DIPHTHERIA, TETANUS, AND PERTUSSIS

Diphtheria is a bacterial infection caused by Corynobacterium diphtheriae, transmitted

from person to person through close physical and respiratory contact.
Diphtheria vaccine is a formaldehyde-inactivated preparation of diphtheria toxin,
adsorbed onto a mineral carrier to increase its antigenicity and reduce adverse
reactions. Immunized individuals can be infected by toxin-producing strains of
diphtheria but systemic manifestations of the disease do not occur. When
administered for primary immunization in infants, diphtheria vaccine is almost always
given together with pertussis and tetanus vaccines as part of a three-component
preparation (DPT). A two-component diphtheria vaccine with tetanus but without
pertussis exists in two forms, DT and Td. Diphtheria-tetanus vaccine for children
(DT) is used for primary immunization in infants who have contraindications to
pertussis vaccine; it is also used in children under the age of 10 years for reinforcing
immunization against diphtheria and tetanus in those countries which recommend it.
Tetanus-diphtheria vaccine for adults, adolescents and children over 10 years of age
(Td), which has a reduced amount of diphtheria toxoid to reduce the risk of
hypersensitivity reactions, is used for primary immunization in persons over the age
of 10 years; it is also used for reinforcing immunization in persons over the age of 10
years in those countries that recommend it. In Jordan, Td is administered to children
at school entry as the second booster dose.
Tetanus is caused by the action of a neurotoxin of Clostridium tetani in necrotic
tissues such as occur in dirty wounds. Tetanus vaccine is available as a single
component vaccine for primary immunization in adults who have not received
childhood immunization against tetanus and for reinforcing immunization. The
vaccine is also used in the prevention of neonatal tetanus and in the management of
clean wounds and tetanus-prone wounds. Some countries recommend a maximum of
5 doses of tetanus vaccine in a life-time; for the fully immunized patient reinforcing
doses at the time of a tetanus-prone injury should only be required if more than 10
years have elapsed since the last dose. Neonatal tetanus due to infection of the baby’s
umbilical stump during unclean delivery is the cause of many deaths of newborn
infants. Control of neonatal tetanus may be achieved by ensuring adequate hygiene
during delivery and by ensuring protective immunity of mothers in late pregnancy.
Tetanus vaccine is highly effective and the efficacy of two doses during pregnancy in
preventing neonatal tetanus ranges from 80–100%. Women of child-bearing age may
be immunized by a course of 5 doses (3 primary and 2 reinforcing) of tetanus vaccine.
Wounds are considered to be tetanus-prone if they are sustained either more than 6
hours before surgical treatment of the wound or at any interval after injury and show
one or more of the following: a puncture-type wound, a significant degree of
devitalized tissue, clinical evidence of sepsis, contamination with soil/manure likely
to contain tetanus organisms. All wounds should receive thorough surgical toilet.
Antibacterial prophylaxis may also be required for tetanus-prone wounds.

For clean wounds , fully immunized individuals (those who have received a total of 5
doses of tetanus vaccine at appropriate intervals) and those whose primary
immunization is complete (with boosters up to date) do not require tetanus vaccine;
individuals whose primary immunization is incomplete or whose boosters are not up
to date require a reinforcing dose of tetanus vaccine (followed by further doses as
required to complete the schedule); non-immunized individuals (or whose
immunization status is not known) should be given a dose of the vaccine immediately
(followed by completion of the full course of the vaccine if records confirm the need).
For tetanus-prone wounds , management is as for clean wounds with the addition of a
dose of antitetanus immunoglobulin given at a different site; in fully immunized
individuals and those whose primary immunization is complete the immunoglobulin
is needed only if the risk of infection is especially high (for example, contamination
with manure). Antibacterial prophylaxis (with benzyl penicillin, or amoxicillin with
clavulinic acid, or metronidazole) may also be required for tetanus-prone wounds.
Pertussis (whooping cough) is a bacterial respiratory infection caused by Bordetella
pertussis . Many of the symptoms are thought to be caused by toxins released by B.
pertussis. Whole cell vaccine composed of whole pertussis bacteria killed by
chemicals or heat is effective in preventing serious illness. It causes frequent local
reactions and fever and rarely may it be associated with neurological reactions.
Neurological complications after pertussis infection are considerably more common
than after the vaccine. It is combined with diphtheria-tetanus vaccine for primary
immunization unless immunization against pertussis is contraindicated. Single
component pertussis vaccines are available in some countries for use when the
pertussis component has been omitted from all or part of the primary immunization
schedule. An acellular form of the vaccine is also available. In some countries it is
recommended that children with a personal or family history of febrile convulsions or
a family history of idiopathic epilepsy should be immunized. It is also recommended
that children with well-controlled epilepsy are immunized. Advice on prevention of
fever should be given at the time of immunization. In children with evolving
neurological problems, immunization with pertussis should be deferred until the
condition is stable; in such children diphtheria and tetanus vaccine should be offered
for primary immunization, and there may be an opportunity at a later date to complete
immunization with a single-component pertussis vaccine. Where there is doubt advice
should be sought from a pediatrician.
DIPHTHERIA VACCINES
Adsorbed diphtheria toxoid
Indications
Diphtheria immunization is part of the standard vaccination schedule.
Contacts of a diphtheria case, or a carrier, when recommended by a public health official (contacts will
also need prophylactic antibiotics).
Immunization against diphtheria, when diphtheria with tetanus vaccine (or other diphtheria-containing
combination vaccine) is inappropriate.
Contraindications
Child vaccine.
Adults and children ≥5 years of age (use adult vaccine).
Specific considerations
Pregnancy: Safe to use adult vaccine; ADEC category A.
Breastfeeding: There is no evidence of risk to the baby if the breastfeeding mother is vaccinated using
live or attenuated vaccines. Breastfeeding does not adversely affect immunization and is not a
contraindication for the administration of any vaccine to the baby.
Adverse effects
Rare: anaphylaxis, transient fever, headache, malaise.
Dosage
Adult vaccine: IM, 0.5 mL for 3 doses (interval of 6–12 weeks between the first 2 doses; 6–12 months
between second and third).
Child vaccine: Child >2 months, IM, 0.5 mL for 3 doses at 2, 3 and 4 months of age for the primary
course.
Contacts of a diphtheria case or carrier, vaccinated, 1 dose (booster); unvaccinated, 3 doses at intervals
of 1–2 months.
Administration instructions
Shake the container before use.
There may be a suboptimal response if a vaccine is injected incorrectly (route or area); local reactions
may also be increased. IM injections should be given slowly to reduce pain.
IM: Adult, child >12 months, deltoid muscle. Child <12 months, anterolateral aspect of the thigh.
SC: Skin of deltoid muscle or the anterolateral thigh.
Patient counselling
Tell the person/parent/guardian:
• of the need to remain in area for at least 15 minutes after vaccination
• of how to manage common adverse events which may occur after immunization (provide a contact
phone number for reporting significant adverse effects occurring within 24–48 hours of
vaccination)
• that routine use of paracetamol to prevent fever, at the time of vaccination, is no longer
recommended except for children with a history of seizures
• that tepid sponging of child to reduce fever is no longer routinely recommended as it may cause
vasoconstriction, reducing heat elimination and increasing temperature
• of the date of next scheduled vaccination (preferably in writing).
Practice points
• adults and children >8 years have reduced tolerance to diphtheria toxoid (severe hypersensitivity
reactions may occur); adult vaccines provide a lower dose than those for children (In Jordan,
we even use the lower dose for the school entry booster dose)
• ideally give booster dose at 4–5 years of age; may give up to 8 years.
Products
DIPHTHERIA VACCINE, ADSORBED INJ, 0.5 mL (diluted for adult use)
DIPHTHERIA VACCINE, ADSORBED INJ, 0.5 mL

DIPHTHERIA ANTITOXIN
A sterile preparation containing the specific antitoxic globulins that have the power of neutralizing the
toxin formed by Corynebacterium diphtheriae. It has a potency of not less than 1000 international units
per mL when obtained from horse serum and not less than 500 international units/mL when obtained
from other mammals.
Indications
Diphtheria antitoxins neutralize the toxin produced by Corynebacterium diphtheriae locally at the site
of infection and in the circulation.
Diphtheria antitoxins are used for passive immunization in suspected cases of diphtheria and should be
given without waiting for bacteriological confirmation of the infection. An antibacterial is usually
given concomitantly
Antitoxin is generally not used for the prophylaxis of diphtheria because of the risk of provoking a
hypersensitivity reaction.
Adverse effects
As for antisera in general,
Dosage
Mild or moderate severity: 10 000 to 40 000 units of diphtheria antitoxin may be given intramuscularly
Severe cases: 40 000 to 100 000 units may be given
Practice points
• Contacts of a diphtheria case should be promptly investigated, given antibacterial prophylaxis and
active immunization with a suitable diphtheria-containing vaccine as appropriate and kept
under observation.
• A test dose of diphtheria antitoxin should always be given to exclude hypersensitivity.
• For doses of more than 40 000 units a portion of the dose is given intramuscularly followed by the
bulk of the dose intravenously after about 0.5 to 2 hours.
Products
DIPHTHERIA ANTOTOXIN VIAL 10,000 IU/VIAL (HORSE ORIGIN) 5 ML VIAL

DIPHTHERIA AND TETANUS VACCINE

Adsorbed diphtheria and tetanus toxoids
Child vaccine is also known as CDT or DT and the adult vaccine as ADT, dT and Td.
Indications
Immunization against diphtheria and tetanus is part of the standard vaccination schedule (as diphtheria–
tetanus–pertussis vaccine).
Tetanus prophylaxis following injury.
Adult vaccine: Adults and children >8 years of age requiring catch-up vaccination with diphtheria and
tetanus
Booster at 50 years of age (after a primary course of 3 doses, and at least 2 booster doses of diphtheria–
tetanus vaccine; not required if a dose has been given in the previous 5 years).
Child vaccine: Diphtheria and tetanus vaccination for children 2 months – 5 years if pertussis is
contraindicated or refused (not used routinely in the standard vaccination schedule).
Contraindications
Child vaccine.
Adults and children >5 years of age (use adult vaccine).
Specific considerations
Pregnancy: Safe to use adult vaccine; ADEC category A.
Breastfeeding: There is no evidence of risk to the baby if the breastfeeding mother is vaccinated using
live or attenuated vaccines. Breastfeeding does not adversely affect immunization and is not a
contraindication for the administration of any vaccine to the baby.
Adverse effects
Infrequent: lethargy, myalgia.
Rare: anaphylaxis, urticaria, transient fever, malaise, headache, peripheral neuropathy.
Common: transient injection site reactions (pain, redness, itching, swelling or burning, small hard lump
which may persist for some weeks), transient fever.
Dosage
Adult vaccine: Adult, child >5 years, IM, 0.5 mL for 3 doses (interval of 1 month between doses if
used as the primary course). Booster doses at 15–17 years and at 50 years are needed.
Child vaccine: Child <5 years, IM, 0.5 mL at 2, 3 and 4 months of age for the primary course.
Administration instructions
Shake the container before use.
There may be a suboptimal response if a vaccine is injected incorrectly (route or area); local reactions
may also be increased. IM injections should be given slowly to reduce pain.
IM: Adult, child >12 months, deltoid muscle. Child <12 months, anterolateral aspect of the thigh.
SC: Skin of deltoid muscle or the anterolateral thigh.
Practice points
• patients with a pertussis contraindication may receive diphtheria–tetanus vaccine with close
observation if benefits outweigh risks
• adults and children >5 years have reduced tolerance to diphtheria toxoid (severe hypersensitivity
reactions may occur); adult vaccines provide a lower dose than those for children
Products
DIPHTHERIA, TETANUS ADSORBED VACCINE, COMBINED EACH SINGLE
HUMAN DOSE 0.5 ML CONTAINS NOT MORE THAN 2 LF OF DIPHTHERIA
TOXOID AND NOT MORE THAN 10 LF OF TETANUS TOXOID VIAL
DIPHTHERIA, FOR ADULTS ONLY

DIPHTHERIA, TETANUS ADSORBED VACCINE, COMBINED EACH SINGLE

HUMAN DOSE 0.5 ML CONTAINS NOT MORE THAN 25 LF DIPHTHERIA
TOXOID AND NOT MORE THAN 10 LF TETANOUS TOXOID, VIAL FOR
CHILDREN

DIPHTHERIA, TETANUS AND PERUTUSSIS ADSORBED VACCINE (DTP)

Adsorbed diphtheria and tetanus toxoids with acellular pertussis; combination vaccines may include
Hib capsular polysaccharide-tetanus toxoid (PRP-T), hepatitis B surface antigen, and or inactivated
polio virus
Combination of diphtheria, tetanus and pertussis is also known as DTP and DTPa (child formulation)
and dTp or dTpa (adult formulation).
Indications
Immunization against diphtheria, tetanus and pertussis (and hepatitis B, H. influenzae type b and polio)
is part of the standard vaccination schedule.
Adult formulation of DTP is now the recommended booster at 15–17 years; may be given at 50 years
(providing a dose has not already been given and the primary course has been completed).
Combination with hepatitis B, Hib, and polio: Booster for children who require boosting against DTP,
hepatitis B, H. influenzae type b and polio.
Combination with hepatitis B and polio: Single booster for children who require boosting against DTP,
hepatitis B and polio.
Combination with polio: Single booster for children who have been immunized against DTP and polio.
Contraindications
Severe acute neurological illness within 7 days of pertussis vaccination (use vaccine(s) without
pertussis component; consider referral to specialist immunization service for vaccination under close
medical supervision).
Specific considerations
Pertussis infections (culture positive) after 3 months of age: pertussis vaccine is not required (still safe
to use DTP).
Active or progressive neurological disease: child may be vaccinated (may be deferred if there was a
seizure in the previous 3 weeks).
Reaction to pertussis vaccination (fever with no other cause, collapse or shock-like state, persistent
crying within 48 hours, seizures, with or without fever, within 3 days): continuing the vaccination
course with an acellular pertussis-containing vaccine is usually appropriate; recurrence of these adverse
effects is uncommon; if in doubt seek specialist advice.
Allergy to neomycin or polymyxin.
Pregnancy: ADEC category B2.
Adverse effects
Frequencies of adverse effects may differ according to the combination of antigens given.
Common: crying, irritability, drowsiness, restlessness, limb swelling.
Vaccines containing polio antigen
common: vomiting, diarrhoea, loss of appetite, fussiness, fever.
Infrequent: lethargy, myalgia, malaise.
Rare: anaphylaxis, urticaria, headache, peripheral neuropathy, encephalopathy, seizure.
Rarely allergic (including anaphylactoid) reactions occur with vaccines containing DTP, and collapse
and hypotonic-hyporesponsiveness episodes with vaccines containing pertussis.
Limb swelling
DTP vaccines
Booster vaccinations at 18 months and 5 years (fourth and fifth doses) may cause extensive swelling of
the arm or thigh (usually with redness and pain) in approximately 2% of patients, and is thought to be
caused by the acellular pertussis component. Swelling subsides spontaneously and completely (usually
within 2 days, may take 7).
It is not clear whether a child who develops this reaction after the fourth dose is more likely to have a
similar reaction to a fifth dose. The fourth dose is now given at age 4 years rather than 18 months;
however, it is still recommended that children who have been vaccinated at 18 months should receive a
vaccine at 4 years.
DTP combination vaccines
Booster vaccinations with other vaccines containing a pertussis component may also cause extensive
swelling of the arm or thigh, usually with redness and pain, in approximately 2% of patients, see above.
It has occurred rarely with the DTP and polio combination, after doses in the primary schedule and
booster doses.
Dosage
Adult, child 5 years and over: IM, 0.5 mL.
Child <5 years: Use a vaccine from the same manufacturer for all doses in the primary course if
possible; any DTP-containing vaccine can be used for the booster at age 4 years, the choice depending
on which other vaccinations are required.
IM, 0.5 mL.
Combination with hepatitis B; hepatitis B, Hib and polio; hepatitis B and polio; polio
Administration instructions
Shake the syringe, add its contents to container with Hib pellet, then shake until pellet is completely
dissolved. This can be kept for up to 8 hours at room temperature.
There may be a suboptimal response if a vaccine is injected incorrectly (route or area); local reactions
may also be increased. IM injections should be given slowly to reduce pain.
IM: Adult, child >12 months, deltoid muscle. Child <12 months, anterolateral aspect of the thigh.
SC: Skin of deltoid muscle or the anterolateral thigh.
Patient counselling
Booster vaccinations of DTP may cause extensive swelling of the arm or thigh (usually with redness
and pain); it subsides completely (usually within 2 days but may take 7).
Practice points
• the schedule now recommends a 4-dose course with the fourth (booster) dose (usually as DTP with
polio vaccine) at 18 months of age
• more than 60% pertussis cases occur in people >10 years of age; booster doses are needed to
decrease this incidence and reduce transmission to children <6 months
• adults and children >5 years have reduced tolerance to diphtheria toxoid; adult vaccines provide a
lower dose than those formulated for children
• patients with a pertussis contraindication may receive diphtheria–tetanus vaccine with close
observation if benefits outweigh risks
• children who have a febrile convulsion after a dose of DTP have an increased risk of a convulsion
after another vaccination; continue with the vaccination course and minimise risk by
preventing fever
• do not give combination vaccines containing hepatitis B at birth; give monovalent hepatitis B
vaccine.
Products
DIPHTHERIA, TETANUS AND PERUTUSSIS ADSORBED VACCINE (DTP)
DTP+Hib (DIPHTHRIA TETANUS PERTUSSIS HAEMOPHILUS INFLUENZAE
TYPE B VACCINE VIAL 10 DOSE
DTP+IPV AND HEAMOPHILLUS INFLUENZA TYPE B VACCINE
(DTP+IPV+Hib) VIAL 1 DOSE

GAS GANGARINE ANTITOXIN HORSE SERUM

Gas gangrene is a severe form of gangrene (tissue death) usually caused by clostridium perfringens. it
can also be from group a streptococcus. Staphylococcus aureus and vibrio vulnificus can cause similar
infections.
Products
GAS GANGARINE ANTITOXIN HORSE SERUM 25,000 IU/VIAL 10 ML VIAL