What should be done for a 32-year-old who sustained a puncture wound from a rusty nail and is unsure of their last Tdap (Tetanus, diphtheria, and pertussis) vaccination?

From the Guidelines

For a 32-year-old with a rusty nail injury and uncertain Tdap vaccination status, they should receive a Tdap booster immediately, as the wound is considered contaminated and the patient's vaccination history is uncertain, according to the guidelines outlined in 1. The recommended approach is to administer a Tdap (tetanus, diphtheria, and acellular pertussis) vaccine dose as soon as possible, ideally within 72 hours of the injury. If the patient has not received a primary series of tetanus vaccination or the history is unknown, they should be considered as not having previous tetanus toxoid–containing vaccine, as stated in 1. Additionally, tetanus immune globulin (TIG) may also be given at a dose of 250 units intramuscularly at a different site from the vaccine, as indicated in 1, for immediate passive immunity. The decision to administer TIG should be based on the primary vaccination history for tetanus, as outlined in Table 6 of 1. Even if the patient received a tetanus-containing vaccine previously, a booster is recommended if it has been more than 5 years since their last dose for a contaminated wound, as suggested in 1 and further supported by the general guidelines for adults in 1. This immediate intervention is crucial because Clostridium tetani spores, which may be present on rusty objects, can enter the body through wounds and produce a neurotoxin causing potentially fatal muscle spasms. The tetanus component of the vaccine stimulates antibody production against this toxin, while TIG provides immediate passive immunity. Key considerations include:

• The type of wound: rusty nail injuries are considered contaminated and thus require immediate attention to prevent tetanus infection.
• The patient's vaccination history: uncertainty or lack of history necessitates treatment as if the patient has never been vaccinated.
• The use of TIG: for immediate protection in cases where the vaccine may not provide sufficient immunity quickly enough.
• Completion of the primary vaccination series: if the patient has never been fully vaccinated against tetanus, diphtheria, or pertussis, they should complete the series as recommended by 1 and 1.

From the FDA Drug Label

Adults with uncertain histories of a complete primary vaccination series should receive a primary series using the combined Td toxoid. To ensure continued protection, booster doses of Td should be given every 10 years. For other wounds, a booster is appropriate if the patient has not received tetanus toxoid within the preceding 5 years.

The patient is a 32-year-old with a rusty nail puncture wound and an uncertain history of last TDAP.

• The patient should receive a Td booster if it has been more than 5 years since the last tetanus toxoid-containing vaccine dose.
• Additionally, the patient's wound should receive proper initial wound care as the use of antitoxin is adjunctive to this procedure.
• If the patient has not completed a primary series of tetanus toxoid immunization, further toxoid injections may be necessary to complete the series 2.

From the Research

TDAP Shot Administration

• A 32-year-old individual who was poked by a rusty nail and is unsure of their last TDAP shot should consider getting a booster shot, as the risk of tetanus infection is high in such cases 3.
• The Advisory Committee on Immunization Practices (ACIP) recommends that adults aged 18-64 years receive a single dose of Tdap vaccine to replace a single decennial dose of tetanus diphtheria (Td) vaccine, even if it has been less than 10 years since their last tetanus vaccination 3.

Safety and Immunogenicity of Tdap Vaccine

• Studies have shown that administering a second dose of Tdap vaccine to adults approximately 10 years after a previous dose is well-tolerated and immunogenic 4.
• The safety of immunizing with Tdap vaccine less than 2 years following previous tetanus vaccination has been assessed, and the results indicate that it is safe to administer Tdap vaccine at an interval of less than 2 years in healthcare personnel 5.
• A randomized, double-blind, non-inferiority clinical trial found that a tetanus, diphtheria, and monocomponent acellular pertussis (TdaP) vaccine was safe and immunogenic when given as a booster vaccination to healthy adults 6.

Administration Guidelines

• Healthcare providers should recommend Tdap vaccination to adults aged 18-64 years whose most recent tetanus vaccination was ≥10 years prior; the interval for healthcare personnel and persons with infant contact can be as short as 2 years 3.
• In cases where an individual is unsure of their last TDAP shot, it is recommended to administer a booster shot to ensure protection against tetanus, diphtheria, and pertussis 3, 4, 5.