Administering Diphtheria, Tetanus, and Pertussis Vaccines

This page provides a brief summary of guidance for administering diphtheria, tetanus, and pertussis vaccines, including route, number of doses, and co-administration with other vaccines.

Visual Inspection

Do not use any diphtheria, tetanus, and pertussis vaccine or diluent (if applicable) beyond the expiration date printed on the label.

Prior to administration, visually inspect the vaccine for particulate matter and/or discoloration. If these conditions exist, do NOT use.

Just before use, shake vial or manufacturer-filled syringe well. Do not use vaccine if it cannot be resuspended after thorough agitation.

• After shaking, Td should be a cloudy, whitish-gray colored liquid.
• After shaking, Tdap should be a cloudy, white-colored liquid.

Route, Site, and Needle Size

All diphtheria, tetanus, and pertussis vaccines (DT, DTaP, Td, and Tdap) should be administered by the intramuscular route. The preferred injection site in infants and young children is the vastus lateralis muscle of the thigh. The preferred injection site in older children and adults is the deltoid muscle in the upper arm. Use a needle length appropriate for the age and size of the person receiving the vaccine.

Number and Timing of Doses

The number and timing of doses depends on the type of vaccine used and the person being vaccinated.

DTaP or DT

DTaP is recommended for all infants and children younger than 7 years of age; however, if the pertussis component is contraindicated, use DT to complete the primary series in this age group.

• The recommended DTaP series is 5 doses, administered at 2, 4, and 6 months, 15 through 18 months, and 4 through 6 years.
• The fourth dose of DTaP should be administered no earlier than 6 months after the third dose. However, the fourth dose does not need to be repeated if it is administered at least four months after the third dose.
• The fourth dose of DTaP should not be administered before 12 months of age. It can be given at 12 through 15 months of age if the child is unlikely to return at 15 through 18 months of age; this is an off-label recommendation from the Advisory Committee on Immunization Practices.
• The fifth dose of DTaP is not necessary if the fourth dose was given on or after the patient’s fourth birthday.

Tdap and Td

One dose of Tdap is recommended for all adolescents.

• The preferred age for Tdap administration in adolescents is 11 to 12 years.
• If adolescents (13 through 18 years) missed getting Tdap at 11 to 12 years of age, administer at the next patient encounter or sooner if adolescent will have close contact with infants.
• Tdap can be administered regardless of interval since the last tetanus toxoid- and diphtheria toxoid-containing vaccine.

One dose of Tdap is recommended for pregnant women during each pregnancy.

• The preferred timing for Tdap administration in pregnancy is 27 through 36 weeks gestation.
• Tdap can be safely administered earlier in pregnancy if it is indicated for wound care or during a community pertussis outbreak. If Tdap is administered earlier in pregnancy, it should not be repeated between 27 and 36 weeks gestation; only one dose is recommended during each pregnancy.
• Tdap can be administered regardless of interval since the last tetanus toxoid- and diphtheria toxoid- containing vaccine.
• Tdap should not be offered as part of routine preconception care.
• Tdap is recommended only in the immediate postpartum period before discharge from the hospital or birthing center for new mothers who have never received Tdap before or whose vaccination status is unknown.

One dose of Tdap is recommended for healthcare personnel who have not previously received Tdap and who have direct patient contact.

• Tdap can be administered regardless of interval since the last tetanus toxoid- and diphtheria toxoid-containing vaccine.

Adults who did not receive Tdap as an adolescent should receive a single dose of Tdap.

• Adults should be vaccinated as soon as feasible.
• This Tdap booster dose can replace one of the 10-year Td booster doses.
• Tdap can be administered regardless of interval since the last tetanus toxoid- and diphtheria toxoid-containing vaccine.

After receipt of Tdap, patients should continue to receive Td for routine booster immunization every 10 years.

Predrawing Vaccine Doses

Predrawing vaccine doses is not recommended because there are no data on the stability of vaccines stored in syringes filled by healthcare professionals.

• Single-dose vials: All of the vaccine should be drawn into a sterile syringe using a sterile needle at the time of administration. Once the protective cap is removed from a single-dose vial, the vaccine should be used or discarded at the end of the workday because single-dose vials do not contain a preservative and it is difficult to tell if the rubber stopper has been penetrated.
  • Pentacel® is supplied in 2 vials that must be mixed together before administration. Unused, reconstituted Pentacel® may be stored in the refrigerator between 2°C and 8°C (36°F and 46°F) for up to 30 minutes.
• Manufacturer-filled syringes: Manufacturer-filled syringes should be activated (i.e., syringe tip removed or needle attached) at the time the vaccine is administered. Once activated, a manufacturer-filled syringe must be used that day or discarded at the end of the workday because the sterile seal has been broken.

Administration with Other Vaccines

There are no contraindications to the co-administration of diphtheria, tetanus, and pertussis vaccines. DTaP, DT, Td, and Tdap may be administered with other indicated vaccines during the same visit. However, each vaccine should be administered using a separate syringe and, if possible, at a different anatomic site.

There is an increased risk for febrile seizures when inactivated influenza vaccine is given around the same time as 13-valent pneumococcal conjugate vaccine (PCV13) and DTaP vaccines in children. A recent Vaccination Safety Datalink study took a closer look at the 2010/2011 febrile seizure signal for trivalent inactivated influenza vaccine (TIV or IIV) and PCV13. The study included the 2006–2009 seasons in addition to the 2010–2011 influenza season. The findings showed that PCV13 and DTaP both increase risk of febrile seizure when given at the same time as the influenza vaccine. CDC found that when TIV was given alone, it was not associated with an increased risk of febrile seizures (in the influenza seasons studied).

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