What are the tetanus (Tetanus Toxoid) vaccine recommendations after stepping on an object?

Tetanus Prophylaxis After Stepping on an Object

For tetanus prophylaxis after stepping on an object, administer tetanus toxoid-containing vaccine (Td or Tdap) if it has been more than 5 years since the last dose for dirty wounds, or more than 10 years for clean minor wounds, and consider tetanus immunoglobulin (TIG) for contaminated wounds in patients with unknown or incomplete vaccination history. 1

Assessment of Wound and Vaccination Status

When evaluating a patient who has stepped on an object, consider:

1. Wound characteristics:

   • Clean, minor wound vs. contaminated wound
   • Contaminated wounds include those with dirt, feces, soil, saliva, puncture wounds, avulsions, and wounds from crushing, burns, or frostbite 1

2. Vaccination history:

   • Complete primary series (≥3 doses of tetanus toxoid)
   • Incomplete or unknown vaccination history
   • Time since last tetanus vaccination

Tetanus Prophylaxis Recommendations

For patients with complete primary vaccination series (≥3 doses):

• Clean, minor wounds:

  • Td or Tdap if >10 years since last tetanus vaccination 1
  • No TIG needed

• All other wounds (contaminated):

  • Td or Tdap if >5 years since last tetanus vaccination 1
  • No TIG needed

For patients with incomplete or unknown vaccination history (<3 doses):

• Clean, minor wounds:

  • Td or Tdap
  • No TIG needed

• All other wounds (contaminated):

  • Td or Tdap AND
  • TIG 250 units intramuscularly 1, 2

Administration Guidelines

• When both TIG and tetanus toxoid-containing vaccine are indicated:

  • Administer using separate syringes at different anatomical sites 1
  • Standard prophylactic dose of TIG is 250 units IM as a single dose 2

• Choice of tetanus toxoid-containing vaccine:

  • For persons ≥11 years: Tdap preferred if not previously received 1
  • For children 7-10 years: Td
  • For children <7 years: DTaP

Important Considerations

• Thorough wound cleaning is critical for tetanus prevention, with gentle irrigation using water or diluted iodopovidone solution 1

• Tetanus vaccination after injury provides protection against future tetanus exposures, not the current injury 3

• The single injection of tetanus toxoid only initiates the series for producing active immunity in patients who have never been vaccinated. The physician must emphasize the need for further toxoid injections at 1 month and 1 year to complete the primary series 2

Contraindications and Precautions

Contraindications:

• Severe allergic reaction (anaphylaxis) to previous dose or vaccine component 4
• History of encephalopathy within 7 days of previous pertussis vaccination (contraindication for pertussis component only; use Td instead of Tdap) 4

Precautions:

• Guillain-Barré syndrome <6 weeks after previous tetanus toxoid-containing vaccine 4
• Progressive or unstable neurologic disorder (precaution for pertussis components) 4
• History of Arthus-type hypersensitivity reactions after previous tetanus toxoid-containing vaccine (defer for at least 10 years) 4
• Moderate or severe acute illness with or without fever (defer until resolved) 4

Special Populations

• Immunocompromised patients: Should receive TIG for contaminated wounds regardless of tetanus immunization history 1

• Pregnant women: Tdap is recommended if tetanus prophylaxis is indicated, with one dose during each pregnancy (preferably between 27-36 weeks) 1

Remember that tetanus is a potentially fatal disease with a case-fatality rate of approximately 25%, highlighting the importance of appropriate prophylaxis 1. Early and appropriate tetanus prophylaxis is essential for preventing this serious condition.