What is the recommended Tdap (Tetanus, diphtheria, and pertussis) and IPV (inactivated poliovirus vaccine) vaccination schedule for adults?

Tdap-IPV Adult Vaccination Series

Primary Vaccination Series for Unvaccinated Adults

Adults who have never been vaccinated against tetanus, diphtheria, pertussis, or polio should receive a 3-dose primary series: one dose of Tdap (preferably combined with IPV if available), followed by Td at least 4 weeks later, and a third dose of Td 6-12 months after the second dose. 1, 2

Detailed Primary Series Schedule

• First dose: Administer Tdap-IPV (if available) or Tdap alone 1, 3
• Second dose: Administer Td ≥4 weeks after the first dose 1, 2
• Third dose: Administer Td 6-12 months after the second dose 1

The combination dTpa-IPV vaccine has been studied and proven safe and immunogenic for primary vaccination in adults ≥40 years, with one dose of dTpa-IPV followed by two doses of Td achieving >98.4% seroprotective anti-polio titers and >99% seroprotection against diphtheria and tetanus after completion of the series. 3

Alternative Acceptable Schedules

• Tdap can substitute for any one of the three Td doses in the primary series, though the preferred approach is Tdap first 1
• If using separate vaccines, administer IPV according to standard adult schedules (typically a 3-dose series at 0,1-2, and 6-12 months) 3

Booster Vaccination for Previously Vaccinated Adults

All adults aged 19-64 years who completed their primary series should receive a single dose of Tdap to replace one Td booster if they have not previously received Tdap, followed by Td or Tdap boosters every 10 years thereafter. 2, 4

Standard Booster Protocol

• Administer Tdap regardless of interval since last tetanus-containing vaccine 4
• After receiving Tdap, continue with Td boosters every 10 years 1, 2
• As of 2019, either Td or Tdap may be used for routine 10-year boosters 2

Accelerated Booster Schedule (High-Risk Populations)

The interval between Td and Tdap can be shortened to as little as 2 years for: 1, 4

• Healthcare personnel with direct patient contact 1
• Adults with close contact to infants <12 months 1, 4
• Postpartum women who did not receive Tdap during pregnancy 1

IPV Considerations for Adults

For adults requiring polio vaccination, IPV is the only polio vaccine used in the United States and should be administered as a separate vaccine or in combination with Tdap when available. 3

• Adults with unknown or incomplete polio vaccination history should receive a 3-dose IPV series 3
• IPV can be administered simultaneously with Tdap using separate syringes at different anatomic sites 1
• The dTpa-IPV combination vaccine provides simultaneous booster protection against all four diseases 3

Wound Management Protocol

Clean, Minor Wounds

• No tetanus vaccination needed if last dose within 10 years 2, 4
• If >10 years since last dose: give Tdap (if never received) or Td 2, 4

Contaminated or Tetanus-Prone Wounds

• Tetanus vaccination needed if >5 years since last dose 2, 4
• Tdap preferred over Td if patient has not previously received Tdap 4, 5
• Tetanus Immune Globulin (TIG) 250 units IM required if primary series incomplete 2
• Administer TIG and tetanus vaccine in separate syringes at different anatomic sites 1, 2

Special Populations

Pregnant Women

• Administer one dose of Tdap during each pregnancy between 27-36 weeks gestation, regardless of prior vaccination history 2, 5
• If not given during pregnancy, administer Tdap immediately postpartum before hospital discharge 1

Adults ≥65 Years

• All adults ≥65 years who have not received Tdap should receive a single dose 2
• Boostrix is preferred for this age group, though either Tdap product is acceptable 2
• Continue Td boosters every 10 years after Tdap 2

Healthcare Personnel

• All HCP with direct patient contact should receive Tdap as soon as feasible if not previously vaccinated 1, 4
• Priority should be given to HCP with contact to infants <12 months 1
• Interval as short as 2 years from last Td is acceptable 1

Administration Details

• Dose: 0.5 mL administered intramuscularly, preferably into the deltoid muscle 1, 4
• Simultaneous vaccination: Multiple vaccines should be given during the same visit using separate syringes at different anatomic sites 1
• Product selection: Only Adacel (Sanofi Pasteur) is licensed for adults >18 years in the US; Boostrix is licensed for ages 10-18 years (though either product is acceptable if inadvertently given) 1

Critical Pitfalls to Avoid

Avoid Over-Vaccination

Do not administer tetanus boosters more frequently than every 10 years for routine immunization, as this increases the risk of Arthus-type hypersensitivity reactions characterized by severe pain, swelling, and induration. 2, 5

Contraindications

• History of anaphylaxis to any vaccine component is an absolute contraindication 4
• History of Arthus reaction following previous tetanus toxoid: defer vaccination until >10 years after most recent dose, even for wound management 1, 5

Product Selection Errors

• Do not use pediatric DTaP in persons ≥7 years; use Tdap or Td instead 1, 2
• Do not restart the vaccination series if doses are delayed; simply continue from where the patient left off 2

Evidence Supporting Repeat Tdap Dosing

Recent high-quality evidence demonstrates that a second dose of Tdap approximately 10 years after the first dose is well-tolerated and highly immunogenic, with antibody responses similar in magnitude to the initial dose and no increase in adverse events. 6, 7 This supports the potential for decennial Tdap boosters rather than alternating with Td, though current US labeling still recommends Tdap for single-dose use only. 7