Can tetanus-containing vaccines, such as Td (tetanus and diphtheria toxoids) or Tdap (tetanus, diphtheria, and pertussis), be administered to patients undergoing chemotherapy?

Tetanus-Containing Vaccines in Patients on Chemotherapy

Yes, tetanus-containing vaccines (Td or Tdap) can and should be administered to patients undergoing chemotherapy, as immunosuppression is explicitly not a contraindication to these inactivated vaccines. 1

Key Guideline Recommendations

Immunosuppression is not a contraindication for tetanus-containing vaccines. The Advisory Committee on Immunization Practices (ACIP) clearly states that immunosuppression, including in patients receiving chemotherapy, is a condition under which Td or Tdap may be administered if otherwise indicated. 1

Important Caveats About Immune Response

• The immunogenicity of Tdap in immunosuppressed persons has not been fully studied and could be suboptimal. 1
• Despite potentially reduced antibody responses, vaccination should not be withheld, as some protection is better than none, particularly given the high morbidity and mortality of tetanus infection. 1

Supporting Clinical Evidence

Research demonstrates that children on maintenance chemotherapy mount adequate antibody responses to tetanus toxoid. A study of 27 children with various malignancies in remission receiving maintenance chemotherapy showed that most children made good antibody responses to both tetanus and diphtheria antigens, irrespective of disease type or treatment regimen. 2

• Only 1 of 27 children failed to respond to either antigen. 2
• Two children failed to develop antitetanus antibodies but responded normally to diphtheria antigen. 2
• This evidence supports that patients on long-term chemotherapy should not be denied protection from nonliving vaccines. 2

Clinical Algorithm for Chemotherapy Patients

For Routine Vaccination:

• Administer Tdap if the patient has never received it, regardless of chemotherapy status. 1
• Give Td boosters every 10 years for ongoing tetanus/diphtheria protection. 1
• Do not defer vaccination due to chemotherapy alone. 1

For Wound Management:

• Follow standard tetanus prophylaxis guidelines based on wound type and vaccination history. 1
• For clean, minor wounds: give tetanus vaccine if >10 years since last dose. 1
• For contaminated/tetanus-prone wounds: give tetanus vaccine if >5 years since last dose. 1
• Tdap is preferred over Td if the patient has not previously received Tdap. 1

Actual Contraindications to Monitor:

• History of anaphylaxis to vaccine components (refer to allergist for possible tetanus toxoid desensitization). 1
• Encephalopathy within 7 days of previous pertussis-containing vaccine (contraindication for Tdap only; give Td instead). 1
• Guillain-Barré syndrome within 6 weeks of previous tetanus-containing vaccine (precaution, not absolute contraindication; evaluate risks/benefits). 1

Common Pitfalls to Avoid

Do not withhold tetanus vaccination simply because a patient is immunosuppressed. This is a widespread misconception that leaves vulnerable patients unprotected against a preventable disease with high mortality. 1

Do not give tetanus boosters more frequently than every 10 years for routine immunization. Excessive vaccination can cause Arthus-type hypersensitivity reactions characterized by severe local pain, swelling, and induration. 1

Do not defer vaccination for moderate or severe acute illness. Wait until the acute illness resolves, but chemotherapy itself is not an acute illness requiring deferral. 1

Timing Considerations

Ideally, administer vaccines before starting chemotherapy when possible to maximize immune response, though this is not always feasible in clinical practice. 2

If vaccination occurs during chemotherapy, document the immunosuppressed state and consider checking antibody titers 1 month post-vaccination to confirm adequate response, particularly if the patient is at high risk for tetanus exposure. 2