What is the recommended schedule for the antitetanus toxoid (tetanus) vaccine?

Tetanus Vaccination Schedule

Primary Vaccination Series

For children, the primary tetanus vaccination series consists of DTaP vaccine given at 2,4, and 6 months of age, followed by doses at 15-18 months and 4-6 years, for a total of 5 doses before age 7 years. 1

• The primary series for tetanus vaccination consists of three doses administered at 4-8 week intervals, followed by a fourth (reinforcing) dose 6-12 months after the third dose 1
• The fourth dose may be administered as early as 12 months of age if at least 6 months have elapsed since the third dose 1
• The total number of doses of vaccines containing diphtheria and tetanus toxoids should not exceed 6 doses before the seventh birthday 2

Adolescent Vaccination

All persons aged 11-18 years should receive a single dose of Tdap, preferably at age 11-12 years. 1

• For persons aged 7-10 years who receive a dose of Tdap as part of a catch-up series, an adolescent Tdap vaccine dose should still be administered at age 11-12 years 2
• After receiving Tdap, booster doses of either Td or Tdap should be administered every 10 years throughout life 1

Adult Vaccination Schedule

Adults aged ≥19 years who have never received Tdap should get one dose of Tdap immediately, regardless of when they last received a tetanus-containing vaccine, followed by Td or Tdap boosters every 10 years. 1

For Never-Vaccinated Adults

• Persons aged >18 years who have never been vaccinated should receive a series of three vaccinations: a single dose of Tdap, followed by a dose of Td at least 4 weeks after Tdap, and another dose of Td 6 to 12 months later 2
• The single dose of Tdap can substitute for any of the Td doses in the 3-dose primary series 2

For Incompletely Vaccinated Adults

• Persons aged >18 years who are not fully immunized should receive 1 dose of Tdap (preferably the first) in the catch-up series; if additional tetanus toxoid-containing doses are needed, use Td vaccine 2
• The vaccination series does not need to be restarted, regardless of the time elapsed between doses for those with incomplete history 1

Elderly Adults (≥65 Years)

All adults aged ≥65 years who have not yet received a dose of Tdap should receive a single dose, regardless of the interval since the last tetanus or diphtheria toxoid-containing vaccine. 1

• When feasible, Boostrix should be used for adults aged ≥65 years; however, either Tdap product (Boostrix or Adacel) is immunogenic and provides protection 1
• After receipt of Tdap, persons should continue to receive Td for routine booster immunization every 10 years 1
• Serosurveys indicate that 49%-66% of adults ≥60 years lack protective levels of circulating antitoxin against tetanus, making adherence to the 10-year booster schedule particularly important 1

Pregnancy

Pregnant women should receive one dose of Tdap during each pregnancy, regardless of prior vaccination history. 1

• Tdap should be administered between 27-36 weeks' gestation, preferably during the earlier part of this period 1
• If a previously unimmunized woman has received at least 2 properly spaced doses of tetanus toxoid-containing vaccine during pregnancy (one being Tdap), the risk of neonatal tetanus is minimal 2
• She should complete the 3-dose primary series at the recommended intervals 2

Wound Management Protocol

For tetanus-prone wounds, a tetanus toxoid-containing vaccine is indicated when >5 years have passed since the last tetanus toxoid-containing vaccine dose. 1

Clean, Minor Wounds

• No tetanus toxoid is needed if the last dose was within 10 years 1
• Tdap is preferred if not previously received, or Td if the last dose was more than 10 years ago 1

Contaminated or Severe Wounds

• Tetanus toxoid is needed if the last dose was more than 5 years ago 1
• Tdap is preferred if not previously received, or Td 1
• Tetanus Immune Globulin (TIG) 250 units IM is required if the patient has not completed the primary series 1, 3
• When both TIG and tetanus toxoid are indicated, they should be administered in separate syringes at different anatomic sites 1, 3

Critical Wound Management Considerations

• Persons with unknown or uncertain vaccination histories should be considered to have had no previous tetanus toxoid doses and require both tetanus toxoid and TIG for contaminated or severe wounds 1
• For persons ≥11 years who have not previously received Tdap or whose Tdap history is unknown, Tdap is preferred over Td for wound management 2, 1
• If a tetanus toxoid-containing vaccine is indicated for a pregnant woman, Tdap should be used 2

Critical Pitfalls to Avoid

Do not administer tetanus boosters more frequently than every 10 years for routine immunization, as this can cause Arthus reactions—severe local hypersensitivity reactions characterized by pain, swelling, and induration developing 4-12 hours post-injection. 1

• Do not administer DTaP to persons aged ≥7 years; use Tdap or Td instead 1
• Do not miss the opportunity to administer Tdap to adults who have never received it, regardless of when they last received Td 1
• Do not restart the vaccination series if doses are delayed; simply continue from where the patient left off 1
• Absolute contraindication includes a history of neurologic or severe hypersensitivity/anaphylactic reaction to a previous dose 1

Duration of Protection and Booster Rationale

Complete primary tetanus vaccination provides long-lasting protection of ≥10 years for most recipients, which forms the scientific basis for the decennial booster recommendation. 1, 3

• Persons who have received at least two doses of tetanus toxoid rapidly develop antibodies upon booster administration 3
• There is no early antitoxin response to tetanus booster within 4 days of administration, which supports the continued use of TIG in tetanus-prone wounds for persons with incomplete or unknown immunization status 4
• The 10-year interval applies to routine prophylactic immunization and ensures continued protection against both tetanus and diphtheria 1