What is the recommended tetanus toxoid (Td) vaccination schedule for an individual with a punctured wound?

Tetanus Toxoid Vaccination Schedule for Punctured Wounds

For punctured wounds, administer tetanus toxoid-containing vaccine if ≥5 years have elapsed since the last dose, and give both vaccine plus tetanus immune globulin (TIG) if the patient has received <3 doses or has unknown vaccination history. 1

Wound Classification

Punctured wounds are classified as "contaminated wounds" (not clean, minor wounds) because they may be contaminated with dirt, feces, soil, and saliva. 1 This classification is critical because it determines whether the 5-year or 10-year interval applies for booster administration.

Vaccination Algorithm Based on Immunization History

Patients with ≥3 Previous Doses (Completed Primary Series)

• If last dose was <5 years ago: No tetanus toxoid-containing vaccine or TIG needed 1, 2
• If last dose was ≥5 years ago: Administer tetanus toxoid-containing vaccine WITHOUT TIG 1, 2
• If last dose was ≥10 years ago: Definitely administer tetanus toxoid-containing vaccine 1

Patients with <3 Previous Doses or Unknown History

• Administer BOTH tetanus toxoid-containing vaccine AND TIG (250 units IM) 1, 2
• Treat unknown or uncertain vaccination histories as if the patient received no previous tetanus toxoid 1
• When giving both products, use separate syringes at different anatomical sites 1, 2

Vaccine Selection

For Persons ≥11 Years Old

• Tdap is preferred over Td if the patient has not previously received Tdap or has unknown Tdap history 1, 3
• For patients with documented previous Tdap vaccination, use Td 3
• This approach provides protection against pertussis in addition to tetanus and diphtheria 1

For Children <7 Years Old

• Use DTaP for active immunization 1

Completing the Primary Series

If the patient has never been vaccinated or has incomplete vaccination:

• First dose: Tdap (at time of wound management) 1, 3
• Second dose: Td administered >4 weeks after the first dose 1, 3
• Third dose: Td administered 6-12 months after the second dose 1, 2

Important: The tetanus toxoid given at the time of wound management counts as part of the primary series and should be documented for future reference. 1

Special Populations

Immunocompromised Patients

• Persons with HIV infection or severe immunodeficiency with contaminated wounds (including puncture wounds) should receive TIG regardless of their tetanus immunization history 1, 4

History of Arthus Reaction

• Do not administer tetanus toxoid-containing vaccine until >10 years after the most recent dose, regardless of wound severity 1, 4
• The decision to administer TIG should still be based on the primary vaccination history 1

Common Pitfalls to Avoid

• Do not assume puncture wounds are "clean, minor wounds" - they require the more aggressive 5-year interval for boosters, not the 10-year interval 1, 2
• Do not delay TIG administration in patients with unknown/incomplete vaccination history - both vaccine and TIG are needed immediately 1, 2
• Do not give tetanus toxoid and TIG in the same syringe or same anatomical site - this reduces effectiveness 1, 2
• Do not assume military service guarantees complete vaccination - vaccination policies have varied over time and between military branches 1