What is the recommended tetanus toxoid (TT) vaccination schedule?

Tetanus Toxoid Vaccination Schedule

All children should receive tetanus toxoid as part of DTaP at 2,4,6, and 15-18 months, with a fifth dose at 4-6 years, followed by Tdap at age 11-12 years, and then Td or Tdap boosters every 10 years throughout life. 1

Primary Childhood Series (Birth to 6 Years)

The foundation of tetanus protection requires five doses of DTaP administered on a specific schedule:

• First three doses: Administer at 2,4, and 6 months of age, with a minimum 4-week interval between doses (8-week intervals preferred) 2
• Fourth dose: Give at 15-18 months of age, but may be administered as early as 12 months if at least 6 months have elapsed since the third dose 2
• Fifth dose: Administer at 4-6 years of age 2

The third dose should not be given before 14 weeks of age to ensure adequate immune response 2. While the same manufacturer's DTaP product is preferred throughout the series, vaccination should not be delayed if the previous brand is unavailable 2.

Adolescent Transition (11-18 Years)

At age 11-12 years, administer a single dose of Tdap to replace the traditional Td booster:

• Tdap is preferred at 11-12 years for all adolescents who completed the childhood DTaP series 2, 1
• Adolescents aged 13-18 years who missed the 11-12 year dose should receive Tdap if they have not previously received it 2, 1
• The earlier scheduling at 11-12 years (rather than 14-16 years) encourages a routine preadolescent preventive care visit and addresses the finding that 28% of persons aged 6-16 years had subprotective tetanus antibody levels 6-10 years after their last dose 2

Adult Maintenance (19 Years and Older)

After the adolescent Tdap dose, continue with Td or Tdap boosters every 10 years:

• All adults aged ≥19 years who have never received Tdap should get one dose regardless of the interval since their last tetanus-containing vaccine 1
• After receiving Tdap, routine boosters of either Td or Tdap should be given every 10 years 1, 3
• For adults ≥65 years, either Td or Tdap is acceptable for the 10-year booster, though Boostrix is preferred when feasible 1

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

Special Population: Pregnancy

Pregnant women require Tdap during each pregnancy regardless of prior vaccination history:

• Administer one dose of Tdap between 27-36 weeks' gestation, preferably during the earlier part of this period 1
• This recommendation applies to every pregnancy, even if the woman received Tdap previously 1

Wound Management Protocol

The timing of tetanus prophylaxis depends on wound type and vaccination history:

For Clean, Minor Wounds:

• Give tetanus toxoid only if >10 years since last dose 1, 3
• Tdap is preferred if the patient has never received it; otherwise use Td 1, 3
• No Tetanus Immune Globulin (TIG) is needed 3

For Contaminated or Severe Wounds:

• Give tetanus toxoid if >5 years since last dose 1, 3
• Tdap is preferred if never received; otherwise use Td 1, 3
• Administer TIG 250 units IM if the patient has not completed the primary series (unknown history or <3 doses) 1, 3
• When both TIG and tetanus toxoid are indicated, administer in separate syringes at different anatomic sites 1, 3

Critical consideration: 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.

Catch-Up Vaccination for Unvaccinated Persons

For unvaccinated persons aged 7-18 years, administer a three-dose series:

• First dose: Tdap 1
• Second dose: Td or Tdap ≥4 weeks after the first dose 1
• Third dose: Td or Tdap 6-12 months after the second dose 1

For adults aged ≥19 years with no prior immunization:

• First dose: Tdap 3
• Second dose: Td 2 months after the first dose 3
• Third dose: Td 6-8 months after the second dose 3

The vaccination series does not need to be restarted for those with incomplete history, regardless of the time elapsed between doses—simply continue from where the patient left off 1.

Important Clinical Caveats

Absolute contraindication: History of neurologic or severe hypersensitivity/anaphylactic reaction to a previous dose 1

Age-specific restrictions:

• Do not administer DTaP to persons aged ≥7 years; use Tdap or Td instead 1
• DTaP-IPV/Hib is not indicated for children >5 years of age 2

Administration details:

• Administer 0.5 mL intramuscularly in the deltoid muscle 3
• Do not inject into the gluteal area or where there may be a major nerve trunk 3
• Do not administer intravenously or subcutaneously 3