Tetanus Immunization

Introduction
Adequate tetanus prophylaxis is important in
patients with multiple injuries, particularly when
open-extremity trauma is present. The average
incubation period for tetanus is 10 days; most often
it is 4 to 21 days. In severe trauma cases, tetanus can
appear as early as 1 to 2 days after injury. All medical
professionals must be cognizant of this important
fact when providing care to injured patients. Recent
General Principles
studies conclude that it is not possible to determine
clinically which wounds are prone to tetanus; tetanus The following general principles for doctors who treat
can occur after minor, seemingly innocuous injuries, trauma patients concern surgical wound care and pas-
yet it is rare after severely contaminated wounds. sive immunization.
Thus, all traumatic wounds should be considered at
risk for the development of tetanus infection. SURGICAL WOUND CARE
Tetanus immunization depends on the patients
Regardless of the active immunization status of the
previous immunization status and the tetanus-prone
patient, meticulous surgical careincluding removal
nature of the wound. The following guidelines
of all devitalized tissue and foreign bodiesshould be
are adapted from the literature, and information
provided immediately for all wounds. If the adequacy
is available from the Centers for Disease Control
of wound debridement is in question or a puncture
and Prevention (CDC). Because this information is
injury is present, the wound should be left open and
continuously reviewed and updated as new data
not closed by sutures. Such care is essential as part
become available, the American College of Surgeons
of the prophylaxis against tetanus. Traditional clinical
Committee on Trauma recommends contacting the
features that influence the risk for tetanus infection in
CDC for the most current information and detailed
soft tissue wounds are listed in Table 1. However, all
guidelines related to tetanus prophylaxis and im-
wounds should be considered at risk for the develop-
munization for injured patients.
ment of tetanus.

PASSIVE IMMUNIZATION
Passive immunization with 250 units of human teta-
nus immune globulin (TIG) administered intramuscu-
larly must be considered for each patient. TIG provides
longer protection than antitoxin of animal origin and
causes few adverse reactions. The characteristics of
the wound, conditions under which it occurred, wound
age, TIG treatment, and the previous active immu-
nization status of the patient must all be considered
(Table 2). Due to the concerns about herd immunity to
both pertussis and diphtheria, and recent outbreaks of
both, Tdap (tetanus, diphtheria, and pertussis) is pre-
ferred to Td (tetanus and diphtheria) for adults who
have never received Tdap. Td is preferred to TT (teta-
nus toxoid) for adults who received Tdap previously
or when Tdap is not available. If TT and TIG are both
used, Tetanus Toxoid Adsorbed rather than tetanus

1
2 Tetanus Immunization

Table 1 Wound Features and Tetanus Risk

CLINICAL FEATURES OF WOUND NONTETANUS-PRONE WOUNDS TETANUS-PRONE WOUNDS

Age of wound 6 hours > 6 hours

Configuration Linear wound, abrasion Stellate wound, avulsion

Depth 1 cm >1 cm

Mechanism of injury Sharp surface (e.g., knife, glass) Missile, crush, burn, frostbite

Signs of infection Absent Present

Devitalized tissue Absent Present

Contaminants (e.g., dirt, feces, soil, saliva) Absent Present

Denervated and/or ischemic tissue Absent Present

Adapted with permission from the Centers for Disease Control and Prevention, Atlanta, GA, www.cdc.gov/epo/mmwr/preview/mmwrhtml/00041645.htm., last
updated 2007.

Table 2 Summary of Tetanus Prophylaxis for Injured Patients

HISTORY OF ADSORBED NON-TETANUS-PRONE WOUNDS TETANUS-PRONE WOUNDS
TETANUS TOXOID (DOSES)
Tda TIG Tda TIG

Unknown or < 3 Yes No Yes Yes

3b Noc No Nod No

Td = Tetanus and diphtheria toxoids adsorbed, for adult use.

TIG = Tetanus immune globulin, human.
a
F or children younger than 7 years old: DTP (DT, if pertussis vaccine is contraindicated) is preferred to tetanus toxoid alone. For patients 7 years old and older: Td
is preferred to tetanus toxoid alone.
b
If only three doses of fluid toxoid have been received, a fourth dose of toxoid, preferably an adsorbed toxoid, should be given.
c
Yes, if more than 10 years since last tetanus-toxoid containing dose.
d
Yes, if more than 5 years since last tetanus-toxoid containing dose. (More frequent boosters are not needed and can accentuate side effects.)
Adapted with permission from the Centers for Disease Control and Prevention, Atlanta, GA, www.cdc.gov/epo/mmwr/preview/mmwrhtml/00041645.htm., last
updated 2007.

toxoid for booster use only (fluid vaccine) should be
used. When tetanus toxoid and TIG are given concur-
rently, separate syringes and separate sites should be
used. If the patient has ever received a series of three
injections of toxoid, TIG is not indicated, unless the
wound is judged to be tetanus-prone and is more than
24 hours old.
Bibliography
1. Advisory Committee on Immunization Practices. Pre-
venting tetanus, diphtheria, and pertussis among adults:
use of tetanus toxoid, reduced diphtheria toxoid and
acellular pertussis vaccine recommendations of the Advi-
sory Committee on Immunization Practices (ACIP) and
recommendation of ACIP, supported by the Healthcare
Infection Control Practices Advisory Committee (HIC-
PAC), for use of Tdap among health-care personnel.
MMWR 2006;December 15.
2. Rhee P, Nunley MK, Demetriades D, Velmahos G, Dou-
cet JJ. Tetanus and trauma: a review and recommenda-
tion. J Trauma 2005;58:1082-1088.
3. U.S. Department of Health and Human Services, Cen-
ters for Disease Control and Prevention. Tetanus. http://
www.cdc.gov/vaccines/pubs/pinkbook/downloads/teta-
nus.pdf. Accessed June 8, 2012.