Pre-Exposure Tetanus Vaccination Schedule
All individuals should receive a primary series of tetanus toxoid-containing vaccines followed by booster doses every 10 years throughout life to maintain protection against tetanus.
Primary Childhood Series (Birth to 6 Years)
Children should receive DTaP at 2,4,6, and 15-18 months of age, with a fifth dose at 4-6 years, as recommended by the American Academy of Pediatrics 1, 2.
The first three doses are administered at 4-8 week intervals (minimum 4 weeks, preferably 8 weeks between doses) 1, 2.
The fourth dose serves as a reinforcing dose given 6-12 months after the third dose, but may be administered as early as 12 months of age if at least 6 months have elapsed since dose three 1, 2.
The fifth dose completes the childhood series and is given at 4-6 years of age 1, 2.
Do not administer DTaP to persons aged ≥7 years; use Tdap or Td instead 1, 2.
Adolescent Transition (11-18 Years)
Adolescents should receive a single dose of Tdap at age 11-12 years, preferably replacing the traditional Td booster 1, 2.
Adolescents aged 13-18 years who missed the 11-12 year dose should receive Tdap if they have not previously received it 2.
Adult Maintenance (≥19 Years)
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, booster doses of either Td or Tdap should be administered every 10 years throughout life 1, 2.
A practical approach is to vaccinate at mid-decade ages (e.g., 25,35,45 years) to ensure compliance 3.
Primary Series for Unvaccinated Adults
Adults lacking a complete primary series should receive three doses: first dose (preferably Tdap), second dose at least 4 weeks later, and third dose 6-12 months after the second dose 3, 4.
The vaccination series does not need to be restarted if doses are delayed; simply continue from where the patient left off 1, 3.
Complete primary vaccination with tetanus toxoid provides nearly 100% protection and long-lasting immunity for at least 10 years in most recipients 3.
Special Populations
Pregnancy
Pregnant women should receive one dose of Tdap during each pregnancy between 27-36 weeks' gestation, preferably during the earlier part of this period, regardless of prior vaccination history 1, 2.
This recommendation applies to every pregnancy, even if the woman received Tdap previously 2.
Elderly Adults (≥65 Years)
All adults aged ≥65 years who have never received Tdap should get one dose, as recommended by the Advisory Committee on Immunization Practices since 2012 1.
When feasible, Boostrix should be used for adults aged ≥65 years, though either Tdap product is acceptable 1.
This population is at higher risk, as 49%-66% of adults ≥60 years lack protective levels of circulating antitoxin 1, 3.
Catch-Up Vaccination (Ages 7-18 Years)
Unvaccinated persons aged 7-18 years should receive a series of three tetanus and diphtheria toxoid-containing vaccines, which includes at least 1 Tdap dose 1.
The preferred schedule is: 1 dose of Tdap, followed by 1 dose of either Td or Tdap ≥4 weeks afterward, and 1 dose of either Td or Tdap 6-12 months later 1.
Critical Clinical Pearls
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) 1.
Persons who have received at least two doses of tetanus toxoid rapidly develop antitoxin antibodies after a booster dose, demonstrating immunological memory 3.
The 10-year booster interval applies to routine prophylactic immunization; wound management follows different rules (5-year interval for contaminated wounds, 10-year for clean minor wounds) 1, 2.
Absolute contraindication includes a history of neurologic or severe hypersensitivity/anaphylactic reaction to a previous dose 1, 2.