Administration of the diphtheria-tetanus-acellular pertussis (DTaP) vaccine is routinely recommended in children, with a single booster dose of a vaccine containing tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) recommended for 11 to 12-year-olds, followed by tetanus toxoid and the reduced diphtheria toxoid in the form of Td recommended at 10-year intervals throughout life (figure 1A-B). (See "Standard immunizations for children and adolescents", section on 'Diphtheria, tetanus, and/or pertussis vaccines' and "Diphtheria, tetanus, and pertussis immunization in infants and children 0 through 6 years of age" and "Diphtheria, tetanus, and pertussis immunization in children 7 through 18 years of age".)
Despite these recommendations, immunity to tetanus and diphtheria continues to wane among adults in the United States. The magnitude of this effect was illustrated in a cross-sectional survey of individuals in the United States who were examined between 1988 and 1994 . Only 47 percent of adults over the age of 20 had protective antibody to both diseases and only 63 percent of adults with immunity to tetanus also had protective antibody to diphtheria. In comparison, 91 percent of children from 6 to 11 years of age had protective antibody to both diseases. Immunity to pertussis also wanes among adolescents and adults. (See "Microbiology, epidemiology, and pathogenesis of Bordetella pertussis infection".)
The rationale and risk-benefit considerations for the administration of tetanus-diphtheria toxoid (Td) vaccination in adults will be reviewed here. The use of the booster vaccine containing tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap), immunizations in pregnant women, and the general principles behind adult immunization are discussed separately. (See "Immunizations during pregnancy", section on 'Tetanus, diphtheria, pertussis (Tdap)' and "Approach to immunizations in healthy adults" and "Treatment and prevention of Bordetella pertussis infection in adolescents and adults", section on 'Prevention'.)
EPIDEMIOLOGY OF DISEASE
The epidemiology of tetanus and diphtheria is discussed in detail elsewhere, but will be briefly reviewed here. Both infections are completely preventable with safe and effective toxoid vaccines.
Tetanus — Because of near universal vaccination of children with tetanus toxoid, the incidence of tetanus in the United States and the rest of the developed world has dropped dramatically and steadily since 1940. During the period between 2001 and 2008, the US Centers for Disease Control and Prevention (CDC) reported that there were 233 cases of tetanus in the United States, with an annual incidence of 0.10 cases/million population overall, and 0.23 cases/million among individuals ≥65 years of age  Unpredictable acute injuries remain the major cause of tetanus in the United States.