Tetanus Immunization Schedule
All children should receive tetanus toxoid as DTaP at 2,4,6, and 15-18 months, with a fifth dose at 4-6 years, followed by Tdap at 11-12 years, and then Td or Tdap boosters every 10 years throughout adult life. 1, 2
Primary Childhood Series (Birth to 6 Years)
Administer DTaP at 2,4, and 6 months of age with a minimum 4-week interval between doses (8-week intervals preferred). 1
Give the fourth dose at 15-18 months, but it may be administered as early as 12 months if at least 6 months have elapsed since the third dose. 3, 1
Administer the fifth dose at 4-6 years of age to complete the primary childhood series. 1, 2
Critical pitfall: Do not administer DTaP to persons aged ≥7 years; use Tdap or Td instead. 1, 2
Adolescent Transition (11-18 Years)
Give a single dose of Tdap at 11-12 years to replace the traditional Td booster, which provides protection against pertussis in addition to tetanus and diphtheria. 1, 2
Adolescents aged 13-18 years who missed the 11-12 year dose should receive Tdap if they have not previously received it. 1
Rationale for earlier timing: Serologic surveys show that 28% of children aged 6-16 years who received their last tetanus vaccination 6-10 years previously had antibody titers below protective levels, supporting the shift from 14-16 years to 11-12 years. 3, 4
Adult Maintenance (19 Years and Older)
All adults aged ≥19 years who have never received Tdap should get one dose immediately, regardless of the interval since their last tetanus-containing vaccine. 1, 2
After receiving Tdap, administer routine boosters of either Td or Tdap every 10 years to maintain protection against tetanus and diphtheria. 1, 2
Important caveat: Do not give tetanus boosters more frequently than every 10 years for routine immunization, as this can cause Arthus reactions (severe local hypersensitivity reactions with pain, swelling, and induration developing 4-12 hours post-injection). 2
Special Population: Pregnancy
Administer one dose of Tdap between 27-36 weeks' gestation (preferably during the earlier part of this period) during every pregnancy, even if the woman received Tdap previously. 1, 2
This strategy provides passive antibody transfer to the newborn for protection during the vulnerable first months of life. 1
Wound Management Protocol
Clean, Minor Wounds
- Give tetanus toxoid only if >10 years since last dose; Tdap is preferred if never received before, otherwise use Td. 1, 2, 5
Contaminated or Severe Wounds (Including Puncture Wounds)
Give tetanus toxoid if >5 years since last dose; Tdap is preferred if never received before, otherwise use Td. 1, 2, 5
Administer TIG 250 units IM if the patient has not completed the primary series (unknown history or <3 doses), given in a separate syringe at a different anatomic site from the vaccine. 1, 2, 5
Clinical pearl: Puncture wounds from nails are considered tetanus-prone because they create anaerobic conditions deep in tissue where Clostridium tetani thrives, triggering the 5-year rule rather than the 10-year rule. 2
Catch-Up Vaccination for Unvaccinated Persons ≥7 Years
For primary immunization in persons ≥7 years: Give three 0.5 mL doses—the first two doses 2 months apart, and the third dose 6-8 months after the second dose. 5
Preferred catch-up schedule for ages 7-18 years: One dose of Tdap, followed by one dose of either Td or Tdap ≥4 weeks later, and one dose of either Td or Tdap 6-12 months after that. 2
Important principle: The vaccination series does not need to be restarted for those with incomplete history, regardless of the time elapsed between doses—simply continue from where the patient left off. 2
Special Considerations for Elderly (≥65 Years)
All adults aged ≥65 years who have never received Tdap should get one dose, regardless of when they last received Td, as 49%-66% of adults ≥60 years lack protective levels of circulating antitoxin. 2
When feasible, use Boostrix for adults aged ≥65 years, though either Tdap product (Boostrix or Adacel) is acceptable to avoid missing vaccination opportunities. 2
Continue 10-year boosters with Td or Tdap after the initial Tdap dose to maintain protection throughout life. 2
Administration Details
Route: Administer 0.5 mL intramuscularly in the deltoid muscle; do not inject into the gluteal area or where there may be a major nerve trunk. 5
Do not administer intravenously or subcutaneously, and do not combine or mix with any other vaccine. 5