When should tetanus toxoid be administered in routine immunisation, during pregnancy, and for tetanus‑prone wounds?

When to Administer Tetanus Toxoid

All individuals aged ≥11 years who have never received Tdap should receive a single dose immediately, followed by Td or Tdap boosters every 10 years for life. 1

Routine Immunization Schedule

Adolescents and Adults

• Adolescents should receive one dose of Tdap at age 11–12 years after completing the DTaP series 1
• Adults ≥19 years who have never received Tdap should receive one dose now, regardless of the interval since their last Td dose, then continue Td or Tdap boosters every 10 years 2, 1
• Adolescents who received Tdap as catch-up between ages 7–10 years must receive an additional adolescent Tdap dose at age 11–12 years 1

Incomplete Primary Series

• Adults lacking a completed primary series should receive a 3-dose series that includes at least one Tdap (preferably first), followed by Td or Tdap ≥4 weeks later, and a final Td or Tdap 6–12 months after the second dose 2, 1
• The vaccination series does not need to be restarted for those with incomplete history, regardless of time elapsed between doses 2

Pregnancy

Administer one dose of Tdap during each pregnancy at 27–36 weeks gestation, regardless of prior Tdap history. 1, 3, 4

• To maximize maternal antibody response and passive antibody transfer to the newborn, vaccination as early as possible in the 27–36 week window is recommended 3, 4
• Tdap may be safely given at any time during pregnancy if needed for wound management, pertussis outbreaks, or other circumstances 3, 4
• Pregnant women who have never been vaccinated should receive a 3-dose primary series starting during pregnancy: first dose as soon as feasible, second dose ≥4 weeks later, third dose 6 months after the second 2
• At least 2 properly spaced doses during pregnancy provide minimal protection against neonatal tetanus 2

The evidence supporting Tdap in pregnancy is robust, with CDC monitoring activities confirming safety 5, and research demonstrating that vaccination during pregnancy achieves protective antibody levels in 93.5% of mothers after one dose and 95.6% after two doses 6.

Tetanus-Prone Wounds

Clean, Minor Wounds

• Provide tetanus toxoid (Tdap preferred if Tdap has never been received; otherwise Td or Tdap) only if ≥10 years have elapsed since the last tetanus vaccine 1, 7
• No TIG required 1

Contaminated/Tetanus-Prone Wounds

Tetanus-prone wounds include those contaminated with dirt, soil, feces, or saliva; puncture wounds; avulsions; and wounds from missiles, crushing, burns, or frostbite 1, 7

• Provide tetanus toxoid (Tdap preferred if Tdap has never been received; otherwise Td or Tdap) if ≥5 years have elapsed since the last tetanus vaccine 1, 7
• No TIG required if ≥3 documented doses 1

Unknown or Incomplete Vaccination History (<3 Doses)

• Administer both a tetanus toxoid-containing vaccine (Tdap preferred) and TIG 250 units IM at separate anatomical sites using separate syringes 1, 7
• Treat unknown or uncertain vaccination histories as zero prior doses 2, 1
• The individual must complete the 3-dose primary series for long-term protection 1

Vaccine Selection for Wound Prophylaxis

• For persons ≥11 years with no prior Tdap or unknown Tdap status, Tdap is preferred over Td 2, 1, 7
• For pregnant women requiring prophylaxis, use Tdap regardless of prior Tdap history 2, 1, 7
• For non-pregnant individuals with documented prior Tdap, either Td or Tdap may be used 2, 1

Special Populations and Precautions

Healthcare Personnel

• Give a single Tdap dose as soon as feasible if they have not previously been vaccinated 1

Older Adults (≥65 Years)

• Continue Td or Tdap boosters every 10 years 1
• Serosurveys indicate that 49–66% of adults ≥60 years lack protective tetanus antibodies, underscoring the importance of adherence 1

Arthus Reaction History

• Persons with a prior Arthus reaction should not receive tetanus toxoid until >10 years after the most recent dose, even for contaminated wounds 1, 7
• More frequent dosing increases the risk of Arthus-type hypersensitivity 1

Severely Immunocompromised Patients

• Individuals with HIV infection or severe immunodeficiency should receive TIG regardless of tetanus immunization history when presenting with contaminated wounds 1, 7

Critical Clinical Pearls

• Persons who completed the primary series and received a tetanus vaccine <5 years ago are considered protected and do not require additional vaccination for wound management 1
• Routine tetanus boosters should not be given more frequently than every 10 years to avoid Arthus reactions 1
• Standard prophylactic TIG dose is 250 units IM for both adults and children; always administer TIG and tetanus toxoid using separate syringes at different anatomical sites 1, 7
• Human TIG is preferred over equine antitoxin due to longer protection and fewer adverse reactions 1