What makes UpToDate so powerful?

  • over 11000 topics
  • 22 specialties
  • 5,700 physician authors
  • evidence-based recommendations
See more sample topics
Find Patient Print
0 Find synonyms

Find synonyms Find exact match

Tetanus-diphtheria toxoid vaccination in adults
UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
Tetanus-diphtheria toxoid vaccination in adults
View in Chinese
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Sep 2017. | This topic last updated: Sep 12, 2017.

INTRODUCTION — 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 "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 [1]. 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 "Pertussis infection: Epidemiology, microbiology, and pathogenesis".)

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, and pertussis vaccination' and "Approach to immunizations in healthy adults" and "Pertussis infection in adolescents and adults: Treatment and prevention", 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 United States 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 [2]. Unpredictable acute injuries remain the major cause of tetanus in the United States.

Despite the low rate of clinical disease, many adults are inadequately vaccinated against tetanus. In the serologic survey cited above in the United States between 1988 and 1994, fully protective levels of antitetanus antibody were present in 72 percent of individuals ≥6 years of age and only 31 percent of adults over the age of 70 [1]. Not surprisingly, protective antibody levels are more likely in adults with a history of military service, higher levels of education, higher incomes, and medical insurance [3,4].

Adults age 65 years and older are at highest risk for both tetanus and tetanus-related death [2]. This is consistent with the decreasing proportion with age of persons who have received tetanus toxoid in the previous ten years among adults in the United States between 1993 and 1997: 65 percent between the ages of 18 and 49, 54 percent between the ages of 50 and 64, and 40 percent ≥65 years of age [4].

In contrast to these observations in developed nations, approximately 1,000,000 cases of tetanus are estimated to occur in developing nations each year. (See "Tetanus", section on 'Epidemiology'.)

Diphtheria — Approximately 20 to 60 percent of adults become susceptible to diphtheria because of waning vaccine-induced immunity and failure to receive recommended booster immunization. This was illustrated in the serologic survey cited above in the United States between 1988 and 1994: fully protective levels of antidiphtheria antibody were present in 61 percent of individuals ≥6 years of age and only 30 percent of adults over the age of 70 [1]. Similar findings were noted in 1995 study of 1000 United Kingdom-born blood donors in North London: 38 percent were susceptible to diphtheria (serum diphtheria antitoxin concentration below 0.01 IU/mL), 31 percent had basic protection, and 31 percent were fully protected [5].

Despite the frequent lack of immunity, there is still a low rate of clinical disease because immunization of the population has minimized the transmission of toxigenic strains. Only 45 cases of respiratory diphtheria were reported to the CDC from 1980 to 1996 (zero to five cases in any given year) [6]. However, unvaccinated or inadequately vaccinated travelers to endemic areas are at risk for acquiring this infection. (See "Epidemiology and pathophysiology of diphtheria".)

For reasons that are not well understood, pockets of diphtheria are reappearing, primarily in developing countries. The epidemics have involved nonimmunized or poorly immunized adults in addition to children.

INDICATIONS FOR TD OR TDAP VACCINATION

Routine immunization — In the serologic survey of individuals examined in the United States 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 [1].

Waning immunity against tetanus and diphtheria is responsible for the recommendation for universal administration of Td boosters every 10 years [7]. The United States Advisory Committee on Immunization Practices (ACIP) also recommends a single dose of a vaccine containing tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap; Adacel or Boostrix) 0.5 mL IM in place of Td for all adults aged 19 years and older who have not received Tdap previously to address waning immunity against pertussis [8,9]. Boostrix has been approved by the US Food and Drug Administration for individuals 10 years of age and older, whereas Adacel has only been approved for individuals between the ages of 10 and 64 years [9,10]. In adults aged 65 years and older, Boostrix should be used when possible. If only Adacel is available, it may be used in this age group, since it has been shown to be immunogenic.

The ACIP recommends that all pregnant women receive vaccination against pertussis with Tdap during each pregnancy [11]. Detailed recommendations are presented separately. (See "Immunizations during pregnancy", section on 'Tetanus, diphtheria, and pertussis vaccination'.)

When indicated, Tdap should be administered regardless of the interval since the last dose of Td [8,9]. This represents a change from previous ACIP guidelines, which recommended that Tdap be given a minimum of two years after the last dose of Td in most cases. The following Figures summarize the ACIP recommendations for immunization of adults without and with comorbidities, respectively (figure 2 and figure 3) [7,9]. The use of Tdap is discussed in detail separately. (See "Pertussis infection in adolescents and adults: Treatment and prevention", section on 'Vaccination'.)

Subsequent tetanus doses, in the form of Td, should be given at 10-year intervals throughout adulthood.

Immunization for patients with injuries — Regardless of prior tetanus and diphtheria immunization, Td immunization should be reviewed when anyone presents with an acute injury or wound and prophylaxis (ie, tetanus toxoid-containing vaccine with or without human tetanus immune globulin) should be administered as indicated (table 1) [7].

Most patients who develop tetanus are not completely vaccinated and do not receive adequate wound prophylaxis, even when they present for medical care [2]. Incomplete vaccination is more likely in the following groups:

Injection drug users

Immigrants

Rural populations

Older adults

For patients who have received fewer than three doses or an unknown number of doses of a tetanus toxoid-containing vaccine, tetanus immunization should be administered (table 1) [7]. The preferred vaccine preparation depends upon the age and vaccination history of the patient. For patients with clean minor wounds who have received three or more doses of a tetanus toxoid-containing vaccine, another dose should be given only if the last dose was given 10 or more years ago. For patients with wounds that are more severe than a clean and minor wound (such as, but not limited to, wounds contaminated with dirt, feces, soil, or saliva; puncture wounds; avulsions; wounds resulting from missiles, crushing, burns, or frostbite) who have received three or more doses of a tetanus toxoid-containing vaccine, another dose should be given only if the last dose was given five or more years ago. The vaccine series should be continued through completion as necessary. If there is any doubt about whether or not an adult received the primary series, three doses of Td should be administered; the first dose and second dose should be separated by four weeks and the third dose should be given 6 to 12 months later (figure 2 and figure 3).

Since inadequate protection against diphtheria and tetanus often occur together [1], Td is the preferred vaccine, not tetanus toxoid alone. The tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine should be used in place of Td in adults who have an indication. (See 'Routine immunization' above and "Pertussis infection in adolescents and adults: Treatment and prevention", section on 'Prevention'.)

The importance of ensuring that pregnant women have completed their primary series and have received a Tdap booster during each pregnancy is discussed separately. (See "Immunizations during pregnancy".)

In addition to tetanus immunization, human tetanus immune globulin (250 units intramuscularly [IM]) is indicated in individuals who have sustained a wound that is more severe than a clean and minor wound (eg, wounds contaminated with dirt, feces, soil, or saliva; puncture wounds; avulsions; wounds resulting from missiles, crushing, burns, or frostbite) and who have either received fewer than three doses of tetanus toxoid previously or in whom the number of previous doses is unknown.

Appropriate tetanus prophylaxis should be administered as soon as possible following a wound but should be given even to patients who present late for medical attention. This is because the incubation period is quite variable; the incubation period of tetanus is approximately 8 days but ranges from 3 to 21 days [12]. (See "Tetanus", section on 'Incubation period'.)

Adverse effects — Severe systemic reactions, such as anaphylaxis, generalized urticaria, angioedema, and neurologic complications, have been reported following Td administration, but a causal relationship between the neurologic complications and vaccine administration have not been established. Patients who develop an arthus-like reaction tend to have high serum antitoxin levels and should be instructed to avoid booster doses more often than every 10 years. (See "Allergic reactions to vaccines".)

CONTRAINDICATIONS AND PRECAUTIONS — Contraindications and precautions are summarized in the Table (table 2).

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Immunizations in adults" and "Society guideline links: Diphtheria, tetanus, and pertussis vaccination".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The Basics” and “Beyond the Basics.” The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on “patient info” and the keyword(s) of interest.)

Basics topics (see "Patient education: Tetanus (The Basics)" and "Patient education: Vaccines for adults (The Basics)" and "Patient education: Vaccines (The Basics)" and "Patient education: Tdap vaccine (The Basics)")

Beyond the Basics topics (see "Patient education: Adult vaccines (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

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 and figure 1B). Despite these recommendations, immunity to tetanus and diphtheria continues to wane among adults in the United States. (See 'Introduction' above.)

The United States Advisory Committee on Immunization Practices (ACIP) recommends a single dose of a vaccine containing tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) 0.5 mL intramuscularly [IM] in place of Td for all adults aged 19 years and older who have not received Tdap previously to address waning immunity against pertussis. The ACIP recommends that all pregnant women receive vaccination against pertussis with Tdap during each pregnancy. (See 'Routine immunization' above.)

Regardless of prior tetanus and diphtheria immunization, Td immunization should be reviewed when anyone presents with an acute injury or wound and prophylaxis administered as indicated (table 1). In addition to tetanus immunization, human tetanus immune globulin is indicated in individuals who have sustained a wound that is more severe than a clean and minor wound (eg, wounds contaminated with dirt, feces, soil, or saliva; puncture wounds; avulsions; wounds resulting from missiles, crushing, burns, or frostbite) and who have either received fewer than three doses of tetanus toxoid previously or in whom the number of previous doses is unknown. (See 'Immunization for patients with injuries' above.)

If there is any doubt about whether or not an adult received the primary series, three doses of Td should be administered; the first dose and second dose should be separated by four weeks and the third dose should be given 6 to 12 months later. Tdap should be used in place of Td in adults who have an indication (table 1). (See 'Immunization for patients with injuries' above.)

Use of UpToDate is subject to the  Subscription and License Agreement.

REFERENCES

  1. McQuillan GM, Kruszon-Moran D, Deforest A, et al. Serologic immunity to diphtheria and tetanus in the United States. Ann Intern Med 2002; 136:660.
  2. Centers for Disease Control and Prevention (CDC). Tetanus surveillance --- United States, 2001-2008. MMWR Morb Mortal Wkly Rep 2011; 60:365.
  3. Gergen PJ, McQuillan GM, Kiely M, et al. A population-based serologic survey of immunity to tetanus in the United States. N Engl J Med 1995; 332:761.
  4. Singleton JA, Greby SM, Wooten KG, et al. Influenza, pneumococcal, and tetanus toxoid vaccination of adults --- United States, 1993--1997. MMWR Surveill Summ 2000; 49:39.
  5. Maple PA, Efstratiou A, George RC, et al. Diphtheria immunity in UK blood donors. Lancet 1995; 345:963.
  6. CDC - Vaccination Coverage in the U.S. http://www.cdc.gov/vaccines/imz-managers/coverage/imz-coverage.html (Accessed on April 17, 2014).
  7. Kim DK, Riley LE, Harriman KH, et al. Recommended Immunization Schedule for Adults Aged 19 Years or Older, United States, 2017. Ann Intern Med 2017; 166:209.
  8. Centers for Disease Control and Prevention (CDC). Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis (Tdap) vaccine from the Advisory Committee on Immunization Practices, 2010. MMWR Morb Mortal Wkly Rep 2011; 60:13.
  9. Centers for Disease Control and Prevention (CDC). Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine in adults aged 65 years and older - Advisory Committee on Immunization Practices (ACIP), 2012. MMWR Morb Mortal Wkly Rep 2012; 61:468.
  10. US Food and Drug Administration. Adacel (Tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine adsorbed). www.fda.gov/BiologicsBloodVaccines/Vaccines/ApprovedProducts/ucm172481.htm (Accessed on April 08, 2014).
  11. Centers for Disease Control and Prevention (CDC). Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) in pregnant women--Advisory Committee on Immunization Practices (ACIP), 2012. MMWR Morb Mortal Wkly Rep 2013; 62:131.
  12. Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-Preventable Diseases. Tetanus. https://www.cdc.gov/vaccines/pubs/pinkbook/tetanus.html (Accessed on September 06, 2017).
Topic 3897 Version 36.0

All topics are updated as new information becomes available. Our peer review process typically takes one to six weeks depending on the issue.