Diphtheria and Tetanus Toxoids Adsorbed, Tetanus and Diphtheria Toxoids Adsorbed

Class: Toxoids
ATC Class: J07AF01
VA Class: IM105
Brands: Decavac

Introduction

Fixed-combination preparations containing formaldehyde-treated tetanus and diphtheria toxins (toxoids) adsorbed onto aluminum adjuvants.^{100 113 114 164} The toxoids are used to stimulate active immunity to diphtheria and tetanus.^{100 113 114 164} Commercially available as diphtheria and tetanus toxoids adsorbed (DT) and tetanus and diphtheria toxoids adsorbed (Td).^{113 114 164} DT contains a higher dose of diphtheria toxoid than Td.^{113 114 164} Single-antigen preparation containing tetanus toxoid adsorbed also commercially available.¹⁴⁰

Uses for Diphtheria and Tetanus Toxoids Adsorbed, Tetanus and Diphtheria Toxoids Adsorbed

Prevention of Diphtheria and Tetanus

DT is used to prevent diphtheria and tetanus in infants and children 6 weeks through 6 years of age.^{100 114} Td is used to prevent diphtheria and tetanus in adults, adolescents, and children ≥7 years of age.^{113 164}

Diphtheria is caused by toxigenic strains of Corynebacterium diphtheriae or, rarely, toxigenic strains of C. ulcerans.^{100 101 115 119 132 133 145 161} The overall case-fatality rate for diphtheria is 5–10% with higher death rates (up to 20%) among individuals <5 years of age and >40 years of age.^{119 162} Diphtheria is uncommon in the US, but toxigenic strains of Corynebacterium continue to circulate in areas of the US where the disease previously was endemic.^{100 101 119 161} Diphtheria continues to circulate worldwide and is endemic in Albania, Russia, and countries in the former Soviet Union and in many countries in Africa, Latin America, Asia/South Pacific, and the Middle East.^{100 101 119} Consult the CDC website () should be consulted for information regarding where diphtheria is endemic.¹¹⁵ Before widespread immunization against diphtheria was initiated in the 1940s, there were approximately 100,000–200,000 cases of diphtheria and 13,000–15,000 diphtheria-related deaths each year in the US.¹¹⁹ Most cases of diphtheria occur in individuals who are unvaccinated or incompletely vaccinated against the disease.^{100 101 119}

Tetanus is a potentially fatal disease caused by a neurotoxic exotoxin (tetanospasmin) produced by Clostridium tetani.^{101 113 114 115 119} C. tetani spores are ubiquitous in the environment worldwide and are found in soil and in animal (e.g., horses, sheep, cattle, dogs, cats, rats, guinea pigs, chickens) and human intestinal tracts.^{100 101 114 115 119 132} The spores can contaminate open wounds, especially puncture wounds or those with devitalized tissue; anaerobic wound conditions allow the spores to germinate and produce exotoxins that disseminate through the blood and lymphatic system.^{101 119 132} Neonatal tetanus (tetanus neonatorum) occurs in infants born under nonsterile conditions to women inadequately vaccinated against tetanus; infection usually involves a contaminated umbilical stump and occurs because infant does not have passively-acquired maternal antibodies against tetanus.^{100 101 113 115 119 132 145} Obstetric tetanus occurs within 6 weeks after delivery or termination of pregnancy because of contaminated wounds or abrasions or unclean deliveries or abortions.¹⁴⁵ Generalized tetanus is characterized by rigidity and convulsive muscle spasms that usually involve the jaw (lockjaw) and neck and then become generalized.^{101 113 115 119 132} Tetanus occurs worldwide, almost exclusively in individuals who are unvaccinated or inadequately vaccinated against the disease.^{101 115} An average of 31 cases reported each year in the US from 2000 through 2007 (case fatality rate 10%);¹¹⁹ a low of 20 cases reported in 2003.¹¹⁹ Most cases of tetanus in the US occur following acute injuries or wounds (puncture wounds, lacerations, abrasions)^{119 126} and usually occur in adults 40 years of age or older; however, an increase in the disease has been reported recently in younger adults (e.g., heroin abusers).^{119 126} Tetanus is not transmitted person-to-person.^{115 119}

USPHS Advisory Committee on Immunization Practices (ACIP), AAP, and American Academy of Family Physicians (AAFP) recommend that all individuals be immunized against diphtheria and tetanus and also immunized against pertussis.^{100 101 102 132 133 134 135 145} Use of a combination vaccine generally is preferred over separate injections of equivalent component vaccines;^{102 163} considerations include provider assessment (e.g., number of injections, vaccine availability, likelihood of improved coverage, likelihood of patient return, storage requirements, cost), patient preference, and potential for adverse effects.^{102 163} Therefore, a fixed-combination preparation containing antigens for all 3 diseases (diphtheria and tetanus toxoids and acellular pertussis vaccine adsorbed; DTaP) is preferred for primary and booster immunization against these diseases in infants and children 6 weeks through 6 years of age.^{100 101 102 119} DT should be used for primary or booster immunization against diphtheria and tetanus only when there is a contraindication to the pertussis antigens contained in DTaP.^{100 101 102 112 113 119}

Td usually is the preparation of choice for primary and booster immunization against diphtheria and tetanus in individuals ≥7 years of age.^{100 101 102 133 134 145} However, to reduce morbidity associated with pertussis in adults, ACIP, AAP, and AAFP recommend that a single dose of a fixed-combination preparation that also contains pertussis antigens (tetanus toxoid and reduced diphtheria toxoid and acellular pertussis vaccine adsorbed; Tdap) be used in place of a required primary or booster dose of Td in all individuals 11–64 years of age, unless the pertussis antigens are contraindicated.^{102 132 133 134 135 145} Any individual in this age group who previously received a single dose of Tdap should then receive Td for all subsequent primary or booster doses.^{102 132 133 134 135 145}

Combined active immunization with a preparation containing tetanus toxoid adsorbed and passive immunization with tetanus immune globulin (TIG) is used to prevent tetanus in individuals with tetanus-prone wounds who are inadequately vaccinated against tetanus or whose tetanus vaccination status is uncertain.^{100 101 110 113 132 133 145 164} (See Postexposure Prophylaxis of Tetanus under Uses.)

DT and Td are not indicated for treatment of diphtheria or treatment of tetanus.^{104 107 114}

Because diphtheria and tetanus infections do not necessarily confer immunity, initiate or complete primary immunization against diphtheria and tetanus at the time of recovery from these infections in any previously unvaccinated or incompletely vaccinated individual.^{100 101 113 119}

Preexposure Vaccination Against Tetanus and Diphtheria in High-risk Groups

Travelers who are unvaccinated or incompletely vaccinated against diphtheria and tetanus should receive the remaining recommended doses prior to travel.¹¹⁵

Tetanus, diphtheria, and pertussis occur worldwide; the incidence of pertussis is highest in developing countries and other countries where routine immunization against pertussis is not widely practiced.¹¹⁵

CDC, AAP, and others recommend that travelers be adequately immunized against diphtheria, tetanus, and pertussis before leaving the US.^{101 108 115}

Adults and children 7 years of age or older who are unvaccinated or incompletely vaccinated against diphtheria and tetanus should receive the remaining recommended doses of Td prior to travel.^{108 115} Those with an uncertain history of vaccination should be considered unvaccinated and should receive the full 3-dose primary immunization series.^{108 115 133} A routine booster dose of Td should be administered prior to travel if ≥10 years have elapsed since primary immunization or the last booster dose.^{108 115} A dose of Tdap can be substituted for a booster dose of Td in any adolescent or adult 11–64 years of age who has not previously received a dose of Tdap.^{108 115 132 133} (See Dosage and Administration.)

Because children 6 weeks through 6 years of age also should be immunized against pertussis, travelers in this age group who are unvaccinated or incompletely vaccinated should receive the remaining required doses of DTaP or, if the pertussis component is contraindicated, the remaining required doses of DT prior to travel.^{108 115} Previously unimmunized children should receive 3 doses (preferably 4 doses) before travel.¹⁰⁸

If necessary to complete the vaccination series before departure, adults, adolescents, and children can receive an accelerated immunization schedule using the age-appropriate minimum intervals between doses.^{101 108 115} (See Dosage under Dosage and Administration.)

Any individual wounded while traveling who received their most recent dose of a tetanus toxoid-containing preparation >5 years previously may require a dose for postexposure prophylaxis of tetanus, depending on the nature of the wound.¹¹⁵ (See Postexposure Prophylaxis of Tetanus under Uses.)

Postexposure Prophylaxis of Tetanus

Postexposure prophylaxis of tetanus in individuals with tetanus-prone wounds who previously received <3 doses of a preparation containing tetanus toxoid adsorbed or whose tetanus vaccination status is unknown or uncertain.^{100 101 110 113 132 133 145 164}

Postexposure prophylaxis of tetanus involves active immunization with a tetanus toxoid-containing preparation with or without passive immunization with a dose of tetanus immune globulin (TIG).^{100 101 110 113 132 133 145 164}

Tetanus-prone wounds include, but are not limited to, wounds contaminated with dirt, feces, soil, or saliva, deep wounds, burns, crush injuries, and wounds containing devitalized or necrotic tissue.^{100 101 115 119} Tetanus also has been associated with apparently clean, superficial wounds, surgical procedures, insect bites, animal bites, dental infections, chronic sores and infections, and IV drug abuse.^{115 119}

In the event of injury and possible exposure to tetanus, the need for active immunization against tetanus with or without passive immunization with TIG depends on the individual’s vaccination status and the likelihood of contamination with tetanus bacilli (e.g., condition of wound, source of contamination).^{100 101 132 133 145}

Table 1 summarizes ACIP guidelines for active and passive immunization against tetanus in routine wound management.

Tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine adsorbed (Tdap). A dose of Tdap is preferred to a dose of Td in adolescents and adults 11 through 64 years of age who have not previously received a dose of Tdap. Use Td in individuals in this age group who previously received a dose of Tdap.

Tetanus and diphtheria toxoids adsorbed for adults use (Td). Td is used in adults, adolescents, and children ≥7 years of age. For children 6 weeks through 6 years of age, DTaP usually is indicated, but DT can be used if pertussis antigens are contraindicated. Monovalent tetanus toxoid adsorbed generally is used only when preparations containing tetanus and diphtheria antigens and preparations containing tetanus, diphtheria, and pertussis antigens are contraindicated or unavailable.

If only 3 doses of tetanus toxoid fluid (no longer commercially available in the US) have been received previously, a fourth dose should be given as a preparation containing tetanus toxoid adsorbed.

Yes, if it has been >10 years since last dose of tetanus toxoid-containing preparation.

Yes, if it has been >5 years since last dose of tetanus toxoid-containing preparation; more frequent booster doses not needed and can accentuate adverse effects.

Adapted from the Recommendations of the Immunization Practices Advisory Committee (ACIP) on prevention of diphtheria, tetanus, and pertussis published in MMWR Recomm Rep. 1991; 40(RR-10):1-28, MMWR Recomm Rep. 2006; 55(RR-3):1-43, and MMWR Recomm Rep. 2006; 55(RR-17):1-37.

Table 1. Summary Guide to Tetanus Prophylaxis in Routine Wound Management100132133

Previous Doses of Tetanus Toxoid Adsorbed Received	Clean, Minor Wounds	All Other Wounds
	Tdap or Td	TIG	Tdap or Td	TIG
Unknown or <3	Yes	No	Yes	Yes
≥3	No	No	No	No

Any individual whose tetanus vaccination status is unknown or uncertain should be considered to have had no previous doses of tetanus toxoid adsorbed.^{100 132 133 145}

ACIP, AAP, and AAFP recommend that a single dose of Tdap be used in place of a dose of Td for postexposure prophylaxis in individuals 11–64 years of age who have not previously received a dose of Tdap and received their last dose of Td ≥5 years earlier.^{102 132 133 135 145} Any individual in this age group who previously received a single dose of Tdap should receive Td for postexposure prophylaxis.^{102 132 133 135 145}

Anti-infectives are not indicated for tetanus postexposure prophylaxis since they do not neutralize exotoxin already formed and cannot eradicate C. tetani spores, which may revert to toxin-producing vegetative forms.^{100 119}

Postexposure Prophylaxis of Diphtheria

Postexposure vaccination in household and other close contacts of an individual with culture-confirmed or suspected diphtheria.¹⁰⁰

Regardless of vaccination status, all household and other close contacts of an individual with culture-confirmed or suspected diphtheria should promptly receive anti-infective postexposure prophylaxis (single IM dose of penicillin G benzathine or oral erythromycin given for 7–10 days).^{100 101 119 161} Take samples for cultures prior to giving the anti-infective and continue to observe individual for 7 days for evidence of disease.^{100 119 161}

In addition, those who previously received <3 doses of a diphtheria toxoid-containing preparation or whose vaccination status is unknown should receive an immediate dose of an age-appropriate preparation containing diphtheria toxoid adsorbed, and the primary vaccination series should be completed.^{100 101 119} Contacts who previously completed the primary vaccination series should receive a booster dose of an age-appropriate preparation containing diphtheria toxoid adsorbed if it has been ≥5 years since their last booster dose.^{100 101 119}

Diphtheria antitoxin (equine) (available in the US only from the CDC under an investigational new drug [IND] protocol) is no longer routinely recommended for postexposure prophylaxis of diphtheria in contacts,^{100 101 119} but may be recommended in exceptional circumstances for postexposure prophylaxis in individuals with known or suspected exposure to toxigenic Corynebacterium.^{143 161} To obtain diphtheria antitoxin (equine), contact the CDC at 404-639-8257 from 8:00 a.m. to 4:30 p.m. EST Monday–Friday or the CDC Director's Emergency Operation Center (DEOC) at 770-488-7100 after hours, on weekends, and holidays.^{119 143 161}

Diphtheria and Tetanus Toxoids Adsorbed, Tetanus and Diphtheria Toxoids Adsorbed Dosage and Administration

Administration

IM Administration

Administer by deep IM injection.^{113 114 164}

Do not administer IV, sub-Q, or intradermally.^{113 114 164}

To ensure a uniform suspension of antigens, shake vial or syringe well prior to administration.^{113 114 164} After shaking, suspension should be turbid, whitish-gray and free from clumps.^{113 114 164} Discard if toxoid cannot be resuspended.^{113 114 164}

Do not dilute.^{113 114 164} Do not mix with any other vaccine or solution.^{113 114 164}

Depending on patient age, administer IM into the midlateral muscles of the thigh or deltoid.^{112 113 114 164} To ensure delivery into muscle, IM injections should be made at a 90° angle to the skin using a needle length appropriate for the individual's age and body mass, the thickness of adipose tissue and muscle at the injection site, and the injection technique.¹¹²

Use the anterolateral thigh for IM injections in infants.¹¹² In young children, use the deltoid muscle if muscle mass is adequate; alternatively, use the anterolateral thigh.¹¹² The deltoid muscle is preferred in adults and adolescents.¹¹²

Avoid administering into the gluteal area or areas where there may be a major nerve trunk.^{113 114 164} Do not use the same muscle site more than once during the course of primary immunization.¹¹⁴

Prior to injection, ensure that needle is not in a blood vessel.¹¹⁴ Although some experts recommend that aspiration (i.e., pulling back on the syringe plunger after needle insertion and before injection) be performed to ensure that a blood vessel has not been entered, ACIP states that this procedure is not required because large blood vessels are not present at recommended IM injection sites.¹¹²

Syncope may occur following vaccination (usually in adolescents and young adults).¹¹² Observe vaccinees for approximately 15 minutes after the vaccine dose is administered;¹¹² if syncope occurs, observe patient until symptoms resolve.¹¹²

When passive immunization with TIG is indicated in addition to active immunization with a preparation containing tetanus toxoid adsorbed for postexposure prophylaxis of tetanus, DT or Td may be given simultaneously with TIG using different syringes and different injection sites.^{100 112 132 133 145 164} (See Postexposure Prophylaxis of Tetanus under Uses.)

May be given simultaneously with other age-appropriate vaccines during the same health-care visit (using different syringes and different injection sites).^{100 101 102 112} (See Interactions.)

When multiple vaccines are administered during a single health-care visit, each vaccine should be given with a different syringe and at different injection sites.¹¹² Separate injection sites by at least 1 inch (if anatomically feasible) to allow appropriate attribution of any local adverse effects that may occur.¹¹² If multiple vaccines must be given into a single limb, the deltoid muscle may be used in older children and adults, but the anterolateral thigh is preferred in infants and younger children.¹¹²

Dosage

DT should only be used in infants and children 6 weeks through 6 years of age.¹¹⁴ Use only when DTaP cannot be used (i.e., when pertussis antigens are contraindicated or cannot be used).^{100 101 102}

Td should only be used in adults, adolescents, and children ≥7 years of age.^{100 113 164}

Medically stable preterm and low birthweight infants should be vaccinated at the usual chronologic age using the usual dosage.^{100 114 144}

The complete vaccination series and recommended booster doses must be administered to ensure optimal protection against diphtheria and tetanus.^{113 114} Interruptions resulting in intervals between doses longer than recommended do not interfere with the final immunity achieved; there is no need to give additional doses or start the vaccination series over.^{100 112 114 119}

If an accelerated immunization schedule is necessary in infants and children 6 weeks through 6 years of age (e.g., for catch-up immunization, immunization prior to travel), minimum intervals between first, second, and third doses of DT are 4 weeks; minimum intervals between third, fourth, and fifth doses are 6 months.^{102 108} In adults and children ≥7 years of age, minimum interval between first and second dose of Td is 4 weeks; minimum interval between second and third dose is 6 months.^{102 108 134}

Pediatric Patients

Prevention of Diphtheria and Tetanus

Infants and Children 6 Weeks Through 6 Years of Age (DT)

IM

Primary immunization consists of a series of 4 doses with or without a fifth (booster) dose.^{100 101 102 114} Each dose is 0.5 mL.^{100 114}

ACIP, AAP, and AAFP recommend that the first 3 doses be given 4–8 weeks apart (usually at 2, 4, and 6 months of age) and the fourth dose given approximately 6–12 months after the third dose (usually at 15–18 months of age).^{100 101 102} Fourth dose may be given as early as 12 months of age, provided at least 6 months have elapsed since the third dose;^{101 102} this flexibility allows scheduling the fourth dose to coincide with administration of other required vaccines.¹⁰¹

At 4–6 years of age (usually just prior to entry into kindergarten or elementary school), give a fifth (booster) dose to those who completed the primary immunization series before their fourth birthday.^{100 101 102 114} Fifth dose not necessary if last dose of the primary series was given on or after the fourth birthday.^{100 101 102 114}

If an accelerated schedule is needed (e.g., for travelers), vaccination series may be started as soon as infant is 6 weeks of age; give second and third doses ≥4 weeks after the previous dose.¹⁰² Give a fourth and fifth dose ≥6 months after the previous dose; fifth (booster) dose not necessary if child received the fourth dosage at ≥4 years of age.¹⁰²

Children 7–10 Years of Age (Td)

IM

Primary immunization consists of a series of 3 doses.^{102 113} Each dose is 0.5 mL.^{113 133 164}

Give second dose 4–8 weeks after first dose and give third dose 6–12 months after second dose.^{102 113 133 164}

Catch-up vaccination recommended for those who did not receive primary immunization against diphtheria and tetanus with DTaP, DT, or diphtheria and tetanus toxoids and whole-cell pertussis vaccine (DTP; not commercially available in the US).^{102 135}

Previously Unvaccinated Adolescents 11–18 years (Td)

IM

Primary immunization consists of a series of 3 doses.^{102 113 133} Each dose is 0.5 mL.^{113 133 164}

Give second dose 4–8 weeks after first dose and give third dose 6–12 months after second dose.^{102 113 133 164}

Adolescents 11–18 years of age who have not previously received a dose of Tdap: Unless the pertussis antigens are contraindicated or should not be used, substitute a single dose of Tdap (0.5 mL) for any 1 of the 3 doses of Td.^{101 102 133 135} The preferred primary immunization schedule in these individuals is a single dose of Tdap, followed by a dose of Td given at least 4 weeks after the Tdap dose and a second dose of Td given 6–12 months after the first dose of Td.^{102 133 135}

Booster Doses in Adolescents 11–18 Years of Age (Td)

IM

Usual dose is 0.5 mL.^{100 101 112 113 133 135 164}

To maintain adequate immunity against diphtheria and tetanus, ACIP, AAP, AAFP, and others recommend that all individuals who received primary immunization with any preparation containing diphtheria and tetanus toxoids (DT, Td, DTaP, DTP) receive a booster dose of a preparation containing diphtheria and tetanus toxoids at 11–12 years of age, provided at least 5 years have elapsed since the last dose.^{100 101 102 112 133 135} Alternatively, a booster dose can be given at 14–16 years of age, but administration at 11–12 years of age ensures immunity in this age group and encourages a routine preadolescent preventive care visit that facilitates administration of other vaccines recommended at this age (e.g., MMR, hepatitis B vaccine, HPV vaccine, varicella vaccine, meningococcal vaccine).^{102 133}

Adolescents 11–18 years of age who have not previously received a dose of Tdap: Unless the pertussis component is contraindicated or should not be used, substitute a singledose of Tdap (0.5 mL) instead of Td for the adolescent booster dose given at 11–18 years of age.^{102 132 135} If Tdap is unavailable or was administered previously, use Td.¹³²

Postexposure Prophylaxis of Tetanus

An emergency dose of a preparation containing tetanus toxoid adsorbed may be indicated with or without a dose of TIG.^{100 101 113 119 133 135 164} (See Postexposure Prophylaxis of Tetanus under Uses.)

Wound care is an essential part of postexposure prophylaxis of tetanus and is necessary regardless of vaccination status.^{100 101} Clean and debride wounds properly, especially if dirt or necrotic tissue are present; remove all necrotic tissue and foreign material.¹⁰¹

Children 7–10 Years of Age (Td)

IM

Usual dose is 0.5 mL.^{100 101 113 164}

Individuals who previously received <3 doses of a tetanus-toxoid-containing preparation: Give an emergency booster dose of Td as soon as possible if an injury and possible exposure to tetanus occurs.^{100 101 113 119}

Individuals who previously received ≥3 doses of a tetanus toxoid-containing preparation: Give an emergency booster dose of Td if the injury is a clean, minor wound (not tetanus prone) and >10 years have elapsed since primary immunization against tetanus or the last booster dose of a tetanus toxoid-containing preparation.^{100 113 119} If injury is extensive (moderately or very tetanus prone), give an emergency booster dose of Td if >5 years have elapsed since primary immunization against tetanus or the last booster dose.^{100 113 119}

Adolescents 11–18 Years of Age (Td)

IM

Usual dose is 0.5 mL.^{100 101 113 164}

Individuals who previously received <3 doses of a tetanus-toxoid-containing preparation: Give an emergency booster dose of age-appropriate preparation containing tetanus toxoid adsorbed as soon as possible if an injury and possible exposure to tetanus occurs.^{100 101 113 119 133}

Individuals who previously received ≥3 doses of a tetanus toxoid-containing preparation: Give an emergency booster dose of an age-appropriate preparation containing tetanus toxoid adsorbed if the injury is a clean, minor wound (not tetanus prone) and >10 years have elapsed since primary immunization against tetanus or the last booster dose of a tetanus toxoid-containing preparation.^{100 113 119 133} If injury is extensive (moderately or very tetanus prone), give an emergency booster dose of Td if >5 years have elapsed since primary immunization against tetanus or the last booster dose.^{100 113 119 133}

Adolescents 11–18 years of age who have not previously received a dose of Tdap and received the last dose of a tetanus toxoid-containing preparation ≥5 years earlier: Unless the pertussis component is contraindicated or should not be used, substitute a singledose of Tdap (0.5 mL) instead of Td.^{133 135} If Tdap is not available or was administered previously, use Td.^{133 135}

Postexposure Prophylaxis of Diphtheria

Household and Other Close Contacts of an Individual with Known or Suspected Diphtheria

IM

Individuals who previously received <3 doses of a diphtheria toxoid-containing preparation or whose vaccination status is unknown: Give an immediate dose of an age-appropriate preparation containing diphtheria toxoid and complete the primary vaccination series.^{100 101 119}

Individuals who previously completed the primary vaccination series but have not received a dose within the last 5 years: Give a booster dose of an age-appropriate preparation containing diphtheria toxoid.^{100 101 119}

Used as an adjunct to anti-infective postexposure prophylaxis.^{100 101 119} (See Postexposure Prophylaxis of Diphtheria under Uses.)

Adults

Prevention of Diphtheria and Tetanus

Primary Immunization in Adults ≥19 Years of Age (Td)

IM

Primary immunization in previously unvaccinated individuals or those with an uncertain vaccination history consists of a series of 3 doses.^{100 113 132 134 164} Each dose is 0.5 mL.^{100 113 132 164}

Give second dose 4–8 weeks after first dose and give third dose 6–12 months after second dose.^{100 113 132 134 164}

Adults 19–64 years of age who have not previously received a dose of Tdap: Unless the pertussis component is contraindicated or should not be used, substitute a single dose of Tdap (0.5 mL) instead of any 1 of the 3 doses of Td in the primary series.^{132 134} Preferably, give a dose of Tdap as the first dose, then give a dose of Td at least 4 weeks after the Tdap dose and at 6–12 months after the first dose of Td.¹³² If Tdap is not available or was administered previously, use Td.^{132 134}

Booster Doses in Adults ≥19 Years of Age (Td)

IM

Usual dose is 0.5 mL.^{100 132 134 164}

After primary immunization, give routine booster dose of Td every 10 years.^{100 132 134 164} In addition, in the event of an injury and possible exposure to tetanus, an emergency booster dose of Td may be indicated.^{100 119 132 164} (See Postexposure Prophylaxis of Tetanus under Dosage and Administration.)

Adults 19–64 years of age who have not previously received a dose of Tdap: Unless the pertussis component is contraindicated or should not be used, substitute a single dose of Tdap (0.5 mL) instead of Td.^{132 134} Thereafter, give routine booster dose of Td every 10 years.^{132 134}

Postexposure Prophylaxis of Tetanus

An emergency dose of a preparation containing tetanus toxoid adsorbed may be indicated with or without a dose of TIG.^{100 101 113 119 132 133 145 164} (See Postexposure Prophylaxis of Tetanus under Uses.)

Wound care is an essential part of postexposure prophylaxis of tetanus.^{100 101} Wound care is necessary regardless of vaccination status.^{100 101} Clean and debride wounds properly, especially if dirt or necrotic tissue are present; remove all necrotic tissue and foreign material.¹⁰¹

Adults ≥19 Years of Age (Td)

IM

Usual dose is 0.5 mL.^{100 113 164}

Individuals who previously received <3 doses of a tetanus-toxoid-containing preparation: Give an emergency booster dose of Td (0.5 mL) as soon as possible if an injury and possible exposure to tetanus occurs.^{100 113 119}

Individuals who previously received ≥3 doses of a tetanus toxoid-containing preparation: Give an emergency booster dose of Td if the injury is a clean, minor wound (not tetanus prone) and >10 years have elapsed since primary immunization against tetanus or the last booster dose of a tetanus toxoid-containing preparation.^{100 113 119} If injury is extensive (moderately or very tetanus prone), give an emergency booster dose of Td if >5 years have elapsed since primary immunization against tetanus or the last booster dose.^{100 113 119}

Adults 19–64 years of age who have not previously received a dose of Tdap: Substitute a single dose of Tdap (0.5 mL) instead a booster dose of Td.^{132 134}

Postexposure Prophylaxis of Diphtheria

Household and Other Close Contacts of an Individual with Known or Suspected Diphtheria

IM

Individuals who previously received <3 doses of a diphtheria toxoid-containing preparation or whose vaccination status is unknown: Give an immediate dose of an age-appropriate preparation containing diphtheria toxoid and complete the primary vaccination series.^{100 101 119}

Individuals who previously completed the primary vaccination series but have not received a dose within the last 5 years: Give a booster dose of an age-appropriate preparation containing diphtheria toxoid.^{100 101 119}

Used as an adjunct to anti-infective postexposure prophylaxis.^{100 119} (See Postexposure Prophylaxis of Diphtheria under Uses.)

Special Populations

Hepatic Impairment

No specific dosage recommendations.

Renal Impairment

No specific dosage recommendations.

Geriatric Patients

No specific dosage recommendations.

Cautions for Diphtheria and Tetanus Toxoids Adsorbed, Tetanus and Diphtheria Toxoids Adsorbed

Contraindications

• 
  

  Anaphylaxis or other serious allergic reaction following a dose of any preparation containing diphtheria or tetanus toxoid.^{113 114 164}