(Replaces No. 438, August 2009)
ABSTRACT: In light of the recent increased incidence of pertussis in the United States, in 2011, the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices approved recommendations for the use of the tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine (Tdap) for pregnant women. Furthermore, the committee updated Tdap recommendations for special situations during pregnancy and for persons in contact with infants. The revised guidelines, which are based on a review of data on Tdap safety, immunogenicity, and barriers to receipt of Tdap, are designed to facilitate the use of Tdap to reduce the burden of disease and risk of transmission to infants. There is no evidence of adverse fetal effects from the vaccination of pregnant women with an inactivated virus, bacterial vaccine, or toxoid, and these should be administered if indicated. The American College of Obstetricians and Gynecologists’ Committee on Obstetric Practice supports the revised recommendations on the administration of Tdap during pregnancy.
Immunization During Pregnancy
Ideally, vaccines should be administered before conception. Prenatal care offers the opportunity to review immunization status. The American College of Obstetricians and Gynecologists (the College) recommends routine assessment of each pregnant woman’s immunization status and appropriate immunization if indicated. There is no evidence of adverse fetal effects from the vaccination of pregnant women with an inactivated virus, bacterial vaccine, or toxoid, and these should be administered if indicated. However, live vaccines do pose a theoretical risk to the fetus and generally should be avoided during pregnancy. The benefits of vaccinations outweigh any unproven potential concerns. There is no evidence that any vaccine is associated with an increased risk of autism or of adverse effects due to exposure to traces of the mercury-containing preservative thimerosal (1–6). When deciding whether to immunize a pregnant woman with a vaccine not routinely recommended in pregnancy, the risk of exposure to the disease, as well as the benefits of vaccination for reducing the deleterious effects on the woman and the fetus, must be balanced against unknown risks of the vaccine. All vaccines administered should be fully documented in the patient’s permanent medical record (7).
Updated Immunization Guidelines: Tetanus, Diphtheria, and Pertussis
In light of the recent increased incidence of pertussis in the United States, in 2011, the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices (ACIP) approved recommendations for the use of the tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine (Tdap) for pregnant women. Furthermore, the committee updated Tdap recommendations for special situations during pregnancy and for persons in contact with infants (8). The revised guidelines, which are based on a review of data on Tdap safety, immunogenicity, and barriers to receipt of Tdap, are designed to facilitate the use of Tdap to reduce the burden of disease and risk of transmission to infants. The College’s Committee on Obstetric Practice supports these revised recommendations, which are summarized as follows.
Use of the Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular Pertussis Vaccine in Pregnant Women
Women’s health care providers should implement a Tdap vaccination program for pregnant women who previously have not received Tdap. Health care providers should administer Tdap during pregnancy, preferably during the third trimester or late second trimester (ie, after 20 weeks of gestation). Alternatively, if not administered during pregnancy, Tdap should be administered immediately postpartum to ensure pertussis immunity and reduce the risk of transmission to the newborn (8). Regardless of the trimester, health care providers are encouraged to report Tdap administration to the appropriate manufacturer’s pregnancy registry.
Special Situations During Pregnancy
Tetanus Booster
Health care providers should administer Tdap during pregnancy, preferably during the third trimester or late second trimester (ie, after 20 weeks of gestation), if a tetanus and diphtheria (TD) booster vaccination is indicated (ie, more than 10 years since the previous TD vaccination) for a pregnant woman who has not received Tdap previously (8).
Wound Management
As part of standard wound management care to prevent tetanus, a tetanus toxoid-containing vaccine might be recommended for a pregnant woman if 5 years or more have elapsed since the previous TD booster vaccination. If a TD booster vaccination is indicated for a pregnant woman who has not received Tdap previously, health care providers should administer Tdap (8).
Unknown or Incomplete Tetanus Vaccination
To ensure protection against maternal and neonatal tetanus, pregnant women who never have been vaccinated against tetanus should receive three vaccinations containing tetanus and reduced diphtheria toxoids during pregnancy. The recommended schedule is 0, 4 weeks, and 6–12 months. One dose of the TD booster vaccine should be replaced by Tdap, preferably during the third trimester or late second trimester (ie, after 20 weeks of gestation) (8).
Vaccination of Adolescents and Adults in Contact With Infants
The ACIP recommends that adolescents and adults, (eg, siblings, parents, grandparents, child care providers, and health care providers, including individuals aged 65 years and older) who have or who anticipate having contact with an infant younger than 12 months of age and who have not received Tdap previously, should receive a single dose of Tdap to protect against pertussis and reduce the likelihood of transmission (8). Ideally, these adolescents and adults should receive Tdap at least 2 weeks before they have contact with the infant.
Current Immunization Guidelines and Information
Immunization guidelines are subject to change. Extensive information for health care providers and consumers about vaccines can be obtained at www.cdc.gov/vaccines and on the College’s immunization web site at www.immunizationforwomen.org/. The ACIP issues recommendations on immunization that are updated regularly and are available at www.cdc.gov/vaccines/pubs/ACIP-list.htm.
Resources
Advisory Committee for Immunization Practices Recommendations, available at http://www.cdc.gov/vaccines/ pubs/ACIP-list.htm
American College of Obstetricians and Gynecologists’ immunization web site, available at http://www.immunizationforwomen.org
Centers for Disease Control and Prevention’s Vaccines and Immunizations Information Page, available at http://www.cdc.gov/vaccines
References
- Thompson WW, Price C, Goodson B, Shay DK, Benson P, Hinrichsen VL, et al. Early thimerosal exposure and neuropsychological outcomes at 7 to 10 years. Vaccine Safety Datalink Team. N Engl J Med 2007;357:1281–92.
- Centers for Disease Control and Prevention. Vaccine safety: thimerosal. Available at: http://www.cdc.gov/vaccinesafety/Concerns/thimerosal/index.html. Retrieved October 28, 2011.
- Food and Drug Administration. Thimerosal in vaccines. Rockville (MD): FDA; 2010. Available at: http://www.fda.gov/BiologicsBloodVaccines/SafetyAvailability/VaccineSafety/UCM096228. Retrieved October 28, 2011.
- Joint statement of the American Academy of Pediatrics (AAP) and the United States Public Health Service (USPHS). Pediatrics 1999;104:568–9.
- Thimerosal in vaccines—An interim report to clinicians. American Academy of Pediatrics. Committee on Infectious Diseases and Committee on Environmental Health. Pediatrics 1999;104:570–4.
- Zaman K, Roy E, Arifeen SE, Rahman M, Raqib R, Wilson E, et al. Effectiveness of maternal influenza immunization in mothers and infants [published erratum appears in N Engl J Med 2009;360:648]. N Engl J Med 2008;359:1555–64.
- Centers for Disease Control and Prevention. Epidemiology and prevention of vaccine-preventable diseases. 12th ed. Washington, DC: Public Health Foundation; 2011. Available at: http://www.cdc.gov/vaccines/pubs/pinkbook/index.html. Retrieved October 28, 2011.
- Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis (Tdap) vaccine from the Advisory Committee on Immunization Practices, 2010. Centers for Disease Control and Prevention (CDC). MMWR Morb Mortal Wkly Rep 2011;60:13–5.