Primary prevention
Active immunization with tetanus vaccine protects against tetanus.[26] In most cases, 5 intramuscular doses at appropriate intervals give lifelong immunity. The vaccine is a purified toxin extracted from a strain of Clostridium tetani, which is treated with formaldehyde to produce tetanus toxoid.[4]
US schedule for tetanus immunization[27][28][29]
Primary immunization in infants and children at ages 0 to 6 years: 5-dose series of DTaP (D=diphtheria, T=tetanus, aP=acellular pertussis) given at 2, 4, 6, and 15 to 18 months of age, and 4 to 6 years of age.
Dose 4 may be administered as early as ages 12 months if ≥5 months since dose 3
If 4th dose inadvertently administered ages 12 to 14 months it may be counted if ≥4 months since dose 3
Dose 5 is not necessary if dose 4 was administered at age ≥4 years, and ≥6 months after dose 3.
First booster in adolescents ages 11 to 12 years: 1 dose of Tdap (T=tetanus, d=low-dose diphtheria, ap=acellular pertussis).
Second booster, all patients: 1 dose of Td (T=tetanus, d=low-dose diphtheria) or Tdap should be given every 10 years.
Patients who did not previously receive Tdap at or after age 11 years should receive one dose of Tdap, then Td or Tdap every 10 years. Adults who have not previously received the primary vaccination series should be given one dose of Tdap, followed by one dose of Td or Tdap at least 4 weeks later, and then another dose of Td or Tdap 6 to 12 months after the second dose. Td or Tdap booster doses are then given every 10 years.
A hexavalent vaccine is also approved by the US Food and Drug Administration to prevent diphtheria, tetanus, pertussis, polio, Haemophilus influenzae b, and hepatitis B. The DTaP-IPV-Hib-HepB vaccine is licensed for use in children ages 6 weeks to 4 years and is indicated for the primary vaccination series in infants at ages 2, 4, and 6 months.[30]
Pregnant women should be vaccinated with Tdap during each pregnancy, ideally between 27 and 36 weeks' gestation.
Tdap may be administered regardless of the time interval since the most recent tetanus-containing or diphtheria-toxoid-containing vaccine.
Other schedules for tetanus immunization
International immunization recommendations and schedules may vary, and local guidelines should be consulted.
The second booster dose is given every 10 years in most countries. Exceptions include France and Sweden, which recommend boosters every 20 years for immune competent adults, and the Czech Republic, which recommends boosters every 10 to 15 years.[31]
Experts have suggested limiting boosters in adults to ages 30 and 60, and then every 10 years after age 65. This suggestion aims to address concerns of over-immunization for tetanus, as antibody concentrations remain high after the primary immunization series in childhood.[32]
Travelers
Travelers at greatest risk for exposure and infection include humanitarian aid workers, pregnant travelers, and travelers not current with tetanus toxoid-containing vaccine. It is particularly important that those traveling to remote areas check they are up to date with tetanus vaccination before departure as tetanus immune globulin (TIG) and proper wound management may not be available, should a tetanus-prone injury occur.[33]
People who inject drugs
People who inject drugs should be fully immunized. Drug practices that are less tetanus prone can be encouraged, such as avoiding intramuscular and subcutaneous injection and using as little citric acid as possible, which devitalizes tissue.[23]
Pregnant women
Immunization of pregnant women, or women of childbearing age, with at least 2 doses of tetanus toxoid is estimated to decrease mortality from neonatal tetanus by 94%.[34] The American College of Obstetricians and Gynecologists has made the following recommendations regarding immunization during pregnancy.[35]
The tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap [T=tetanus, d=low-dose diphtheria, ap=acellular pertussis]) vaccine should be administered during each pregnancy, as early in the 27 to 36 weeks’ gestation window as possible.
In extenuating circumstances, it may be appropriate for a pregnant woman to receive the Tdap vaccine outside of this window, for example in cases of wound management or a pertussis outbreak.
If the Tdap vaccine is not administered during pregnancy, it should be given immediately postpartum if the woman has never received a prior dose of Tdap as an adolescent, adult, or during a previous pregnancy.
If the Tdap vaccine is administered early in the woman’s pregnancy (i.e., before 27 to 36 weeks of gestation), the woman does not need to be vaccinated again during 27 to 36 weeks of gestation.
Neonatal tetanus
In resource-poor settings, the World Health Organization advocates six clean methods to improve birth hygiene: clean birth surface, clean hands, clean perineum, cord cutting, cord tying, and cord care.[16][36]
Available evidence supports the implementation of immunization practices for women of childbearing age or pregnant women in communities with high levels of risk of neonatal tetanus.[37] [
]
Management of tetanus-prone wounds
Management of tetanus-prone wounds to prevent clinical tetanus depends on risk assessment of the wound and the immunization history of the patient.
In the US, patients with clean, minor wounds who have only had up to 2 doses of a tetanus toxoid-containing vaccine or an uncertain vaccination history should be given tetanus toxoid-containing vaccine, while patients who have received ≥3 doses do not require tetanus toxoid-containing vaccine unless they have not received a dose in the last 10 years. Clean, minor wounds do not require TIG.[3][38] For all other wounds, patients who have only had up to 2 doses of tetanus toxoid-containing vaccine or have an uncertain vaccination history should be given tetanus toxoid-containing vaccine and TIG; patients who have received ≥3 doses do not require TIG and do not require tetanus toxoid-containing vaccine unless they have not received a dose in the last 5 years.[3][38][Figure caption and citation for the preceding image starts]: US recommendations for tetanus wound management. DTaP = diphtheria and tetanus toxoids and acellular pertussis vaccine; Tdap = tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis; Td = tetanus and diphtheria toxoids; TIG = tetanus immune globulin. *DTaP is recommended for children aged <7 years. Tdap is preferred to Td for persons aged ≥11 years who have not previously received Tdap. Persons aged ≥7 years who are not fully immunized against pertussis, tetanus or diphtheria should receive one dose of Tdap for wound management and as part of the catch-up series. **Immunosuppressed patients should be managed as if they were incompletely immunized (i.e., those with contaminated wounds should also receive TIG, regardless of their history of tetanus immunization)Liang JL et al. Prevention of pertussis, tetanus, and diphtheria with vaccines in the United States: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2018;67:1-44. [Citation ends].
Immunosuppressed patients may not be adequately protected and additional boosting and/or TIG may be required; in the US, immunosuppressed patients should be managed as if they were incompletely immunized.[3][4][38]
If a tetanus booster is indicated for wound management during pregnancy, Tdap should be administered instead of Td if the woman has not received Tdap previously.[35]
Secondary prevention
Natural disease does not confer immunity; therefore, full tetanus immunization must be undertaken.
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