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Question:

A 15-month-old full-term boy is brought to the clinic for a well-child examination. He has been eating and sleeping well and is meeting all developmental milestones. His day care center had an outbreak of pertussis 6 weeks ago that required it to close for a few days, but the patient has had no cough, nasal congestion, or rhinorrhea. At age 6 months, he had a generalized seizure that lasted approximately 2 minutes within hours of receiving the diphtheria–tetanus–acellular pertussis vaccine. He was taken to the emergency department for observation and discharged later that day. The patient has had no other seizures or medical concerns and takes no medications. His uncle has a history of childhood-onset epilepsy. Vital signs and physical examination are normal. The child is due for the fourth dose of the diphtheria–tetanus–acellular pertussis vaccine. Which of the following is the best next step in management of this patient?

Answers:

A. Administer the diphtheria and tetanus toxoids; avoid the pertussis component

Correct answer:

B. Administer the diphteria-tetanus-pertussis vaccine as scheduled

Your reply:

C. Administer only the tetanus toxoid at this time

D. Hold all immunizations containing diphteria, tetanus or pertussis components

E. Postexposure antibiotic prophylaxis

Explanation:

(Choices A and C). In addition, unstable neurologic disorders (eg, infantile spasms, uncontrolled epilepsy) and encephalopathy (ie, coma, decreased level of consciousness, prolonged seizures) within a week of DTaP vaccine administration are contraindications to the combination vaccine; as a result, diphtheria and tetanus toxoids should be administered without pertussis

Explanation

The diphtheria–tetanus–acellular pertussis (DTaP) vaccine is a combination vaccine containing acellular pertussis antigen with diphtheria and tetanus toxoids. Combination vaccines are safe, effective at preventing infection, and beneficial in reducing the number of needlesticks required (resulting in decreased pain and improved compliance). Children should receive 5 doses of the inactivated DTaP vaccine at ages 2, 4, and 6 months; 15-18 months; and 4-6 years.

The risk of an adverse reaction to the DTaP vaccine is low and generally includes minor erythema/swelling at the injection site and/or fever. Seizure, triggered by fever or by the pertussis vaccine component, is rare and is typically short (<5 minutes) and self-limited, as in this child. Patients with a family history of febrile seizures or epilepsy may be at increased risk. However, neither personal nor family history of seizures is a contraindication to immunization. Specifically, uncomplicated seizure following vaccine administration is not a contraindication to future vaccination. The benefit of DTaP vaccination, especially in the setting of a pertussis outbreak, outweighs the unlikely risk of significant side effects.

The DTaP vaccine is contraindicated in a few circumstances. When anaphylaxis develops following DTaP administration, the patient should not receive future doses (Choice D). In addition, unstable neurologic disorders (eg, infantile spasms, uncontrolled epilepsy) and encephalopathy (ie, coma, decreased level of consciousness, prolonged seizures) within a week of DTaP vaccine administration are contraindications to the combination vaccine; as a result, diphtheria and tetanus toxoids should be administered without pertussis

(Choice D).The DTaP vaccine is contraindicated in a few circumstances. When anaphylaxis develops following DTaP administration, the patient should not receive future doses . In addition, unstable neurologic disorders (eg, infantile spasms, uncontrolled epilepsy) and encephalopathy (ie, coma, decreased level of consciousness, prolonged seizures) within a week of DTaP vaccine administration are contraindications to the combination vaccine

(Choice E) Postexposure antibiotic prophylaxis is indicated for close contacts (eg, household, day care) of anyone with pertussis within the last 21 days. Because this child was exposed to pertussis 6 weeks ago, prophylactic antibiotics are no longer required.

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