Tetanus Prophylaxis Dosing Recommendations
For tetanus prophylaxis, administer tetanus toxoid-containing vaccine if more than 5 years have passed since the last dose for contaminated wounds, or 10 years for clean minor wounds, along with tetanus immune globulin (TIG) 250 units IM for patients with unknown or <3 previous tetanus vaccinations who present with contaminated wounds. 1
Primary Vaccination Series
- For persons who have never been vaccinated against tetanus, a 3-dose primary series is recommended 1:
- Adults (≥18 years): One dose of Tdap (tetanus, diphtheria, acellular pertussis), followed by Td (tetanus, diphtheria) at least 4 weeks later, and another dose of Td 6-12 months after the second dose 1
- Children (7-18 years): One dose of Tdap, followed by Td at appropriate intervals to complete the 3-dose primary series 1
- Children (<7 years): DTaP (diphtheria, tetanus, acellular pertussis) according to childhood immunization schedule 2
Booster Doses
- After completing the primary series, tetanus booster doses are recommended every 10 years 1, 2
- For wound management, earlier boosters may be indicated based on wound characteristics and vaccination history 1
Wound Management Protocol
The decision to administer tetanus prophylaxis depends on the patient's vaccination history and wound characteristics:
Clean, Minor Wounds:
- ≥3 doses of tetanus toxoid-containing vaccine:
- Unknown or <3 doses of tetanus toxoid-containing vaccine:
- Administer tetanus toxoid-containing vaccine (no TIG needed) 1
All Other Wounds (Contaminated, Puncture, Avulsion, Burns, Frostbite, etc.):
- ≥3 doses of tetanus toxoid-containing vaccine:
- Unknown or <3 doses of tetanus toxoid-containing vaccine:
Tetanus Immune Globulin (TIG) Dosing
- Standard prophylactic dose: 250 units IM for adults and children ≥7 years 3
- For smaller children: Can calculate by body weight (4.0 units/kg), but administering the full 250 units is generally advised regardless of size 3
- TIG and tetanus toxoid-containing vaccines should be administered at different sites using separate syringes 3
Vaccine Selection Based on Age and History
- For persons ≥11 years who have not previously received Tdap, use Tdap (rather than Td) when a tetanus toxoid-containing vaccine is indicated 1
- For persons with previous Tdap vaccination, use Td when a tetanus toxoid-containing vaccine is indicated 1
- For pregnant women requiring tetanus prophylaxis, Tdap should be used 1
- If Td is unavailable, Tdap may be administered 1
Special Considerations
- Persons with a history of Arthus reaction following a previous dose of tetanus toxoid-containing vaccine should not receive another dose until >10 years have elapsed, even for contaminated wounds 1, 2
- For persons with uncertain vaccination histories, consider them unvaccinated and start the primary series 1
- Alternative approach for adults with uncertain histories: Serologic testing for tetanus antibodies (if levels >0.01 IU/mL, previous vaccination is presumed, and a single dose of Tdap is indicated) 1
- The single injection of tetanus toxoid only initiates the series for producing active immunity and must be followed by additional doses to complete the series 3
Common Pitfalls to Avoid
- Failing to administer TIG for high-risk wounds in patients with unknown or incomplete vaccination history 1
- Overuse of TIG in fully vaccinated individuals 4
- Delaying tetanus prophylaxis when indicated 4
- Assuming that clean, minor wounds cannot cause tetanus - tetanus can occur after seemingly innocuous injuries 4
- Forgetting that tetanus toxoid provides protection against future injuries, not the current one 4
- Not completing the full primary vaccination series after initial dose for wound management 3