Is a tetanus (lockjaw) shot required after a burn, considering the patient's vaccination history and burn severity?

Tetanus Vaccination After Burns

Yes, tetanus vaccination is required after a burn if ≥5 years have elapsed since the last dose, because burns are classified as contaminated/tetanus-prone wounds that require the shorter 5-year interval rather than the standard 10-year interval used for clean, minor wounds. 1

Wound Classification

• Burns are definitively classified as contaminated/tetanus-prone wounds, which fundamentally changes the prophylaxis algorithm from the routine 10-year booster schedule to a more aggressive 5-year threshold 1
• This classification is critical because it determines whether tetanus prophylaxis is needed in the acute injury setting 2, 1

Vaccination Algorithm Based on Immunization History

For patients with ≥3 previous documented doses:

• If last dose was <5 years ago: No tetanus toxoid-containing vaccine or TIG is needed 2, 1
• If last dose was ≥5 years ago: Administer tetanus toxoid-containing vaccine (Tdap preferred if never previously received Tdap or Tdap history unknown) WITHOUT TIG 2, 1
• Tdap is strongly preferred over Td alone because it provides additional protection against pertussis 2, 1

For patients with <3 previous doses or unknown/uncertain vaccination history:

• Administer BOTH tetanus toxoid-containing vaccine AND TIG (250 units IM) at separate anatomic sites using separate syringes 2, 1
• These patients must complete a full 3-dose primary vaccination series for long-term protection 2
• Treat patients with unknown or uncertain histories as having zero previous doses 2

Special Populations Requiring Modified Approach

• Severely immunocompromised patients (HIV infection, severe immunodeficiency): Receive TIG regardless of tetanus immunization history when they have contaminated wounds including burns 1
• Patients with history of Arthus reaction: Do not administer tetanus toxoid-containing vaccine until >10 years after the most recent dose, even for contaminated wounds like burns 1
• Pregnant women: If tetanus toxoid-containing vaccine is indicated, Tdap should be used regardless of prior Tdap history 2

Administration Guidelines

• When both TIG and tetanus toxoid-containing vaccine are indicated, each product must be administered using separate syringes at different anatomic sites to prevent interference with immune response 1, 3
• The preferred administration site is the deltoid muscle 3
• Do not administer intravenously, subcutaneously, or into the gluteal area 3

Critical Clinical Pearls and Common Pitfalls

• 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 2
• More frequent doses than recommended may be associated with increased incidence and severity of adverse reactions, including Arthus-type hypersensitivity reactions 2, 3
• There is no urgency for tetanus toxoid administration in the acute setting, as it provides protection against the next injury, not the current injury 4
• Proper wound cleaning and debridement are crucial components of tetanus prevention in addition to vaccination 2
• Antibiotic prophylaxis is NOT indicated or useful for tetanus prevention 2

Evidence Quality Considerations

The CDC guidelines provide clear, consistent recommendations across multiple wound types 2, 1. A 2024 case report demonstrated the real-world consequences of failing to administer tetanus vaccine when indicated: a 79-year-old woman with proper vaccination history (last booster 7 years prior) developed generalized tetanus after a contaminated agricultural wound when prophylaxis was not given at initial presentation 5. This case underscores that the 5-year interval for contaminated wounds must be strictly followed, even in previously vaccinated individuals.