ATLANTA -- In certain cases where the tetanus and diphtheria (Td) vaccine is recommended, clinicians may substitute the tetanus, diphtheria, and acellular pertussis (Tdap) vaccine, the CDC's Advisory Committee on Immunization Practices (ACIP) recommended at its October meeting here.
In a unanimous 14-0 vote, the ACIP backed a change in policy, calling for use of either the Td or Tdap vaccine to be used in situations where currently only the Td vaccine is currently recommended. This included the decennial (every 10 years) Td booster, tetanus prophylaxis for wound management, and a catch-up immunization schedule for people age 7 and older, including for pregnant women.
An update to the language for the Vaccines for Children program was also recommended unanimously.
When discussing the potential benefits of using Tdap in place of the Td vaccine, Pedro Moro, MD, of the CDC, cited "increased flexibility for providers," as well as evidence of widespread use of Tdap over the Td vaccine.
In addition, there were no substantive safety concerns. Moro said that the Pertussis Vaccines group found that published data on closely spaced Tdap doses showed no increase in adverse events when Tdap or Td was administered as a second or third dose, and that "regimens similar to the current and proposed catch-up schedule did not show differences in reactogenicity." Unpublished data did not show any unusual or increased reporting of any adverse event, they added.
"While data on multiple Tdap doses is limited, our review of published and unpublished safety data is reassuring," the group concluded.
There was one instance of an acute event (excessive limb swelling) in a pregnant woman reported out of 187 patients in the examined safety data, though the group noted it occurred 7 days after vaccination.
ACIP committee member Helen Keipp Talbot, MD, of Vanderbilt University in Nashville, urged providers to talk to patients and inform them "this type of event will resolve" and "there will be no sequelae."
Most committee members and liaison members applauded the change in this recommendation. However, Robert Atmar, MD, of Baylor College of Medicine in Houston, wondered if it would lead to the "extinction" of the Td vaccine in this country.
"Td will still be used in certain situations that are catching people up [such as] refugee clinics with strict cost restraints," said Paul Hunter, MD, of the City of Milwaukee Health Department. "But my personal opinion for the average family medicine clinic or internal medicine clinic where they're doing decennial boosters, it's a lot simpler and easier to have one vaccine."
The group chose not to offer a preferential recommendation for Tdap over the Td vaccine, but liaison member Patricia Stinchfield, RN, of the National Association of Pediatric Nurse Practitioners, shared some recent sobering data as an important reminder of the severity of pertussis.
"For children with pertussis who go on ECMO [extracorporeal membrane oxygenation], the survival rate is only 28%," she said.
'Good and Evil'
As has been the case for the last several ACIP meetings, the committee allowed one hour of public comment prior to the vote today. Most of those speaking railed against the committee, sharing personal stories, calling for better data on vaccine safety, and openly declaring that vaccines are not safe or effective. One public commenter even called the divide between those against vaccines and those in support of vaccines "a war between good and evil."
But Eve Switzer, MD, a pediatrician in Oklahoma, commended the committee, as she discussed how vaccine advocates such as pediatricians, and even parents who have lost children to vaccine-preventable diseases, have been harassed both on- and offline.
"I applaud the work you do ... and condemn the abuse you are subjected to," she said.
A vote was also scheduled for the 2020 adult immunization schedule and childhood immunization schedule, but it was postponed to resolve certain issues brought up by committee members.
Recommendations made by the ACIP are not considered final until they are published in the Morbidity and Mortality Weekly Report.