What are the indications and schedule for tetanus vaccination, including routine dosing, pregnancy, wound management, and special populations?

Tetanus Vaccination Criteria

All persons aged ≥11 years who have never received Tdap should receive one dose immediately, regardless of the interval since their last tetanus-containing vaccine, followed by Td or Tdap boosters every 10 years throughout life. 1

Routine Vaccination Schedule

Adolescents (11-18 years)

• Administer a single dose of Tdap at age 11-12 years for those who completed the childhood DTaP series 1
• After receiving Tdap, give booster doses of either Td or Tdap every 10 years to maintain protection 1
• For adolescents aged 7-10 years who received Tdap as part of catch-up vaccination, still administer an additional adolescent Tdap dose at age 11-12 years 1

Adults (≥19 years)

• Adults who never received Tdap should get one dose now, regardless of when they last received Td 1
• After the initial Tdap dose, administer Td or Tdap boosters every 10 years 1
• For adults who never completed primary vaccination: give a 3-dose series with at least one Tdap dose—preferably Tdap first, then Td ≥4 weeks later, then Td 6-12 months after the second dose 1

Special Populations

Pregnant Women:

• Administer one dose of Tdap during EACH pregnancy at 27-36 weeks gestation, regardless of prior Tdap history 1
• This recommendation applies even if the woman received Tdap recently 1

Healthcare Workers:

• All healthcare personnel should receive a single dose of Tdap as soon as feasible if not previously received 1

Elderly (≥65 years):

• Continue Td or Tdap boosters every 10 years 1
• Serosurveys show 49-66% of adults ≥60 years lack protective tetanus antibody levels, making adherence to the 10-year schedule particularly important 1

Wound Management Algorithm

Wound Classification

Clean, minor wounds: Superficial injuries with minimal contamination 1

Tetanus-prone wounds: Wounds contaminated with dirt, feces, soil, or saliva; puncture wounds; avulsions; wounds from missiles, crushing, burns, or frostbite 1

Vaccination Decision Based on History and Wound Type

For patients with ≥3 documented tetanus doses:

Clean, minor wounds:

• Give tetanus toxoid (Tdap preferred if never received Tdap; otherwise Td or Tdap) ONLY if ≥10 years since last dose 1
• No TIG needed 1

Tetanus-prone wounds:

• Give tetanus toxoid (Tdap preferred if never received Tdap; otherwise Td or Tdap) if ≥5 years since last dose 1
• No TIG needed 1

For patients with <3 documented doses OR unknown history:

Any wound type:

• Give BOTH tetanus toxoid-containing vaccine (Tdap preferred) AND TIG 250 units IM 1
• Administer at separate anatomic sites using separate syringes 1
• Patient must complete the 3-dose primary series for long-term protection 1

Vaccine Selection for Wound Management

• For persons aged ≥11 years who have not previously received Tdap or whose Tdap history is unknown, Tdap is preferred over Td 1
• For pregnant women requiring tetanus prophylaxis, use Tdap regardless of prior Tdap history 1
• For nonpregnant persons with documented previous Tdap vaccination, either Td or Tdap may be used 1

Catch-Up Vaccination

Children and Adolescents (7-18 years)

• Give one dose of Tdap (preferably as the first dose in the catch-up series) 1
• If additional doses needed, use either Td or Tdap 1
• The series does not need to be restarted regardless of time elapsed between doses 1
• Minimum intervals: second dose ≥4 weeks after first; third dose 6-12 months after second 1

Adults (≥19 years) with Incomplete Vaccination

• Preferred schedule: Tdap now, then Td or Tdap ≥4 weeks later, then Td or Tdap 6-12 months after the second dose 1
• Tdap can substitute for any dose in the 3-dose primary series 1

Unknown Vaccination History

• Treat patients with unknown or uncertain vaccination histories as having zero previous doses 1
• For wound management: give both tetanus toxoid and TIG 250 units IM at separate sites 1
• Alternative: consider serologic testing—if tetanus and diphtheria antitoxin levels are each >0.01 IU/mL, previous vaccination is presumed and only a single dose of Tdap is indicated 1

Critical Clinical Considerations

Contraindications and Precautions

• History of Arthus reaction: Do not give tetanus toxoid until >10 years after the most recent dose, even for contaminated wounds 1
• More frequent doses than recommended may increase the risk of Arthus-type hypersensitivity reactions 1

Immunocompromised Patients

• Persons with HIV infection or severe immunodeficiency should receive TIG regardless of tetanus immunization history when they have contaminated wounds 1

TIG Administration Details

• Standard prophylactic dose: 250 units IM for both adults and children 1
• Always use separate syringes at different anatomical sites when giving TIG and tetanus toxoid concurrently 1
• Human TIG is preferred over equine antitoxin due to longer protection and fewer adverse reactions 1

Common Pitfalls to Avoid

• 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
• Do not administer DTaP to persons aged ≥7 years; use Tdap or Td instead 1
• Do not restart the vaccination series if doses are delayed—simply continue from where the patient left off 1
• Do not give tetanus boosters more frequently than every 10 years for routine immunization to avoid Arthus reactions 1
• Persons who completed the primary series and received tetanus vaccine <5 years earlier are protected and do not require additional vaccination for wound management 1

Timing Considerations

• There is no urgent rush for tetanus toxoid administration in the acute wound setting, as it provides protection against the next injury, not the current one 3
• However, for contaminated wounds in patients requiring vaccination, administer within 24-48 hours as part of standard wound management 2
• Proper wound cleaning and debridement are critical components of tetanus prevention in addition to vaccination 1, 2