What are the guidelines for administering a tetanus (Td) shot?

Tetanus Vaccination Guidelines

Administer Tdap (preferred over Td) if the patient has never received Tdap or Tdap history is unknown, regardless of when they last received a tetanus-containing vaccine; otherwise, use Td for routine 10-year boosters. 1, 2

Routine Vaccination Schedule

Primary Series and Boosters:

• Adults who completed childhood vaccination should receive booster doses every 10 years throughout life 1, 3, 4
• One dose should be Tdap if never previously received; all subsequent boosters should be Td 1, 2
• Tdap should be given regardless of interval since last tetanus vaccine 1, 2
• For unvaccinated adults, administer a 3-dose series: first dose (preferably Tdap), second dose at ≥4 weeks, third dose at 6-12 months 1, 3, 4

Wound Management Algorithm

The critical decision point is wound classification and vaccination history:

For Clean, Minor Wounds:

• If ≥3 previous doses and last dose <10 years ago: No vaccine needed 5, 4
• If ≥3 previous doses and last dose ≥10 years ago: Give tetanus toxoid (Tdap preferred if never received Tdap; otherwise Td) 1, 5, 4
• If <3 doses or unknown history: Give tetanus toxoid AND Tetanus Immune Globulin (TIG) 250 units IM at separate site 1, 4

For Contaminated/Tetanus-Prone Wounds:

Includes puncture wounds, wounds contaminated with dirt/soil/feces, traumatic wounds 1, 5, 4

• If ≥3 previous doses and last dose <5 years ago: No vaccine needed 1, 5, 4
• If ≥3 previous doses and last dose ≥5 years ago: Give tetanus toxoid WITHOUT TIG (Tdap preferred if never received Tdap; otherwise Td) 1, 5, 4
• If <3 doses or unknown history: Give BOTH tetanus toxoid AND TIG 250 units IM at separate anatomic sites 1, 5, 4

The 5-year interval for contaminated wounds versus 10-year interval for clean wounds is the most critical distinction and most common source of error. 5

Special Populations

Pregnant Women:

• Administer Tdap during EACH pregnancy at 27-36 weeks gestation, regardless of prior Tdap history 1, 3, 2
• For wound management in pregnancy, use Tdap regardless of prior Tdap history 1, 5, 2

Healthcare Personnel:

• All HCP should receive a single dose of Tdap as soon as feasible if not previously received 1
• After Tdap, continue routine Td boosters every 10 years 1

Adults ≥65 Years:

• Give Tdap if never received, preferably using Boostrix (though either product acceptable) 3, 2
• This population has lower seroprotection rates (49-66% lack protective antibody levels), making adherence to guidelines particularly important 5, 3

Immunocompromised Patients:

• Patients with HIV infection or severe immunodeficiency should receive TIG regardless of tetanus immunization history when they have contaminated wounds 1, 5

Critical Clinical Pearls and Pitfalls

Common Errors to Avoid:

• Do NOT confuse the 10-year routine booster interval with the 5-year interval for contaminated wounds 5
• Do NOT give tetanus boosters more frequently than every 10 years for routine immunization, as this increases risk of Arthus-type hypersensitivity reactions 5, 4
• Do NOT use DTaP in persons ≥7 years; use Tdap or Td instead 3
• Do NOT restart the vaccination series if doses are delayed; simply continue from where the patient left off 1, 3

Contraindications:

• Severe allergic reaction (anaphylaxis) to previous dose is absolute contraindication 4
• Patients with history of Arthus reaction should not receive tetanus toxoid until >10 years after most recent dose, even for wound management 5, 4
• If Guillain-Barré syndrome occurred within 6 weeks of prior tetanus-containing vaccine, carefully weigh benefits versus risks 4

Documentation:

• Maintain personal vaccination records to minimize unnecessary vaccinations 5
• Unknown or uncertain vaccination history should be treated as no previous doses 5, 3

Timing Considerations:

• There is no urgency for tetanus toxoid administration in the acute wound setting, as it provides protection against the next injury, not the current one 6
• However, vaccination should occur within 24-48 hours as part of standard wound management 3
• Complete primary series provides nearly 100% protection and long-lasting immunity for at least 10 years 5, 3