Should an 18-year-old with a burn and prior Tetanus, diphtheria, and pertussis (Tdap) vaccination receive a Tetanus and diphtheria (Td) booster or repeated Tdap?

Tetanus Prophylaxis for an 18-Year-Old with a Burn and Prior Tdap History

For an 18-year-old with a burn who has previously received Tdap vaccination, Tdap should be administered instead of Td if it has been more than 5 years since the previous Tdap dose. 1

Decision Algorithm for Tetanus Prophylaxis in Burn Wounds

Step 1: Determine Time Since Last Tetanus-Containing Vaccine

• If the previous Tdap was administered more than 5 years ago: Administer Tdap
• If the previous Tdap was administered less than 5 years ago: No tetanus-containing vaccine needed as protection is still adequate

Step 2: Assess Wound Characteristics

• For clean, minor wounds: Follow Step 1 guidance
• For wounds that are contaminated, deep, or at higher risk for tetanus (puncture wounds, burns, crush injuries):
  • If primary tetanus vaccination series is complete and last dose was <5 years ago: No tetanus toxoid needed
  • If primary series is complete but last dose was ≥5 years ago: Administer Tdap (if not previously given) or Td
  • If primary series is incomplete or unknown: Administer Tdap AND tetanus immune globulin (TIG)

Evidence-Based Rationale

The American Academy of Pediatrics and the Advisory Committee on Immunization Practices (ACIP) specifically recommend that adolescents who require tetanus toxoid vaccine as part of wound management should receive Tdap instead of Td if they have not previously received Tdap. 1

The guidelines state: "Adolescents 11 to 18 years of age who require tetanus toxoid vaccine as part of wound management should receive a single dose of Tdap instead of Td if they have not previously received Tdap." 1

For cases where Tdap was previously administered but more than 5 years ago, the guidelines recommend: "If Tdap is not available or if Tdap was administered more than 5 years previously, adolescents who need a tetanus toxoid vaccine as part of wound management should receive Td vaccine." 1

Important Considerations

• Wound assessment is critical: Burns are considered higher-risk wounds for tetanus infection, requiring careful evaluation of tetanus prophylaxis needs.
• Verify vaccination history: A thorough attempt must be made to determine if the patient has completed the 3-dose primary tetanus vaccination series. Persons with unknown or uncertain histories should be considered to have had no previous doses. 1
• Separate administration sites: If both tetanus immune globulin and a tetanus toxoid-containing vaccine are indicated, administer each using a separate syringe at different anatomic sites. 1

Special Situations

• If the patient has a history of an Arthus reaction (severe local reaction) after a previous tetanus toxoid-containing vaccine, avoid administering any tetanus toxoid-containing vaccine until >10 years after the most recent dose. 1
• If the patient is pregnant, Tdap is still recommended and is not contraindicated. 1

Safety of Repeat Tdap Administration

Research has demonstrated that administering Tdap to individuals who previously received Tdap is safe. A study of 61,394 subjects who received repeated Tdap doses showed no significantly elevated risk of adverse events compared to those who received Td after a prior Tdap dose. 2

By following these evidence-based guidelines, you can ensure appropriate tetanus prophylaxis for this 18-year-old patient with a burn injury while also providing protection against pertussis.