of 0.5 mL IM 4 to 8 weeks apart, followed by 2 booster doses, administered at 15 to 18 months of age and at 4 to 6 years of age

Other combination vaccines exist that include DTaP/DT and may be substituted for DTaP or DT as appropriate

Pediatric BOOSTER

  • INFANRIX or DAPTACEL (DTaP): 0.5 mL IM given according to ACIP primary schedule or catch-up schedule, see ACIP immunization schedule
  • DT, for children < 7 years of age in whom pertussis vaccine is contraindicated: 0.5 mL IM given according to ACIP primary schedule or catch-up schedule, see ACIP immunization schedule
  • TdaP (ADACEL or BOOSTRIX): single 0.5 mL IM at age 11-12 years. May be administered to children 7 years and older according to ACIP catch-up schedule, see ACIP immunization schedule

Other combination vaccines exist that include DTaP/DT/Tdap/Td and may be substituted for DTaP, DT, Tdap, or Td as appropriate

ADVERSE DRUG REACTIONS

GENERAL

  • Generally well tolerated.

COMMON

  • Pain and tenderness at the injection site; rate increases with more doses.

RARE

  • Anaphylaxis
  • Encephalopathy
  • Arthralgia
  • Fever
  • Guillain-Barre syndrome
  • Arthus reaction (severe pain, swelling, induration, edema, hemorrhage, and occasional local necrosis)

VACCINE/DRUG INTERACTIONS

  • The simultaneous administration of DT, MMR, OPV, or inactivated poliovirus vaccine (IPV), and Haemophilus b Conjugate Vaccine (HbCV) is acceptable.
  • Immunosuppressive therapies, including irradiation, antimetabolites, alkylating agents, cytotoxic drugs, and corticosteroids (used in greater than physiologic doses), may reduce the immune response to vaccines.

CONTRAINDICATIONS

  • History of anaphylaxis to vaccine components.
  • Encephalopathy within 7 days of administration of pertussis vaccine should not receive Tdap.
  • Use with caution with history of Guillain-Barre syndrome (within 6 weeks after previous tetanus toxoid-containing vaccine), moderate or acute severe illness, unstable neurological conditions, and Arthus hypersensitivity reaction.

IMMUNE RESPONSE

  • The response usually good, but reduced in the elderly.
  • Anti-diphtheria response: 99.9% had seroprotective anti-diphtheria levels >0.1 IU/mL and booster response was 91-96%.

CLINICAL EFFICACY

  • Clinical efficacy of ~ 97%
  • < 5 diphtheria cases have been reported in the U.S. since 2000, but 7,100 reported to the WHO (2016).

OTHER INFORMATION

  • Additional details can also be found in the Corynebacterium diphtheriae module
  • Td preferred for adults (less local reactions) and during pregnancy
  • DT: Pediatric preparation, contraindicated in persons >7 yrs.
  • Use in HIV positive patients
    • It is well-tolerated among people with HIV. Use general indications for vaccination. The immune response is likely best when CD4 count is >200 cells/mm3.

Basis for recommendation

  1. Liang JL, Tiwari T, Moro P, et al. Prevention of Pertussis, Tetanus, and Diphtheria with Vaccines in the United States: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2018;67(2):1-44.  [PMID:29702631]

    Comment: This report does not contain any new recommendations but rather consolidates all prior recommendations into a comprehensive document.

References

  1. Maple PA, Efstratiou A, George RC, et al. Diphtheria immunity in UK blood donors. Lancet. 1995;345(8955):963-5.  [PMID:7715300]

    Comment: The report suggests that to maintain protective immunity against diphtheria, a booster is needed based on waning protective titers over time.


  2. Recommended Child and Adolescent Immunization Schedule for Ages 18 Years or Younger—United States, 2020.
    www.cdc.gov/vaccines/schedules/downloads/child/0-18yrs-child-combined-schedule.pdf


    Comment:



Last updated: February 15, 2021