What vaccine should be administered to a 30-year-old individual with no history of a booster dose (tetanus toxoid-containing vaccine) who has been punctured by a nail?

Tetanus Vaccination for 30-Year-Old with Nail Puncture and No Booster History

Administer Tdap vaccine immediately without tetanus immune globulin (TIG), as this patient has a contaminated wound and no documented booster dose. 1

Wound Classification

• Nail puncture injuries are classified as contaminated, tetanus-prone wounds because they may be contaminated with dirt, soil, and debris, and create anaerobic environments favorable for Clostridium tetani spore germination. 1
• This classification determines a critical 5-year interval (rather than 10-year) for booster administration in wound management. 1

Vaccination Decision Algorithm

For patients with ≥3 previous doses (completed primary series) and last dose ≥5 years ago:

• Administer tetanus toxoid-containing vaccine WITHOUT TIG. 1
• Tdap is strongly preferred over Td for adults who have not previously received Tdap or whose Tdap history is unknown, as this provides additional protection against pertussis in addition to tetanus and diphtheria. 1, 2
• The CDC recommends that Tdap should be administered regardless of the interval since the last tetanus or diphtheria toxoid-containing vaccine when indicated for pertussis protection. 3

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

• Administer BOTH tetanus toxoid-containing vaccine (Tdap preferred) AND TIG 250 units IM at separate anatomic sites using separate syringes. 1, 2
• These patients must complete a 3-dose primary vaccination series for long-term protection. 1

Why Tdap Over Td Alone

• The Advisory Committee on Immunization Practices (ACIP) recommends Tdap as the preferred choice for persons aged ≥11 years when tetanus toxoid-containing vaccine is indicated for wound management, particularly if prior Tdap history is unknown. 1
• For nonpregnant persons with documented previous Tdap vaccination, either Td or Tdap may be used. 1
• The benefits of protection against pertussis outweigh the potential risk for adverse events from administering Tdap regardless of interval since last tetanus-containing vaccine. 3

Administration Details

• The dose is 0.5 mL administered intramuscularly, preferably into the deltoid muscle. 3, 4
• If both TIG and tetanus toxoid are indicated, administer using separate syringes at different anatomical sites to prevent interference with immune response. 1, 2
• The standard prophylactic dose of TIG is 250 units IM. 1

Special Population Considerations

• Pregnant women: If tetanus toxoid-containing vaccine is indicated, Tdap should be used regardless of prior Tdap history. 1
• Severely immunocompromised patients (HIV infection, severe immunodeficiency): Should receive TIG regardless of tetanus immunization history when they have contaminated wounds. 1, 2
• History of Arthus reaction: Should not receive tetanus toxoid-containing vaccine until >10 years after the most recent dose, regardless of wound severity. 1

Critical Clinical Pearls

• Do not confuse the 10-year routine booster interval with the 5-year interval required for contaminated wounds—this is the most common error in tetanus prophylaxis. 1
• More frequent doses than recommended may be associated with increased incidence and severity of adverse reactions, including Arthus-type hypersensitivity reactions. 1, 4
• Proper wound cleaning and debridement are crucial components of tetanus prevention in addition to vaccination. 1, 2
• Failure to provide tetanus vaccination when needed could result in preventable illness, whereas unnecessary vaccination is unlikely to cause harm. 1