What is the recommended tetanus‑diphtheria (Td) booster schedule for adults, including dose, timing, wound‑related dosing, contraindications, and special considerations for immunocompromised or severely allergic patients?

Td Booster Recommendations for Adults

Adults should receive Td or Tdap booster doses every 10 years throughout life after completing the primary vaccination series, with at least one dose being Tdap if never previously received. 1

Primary Vaccination Series

For adults who never completed childhood vaccination or have uncertain vaccination history:

• Administer a 3-dose primary series: First dose (preferably Tdap), second dose ≥4 weeks later (Td or Tdap), and third dose 6-12 months after the second dose 2, 1, 3
• Treat patients with unknown vaccination history as unvaccinated and initiate the complete primary series 1
• Do not restart the series if doses are delayed—simply continue from where the patient left off 1, 3

Routine Booster Schedule

After completing the primary series:

• Administer boosters every 10 years to maintain protection against tetanus and diphtheria 2, 1, 3
• Give one dose of Tdap if the patient has never received it, regardless of interval since last Td 1, 3
• Use either Td or Tdap for subsequent 10-year boosters after receiving the initial Tdap dose 1
• For adults ≥65 years, Boostrix is preferred when feasible, though either Tdap product is acceptable 1

Wound Management Protocol

The timing of tetanus prophylaxis depends critically on wound classification:

Clean, Minor Wounds

• Give tetanus toxoid only if ≥10 years since last dose 1, 4
• Tdap is preferred if never previously received 1, 4
• No TIG is needed for patients with ≥3 documented doses 4

Contaminated/Tetanus-Prone Wounds

These include puncture wounds, injuries contaminated with dirt/soil/feces, or wounds creating anaerobic conditions:

• Give tetanus toxoid if ≥5 years since last dose 1, 4
• Tdap is strongly preferred over Td if never previously received 1, 4
• Administer both tetanus toxoid AND TIG 250 units IM at separate anatomic sites if <3 documented doses or unknown vaccination history 1, 4
• TIG is NOT required for patients with complete primary series (≥3 doses), even with contaminated wounds 4

Special Populations

Pregnant Women

• Administer one dose of Tdap during EACH pregnancy at 27-36 weeks gestation, regardless of prior Tdap history 1, 3

Healthcare Personnel

• Give Tdap as soon as feasible if not previously received, with intervals as short as 2 years after last Td acceptable 3

Immunocompromised Patients

• Administer TIG regardless of vaccination history when contaminated wounds are present in patients with HIV infection or severe immunodeficiency 1, 4
• Give both tetanus toxoid and TIG 250 units IM at separate sites for tetanus-prone wounds 4

Elderly Patients (≥60 years)

• Maintain the 10-year booster schedule, as 49-66% of this population lacks protective antibody levels 1
• Either Td or Tdap is acceptable for routine boosters 1

Contraindications

Absolute contraindications include:

• History of anaphylaxis to any vaccine component 2
• Encephalopathy within 7 days of previous pertussis-containing vaccine (use Td instead of Tdap) 2

Precautions

Evaluate risks versus benefits when:

• Guillain-Barré syndrome occurred ≤6 weeks after previous tetanus toxoid dose (if continuing, Tdap is preferred) 2
• History of Arthus reaction following previous tetanus toxoid—do not give any tetanus-containing vaccine until >10 years after most recent dose, even for wound management 1, 3
• Progressive neurologic disorder or uncontrolled epilepsy (withhold pertussis component; use Td instead) 2

Critical Pitfalls to Avoid

• Do NOT give tetanus boosters more frequently than every 10 years for routine immunization, as this increases risk of Arthus-type hypersensitivity reactions 1, 3
• Do NOT confuse the 10-year routine interval with the 5-year wound management interval for contaminated wounds—this is the most common error 1, 4
• Do NOT use DTaP in persons ≥7 years—use Tdap or Td instead 1, 3
• Do NOT restart the vaccination series if doses are delayed—continue from where the patient left off 1, 3
• Do NOT administer TIG to patients with complete primary series (≥3 doses) unless severely immunocompromised with contaminated wounds 4

Shorter Interval Considerations

While the standard 10-year interval applies to routine boosters, Tdap may be given at intervals <10 years in specific situations:

• During pertussis outbreaks or periods of increased community activity 1
• For wound management when ≥5 years since last dose with contaminated wounds 1, 4
• Healthcare workers may receive Tdap as early as 2 years after last Td 3

However, research suggests that after completing childhood vaccination, decennial boosters may no longer be necessary to maintain protective immunity in the general population, though current CDC guidelines still recommend the 10-year schedule 5

Administration Details

• Dose: 0.5 mL intramuscularly, preferably in the deltoid muscle 1, 3
• When giving TIG concurrently, use separate syringes at different anatomic sites 1, 4
• TIG prophylactic dose: 250 units IM for both adults and children 1, 4