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
studies conclude that it is not possible to determine
clinically which wounds are prone to tetanus; tetanus
can occur after minor, seemingly innocuous injuries,
yet it is rare after severely contaminated wounds.
Thus, all traumatic wounds should be considered at
risk for the development of tetanus infection.

Tetanus immunization depends on the patients
previous immunization status and the tetanus-prone
nature of the wound. The following guidelines
are adapted from the literature, and information
is available from the Centers for Disease Control
and Prevention (CDC). Because this information is
continuously reviewed and updated as new data
become available, the American College of Surgeons
Committee on Trauma recommends contacting the
CDC for the most current information and detailed
guidelines related to tetanus prophylaxis and immunization for injured patients.

General Principles

The following general principles for doctors who treat

trauma patients concern surgical wound care and passive immunization.

SURGICAL WOUND CARE

Regardless of the active immunization status of the
patient, meticulous surgical careincluding removal
of all devitalized tissue and foreign bodiesshould be
provided immediately for all wounds. If the adequacy
of wound debridement is in question or a puncture
injury is present, the wound should be left open and
not closed by sutures. Such care is essential as part
of the prophylaxis against tetanus. Traditional clinical
features that influence the risk for tetanus infection in
soft tissue wounds are listed in Table 1. However, all
wounds should be considered at risk for the development of tetanus.

PASSIVE IMMUNIZATION
Passive immunization with 250 units of human tetanus immune globulin (TIG) administered intramuscularly 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 immunization 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 preferred to Td (tetanus and diphtheria) for adults who
have never received Tdap. Td is preferred to TT (tetanus 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

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
TETANUS TOXOID (DOSES)

NON-TETANUS-PRONE WOUNDS

TETANUS-PRONE WOUNDS

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.
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.)
a

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 concurrently, 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. Preventing tetanus, diphtheria, and pertussis among adults:
use of tetanus toxoid, reduced diphtheria toxoid and

acellular pertussis vaccine recommendations of the Advisory Committee on Immunization Practices (ACIP) and
recommendation of ACIP, supported by the Healthcare
Infection Control Practices Advisory Committee (HICPAC), for use of Tdap among health-care personnel.
MMWR 2006;December 15.
2. Rhee P, Nunley MK, Demetriades D, Velmahos G, Doucet JJ. Tetanus and trauma: a review and recommendation. J Trauma 2005;58:1082-1088.
3. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Tetanus. http://
www.cdc.gov/vaccines/pubs/pinkbook/downloads/tetanus.pdf. Accessed June 8, 2012.