Diphtheria, Tetanus, and Pertussis:

Diphtheria. Diphtheria is caused by the bacterium Corynebacterium diphtheriae, which can occur as either a toxic or nontoxic strain. When only the skin is involved, it is known as cutaneous diphtheria, and is likely to be a nontoxic strain. If the toxic strain affects the mucus linings in the body, such as the throat, diphtheria becomes life threatening. Between 1900 and 1925, diphtheria infected 200,000 people every year and killed between 5 - 10% of them, mostly the very young and very old. Because of immunizations, only 6 cases were reported in the United States between 2000 and 2003, inclusive.

Tetanus. Tetanus is a disease that causes severe muscular contractions and convulsions. It is caused by a powerful toxin secreted by the bacterium Clostridium tetani. The bacterium is anaerobic, which means it lives without oxygen. People become infected by this dangerous bacterium through skin wounds. It is fatal in 15 - 40% of cases. Only 168 cases were reported in the U.S. between 2000 and 2007, inclusive, mostly in adults. One case, however, occurred in a 12-year-old boy whose parents refused to vaccinate him.

Pertussis. Pertussis (whooping cough) was a very common childhood illness throughout the first half of the 1900s. The disease is very easily spread from one person to another, and it is most severe in babies. Because of immunizations, cases of whooping cough in the U.S reached an all-time low of 1,010 in 1976. The incidence has risen recently, with almost 25,837 cases reported in 2004, but dropped to 8,739 in 2007, the last year reported by the World Health Organization.

The benefit of the vaccine wears off by adolescence. Therefore, more cases are seen in adults. Such cases may be greatly underreported. The younger a whooping cough patient is, the higher the risk for severe complications, including pneumonia, seizures, and even death. Children younger than 6 months are at particular risk because even with vaccination, their protection is incomplete due to an immature immune system.

Vaccinations for Diphtheria, Tetanus, and Pertussis

The Initial Vaccination. Vaccination against diphtheria, tetanus, and pertussis has been routinely given to children since the 1940s. The standard vaccine now is DTaP. DTaP uses a form of the pertussis component known as acellular pertussis, which consists of a single weakened pertussis toxoid. DTaP is just as effective but has fewer side effects than DTP, the previous vaccine.

The Booster.

• Protection against diphtheria and tetanus lasts about 10 years. At that point a booster may be given against tetanus and diphtheria (Td). The Td vaccine contains the standard dose against tetanus and a less potent one against diphtheria. It does not contain the pertussis component.
• The infant pertussis vaccine can start to wear off after about 5 years, and some previously immunized teens and adults can get a mild form of the disease. There are now two pertussis-containing boosters approved for teens and adults.

DTaP Schedule in Childhood. All children younger than 7 years old should receive the DTaP vaccine. In general, the vaccinations are given as follows:

• Infants receive a series of three vaccinations at 2, 4, and 6 months of age. The only reason to delay a vaccination is in infants with suspected neurologic problems until their neurologic situation is clarified. Children with neurological problems that have been corrected can be vaccinated. , (This vaccine should be given no later than their first birthday).
• A fourth dose is given between 15 and 18 months. (Infants at higher risk, such as those exposed to an outbreak of pertussis, may be given this vaccine earlier.)
• A fifth dose is given at 4 - 6 years. This fifth dose now usually includes a vaccine against H. influenzae as well.
• Children between the ages of 11 and 15 years old should receive a DTaP booster shot.

If a child has a moderate or severe current or recent fever-related illness, vaccinations should be postponed until after recovery. Colds or other mild respiratory infections are no cause for delay. Parents should not be unduly concerned if the interval between doses is longer than that recommended. The immunity from any previous vaccinations persists, and the doctor does not have to start a new series from scratch.

Recommendations for Adults. Many people are currently not getting routine boosters.

All adults who have been fully vaccinated either as a child or an adult should have a Td booster at least every 10 years. If they had not received a DTaP vaccination after age 19, they will need it for the next booster, but not afterwards..

Adults who have not previously been immunized to diphtheria, tetanus, and pertussis at any age:

• Should receive a series of three doses. 1 may be the tetanus, diphtheria, and pertussis (DTaP) vaccine.
• If pregnant, a woman should receive the Td vaccine in the second or third trimester.

Previously vaccinated pregnant women should have a DTaP booster immediately after delivery.

Any patient who requires medical care for any wound may be a candidate for a tetanus vaccine. Wounds that put patients at highest risk for tetanus are puncture wounds or wounds contaminated with dirt or feces. Some considerations for tetanus vaccinations in wounded people are as follows:

• A booster is needed if the last dose was given 5 or more years before the injury.
• Children under 7 are usually given DTaP if they are not fully vaccinated.
• Patients who have not completed their primary series of tetanus immunizations and people who had experienced an allergic response to a previous tetanus booster may be given tetanus immune globulin (TIG).

Side Effects of Diphtheria-Tetanus-Pertussis (DTP) Vaccine

Allergic Reactions. In rare cases, people may be allergic to the older diphtheria, tetanus, and pertussis vaccine, DTP. Parents should tell their doctor if their children have any allergies. The newer vaccine, DTaP, may pose a slightly higher risk for an allergic reaction than the older vaccine, DTP. Children who have severe responses should not be given further vaccinations. A rash that occurs after a dose of DTP is of little consequence. In fact, it does not usually indicate an allergic response but only a temporary immune reaction and does not usually recur with subsequent shots. It should be noted that no deaths have been reported from allergic reactions, even severe (anaphylactic) ones, to the DTP vaccine.

Pain and Swelling at the Injection Site. Children may feel pain at the injection site. In some cases, a small lump may remain at the site for several weeks. Placing a clean, cool washcloth over any swollen, hot, or red area can help. Children should not be covered or wrapped tightly in clothes or blankets.

The risk for swelling, including of the whole arm or leg, increases with subsequent injections, particularly the fourth and fifth doses. If possible, parents should request that their children receive the same vaccine brand each time to help reduce the risk of side effects.

Fever and Other Symptoms. A child may develop a mild fever, irritability, drowsiness, and loss of appetite after a shot.

The following remedies may be helpful:

• Acetaminophen (for example, Children's Tylenol) and a sponge bath in lukewarm -- NOT cold -- water may help relieve fever and pain.
• The doctor may suggest that children who have had previous high fevers or other reactions to the injection be given acetaminophen at the time of the vaccination and every 4 hours afterward for 24 hours. (The doctor will determine the dosage according to the weight of the child.)
• Children should NEVER be given aspirin.

Fevers that should cause concern include the following:

• Any very high fever (over 105 °F) in children that causes convulsions should be reported immediately to the doctor. The newer DTaP vaccine has significantly reduced the risk for this side effect when compared to older vaccinations. Although frightening, such fever-related seizures are uncommon and rarely have long-term effects. A recurrence after a subsequent vaccination is very unlikely.
• A new fever that develops 24 hours after the vaccination, or a fever that persists for longer than 24 hours are most likely due to other causes and not the vaccination. This is true also for seizures that develop after 24 hours.

Hypotonic-Hyporesponsive Episode (HHE). HHE is an uncommon response to the pertussis component and occurs within 48 hours of the injection in children under 2. The child usually starts out feverish and irritable and then becomes pale, limp, and unresponsive. Breathing is shallow, and the child's skin may turn bluish. The reaction lasts an average of 6 hours and, although it is frightening, virtually all children return to normal. This side effect is less common since the introduction of the DTaP vaccine, but it can still occur.

Neurologic Effects in Pertussis Component. Of concern have been a few reports of permanent neurologic abnormalities that have occurred after children have been vaccinated. Such reports include attention deficit disorder, learning disorders, autism, brain damage (encephalopathy), and even death.

It is well established that the diphtheria and tetanus components cause no adverse neurologic effects, so some people suspect the pertussis component. However, many major studies found no causal relationship between neurologic problems and the pertussis vaccination. Studies on the newer DTaP have reported no safety concerns to date.

Studies suggest that in cases where neurological problems have been strongly linked to the vaccination, high fevers -- not immunization -- are responsible. Children with known neurological abnormalities may also be at risk for an outbreak of symptoms 2 or 3 days after the vaccination. Such a temporary worsening of their disease rarely poses a danger to the child. Children who have new neurologic events following their shot may already have a preexisting impairment, such as epilepsy, which is revealed -- but not caused -- by the vaccine. To date, there is no proof that the pertussis vaccine causes these neurologic events, which, in any case, are so infrequent as to be nearly statistically immeasurable.

Important Note: Unwarranted fears of side effects from vaccinations can be dangerous. In England such fears have caused a significant decline in immunization rates since the 1970s. Outbreaks of whooping cough have occurred as a result, causing a number of deaths and brain damage in many children. Small babies are particularly endangered if they become infected from older unvaccinated children (who usually have a mild disease).