What are the indications for tetanus toxoid (tetanus vaccine) administration in wound management?

From the Guidelines

Tetanus toxoid administration is indicated in wound management for individuals with unknown or incomplete tetanus vaccination history, or if the last tetanus toxoid-containing vaccine dose was more than 5 years ago for contaminated wounds or more than 10 years ago for clean and minor wounds 1.

Key Indications

• Unknown or <3 doses of tetanus toxoid-containing vaccines: Yes, administer tetanus toxoid and tetanus immune globulin (TIG) for all wounds
• ≥3 doses of tetanus toxoid-containing vaccines:
  • Clean and minor wound: No tetanus toxoid or TIG needed if last dose was within 10 years
  • All other wounds: No tetanus toxoid or TIG needed if last dose was within 5 years

Special Considerations

• Pregnant women: Tdap is preferred if a tetanus toxoid-containing vaccine is indicated
• Persons with HIV infection or severe immunodeficiency: TIG should be administered regardless of tetanus immunization history for contaminated wounds
• History of Arthus reaction: Do not administer tetanus toxoid-containing vaccine until >10 years after the most recent dose

Vaccine Administration

• Tdap: Preferred for persons aged ≥11 years who have not previously received Tdap
• Td: Used if Tdap is unavailable or for nonpregnant persons with documentation of previous vaccination with Tdap
• TIG: Administered using separate syringes at different anatomical sites when both TIG and a tetanus toxoid-containing vaccine are indicated 1.

From the FDA Drug Label

Available evidence indicates that complete primary vaccination with tetanus toxoid provides long lasting protection ≥10 years for most recipients. Consequently, after complete primary tetanus vaccination, boosters-even for wound management-need be given only every 10 years when wounds are minor and uncontaminated For other wounds, a booster is appropriate if the patient has not received tetanus toxoid within the preceding 5 years.

The indications for tetanus toxoid administration in wound management are:

• Minor and uncontaminated wounds: booster every 10 years
• Other wounds: booster if the patient has not received tetanus toxoid within the preceding 5 years This is based on the principle that complete primary vaccination with tetanus toxoid provides long-lasting protection for most recipients 2.

From the Research

Indications for Tetanus Toxoid Administration

The indications for tetanus toxoid administration in wound management are as follows:

• Tetanus toxoid is recommended for adults only if it has been more than 10 years since their last immunization 3
• There is no urgency for the administration of tetanus toxoid in the acute setting, as it provides protection against the next injury and not the current injury 3
• Tetanus-diphtheria toxoid is not required unless there are plans for the injured patient to travel to diphtheria-prone countries in the future 3
• Tetanus immunoglobulin should be reserved for patients with wounds who had never received primary immunization against tetanus 3

Wound Management and Tetanus Prophylaxis

• Cleansing and debridement is paramount in dealing with tetanus-prone wounds, and prophylaxis is relatively easy in persons who have been actively immunized by toxoid injections 4
• A "booster" injection is indicated for individuals who have been actively immunized by toxoid injections 4
• The use of antitoxin is hazardous, and decision to use it must be weighed against the possibility of the development of tetanus in each case 4
• Experimental evidence suggests that antibiotics of the tetracycline group, given soon after injury, may have prophylactic effect against tetanus 4

Tetanus Vaccinations and Pharmacy-Driven Education

• Current recommendations from the Centers for Disease Control and Prevention (CDC) and Advisory Committee on Immunization Practices (ACIP) regarding tetanus administration for wound prophylaxis differentiate between the tetanus and diphtheria (Td) and the tetanus, diphtheria, acellular pertussis (Tdap) formulations and when they should be administered 5
• Pharmacy-driven education can decrease the percentage of duplicate and inappropriate tetanus vaccinations administered in a level I trauma center ED 5
• Multiple formulations of tetanus vaccinations and fragmented documentation of immunizations increase the prevalence of medication errors related to tetanus vaccinations 5

Optimal Tetanus Prophylaxis Procedures

• The introduction of comprehensive infant vaccination programmes dramatically reduced the incidence of tetanus in the UK 6
• To achieve comprehensive protection against tetanus, the World Health Organization guidelines recommend the administration of the five-dose childhood immunisation regimen and an additional sixth dose, after approximately 10 years, to ensure long-lasting immunity 6
• Tetanus prophylaxis with human tetanus immunoglobulin is considered essential for incompletely immunised individuals presenting with dirty wounds 6
• The use of a new rapid, point-of-care immunoassay to assess tetanus immune status may facilitate the optimal management of patients with wounds 6