A Missed Opportunity: Could a Simple Vaccine Switch Curb Australia's Whooping Cough Surge?

Australia is in the grip of a major pertussis (whooping cough) resurgence. Queensland has reported 15,028 notifications in 2024, a sixteen-fold increase from 2023, and at least one infant death. National notifications have also risen sharply, potentially marking the largest pertussis epidemic on record.

Many cases occur in older children and adults, whose immunity from prior infection or vaccination wanes over time. These adults can experience mild illness but remain infectious, posing a risk to infants, who are most vulnerable to severe disease and death.

The Routine Practice in Emergency Departments

Emergency departments (EDs) are a critical point for administering tetanus boosters during wound management. The standard practice has been to use the dT/ADT vaccine, which protects against tetanus and diphtheria but not pertussis.

However, an alternative vaccine exists: dTpa. It offers equivalent protection against tetanus and diphtheria while also providing a booster for pertussis immunity for approximately four years. The administration process for dTpa is identical to dT/ADT.

A Persistent Gap in Practice

Despite national guidelines allowing and often recommending pertussis-containing vaccines for adults needing a tetanus booster, practice has not changed.

A national audit by the Immunisation Foundation of Australia found that over 85% of Australian hospitals still use dT/ADT as the routine adult tetanus booster.

In 2024, Queensland distributed 72,980 doses of dT/ADT to hospitals, representing thousands of missed opportunities to boost community protection against pertussis.

Emergency departments serve as a crucial point of contact for adult vaccination, especially for individuals without regular general practitioners. Local audits in Queensland EDs showed that over 93% of adult tetanus-containing vaccines were given in EDs, and all 3,603 boosters administered at those sites in 2024 were dT/ADT.

Adult pertussis vaccination coverage remains low, with only about 20.8% of people aged 50 and over up to date in 2023. Switching to dTpa in EDs could help close this immunity gap.

Addressing the Barriers to Change

Concerns about cost, supply, and patient acceptance are considered manageable.

• Cost: The price difference between dT/ADT and dTpa (around $6-11) is modest compared to the community economic burden of a pertussis infection ($473-909).
• Supply & Process: Both vaccines are already within hospital systems. A switch primarily involves updating pharmacy stocking, protocols, and electronic order sets, without needing extra staff or training.
• Acceptance: Studies indicate many patients accept opportunistic vaccination when offered as routine care.

Preliminary modeling suggests that replacing dT/ADT with dTpa could prevent thousands of pertussis cases and generate over $1 million in community savings over several years.

A Path Forward

Strategies to facilitate this shift include:

• Clear State/Territory guidance designating dTpa as the first-line vaccine for adult tetanus prophylaxis in ED wound care.
• Updated local protocols and electronic prompts to make dTpa the default choice.
• Ensuring reliable pharmacy supply of dTpa.
• Targeted education for clinicians.

Implementing this change is an organizational decision that could provide significant public health benefits by ensuring the care already provided delivers broader protection against pertussis.