Tetanus Prophylaxis for Unknown or Outdated Vaccination Status
For patients with unknown or fewer than 3 documented tetanus vaccine doses presenting with any wound, administer both tetanus toxoid-containing vaccine (Tdap preferred) AND tetanus immune globulin (TIG) 250 units IM at separate sites for all wounds except clean, minor ones; for clean, minor wounds, give vaccine only without TIG. 1
Wound Classification Determines Management
The type of wound fundamentally changes your approach:
Clean, Minor Wounds:
- Administer tetanus toxoid-containing vaccine if unknown/uncertain vaccination history 1
- Do NOT give TIG for clean, minor wounds regardless of vaccination status 1
All Other Wounds (Tetanus-Prone):
- These include wounds contaminated with dirt, feces, soil, saliva; puncture wounds; avulsions; wounds from missiles, crushing, burns, or frostbite 1, 2
- Administer BOTH tetanus toxoid-containing vaccine AND TIG 250 units IM 1, 2
- Give at separate anatomical sites using different syringes 1
Vaccine Selection Algorithm
For patients ≥11 years old:
- Tdap is strongly preferred if they have not previously received Tdap or Tdap history is unknown 1, 2
- This provides critical pertussis protection in addition to tetanus and diphtheria 2
For pregnant women:
For children <7 years:
- Use DTaP 1
Critical Time Intervals for Documented Vaccination
If the patient can produce documentation of ≥3 prior doses, the timing matters:
For clean, minor wounds:
For contaminated/tetanus-prone wounds:
- No vaccine needed if last dose was <5 years ago 1, 2, 3
- Give vaccine (without TIG) if ≥5 years since last dose 1, 2, 3
The Unknown History Problem
Persons with unknown or uncertain vaccination histories must be considered to have had no previous tetanus toxoid-containing vaccine. 1 This is the default assumption that prevents preventable tetanus deaths. 3
Optional Serologic Testing Approach
For adults >18 years who probably received vaccination but lack documentation, you may consider serologic testing for tetanus and diphtheria antibodies to avoid unnecessary vaccination 1:
- If tetanus and diphtheria antitoxin levels are each >0.01 IU/mL, previous vaccination is presumed 1
- Then give a single dose of Tdap 1
However, this approach delays prophylaxis and is not standard practice in acute wound management.
Completing the Primary Series
Patients requiring vaccine due to unknown/incomplete vaccination must complete a 3-dose primary series 1, 2:
- First dose: Tdap (given at time of wound management)
- Second dose: Td at least 4 weeks after first dose 1
- Third dose: Td 6-12 months after second dose 1
Special Populations Requiring TIG Regardless of History
Immunocompromised patients (HIV infection or severe immunodeficiency) with contaminated wounds should receive TIG regardless of their tetanus immunization history 1, 2
Common Pitfalls to Avoid
Do not confuse the 10-year routine booster interval with the 5-year interval for contaminated wounds - this is the most common error in tetanus prophylaxis. 2 A case report documented generalized tetanus in a 79-year-old woman with proper vaccination (last booster 7 years prior) who sustained a high-risk agricultural injury but did not receive prophylaxis because providers failed to recognize the 5-year rule for contaminated wounds. 3
Tetanus toxoid does not provide immediate protection for the current injury - it takes days to generate an antibody response. 4 A study of 31 adults showed no antitoxin response within 4 days of booster vaccination, confirming that TIG is essential for immediate passive immunity in high-risk scenarios. 4
More frequent boosters than recommended increase adverse reactions, including Arthus-type hypersensitivity reactions. 2, 5 Do not give unnecessary vaccines.