When should tetanus toxoid (TT) and tetanus immunoglobulin (TIG) be administered to a burn patient?

Tetanus Prophylaxis in Burn Patients

Direct Recommendation

For burn patients, administer tetanus toxoid (Td or Tdap) if ≥5 years have elapsed since the last dose, and add tetanus immunoglobulin (TIG) only if the patient has <3 documented tetanus toxoid doses or unknown vaccination history. 1, 2, 3

Wound Classification

• Burns are classified as contaminated/tetanus-prone wounds (similar to wounds contaminated with dirt, feces, soil, puncture wounds), which determines the critical 5-year interval rather than the standard 10-year interval used for clean, minor wounds. 4, 2, 3

Vaccination Algorithm Based on Immunization History

Patients with ≥3 Previous Doses (Completed Primary Series)

• If last dose was <5 years ago: No tetanus toxoid or TIG needed. 4, 5, 2, 3

• If last dose was ≥5 years ago: Administer tetanus toxoid-containing vaccine WITHOUT TIG. 1, 4, 2, 3

  • Tdap is preferred over Td for adults who have not previously received Tdap or whose Tdap history is unknown. 1, 4, 6
  • For patients with documented previous Tdap vaccination, either Td or Tdap may be used. 4, 6

Patients with <3 Previous Doses or Unknown History

• Administer BOTH tetanus toxoid-containing vaccine AND TIG (250 units IM) at separate anatomic sites using separate syringes. 1, 4, 2, 3

• Patients with unknown or uncertain vaccination histories should be considered to have had no previous tetanus toxoid-containing vaccine. 1, 6, 2

• These patients must complete the 3-dose primary series: Tdap as first dose, followed by Td at >4 weeks and 6-12 months later. 4, 6

Special Populations

Immunocompromised Patients

• Patients with HIV infection or severe immunodeficiency should receive TIG regardless of their tetanus immunization history when they have contaminated wounds (including burns). 4, 6, 5

Patients with History of Arthus Reaction

• Do not administer tetanus toxoid-containing vaccine until >10 years after the most recent dose, even for contaminated wounds like burns. 1, 6, 5
• The decision to administer TIG is based solely on the primary vaccination history for tetanus. 1

Critical Clinical Pearls

• There is no urgency for tetanus toxoid administration in the acute burn setting—it provides protection against the next injury, not the current one, as antitoxin response does not occur within the first 4 days after booster. 7, 8

• The most common error is confusing the 10-year routine booster interval with the 5-year interval required for contaminated wounds like burns. 4

• More frequent doses than recommended may increase the incidence and severity of adverse reactions, including Arthus-type hypersensitivity reactions. 4

• A case report documented generalized tetanus in a properly vaccinated patient whose last booster was 7 years prior to a high-risk agricultural injury—TTV was not administered at initial presentation, highlighting the critical importance of the 5-year rule for contaminated wounds. 9

• When both TIG and tetanus toxoid-containing vaccine are indicated, each product must be administered using separate syringes at different anatomic sites. 1, 2, 3