Technically Speaking: History of Fever ≥ 105 Degrees, Inconsolable Crying, and Hypotonic Episode Following a Previous DTaP Dose Are No Longer Precautions According to ACIP

On April 27, 2018, CDC published "Prevention of Pertussis, Tetanus, and Diphtheria with Vaccines in the United States: Recommendations of the Advisory Committee on Immunization Practices (ACIP)." This 44-page guidance document compiled and summarized all previously published ACIP recommendations for the use of DTaP, DT, Tdap, and Td vaccines. It replaces all previously published MMWR reports and policy notes regarding these vaccines.

While there were no major additions to the vaccine recommendations, some noteworthy changes were made to the precautions listed in the new guidance. The following items, formerly listed as precautions in earlier recommendations, are no longer included in Table 2: Contraindications and precautions for DTaP, Tdap, DT, and Td vaccines found on page 3.

• Temperature of ≥ 105°F (≥ 40.5°C) within 48 hours after vaccination with a previous dose of DTP or DTaP
• Collapse or shock-like state (i.e., hypotonic hyporesponsive episode) within 48 hours after receiving a previous dose of DTP/DTaP
• Seizure ≤ 3 days after receiving a previous dose of DTP/DTaP
• Persistent, inconsolable crying lasting ≥ 3 hours within 48 hours after receiving a previous dose of DTP/DTaP

The precautions that existed previously and that remain in the updated guidance are the following:

• Progressive or unstable neurologic disorder, including infantile spasms, uncontrolled seizures, or  progressive encephalopathy; defer DTaP until neurologic status clarified and stabilized
• Guillain-Barré syndrome < 6 weeks after previous dose of tetanus toxoid-containing vaccine
• History of Arthus-type hypersensitivity reactions after a previous dose of diphtheria toxoid-containing or tetanus toxoid-containing vaccine; defer vaccination until at least 10 years have elapsed since the last tetanus toxoid-containing vaccine
• Moderate or severe acute illness with or without fever

As of this writing (June 15, 2018), CDC has not yet updated its online "General Best Practice Guidelines for Immunization: Best Practices Guidance of the ACIP," which includes information about vaccine contraindications and precautions, but I have been informed by CDC it will be updated soon.