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12/1/2017

Pertussis Prophylaxis in Pregnancy

Pertussis, also known as whooping cough, is a highly contagious respiratory disease caused by the bacterium Bordetella pertussis.  Infection causes paroxysms of coughing which can lead to dyspnea, hypoxia, and apneic spells in infants.  Half of affected infants require hospital care, one in four will get pneumonia, and mortality is 1%.  Although infected adults suffer less, coughing may be severe enough to fracture ribs.  It is uncertain if pertussis infection in a pregnant adult is associated with increased morbidity or mortality.

Pertussis infections in infants generally are contracted from family members and caregivers.  Pertussis occurring in the first three months of life accounts for the majority of pertussis-related morbidity and mortality.  Infants do not begin the pertussis vaccine series until two months of age, when a diphtheria, tetanus, and acellular pertussis (DTaP) vaccine is recommended.  This period of immunologic vulnerability for the infant is best addressed by maternal vaccination during pregnancy and vaccinating those close to and caring for the infant.  Tetanus toxoid, reduced diphtheria toxoid and acellular pertussis (Tdap) stimulates development of maternal anti-pertussis antibodies that pass through the placenta to result in passive immunization of the fetus. Repeat Tdap administration is required each pregnancy because the immune response wanes rapidly.  There has been no evidence of adverse fetal effects when women are vaccinated with Tdap during pregnancy. 

The CDC’s Advisory Council on Immunization Practices (ACIP) updated their recommendations in response to the infant’s lack of endogenous protective antibody in the early months.  Tdap vaccination is recommended during every pregnancy, irrespective of the patient’s age and history of immunization with Tdap or other related vaccines.  To maximize maternal antibody response, passive antibody transfer, and antibody levels in the neonate, the optimal timing of Tdap administration is between 27 and 36 weeks’ gestation.  Increasing evidence supports vaccination earlier in this window to allow maximal maternal immune response prior to birth.  Tdap vaccination at any time during the pregnancy is safe.  If Tdap is not administered during the pregnancy, vaccination should occur immediately post-partum. It is safe to administer Tdap to breastfeeding women. 

All adults and adolescents who have not previously received Tdap vaccine and who will have close contact with an infant younger than 12 months of age should receive the Tdap vaccine at least two weeks prior to contact.

Reproductive-age women who live or work in areas with pertussis epidemics should be immunized per recommendations for non-pregnant adults. Vaccination of pregnant women in epidemic areas is encouraged outside the 27 to 36 week window.  Women should not be re-vaccinated with Tdap if it was administered during the first or second trimester.  If a tetanus and diphtheria (Td) booster is required by a pregnant woman as part of a wound management protocol, it should be replaced with a Tdap vaccine, irrespective of gestational age.  Pregnant woman who have never been vaccinated for tetanus should start the Td three-vaccine series (0 weeks, 4 weeks and 6-12 months). One dose of Td should be replaced with Tdap, preferably timed near or in the 27 to 36 week window.

Further Reading:

Havers FP, Moro PL, Hunter P, Hariri S, Bernstein H. Use of Tetanus Toxoid, Reduced Diphtheria Toxoid, and Acellular Pertussis Vaccines: Updated Recommendations of the Advisory Committee on Immunization Practices - United States, 2019. MMWR Morb Mortal Wkly Rep. 2020 Jan 24;69(3):77-83. doi: 10.15585/mmwr.mm6903a5. PMID: 31971933; PMCID: PMC7367039.  Also available in full text at: http://dx.doi.org/10.15585/mmwr.mm6903a5

Committee Opinion No. 718: Update on Immunization and Pregnancy: Tetanus, Diphtheria, and Pertussis Vaccination. Obstet Gynecol. 2017 Sep;130(3):e153-e157. doi: 10.1097/AOG.0000000000002301. PMID: 28832489.  Also available in full text at: https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/09/update-on-immunization-and-pregnancy-tetanus-diphtheria-and-pertussis-vaccination

Initial approval November 2017. Reaffirmed May 2019, Revised December 2020. Reaffirmed July 2022

 

Previously titled: Pertussis in Pregnancy – title changed July 2022

 

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