1. CDC recommends Tdap during each pregnancy
Sarah S. Long
AAP News 2013;34;8
DOI: 10.1542/aapnews.2013342-8
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2. Volume 34 • Number 2
February 2013
www.aapnews.org
CDC recommends Tdap during each pregnancy
by Sarah S. Long, M.D., FAAP
The Centers for Disease Control and Prevention now recommends
tetanus, diphtheria and acellular pertussis vaccine (Tdap) for pregnant
adolescents and adults during each pregnancy. The recommendation
is included in the 2013 immunization schedule (see page 17).
This approach was in response to increasing cases of pertussis
nationally and a recognition that the greatest burden of disease,
morbidity and mortality occurs in infants before they can achieve
protection from their primary series with diphtheria and tetanus
toxoids and acellular pertussis vaccine (DTaP). Data on the safety
and efficacy of multiple Tdap doses are limited.
The AAP Committee on Infectious Diseases agrees that adolescents
and young adults who received Tdap prior to their pregnancy should
receive a second dose during pregnancy regardless of the interval With the increase in pertussis cases, one of the changes in the 2013
since the first dose. This includes pregnant adolescents who received immunization schedule is a recommendation to administer tetanus,
Tdap during a prior pregnancy, postpartum or as part of the ado- diphtheria and acellular pertussis (Tdap) vaccine to pregnant adoles-
lescent immunization schedule. cents and adults during each pregnancy. In 2010, the 27,555 U.S.
Optimal timing for Tdap administration is between 27 and 36 cases of pertussis were the highest in the preceding five years.
weeks’ gestation to maximize antibody passively transferred before
birth. However, Tdap is safe in all trimesters and can be given at
any time during pregnancy. If not administered during pregnancy, added to universal Tdap recommendations. All persons in the United
Tdap should be administered immediately postpartum. Additional States 11 years of age and older who have not received Tdap should
Tdap doses for subsequent pregnancies will be addressed in a future receive it now; they should not wait to replace Tdap for the decennial
AAP policy statement and in the 2014 immunization schedule. tetanus-diphtheria vaccine (Td).
Protecting young infants by neonatal dosing of DTaP products
Burden of disease is not an option as this appears to interfere with subsequent response
Pertussis has increased in the United States in recent years. The to other vaccines routinely administered in infancy. The burden of
27,555 cases reported in 2010 were the highest number in the pre- pertussis in young infants has risen despite cocooning policies in
ceding five years. In 2012, at least 34 states reported surges, with place since 2006 that target single doses of Tdap. Such recommen-
final numbers likely to exceed 35,000 cases and 20 infant deaths. dations included Tdap immunization for all adolescents (AAP, 2006)
Incidence is highest among infants younger than 3 months (who and cocooning strategy preferring immediate postpartum maternal
are too young to be protected by infant DTaP) and 7- to 10-year- immunization (CDC, 2006). In 2011, the CDC revised its recom-
olds (who have waning immunity). mendation, preferring immunization of pregnant women during
The threat of loss of control of pertussis in the United States is the second or third trimester. By 2012, fewer than 3% of pregnant
real. Despite recommendations for universal administration, Tdap women had received Tdap, and cocooning through immunization
coverage among adolescents was only 78% in 2011, and only 8% of infant contacts was abysmally low.
of adults had received Tdap in 2010. The 2013 CDC recommendation for Tdap during each pregnancy
will remove real and perceived barriers to maternal immunization.
Changing recommendations
Recommendations for Tdap usage have expanded incrementally AAP involvement in recommendation
as the burden of pertussis and safety data on the vaccine increased The Academy has participated in the CDC’s Tdap Working
over the last five years. Some practitioners, however, may not be Group, which evaluates all available data to inform decision-
aware of these changing recommendations. making by the Advisory Committee on Immunization Practices.
In 2012, the last age group, i.e., those 65 years and older, were Published and preliminary data indicate that while Tdap is
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3. immunogenic in pregnancy and transplacental passage of antibodies infant’s response to DTaP, but limited recent data are reassuring that
is adequate, there is rapid fall of antibody to pertussis toxin after this appears to be transient.
immunization and rapid decay of transplacentally acquired anti- In sum, the CDC and Academy consider the benefits of Tdap re-
body postnatally. A second dose of Tdap is immunogenic in non- vaccination in pregnancy to outweigh theoretical risks. The Vaccine
pregnant adults. Adverse Event Reporting System and the Vaccine Safety Datalink
The working group concluded that a single dose of Tdap in one will be used to monitor the safety of Tdap in pregnant women.
pregnancy likely is insufficient to protect offspring of subsequent Pertussis likely will remain a perpetual, perplexing problem. The
pregnancies. Therefore, a repeated dose, especially during the latter CDC and Academy will consider changes in DTaP and Tdap sched-
part of pregnancy, would bolster antibody levels. ules as well as second doses of Tdap for health care personnel and
Tdap is licensed by the Food and Drug Administration for a single the public as additional safety, efficacy and cost-effectiveness data
lifetime dose. The working group concluded, however, that data become available.
and experience with tetanus toxoid-containing vaccines in pregnancy
suggest no increased risk of adverse events if a second dose is admin- Dr. Long is an ex officio member of the AAP Committee
istered. Extensive safety data with nonpregnant persons do not show on Infectious Diseases and associate editor of the AAP
increased reactogenicity of Tdap compared with Td, and smaller Red Book.
studies of second doses of Tdap in nonpregnant persons in Canada
and Finland do not show increased reactogenicity compared with
administration to Tdap-naive persons. Prior studies suggested a pos-
sible blunting effect of high pre-vaccine antibody levels on the
©Copyright 2013 AAP News
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4. CDC recommends Tdap during each pregnancy
Sarah S. Long
AAP News 2013;34;8
DOI: 10.1542/aapnews.2013342-8
Updated Information & including high resolution figures, can be found at:
Services http://aapnews.aappublications.org/content/34/2/8.1
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