What are the guidelines for tetanus (Td) injection and booster doses?

Tetanus Vaccination Guidelines

Tetanus vaccination requires a primary series of three doses followed by booster doses every 10 years throughout life, with special considerations for wound management based on wound type and vaccination history.

Primary Vaccination Series

• Adults (≥19 years) who have never been vaccinated against tetanus:

  • 1 dose of Tdap (preferred as first dose)
  • 1 dose of either Td or Tdap ≥4 weeks later
  • 1 dose of either Td or Tdap 6-12 months after second dose 1

• Children and adolescents (7-18 years) who are not fully immunized:

  • 1 dose of Tdap (preferred as first dose in catch-up series)
  • Additional doses with either Td or Tdap to complete the 3-dose series 1
  • The vaccination series does not need to be restarted regardless of time elapsed between doses 2

Booster Doses

• Routine booster doses:

  • Every 10 years throughout life with either Td or Tdap 1, 2
  • For adults who have completed primary vaccination, a booster is recommended when ≥10 years have elapsed since the last dose 1

• Special populations:

  • Pregnant women: One dose of Tdap during each pregnancy at 27-36 weeks gestation, regardless of prior vaccination history 2
  • Healthcare workers: Should receive Tdap if they have not previously received it, regardless of time since last tetanus-containing vaccine 1, 3

Wound Management

• For clean, minor wounds:

  • No tetanus prophylaxis needed if patient has received ≥3 doses of tetanus toxoid and last dose was within 10 years 4
  • For patients with unknown/uncertain history or <3 doses: Td or Tdap vaccination 4

• For contaminated or tetanus-prone wounds (puncture wounds, wounds contaminated with dirt/soil/saliva, avulsions, crush injuries, burns):

  • If patient has received ≥3 doses of tetanus toxoid but last dose was >5 years ago: Td or Tdap booster 1, 4
  • For patients with unknown/uncertain history or <3 doses: Td or Tdap vaccination AND Tetanus Immune Globulin (TIG) 250 units IM 1, 4

Important Considerations

• Military service since 1941 can be considered evidence of at least one dose of tetanus toxoid, but complete primary series cannot be assumed 4

• Persons with unknown or uncertain vaccination histories should be considered to have had no previous tetanus toxoid doses 1

• When both TIG and tetanus toxoid are given concurrently, they should be administered at separate sites with separate syringes 1, 4

• There is no urgency for tetanus toxoid administration in acute settings as it provides protection against future injuries, not the current one 5

• Clinical decision support systems can reduce unnecessary tetanus vaccinations in emergency departments by alerting providers when patients have received tetanus vaccination within the past 10 years 6

Safety of Shortened Intervals

• A study found that Tdap can be safely administered at intervals of ≥18 months since a previous tetanus-diphtheria vaccine, with only slight increases in injection site reactions 7

• Another study demonstrated that a repeat dose of Tdap vaccine 10 years after the first dose was well-tolerated and immunogenic in adults 8

Common Pitfalls to Avoid

1. Overuse of tetanus vaccination in emergency settings: Studies show that up to 22.1% of patients receiving tetanus vaccines in emergency departments had prior vaccination within 5 years 6

2. Failing to identify patients who need primary series completion: Always attempt to determine whether a patient has completed primary vaccination rather than simply providing a booster 1

3. Missing opportunities to vaccinate pregnant women: Each pregnancy requires Tdap vaccination regardless of prior history 2

4. Neglecting to provide TIG for high-risk wounds in patients with uncertain vaccination history: TIG is critical for preventing tetanus in contaminated wounds when vaccination history is unknown 1, 4