What is the recommended tetanus vaccination schedule and administration (dose, route, timing) for pediatric and adult patients in the Philippines?

Tetanus Vaccination Guidelines for the Philippines: Pediatric and Adult Schedules

Pediatric Primary Series (Children <7 years)

For infants and young children, administer DTaP (diphtheria-tetanus-acellular pertussis) starting at 6 weeks of age with a total of 5 doses to complete the primary series. 1

Primary Vaccination Schedule:

• Dose 1: 6 weeks of age (minimum age) 1
• Dose 2: 4-8 weeks after first dose 2
• Dose 3: 4-8 weeks after second dose 2
• Dose 4: 6-12 months after third dose (may be given as early as 12 months if 6 months have elapsed since dose 3) 1, 2
• Dose 5: 4-6 years of age (final dose) 1

Administration Details:

• Dose: 0.5 mL intramuscularly 1
• Route: Intramuscular injection 1
• Site: Anterolateral thigh (infants) or deltoid muscle (older children) 1

Critical Pitfall to Avoid:

Never administer DTaP to children ≥7 years old—use Tdap or Td instead. 2 Pediatric formulations contain higher diphtheria toxoid concentrations that can cause severe reactions in older children and adults. 1

Adolescent Vaccination (11-18 years)

All adolescents aged 11-12 years who completed the childhood DTaP series should receive a single dose of Tdap (tetanus-diphtheria-acellular pertussis). 1, 2

Catch-Up Schedule:

• Adolescents aged 13-18 years who missed the 11-12 year dose should receive Tdap if they completed the childhood series 1
• Minimum age: 10 years for Boostrix®, 11 years for Adacel™ 1

Administration:

• Dose: 0.5 mL intramuscularly 1
• Site: Deltoid muscle (preferred) 1

Adult Vaccination (≥19 years)

All adults who have never received Tdap should receive one dose immediately, regardless of interval since last Td, followed by Td or Tdap boosters every 10 years. 1, 2

Primary Series for Unvaccinated Adults:

If an adult has never completed a primary tetanus series, administer three doses: 2

1. Dose 1: Tdap (immediately)
2. Dose 2: Td or Tdap ≥4 weeks after first dose
3. Dose 3: Td or Tdap 6-12 months after second dose

Routine Booster Schedule:

• Every 10 years after completing primary series 1, 2
• Either Td or Tdap may be used for routine boosters (since 2019 guidelines) 2

Administration:

• Dose: 0.5 mL intramuscularly 1
• Route: Intramuscular injection 1
• Site: Deltoid muscle (preferred) 1

Special Populations

Pregnant Women:

Administer one dose of Tdap during EACH pregnancy at 27-36 weeks gestation, regardless of prior Tdap history. 2 This provides passive antibody protection to the newborn against pertussis. 2

Healthcare Workers:

All healthcare personnel should receive a single dose of Tdap as soon as feasible if not previously received, with intervals as short as 2 years after last Td acceptable. 1 Priority should be given to those with direct contact with infants <12 months. 1

Elderly Adults (≥65 years):

Adults ≥65 years should receive Tdap if never previously received, with Boostrix preferred when feasible. 2 However, either Tdap product is acceptable to avoid missing vaccination opportunities. 2 This population has particularly low protective antibody levels (49-66% lack protection). 2

Wound Management Protocol

Clean, Minor Wounds:

Administer tetanus toxoid-containing vaccine only if ≥10 years since last dose. 2, 3

• ≥3 previous doses + last dose <10 years ago: No vaccine needed 2, 3
• ≥3 previous doses + last dose ≥10 years ago: Give Tdap (if never received) or Td 2, 3
• <3 doses or unknown history: Give Tdap AND TIG 250 units IM at separate sites 2, 3, 4

Contaminated/Tetanus-Prone Wounds:

Administer tetanus toxoid-containing vaccine if ≥5 years since last dose. 2, 3 Contaminated wounds include puncture wounds (like nail injuries), wounds with dirt/soil/feces, and wounds from crushing or burns. 2, 3

• ≥3 previous doses + last dose <5 years ago: No vaccine needed 2, 3
• ≥3 previous doses + last dose ≥5 years ago: Give Tdap (if never received) or Td; NO TIG needed 2, 3
• <3 doses or unknown history: Give BOTH Tdap AND TIG 250 units IM at separate anatomic sites using separate syringes 2, 3, 4

Tetanus Immune Globulin (TIG) Administration:

• Dose: 250 units intramuscularly (universal dose for adults and children) 2, 3, 4
• Administration: Use separate syringe at different anatomic site from tetanus toxoid 2, 3, 4
• Indications: <3 documented doses OR unknown vaccination history with any wound; severely immunocompromised patients with contaminated wounds regardless of history 2, 3

Patients with Unknown Vaccination History

Treat all patients with unknown or uncertain vaccination history as having zero previous doses. 2, 5

For Wound Management:

• Any wound: Give BOTH Tdap AND TIG 250 units IM at separate sites 2, 5
• After wound management: Complete the 3-dose primary series 2, 5

For Routine Vaccination:

Administer complete 3-dose primary series as outlined above for unvaccinated adults. 2

Critical Contraindications and Precautions

Absolute Contraindications:

• History of anaphylaxis to any vaccine component 1, 2
• Encephalopathy within 7 days of prior pertussis-containing vaccine (use Td instead of Tdap) 1, 2

Precautions:

• Guillain-Barré syndrome ≤6 weeks after prior tetanus dose: Tdap preferred over Td if vaccination needed 2
• Progressive neurologic disorder or uncontrolled epilepsy: Use Td instead of Tdap 2
• History of Arthus reaction: Do not give tetanus toxoid until >10 years after most recent dose, even for wound management 2, 3

Common Clinical Pitfalls to Avoid

1. Do NOT give tetanus boosters more frequently than every 10 years for routine immunization—this increases risk of Arthus-type hypersensitivity reactions (severe local reactions with pain, swelling, induration). 2, 3

2. Do NOT confuse the 10-year routine interval with the 5-year wound management interval for contaminated wounds—this is the most common error. 2, 3

3. Do NOT restart the vaccination series if doses are delayed—simply continue from where the patient left off. 2

4. Do NOT administer DTaP to persons ≥7 years—use Tdap or Td instead to avoid severe reactions. 1, 2

5. Do NOT give TIG to patients with documented complete primary series (≥3 doses) unless severely immunocompromised—this wastes resources and provides no additional benefit. 2, 3

6. Do NOT delay Tdap when indicated—it should be given regardless of interval since last Td. 1, 2

Documentation and Follow-Up

Maintain permanent vaccination records documenting vaccine type, manufacturer, anatomic site, route, date of administration, and administering facility. 1 Encourage patients to keep personal vaccination records to minimize unnecessary vaccinations. 1

For patients receiving TIG, ensure completion of the 3-dose primary series for long-term protection, as passive immunization does not confer lasting immunity. 2, 3