Diphtheria, Tetanus Toxoids, Acellular Pertussis, Hepatitis B (Recombinant), and Poliovirus (Inactivated) Vaccine
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- Acellular pertussis
- Diphtheria and Tetanus Toxoids and Acellular Pertussis Adsorbed, Hepatitis B (Recombinant) and Inactivated Poliovirus Vaccine Combined
- Diphtheria, Tetanus Toxoids, Acellular Pertussis, Hepatitis B (Recombinant), and Poliovirus (Inactivated) Vaccine
- Diphtheria, Tetanus Toxoids, Acellular Pertussis, Hepatitis B (Recombinant), and Poliovirus Vaccine
- Hepatitis B
Excipient information presented when available (limited, particularly for generics); consult specific product labeling.
Injection, suspension [preservative free]:
Pediarix: Diphtheria toxoid 25 Lf, tetanus toxoid 10 Lf, acellular pertussis antigens [inactivated pertussis toxin 25 mcg, filamentous hemagglutinin 25 mcg, pertactin 8 mcg, HBsAg 10 mcg, type 1 poliovirus 40 D antigen units, type 2 poliovirus 8 D antigen units and type 3 poliovirus 32 D antigen units] per 0.5 mL (0.5 mL) [contains aluminum, neomycin sulfate (trace amounts), polymyxin B (trace amounts), polysorbate 80, and yeast protein ≤5%; may contain natural rubber/natural latex in prefilled syringe]
Brand Names: U.S.
- Vaccine, Inactivated (Bacterial)
- Vaccine, Inactivated (Viral)
Promotes active immunity to diphtheria, tetanus, pertussis, hepatitis B and poliovirus (types 1, 2 and 3) by inducing production of specific antibodies and antitoxins.
Onset of Action
Immune response observed to all components 1 month following the 3-dose series.
Use: Labeled Indications
Diphtheria, tetanus, pertussis, poliomyelitis, and hepatitis B prevention: Active immunization against diphtheria, tetanus, pertussis, hepatitis B virus (all known subtypes), and poliomyelitis in infants born of HBsAg-negative mothers, beginning as early as 6 weeks of age through 6 years of age (prior to the seventh birthday).
The Advisory Committee on Immunization Practices (ACIP) recommends Pediarix for the following (CDC 52 2003):
- Primary vaccination for DTaP, Hep B, and IPV in children at 2, 4, and 6 months of age.
- To complete the primary vaccination series in children who have received DTaP (Infanrix) and who are scheduled to receive the other components of the vaccine. Whenever feasible, the same manufacturer should be used to provide the pertussis component; however, vaccination should not be deferred if a specific brand is not known or is not available. HepB and IPV from different manufacturers are interchangeable.
Hypersensitivity to diphtheria and tetanus toxoids, pertussis, hepatitis B, poliovirus vaccine, or any component of the vaccine; encephalopathy occurring within 7 days of a previous pertussis vaccine (not attributable to another identifiable cause); progressive neurologic disorders (including infantile spasms, uncontrolled epilepsy, or progressive encephalopathy)
Primary immunization: Infants and Children 6 weeks to <7 years: IM: 0.5 mL/dose; administer as a 3-dose series at 2-, 4-, and 6 months of age in 6- to 8-week intervals (preferably 8-week intervals). Vaccination usually begins at 2 months, but may be started as early as 6 weeks of age.
Note: Pediarix is approved for the first 3 doses of polio vaccine. Per the ACIP, polio vaccine is given at 2, 4 and 6 to 18 months of age. The minimum age and minimum intervals during the first 6 months of life should only be used when the vaccine recipient is at risk for imminent exposure to circulating poliovirus (shorter intervals and earlier start dates may lead to lower seroconversion) (CDC 58 2009).
Use in infants and children previously vaccinated with one or more component, and who are also scheduled to receive all vaccine components:
Infants previously vaccinated with hepatitis B vaccine: Infants previously vaccinated with 1 or 2 doses of another hepatitis B vaccine may use Pediarix to complete the 3-dose series. Not for use as birth dose of hepatitis B vaccine. Infants born to HBsAg-positive women should begin dosing with DTaP-HepB-IPV at age 1 or 2 months (minimum age: 6 weeks) after receiving the single antigen hepatitis B vaccine at birth (ACIP [Robinson 2017]).
Infants previously vaccinated with diphtheria and tetanus toxoids, and acellular pertussis vaccine (DTaP): Infants previously vaccinated with 1 or 2 doses of Infanrix may use Pediarix to complete the first 3 doses of the series; use of Pediarix to complete DTaP vaccination started with products other than Infanrix has not been studied.
Infants previously vaccinated with inactivated polio vaccine (IPV): Infants previously vaccinated with 1 or 2 doses of IPV may use Pediarix to complete the first 3 doses of the series.
Dosing: Renal Impairment
There are no dosage adjustment provided in the manufacturer's labeling.
Dosing: Hepatic Impairment
There are no dosage adjustment provided in the manufacturer’s labeling.
IM: For IM use only; do not administer IV, SubQ, or intradermally. Shake well prior to use; do not use unless a homogeneous, turbid, white suspension forms. Administer in the anterolateral aspects of the thigh or the deltoid muscle of the upper arm. Do not inject in the gluteal area (suboptimal hepatitis B immune response) or where there may be a major nerve trunk. Do not mix with other vaccines or injections; separate needles and syringes should be used for each injection (ACIP [Kroger 2017]). US law requires that the date of administration, the vaccine manufacturer, lot number of vaccine, and the administering person's name, title, and address be entered into the patient's permanent medical record.
For patients at risk of hemorrhage following intramuscular injection, the vaccine should be administered intramuscularly if, in the opinion of the physician familiar with the patient's bleeding risk, the vaccine can be administered by this route with reasonable safety. If the patient receives antihemophilia or other similar therapy, intramuscular vaccination can be scheduled shortly after such therapy is administered. A fine needle (23 gauge or smaller) can be used for the vaccination and firm pressure applied to the site (without rubbing) for at least 2 minutes. The patient should be instructed concerning the risk of hematoma from the injection. Patients on anticoagulant therapy should be considered to have the same bleeding risks and treated as those with clotting factor disorders (ACIP [Kroger 2017]).
Store under refrigeration at 2°C to 8°C (36°F to 46°F); do not freeze. Discard if frozen. The following stability information has also been reported for Pediarix: May be stored at room temperature for up to 24 hours (Cohen 2007).
Belimumab: May diminish the therapeutic effect of Vaccines (Inactivated). Management: Patients should receive inactivated vaccines prior to initiation of belimumab therapy whenever possible, due to the risk for an impaired response to the vaccine during belimumab therapy. Consider therapy modification
Fingolimod: May diminish the therapeutic effect of Vaccines (Inactivated). Management: Vaccine efficacy may be reduced. Complete all age-appropriate vaccinations at least 2 weeks prior to starting fingolimod. If vaccinated during fingolimod therapy, revaccinate 2 to 3 months after fingolimod discontinuation. Consider therapy modification
Immunosuppressants: May diminish the therapeutic effect of Vaccines (Inactivated). Management: Vaccine efficacy may be reduced. Complete all age-appropriate vaccinations at least 2 weeks prior to starting an immunosuppressant. If vaccinated during immunosuppressant therapy, revaccinate at least 3 months after immunosuppressant discontinuation. Exceptions: Cytarabine (Liposomal). Consider therapy modification
Meningococcal Polysaccharide (Groups A / C / Y and W-135) Tetanus Toxoid Conjugate Vaccine: May diminish the therapeutic effect of Tetanus Toxoids Vaccines. Management: When possible, administer the meningococcal polysaccharide (groups A / C / Y and W-135) tetanus toxoid conjugate vaccine either together with or at least one month before a tetanus toxoids-containing vaccine. Consider therapy modification
Venetoclax: May diminish the therapeutic effect of Vaccines (Inactivated). Monitor therapy
Adverse events reported within 4 days of vaccination at 2-, 4-, and 6 months of age in patients given Pediarix concomitantly with Hib conjugate vaccine and PCV7 vaccine.
Central nervous system: Irritability (≤61% to 65%; grade 3: ≤3% to 4%), drowsiness (41% to 57%)
Gastrointestinal: Anorexia (26% to 31%; grade 3: <1%)
Local: Erythema at injection site (25% to 40%; >20 mm: 1% to 3%), pain at injection site (31% to 36%; grade 3: 2% to 3%), swelling at injection site (17% to 29%; >20 mm: 2% to 3%)
Miscellaneous: Fussiness (≤61% to 65%; grade 3: ≤3% to 4%), fever (≥100.4°F: 28% to 39%; >103.1°F: ≤1%)
<1% (Limited to important or life-threatening): Abnormal hepatic function tests, anaphylactoid reaction, anaphylaxis, angioedema, apnea, arthus phenomenon, bulging fontanel, cough, cranial nerve dysfunction (cranial mononeuropathy), crying, cyanosis, demyelinating disease, diarrhea, dyspnea, encephalitis, erythema, fatigue, febrile seizures, Guillain-Barré syndrome, hypersensitivity reaction, hypotonia, hypotonic/hyporesponsive episode, impaired consciousness, injection site reaction (cellulitis at injection site, induration at injection site, injection site nodule, injection site pruritus, injection site vesicle, warm sensation at injection site), insomnia, lethargy, limb pain, nervousness, neuritis (brachial), pallor, peripheral neuropathy (mononeuropathy), petechia, restlessness, screaming, seizure, skin rash, sudden infant death syndrome, swelling of extremities, upper respiratory tract infection, urticaria, vomiting
Concerns related to adverse effects:
• Anaphylactoid/hypersensitivity reactions: Immediate treatment (including epinephrine 1 mg/mL) for anaphylactoid and/or hypersensitivity reactions should be available during vaccine use (ACIP [Kroger 2017]).
• Arthus-type hypersensitivity: Patients with a history of severe local reaction (Arthus-type) following a previous diphtheria toxoid or tetanus toxoid-containing vaccine dose should not be given further routine or emergency doses of Td more frequently than every 10 years, even if using for wound management with wounds that are not clean or minor; these patients generally have high serum antitoxin levels (ACIP [Kroger 2017]).
• Fever: The use of Pediarix combination vaccine is associated with higher rates of fever in comparison to the separate administration of individual components. Per the manufacturer, antipyretic prophylaxis may be considered for patients at high risk for seizures. However, antipyretics have not been shown to prevent febrile seizures; antipyretics may be used to treat fever or discomfort following vaccination (ACIP [Kroger 2017]). One study reported that routine prophylactic administration of acetaminophen to prevent fever prior to vaccination decreased the immune response of some vaccines; the clinical significance of this reduction in immune response has not been established (Prymula 2009).
• Reactions from previous pertussis vaccine: Carefully consider use in patients with history of any of the following effects from previous administration of a pertussis-containing vaccine: Fever ≥105°F (40.5°C) within 48 hours of unknown cause; seizures with or without fever occurring within 3 days; persistent, inconsolable crying episodes lasting ≥3 hours and occurring within 48 hours; collapse or shock-like state (hypotonic-hyporesponsive episode) occurring within 48 hours (ACIP [Kroger 2017]).
• Syncope: Syncope has been reported with use of injectable vaccines and may result in serious secondary injury (eg, skull fracture, cerebral hemorrhage); typically reported in adolescents and young adults and within 15 minutes after vaccination. Procedures should be in place to avoid injuries from falling and to restore cerebral perfusion if syncope occurs (ACIP [Kroger 2017]).
• Acute illness: The decision to administer or delay vaccination because of current or recent febrile illness depends on the severity of symptoms and the etiology of the disease. Defer administration in patients with moderate or severe acute illness (with or without fever); vaccination should not be delayed for patients with mild acute illness (with or without fever) (ACIP [Kroger 2017]).
• Bleeding disorders: Use with caution in patients with bleeding disorders (including thrombocytopenia); bleeding/hematoma may occur from IM administration; if the patient receives antihemophilia or other similar therapy, IM injection can be scheduled shortly after such therapy is administered (ACIP [Kroger 2017]).
• Guillain-Barré syndrome: Use with caution if Guillain-Barré syndrome occurred within 6 weeks of prior tetanus toxoid-containing vaccine (ACIP [Kroger 2017]).
• Neurologic disorders: According to the manufacturer, use is contraindicated in patients with, progressive neurologic diseaseincluding infantile spasms, uncontrolled seizure, or a progressive encephalopathy. ACIP guidelines recommend deferring immunization until health status can be assessed and condition stabilized (ACIP [Kroger 2017]).
Concurrent drug therapy issues:
• Anticoagulant therapy: Use with caution in patients receiving anticoagulant therapy; bleeding/hematoma may occur from IM administration (ACIP [Kroger 2017]).
• Vaccines: In order to maximize vaccination rates, the ACIP recommends simultaneous administration (ie, >1 vaccine on the same day at different anatomic sites) of all age-appropriate vaccines (live or inactivated) for which a person is eligible at a single clinic visit, unless contraindications exist. The use of combination vaccines is generally preferred over separate injections, taking into consideration provider assessment, patient preference, and adverse events. When using combination vaccines, the minimum age for administration is the oldest minimum age for any individual component; the minimum interval between dosing is the greatest minimum interval between any individual components. The ACIP prefers each dose of a specific vaccine in a series come from the same manufacturer when possible; however, vaccination should not be deferred because a specific brand name is unavailable (ACIP [Kroger 2017]).
• Altered immunocompetence: Consider deferring immunization during periods of severe immunosuppression (eg, patients receiving chemo/radiation therapy or other immunosuppressive therapy [including high-dose corticosteroids]); may have a reduced response to vaccination. In general, household and close contacts of persons with altered immunocompetence may receive all age appropriate vaccines. Inactivated vaccines should be administered ≥2 weeks prior to planned immunosuppression when feasible; inactivated vaccines administered during chemotherapy should be readministered after immune competence is regained (ACIP [Kroger 2017]; (IDSA [Rubin 2014]).
• Pediatric: Infants born of HBsAg-positive mothers should receive monovalent hepatitis B vaccine and hepatitis B immune globulin; infants born of HBsAg-unknown mothers should receive monovalent hepatitis B vaccine; use of combination product in these patients to complete the hepatitis B vaccination series is limited but is considered acceptable by the ACIP. Apnea has been reported following IM vaccine administration in premature infants; consider clinical status implications. In general, preterm infants should be vaccinated at the same chronological age as full-term infants (ACIP [Kroger 2017]).
Dosage form specific issues:
• Aluminum: Product may contain aluminum.
• Latex: Packaging may contain natural latex rubber.
• Neomycin: Product may contain neomycin.
• Polymyxin B: Product may contain polymyxin B.
• Polysorbate 80: Product may contain polysorbate 80. Some dosage forms may contain polysorbate 80 (also known as Tweens). Hypersensitivity reactions, usually a delayed reaction, have been reported following exposure to pharmaceutical products containing polysorbate 80 in certain individuals (Isaksson 2002; Lucente 2000; Shelley 1995). Thrombocytopenia, ascites, pulmonary deterioration, and renal and hepatic failure have been reported in premature neonates after receiving parenteral products containing polysorbate 80 (Alade 1986; CDC 1984). See manufacturer’s labeling.
• Yeast protein: Product may contain yeast protein.
• Booster dose: Not approved for the fourth dose of the IPV series or the fourth and fifth doses of the DTaP series.
• Effective immunity: Vaccination may not result in effective immunity in all patients. Response depends upon multiple factors (eg, type of vaccine, age of patient) and may be improved by administering the vaccine at the recommended dose, route, and interval. Vaccines may not be effective if administered during periods of altered immune competence (ACIP [Kroger 2017]).
Monitor for syncope for 15 minutes following administration (ACIP [Kroger 2017]). If seizure-like activity associated with syncope occurs, maintain patient in supine or Trendelenburg position to reestablish adequate cerebral perfusion.
Pregnancy Risk Factor
Reproduction studies have not been conducted; not indicated for women of childbearing age.
• Discuss specific use of vaccine and side effects with patient as it relates to treatment. (HCAHPS: During this hospital stay, were you given any medicine that you had not taken before? Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? How often did hospital staff describe possible side effects in a way you could understand?)
• Patient may experience fatigue, irritability, lack of appetite, or injection site pain or irritation. Have caregiver report immediately to prescriber severe dizziness, passing out, vision changes, burning or numbness feeling, abnormal movements, or abnormal crying (children) (HCAHPS).
• Educate patient about signs of a significant reaction (eg, wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat). Note: This is not a comprehensive list of all side effects. Patient should consult prescriber for additional questions.
Intended Use and Disclaimer: Should not be printed and given to patients. This information is intended to serve as a concise initial reference for healthcare professionals to use when discussing medications with a patient. You must ultimately rely on your own discretion, experience and judgment in diagnosing, treating and advising patients.
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