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JAMA. 2000;284:2712.

MMWR. 2000;49:1029-1030

A temporary shortage of adult tetanus and diphtheria toxoids (Td) in the United States has resulted from two coincident situations: (1) a decrease in the number of lots released by Wyeth Lederle (Pearl River, New York), and (2) a temporary decrease in inventory of vaccine following routine maintenance activities at the production facilities by Aventis Pasteur (Swiftware, Pennsylvania) that lasted longer than anticipated. Approximately one half of the usual number of Td doses has been distributed this year. Although there have been no decreases in production of tetanus toxoid (TT), availability is low because of increased use during the Td shortage. On the basis of information provided by Aventis Pasteur, the Public Health Service expects vaccine supplies to be restored early in 2001. Until then, Aventis Pasteur will be limiting orders to assure the widest possible distribution of available doses.

The shortage will only impact persons aged 7 years who (1) require tetanus prophylaxis in wound management, (2) have not completed a primary series (three doses) of vaccine containing Td, or (3) have not been vaccinated during the preceding 10 years with Td, diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP) or diptheria and tetanus toxoids (DT).¹ This shortage will not affect vaccination of children aged <7 years who require additional doses of a vaccine-containing TT; they should receive DTaP or pediatric DT,² which are not in short supply. Td is preferred to TT because Td provides protection against both tetanus and diphtheria.¹ However, during this shortage, if Td is not available, TT can be used as an alternative for persons aged 7 years who require immediate boosting with TT (e.g., wound management), or who are unlikely to return to a clinic if vaccination is delayed. If TT is administered, patients and health-care providers must weigh risks and benefits of subsequent vaccination with Td. Arthus-type reactions may occur among persons who receive multiple doses of TT, especially within short intervals (<10 years). However, if vaccination with Td is delayed for >10 years following their last Td administration, persons may be protected inadequately against diphtheria.

Clinics experiencing shortages of Td may need to prioritize their use of available supplies. If administration of Td is delayed, clinics should implement a call-back system when vaccine is available. Recommendations for use (highest to lowest priority) of Td are:

1. Persons traveling to a country where the risk for diphtheria is high.*
   
2. Persons requiring tetanus vaccination for prophylaxis in wound management.
   
3. Persons who have received <3 doses of vaccine containing Td.
   
4. Pregnant women and persons at occupational risk for tetanus-prone injuries who have not been vaccinated with Td within the preceding 10 years.
   
5. Adolescents who have not been vaccinated with a vaccine containing Td within the preceding 10 years.
   
6. Adults who have not been vaccinated with Td within the preceding 10 years.
   

*Travelers to certain countries may be at substantial risk for exposure to toxigenic strains of C. diphtheriae, especially with prolonged travel, extensive contact with children, or exposure to poor hygiene. On the basis of surveillance data and consultation with the World Health Organization, countries with highest risk are in Africa (Algeria, Egypt, and sub-Saharan Africa); the Americas (Brazil, Dominican Republic, Ecuador, and Haiti); Asia/Oceania (Afghanistan, Bangladesh, Cambodia, China, India, Indonesia, Iran, Iraq, Laos, Mongolia, Myanmar, Nepal, Pakistan, Philippines, Syria, Thailand, Turkey, Vietnam, and Yemen); and Europe (Albania and all countries of the former Soviet Union).³

REFERENCES

1. Immunization Practices Advisory Committee. Diphtheria, tetanus, and pertussis: recommendations for vaccine use and other preventive measures—recommendations of the Immunization Practices Advisory Committee. MMWR. 1991;40(no. RR-10). 2. Advisory Committee on Immunization Practices. Pertussis vaccination: use of acellular pertussis vaccines among infants and young children—recommendations of the Advisory Committee on Immunization Practices. MMWR. 1997;46(no. RR-7). 3. CDC. Recall of Tripedia^TM Vaccine. MMWR. 1999;48:146-7. PUBMED

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