Tetanus, diphtheria and pertussis can be very serious diseases, even for adolescents and adults. These diseases are caused by bacteria. Diphtheria and pertussis are spread from person to person through coughing or sneezing. Tetanus enters the body through cuts, scratches, or wounds.

TETANUS (Lockjaw) causes painful muscle tightening and stiffness, usually all over the body. It can lead to tightening of muscles in the head and neck so you can’t open your mouth, swallow, or sometimes even breathe. Tetanus kills about 1 out of 5 people who are infected.

DIPHTHERIA can cause a thick coating to form in the back of the throat. It can lead to breathing problems, paralysis, heart failure, and death.

PERTUSSIS (Whooping Cough) causes severe coughing spells, which can cause difficulty breathing, vomiting and disturbed sleep. It can also lead to weight loss, incontinence, and rib fractures. Up to 2 in 100 adolescents and 5 in 100 adults with pertussis are hospitalized or have complications, which could include pneumonia or death.

The overwhelming majority of morbidity and mortality attributable to pertussis infection occurs in infants who are less than or equal to 3 months of age. Infants do not begin their own vaccine series against pertussis (with the diphtheria, tetanus and acellular pertussis vaccine [DTaP]) until 2 months of age. This situation leaves a window of significant vulnerability for newborns, many of whom appear to contract serious pertussis infections from family members and caregivers, including the mother.

Advisory Committee on Immunization Practices (ACIP) Recommendations

The ACIP of the Centers for Disease Control and Prevention (CDC) published its updated recommendation in February 2013, which recommends that health care personnel administer a dose of Tdap during each pregnancy, irrespective of the patient’s prior history of receiving Tdap. To maximize the maternal antibody response and passive antibody transfer and levels in the newborn, optimal timing for Tdap administration is between 27 weeks and 36 weeks of gestation, although Tdap may be given at any time during pregnancy. Receipt of Tdap at some point during pregnancy is critical, and there may be compelling reasons to vaccinate earlier in pregnancy (e.g., under “Special Situations During Pregnancy” [Click to follow link]).

For women who previously have not received Tdap, if Tdap was not administered during pregnancy, it should be administered immediately postpartum to the mother in order to reduce the risk of transmission to the newborn.

The ACIP recommends that all adolescents and adults who have or who anticipate having close contact with an infant younger than 12 months (e.g., siblings, parents, grandparents, child care providers, and health care providers) who previously have not received Tdap should receive a single dose of Tdap to protect against pertussis and reduce the likelihood of transmission. Ideally, these adolescents and adults should receive Tdap at least 2 weeks before they have close contact with the infant.

American College of Obstetricians and Gynecologists (ACOG) Recommendations

(a) General Considerations Surrounding Immunization during Pregnancy:

ACOG recommends routine assessment of each pregnant woman’s immunization status and administration of indicated immunizations. The benefits of nonlive vaccines outweigh any unproven potential concerns. There is no evidence of adverse fetal effects from vaccinating pregnant women with an inactivated virus or bacterial vaccines or toxoids, and a growing body of robust data demonstrates safety of such use. Co-administration of indicated inactivated vaccines during pregnancy (i.e., Tdap and influenza) is also acceptable, safe, and may optimize effectiveness of immunization efforts. It should be remembered, however, that live attenuated vaccines (e.g., measles-mumps-rubella [MMR], varicella, and live attenuated influenza vaccine) do pose a theoretical risk (although never documented or proved) to the fetus and generally should be avoided during pregnancy. All vaccines administered during pregnancy as well as health care provider-driven discussions about the indications and benefits of immunization during pregnancy should be fully documented in the patient’s prenatal record. In addition, if a patient declines vaccination, this should be documented in the patient’s prenatal record, and the health care provider is advised to revisit the issue of vaccination at subsequent visits.

(b) Special Situations During Pregnancy:

• Ongoing Epidemics

Pregnant women who live in geographic regions with epidemics of pertussis should be immunized as soon as feasibly possible for their own protection in accordance with local recommendations for nonpregnant adults. Less emphasis should be given to targeting the proposed optimal gestation window (between 27 weeks and 36 weeks of gestation) in these situations given the imperative to protect the mother from locally prevalent disease. Newborn protection will still be garnered from vaccination earlier in the same pregnancy. Importantly, a pregnant woman should not be re-vaccinated later in the same pregnancy if she already received the vaccine in the first or second trimester.

• Wound Management

As part of standard wound management care to prevent tetanus, a tetanus toxoid-containing vaccine is recommended in a pregnant woman if 5 years or more have elapsed since her previous tetanus and diphtheria (Td) vaccination. If a Td booster vaccination is indicated in a pregnant woman for acute wound management, health care providers should administer Tdap irrespective of gestational age. A pregnant woman should not be re-vaccinated with Tdap in the same pregnancy if she received the vaccine in the first or second trimester.

• Due for Tetanus and Diphtheria Booster Vaccination

If a Td booster vaccination is indicated during pregnancy (i.e., more than 10 years since the previous Td vaccination) then health care providers should administer Tdap during pregnancy, preferably between 27 weeks and 36 weeks of gestation. Because of the nonurgent nature of this indication, waiting until 27–36 weeks of gestation appears to be the appropriate management plan to obtain maternal immunity and maximize antibody transfer to the newborn.

• Unknown or Incomplete Tetanus Vaccination

To ensure protection against maternal and neonatal tetanus, pregnant women who have never been vaccinated against tetanus should begin the three-vaccination series, containing tetanus and reduced diphtheria toxoids, during pregnancy. The recommended schedule for this vaccine series is 0, 4 weeks, and 6–12 months; Tdap should replace one dose of Td, preferably given between 27 weeks and 36 weeks of gestation.