Supplementary Statement of Contraindications to Receipt of
Pertussis Vaccine
The following statement updates some of the previous
recommendations regarding pertussis vaccine (1). The Immunization
Practices Advisory Committee (ACIP) reviewed the available data
concerning the risks of pertussis disease and pertussis vaccine to
infants and children with personal or family histories of
convulsions. Based on available evidence, the ACIP does not
consider
a family history of convulsion to be a contraindication to receipt
of
pertussis vaccine. However, a personal history of a prior
convulsion
should be evaluated before initiating or continuing immunization
with
vaccines containing a pertussis component (i.e., diphtheria and
tetanus toxoids with pertussis vaccine (DTP)) (Table 1).
DEFERRAL OF DTP FOR INFANTS AND CHILDREN WITH PERSONAL HISTORIES
OF CONVULSION(S)
Although there are uncertainties in the reported studies,
recent
data suggest that infants and young children who have previously
had
convulsions (whether febrile or nonfebrile) are more likely to have
seizures following pertussis vaccination than those without such
histories (2). Available data do not indicate that seizures
temporally associated with vaccine administration predispose to
permanent brain damage or exacerbate existing conditions. The
incidence of pertussis in most areas of the United States is
presently
quite low. Consequently, for infants and young children who have
histories of seizures before initiation of DTP immunization or who
develop seizures before the four-dose primary series is completed,
initiating or continuing pertussis immunization should be deferred
until it can be determined that there is not an evolving neurologic
disorder present. If such disorders are found, the infants or
children should be given diphtheria and tetanus toxoids (DT)
instead
of DTP. If DT is used, three doses at least 4 weeks apart,
followed
by a fourth dose 6-12 months later, are recommended for infants.
For
children 1 year of age or older, two doses of DT at least 4 weeks
apart, followed by a third dose 6-12 months later, are recommended.
RECOMMENDATIONS FOR BEGINNING OR CONTINUING DTP AFTER DEFERRAL
For infants and children whose DTP immunizations are deferred
because of histories of convulsion(s), the decision whether to
proceed
with DTP immunization can usually be made within the next few
months.
For infants who have received fewer than three doses of DTP, such a
decision in most instances should be made no later than at 1 year
of
age. Following individual assessment, it may be decided to proceed
with DTP, because infants and young children with convulsive
disorders
also appear to be at higher risk of adverse outcomes if they
contract
pertussis disease. Further, if unimmunized infants attend day-care
centers, special clinics, and residential-care settings where other
children may be unimmunized or if they travel to or reside in areas
where the disease is endemic, they may be at increased risk of
exposure to pertussis.
For infants and children with stable neurologic conditions,
including well-controlled seizures, the benefits of pertussis
immunization outweigh the risks, and such children may be
vaccinated.
The occurrence of single seizures (temporally unassociated with
DTP)
in infants and young children, while necessitating evaluation, need
not contraindicate DTP immunization, particularly if the seizures
can
be satisfactorily explained. An example might be a febrile seizure
in
the course of exanthem subitum in a 14-month-old child. As with
all
infants or children with one or more febrile seizures,
consideration
of continuous anticonvulsant prophylaxis may be warranted.
Parents should be fully informed of the benefits and risks of
immunization with DTP. Parents of infants and children with
histories
of convulsions should particularly be made aware of the slightly
increased chance of post-immunization seizures. A minimum of three
doses of DTP given at intervals of at least 4 weeks is necessary to
provide adequate protection against pertussis. A fourth dose 6-12
months later is also recommended.
CONTRAINDICATIONS TO PERTUSSIS VACCINE
Hypersensitivity to vaccine components, presence of an evolving
neurologic disorder, or a history of a severe reaction (usually
within
48 hours) following a previous dose all remain definitive
contraindications to the receipt of pertussis vaccine. Severe
reactions include collapse or shock, persistent screaming episode,
temperature 40.5 C (105 F) or greater, convulsion(s) with or
without
accompanying fever, severe alterations of consciousness,
generalized
and/or local neurologic signs, or systemic allergic reactions.
Although hemolytic anemia and thrombocytopenic purpura have
previously
been considered contraindications by the ACIP, the evidence of a
causal link between these conditions and pertussis vaccination is
not
sufficient to retain them as contraindications.
OTHER IMMUNIZATIONS FOR INFANTS AND CHILDREN FOR WHOM PERTUSSIS
VACCINE IS CONTRAINDICATED
Immunization with DT and/or oral polio vaccine is not known to
be
associated with an increased risk of convulsions. Therefore, a
history of prior convulsions is not a contraindication to receipt
of
these toxoids and vaccine. In addition, a history of prior
convulsion(s) is not a contraindication for measles-mumps-rubella
(MMR) vaccine. Further details concerning DTP vaccine or DT
toxoids
can be found in the 1981 ACIP statement (1).
References
ACIP. Diphtheria, tetanus, and pertussis: guidelines for
vaccine
prophylaxis and other preventive measures. MMWR 1981;30:392-6,
401-7.
CDC. Adverse events following immunization. Surveillance
Report
No. 1, 1979-1982 (in press).
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