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Tdap vaccine for adults gets boost.

ATLANTA -- The recommendation for use of the new tetanus-diphtheria-acellular pertussis vaccine has been expanded to adults aged 19-64 years, according to a vote by the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices taken at its fall meeting.

The tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine, adsorbed (Tdap) was licensed in June for use as a single-dose booster immunization in persons aged 11-64 and was previously recommended by ACIP for use in adolescents. The routine interval for administering booster doses is 10 years.

This vaccine (Adacel, Sanofi-Pasteur), when used instead of the tetanus-diphtheria (Td) booster, will provide adults with immunity against pertussis with its associated morbidity, said Margaret M. Cortese, M.D., of the CDC's National Immunization Program. Of the 26,000 cases of pertussis reported in 2004, 28% were among adults, and available data suggest that pertussis is endemic among U.S. adults, she said.

The spectrum of illness in adults ranges from asymptomatic to classic pertussis with its paroxysmal cough and post-tussive vomiting. Many adults experience difficulty breathing and sleeping, weight loss, and urinary incontinence. The high-pressure coughing also has resulted in complications such as rib fractures, pneumothorax, pneumomediastinum, and herniated lumbar disks. There was one report from Canada of a man who had a carotid dissection from coughing.

Five deaths were reported in the United States between 1990 and 2004, all since 1997 and all in patients with underlying illness. "There was a report from the Netherlands of an outbreak among elderly women living in a religious institution, where the attack rate was high, at 53%, and four deaths occurred," Dr. Cortese said. Three of the deaths resulted from acute intracranial hemorrhage following pertussis cough illnesses exceeding 100 days.

This prolonged cough is a common feature of pertussis in adults. "Almost everyone coughs for at least 3 weeks. The median in adults is about 2-3 months, with ranges from a couple of weeks to 32 weeks," she said. By the time the diagnosis is made, 50% of adult patients have been coughing for more than a month--plenty of time for them to transmit the illness.

Disease transmission, particularly to infants younger than 6 months, was a factor cited by ACIP's working group on pertussis in recommending adult immunization. Of the 100 U.S. pertussis deaths reported between 2000 and 2004, 92 were in infants younger than 6 months, and infant pertussis deaths are underreported, Dr. Cortese said. In a recent study, the source of infection in the very young was an adult--a parent or grandparent--in one-fourth of cases (Pediatr. Infect. Dis. J. 2004;23:985-9).

With regard to the safety of the vaccine, John Iskander, M.D., of the CDC's Immunization Safety Office, noted that only 39 reports had been received by the Vaccine Adverse Event Reporting System. Most were for local and mild systemic reactions, he said.

One death was reported; this was a case of sudden cardiac death relating to a cardiac arrhythmia occurring 2 weeks after vaccination. There have been no other Tdap reports involving cardiac disease or heart rhythm disturbances, Dr. Iskander said. A total of five reports of seizures have been received, but there have been no reports of Guillain-Barre syndrome, brachial neuritis, transverse myelitis, or Bell's palsy, he added.

The working group cited two contraindications to the Tdap vaccine: a history of serious allergic reaction to any component of the vaccine, and a history of encephalopathy that cannot be attributed to another cause within 7 days of administration of a pertussis vaccine.

The committee recommended that, during an outbreak situation, consideration be given to administration of Tdap at intervals shorter than 10 years. Data support the safety of intervals as short as 2 years, said Katrina Kretzinger, M.D., of the CDC's National Immunization Program.

No recommendations were made for adults older than 65 years, because there are no prelicensure data on safety and immunogenicity in this population.

The issue of using the vaccine during pregnancy presented particular difficulties. Members of the working group expressed "very divergent" views on the topic, said Trudy Murphy, M.D., also of the CDC's National Immunization Program.

Because no consensus was reached on using the vaccine in pregnancy, the working group offered a "place holder" option until the issue can be revisited at the February 2006 meeting. This option states that:

* Tdap is preferred to Td for protection against tetanus if 10 or more years have elapsed since the administration of the last tetanus toxoid-containing vaccine.

* Td is an acceptable alternative.

* Second or third trimester is the preferred time for giving either Tdap or Td.

* Providers are encouraged to report women vaccinated with Tdap during pregnancy to a registry set up by Sanofi-Pasteur.

* Tdap may be considered at intervals shorter than 10 years after the last tetanus toxoid-containing vaccine in settings with increased risk of exposure to pertussis in pregnant women.

BY NANCY WALSH

New York Bureau
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Title Annotation:tetanus-diphtheria-acellular pertussis vaccine
Author:Walsh, Nancy
Publication:Internal Medicine News
Geographic Code:1USA
Date:Nov 15, 2005
Words:817
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