1. Tetanus, Diphtheria and Pertussis Vaccine (Tdap) for Adolescents and Adults
Trudy V. Murphy, MD
March 8, 2006
National Immunization Program
Centers for Disease Control and Prevention

2. Tdap for Adolescents and Adults
Background rationale
Recommendations
Challenges

3. Reported Pertussis Cases
5,000
10,000
15,000
20,000
25,000
30,000
1990
1995
2000
50,000
100,000
150,000
200,000
250,000
300,000
1922
1930
1940
1950
1960
1970
1980
1990
2000
Year
Number of cases
> 18 yrs
11-18 yrs
DTP
< 11 yrs

4. Adolescent and Adult Pertussis Estimated Annual Number of Cases
Age
(years)
Population
(Millions)*
Incidence/100,000
100
350
11-18
~30
~30,000
cases
~105,000cases
19-64
~170
~170,000
~600,000
*2000 census
Incidence from MA, WI DOH: unpublished data, Ward 2005, Strebel 2001, Nennig 1996

5. Reported Pertussis Deaths10 20 30
1980
1990
2000
5000
10000
1930
1940
1950
1960
1970
1980
1990
2000
Year
Number of Deaths Reported
DTP

6. Relationship of Reported Source to 494
Relationship of Reported Source to * Infants <4 Months of Age with Pertussis,
Relationship of source to infant
Number %*
Unknown %
Mother %
Father %
Grandparent %
Sibling %
Other %
24%
Adapted from Bisgard K et al. Pediatr Infect Dis J 2004

7. Health-Care Workers with Pertussis Adult-Care Settings
Author (year)
Location
Index Case
20 Cases
Close Contacts
Boulay (2006)
Hem-Oncology Care Unit
HCW 10
117
Ward, 2005
General Hospital (France) 17 74
Zivna
(2005)*
PACU* 3
191
Bagget (2005)*
Obstetric Clinic 7
737

8. Pertussis or “Whooping Cough” Adolescents and Adults
Paroxysmal cough 80% -100%
Lasting median 6-9 weeks
Post-tussive vomiting ~50%
Whoop ~30% - 60%
Disturbed sleep 3/4
Weight loss 1/3
ACIP June & October 2005

9. Morbidity from Pertussis Reported Cases among Adolescents and Adults
Incontinence, 28% >18 years
Rib fracture, 1%-4%
Syncope 3%-6%
Pneumonia 2%-5%
Hospitalization 1% -3%
Lee G. et al CID 2004;39:1572
ACIP June & October 2005

10. Impact of Pertussis among Adolescents and Adults
Medical costs
Missed school (mean 5.5 days) or work (mean 10 days)
Public health and infection control responses: time, testing, treatment, prophylaxis
Lee G. et al CID 2004;39:1572
ACIP June & October 2005

11. Rationale for a Tdap Vaccination Program for Adolescents and Adults
To protect the Tdap recipient from pertussis
To decrease spread of B. pertussis to persons at risk of severe pertussis (e.g., infants aged <12 months, adults with co-morbid conditions)
To reduce cost and disruption of pertussis in institutional settings
To reduce the reservoir B. pertussis

12. ADACEL™ (sanofi pasteur) June 10, 2005
Tetanus Toxoid, Reduced Diphtheria Toxoid and Pertussis Antigens (Tdap)
BOOSTRIX® (GSK) May 3, 2005
Licensed use:10-18 years of age
ADACEL™ (sanofi pasteur) June 10, 2005
Licensed use: years of age
Single Dose

13. Efficacy against pertussis ~85%
Tdap Background
Safe and immunogenic
Efficacy against pertussis ~85%
Inferred from non-inferiority with responses among infants protected after 3-doses DTaP
Protection 5-10 years; boosters likely to maintain protection
Cost ~ $20 per dose more than Td

14. ACIP Recommends Tdap for Adolescents, June 2005
Routine: years of age instead of Td
Catch-up for pertussis protection
11-18 years of age if >5 years since last Td, DTaP (DTP, DT)
Interval shorter than 5 years can be used in settings with increased risk for pertussis or its complications

15. Safety of Short Interval Tdap after Td (or DTP/DTaP) 3 Canadian Studies
Largest: province-wide, school-based, non-randomized, open label, >7000 students
Tdap ~ 2 years (18-23 months) vs >10 years after last Td
No increase in adverse events
Halperin SA. Pediatr Infect Dis J 2006 (in press)

16. ACIP Recommends* Tdap for Adults October 2005-February 2006
Routine: Adults years of age to replace next dose of Td
Short interval since last Td
To protect infants (“Cocoon”)
To protect health-care workers
*Provisional until published by MMWR

17. ACIP Recommends* Tdap for Adults October 2005
To protect infants (“Cocoon”)
Adults <65 years of age who have or who anticipate having contact with an infant <12 months of age
Women in the immediate post-partum period (if no previous Tdap)
An interval of 2 years or more since last Td is suggested
*Provisional until published by MMWR

18. ACIP Recommends* Tdap for Adults February 2006
To protect health-care workers
Direct patient contact in hospitals and ambulatory care settings
Interval of 2 years or more since last Td is recommended
Priority Tdap for workers in contact with infants <12 months of age
Facilities should provide the Tdap and maximize uptake
*Provisional until published by MMWR

19. Tdap for Adolescents and Adults Challenges
Educate: physicians, public
Morbidity, mortality from pertussis
Improve coverage among adults
years of age, Td 55%-67% (NHIS 1999)
Laboratory diagnostics
Potential benefits of Tdap for pregnant women and their infant

20. Tdap for Adolescents and Adults Challenges
Post-exposure prophylaxis among exposed, vaccinated persons?
Effectiveness of Tdap strategies over time; monitor post-licensing safety
Burden of pertussis, and high risk groups among older adults

21. Reported Cases of Vaccine-Preventable Diseases, United States
Average Annual No. Cases
Pre-vaccine
2004
Smallpox
29,005
Diphtheria
21,053
Pertussis
192,752
25,827
Tetanus
580 34
Polio (paralytic)
16,316
Measles
4,000,000 37
Mumps
162,344
258
Rubella
47,745 10
Congenital Rubella
152
Hib (invasive <5 years)
20,000 17

22. Acknowledgements ACIP Pertussis Working Group,
John Moran, CDC/NIP/BVPD & the
DTP-Hib Team
Karen Broder
Kristin Brown
Amanda Cohn
Margaret Cortese
Kashif Iqbal
Patricia Joyce
Katrina Kretsinger
Christina Mijalski
Manisha Patel
Pam Srivastava
Barbara Slade
Tej Tiwari

23. THANK YOU