What is TD (Tetanus and Diphtheria) used for?

TD Vaccine Uses

TD (Tetanus and Diphtheria toxoids) vaccine is used for active immunization against tetanus and diphtheria in persons 7 years of age and older, including primary vaccination series, routine booster doses every 10 years, wound management, and diphtheria post-exposure prophylaxis. 1, 2

Primary Immunization Series

• Adults with uncertain or incomplete vaccination histories should receive a complete 3-dose primary series using Td: first two doses administered at least 4 weeks apart, with the third dose given 6-12 months after the second dose 1, 2
• Patients with unknown or uncertain previous vaccination histories should be considered to have had no previous tetanus toxoid doses 1
• Complete primary vaccination with tetanus toxoid provides nearly 100% protection against tetanus and long-lasting immunity for at least 10 years in most recipients 3
• If the vaccination schedule is delayed, doses need not be repeated—simply continue from where the patient left off 3

Routine Booster Immunization

• After completing the primary series, booster doses of Td should be administered every 10 years throughout life to maintain adequate protection 1, 2
• At least 40% of persons ≥60 years of age may lack protective levels of circulating antitoxins against diphtheria and tetanus, making routine boosters particularly important in older adults 1
• One practical approach is to vaccinate persons routinely at mid-decade ages (e.g., 25,35,45 years) to ensure compliance 3
• Every visit of an adult to a health-care provider should be regarded as an opportunity to assess vaccination status and provide protection against tetanus and diphtheria if indicated 1

Tetanus Prophylaxis in Wound Management

Clean, Minor Wounds

• No Td vaccine is needed if the patient has ≥3 previous doses and the last dose was <10 years ago 3, 4, 2
• Administer Td if ≥10 years have elapsed since the last dose 3, 2
• Tetanus Immune Globulin (TIG) is never required for clean, minor wounds in patients with ≥3 previous doses 2

Contaminated/Tetanus-Prone Wounds

• For patients with ≥3 previous doses: administer Td if ≥5 years have elapsed since the last dose; TIG is not required 3, 4, 2
• For patients with <3 doses or unknown vaccination history: administer BOTH Td vaccine AND TIG (250 units IM) at separate anatomic sites 3, 4, 2
• Contaminated wounds include puncture wounds, wounds contaminated with dirt/feces/soil/saliva, and injuries from metal objects 3, 4
• The critical time interval for booster administration is 5 years for contaminated wounds versus 10 years for clean wounds—this is the most common error in tetanus prophylaxis 3

Special Wound Management Considerations

• Td is preferred over single-antigen tetanus toxoid for wound management in all persons ≥7 years of age to enhance diphtheria protection 1, 2
• The routine use of Td in all medical settings (office practices, clinics, emergency rooms) improves levels of protection against both tetanus and diphtheria, especially among adults 1
• Proper wound cleaning and debridement remain essential components of tetanus prevention 4

Diphtheria Post-Exposure Prophylaxis

• Td may be used for post-exposure diphtheria prophylaxis in persons ≥7 years of age who have not completed primary vaccination, whose vaccination status is unknown, or who have not been vaccinated with diphtheria toxoid within the previous 5 years 2
• Adults may be even less likely to have adequate levels of diphtheria antitoxin than tetanus antitoxin 1

Prevention of Neonatal Tetanus

• A previously unvaccinated pregnant woman whose child might be born under unhygienic circumstances should receive two doses of Td 4-8 weeks apart before delivery, preferably during the last two trimesters 1
• Pregnant women in similar circumstances who have not completed the vaccination series should complete the three-dose series 1
• Those vaccinated more than 10 years previously should have a booster dose 1
• No evidence exists to indicate that tetanus and diphtheria toxoids administered during pregnancy are teratogenic 1

Special Populations

Immunocompromised Patients

• Persons with HIV infection or severe immunodeficiency should receive TIG regardless of their tetanus immunization history when they have contaminated wounds 3, 4, 5

Patients with History of Arthus Reaction

• Adults with a history of Arthus reaction following a previous tetanus toxoid dose should not receive Td until >10 years after the most recent dose, regardless of wound severity 3, 5
• More frequent doses than recommended may be associated with increased incidence and severity of adverse reactions, including Arthus-type hypersensitivity reactions 3

Elderly Patients

• Elderly patients are at higher risk for tetanus due to lower prevalence of protective antibody levels—serosurveys indicate that 49%-66% of those ≥60 years of age lack protective levels of circulating antitoxin 3
• Patients >60 years and immigrants from regions outside North America/Europe should be prioritized for TIG if supplies are limited, as they are less likely to have adequate antitetanus antibodies 3

Administration Details

• The standard single-dose volume of Td is 0.5 mL administered intramuscularly, preferably in the deltoid muscle 2
• The vaccine should not be injected into the gluteal area or areas where there may be a major nerve trunk 2
• Do not administer Td intravenously or subcutaneously 2
• When TIG is indicated, it should be administered at a separate site with a separate needle and syringe 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 3
• Failing to obtain an accurate immunization history can lead to unnecessary vaccinations or inadequate protection 4
• Assuming that military service guarantees complete tetanus immunization—while most people in the military since 1941 may have received at least one dose, complete vaccination cannot be assumed 4
• Failure to provide tetanus vaccination when needed could result in preventable illness, whereas unnecessary vaccination is unlikely to cause harm 3