Contents

19 Tetanus

19.5 Recommended immunisation schedule

Table 19.1: Immunisation schedule for tetanus-containing vaccines (excluding catch-up)

Age Vaccine Comment
6 weeks DTaP-IPV-HepB/Hib Primary series
3 months DTaP-IPV-HepB/Hib Primary series
5 months DTaP-IPV-HepB/Hib Primary series
4 years DTaP-IPV Booster
11 years Tdap Booster
45 years Td Booster
65 years Td Booster

19.5.1 Usual childhood schedule

A primary course of tetanus vaccine is given as DTaP-IPV-HepB/Hib (Infanrix-hexa) at ages 6 weeks, 3 months and 5 months, followed by a dose of DTaP-IPV (Infanrix-IPV) at age 4 years. A booster is given at age 11 years (school year 7), which includes a pertussis component, given as the vaccine Tdap (Boostrix).

If a course of immunisation is late or interrupted for any reason, it may be resumed without repeating prior doses (see Appendix 2).

Dose intervals between Td and Tdap

No minimum interval between Td and Tdap is required,5–7 unless Tdap is being given as part of a primary immunisation course.

Alternatives to pertussis-containing vaccines

Some parents or guardians may ask about alternatives to pertussis-containing vaccines. The recommended and funded vaccines for children are those described above. There are no diphtheria-only or tetanus-only vaccines available. The Td vaccine contains half the amount of tetanus toxoid and one-fifteenth the amount of diphtheria toxoid compared to the DTaP-containing vaccines. Td was not clinically designed or tested for use to provide the primary vaccine course in children and it is not registered for use in children aged under 5 years. Although there are no safety concerns relating to administration of the vaccine, there is no data on the use of this vaccine for a primary course in children and it is not recommended.

19.5.2 Adults and children from age 10 yearsTop

For adults and children who present with a tetanus-prone wound, boosters are recommended in accordance with the guidelines in the following sections and Table 19.2.

For partially immunised or previously unimmunised individuals aged 10 years and older, a primary immunisation course consists of three doses of a tetanus toxoid-containing vaccine at intervals of not less than four weeks (see Appendix 2). A booster dose is recommended at least six months after the third dose. Children aged under 18 years may receive Tdap (funded from age 7 to under 18 years); adults aged 18 years and older may receive Td (funded) or Tdap (unfunded). Although Tdap and Td are not approved for use (registered) as a primary course, there are expected to be no safety concerns.

For children given a primary course as infants and a booster at age 4 years, a further booster of tetanus toxoid-containing vaccine is given at age 11 years as Tdap vaccine.

Adults are recommended to have their tetanus immunisation status assessed at ages 45 and 65 years, and either given a booster dose of tetanus toxoid-containing vaccine if more than 10 years has elapsed since the previous dose, or a primary course if there is any doubt about the adequacy of previous tetanus immunisation (uncertain or no history of a prior primary course).

Protection against tetanus is expected to last at least 20 years following a booster dose after the primary series. The recommendation for a booster dose at ages 45 and 65 years is intended to ensure ongoing protection, and to facilitate delivery by recommending the booster during routine preventive care for adults.

People born before 1960 are less likely to have had a primary series of tetanus vaccine. GP visits at or around ages 45 and 65 years should be used to check on the immunisation history. If there is no reliable history of the patient having received a primary series, the vaccine at that episode should be considered the first of a funded primary series (both the vaccine and the administration are funded). The next two doses in the primary series should be given at four-week intervals, and a booster dose is recommended at least six months after the third dose (note that the vaccine is funded for the booster but not the administration).

Prior clinical tetanus does not usually confer immunity, and immunisation is required. In 1995 a 40-year-old man developed tetanus for a second time because he failed to complete the recommended course of immunisation after the first episode of tetanus.8

Tdap boosters are also funded for pregnant women, from 28 to 38 weeks’ gestation (see section 14.5.2).

Offer a booster dose of Td for someone travelling overseas if it has been more than 10 years since the last dose (not funded) (see section 5.5.3).

Dose intervals between Td and Tdap

No minimum interval between Td and Tdap is required,5–7 unless Tdap is being given as part of a primary immunisation course.

19.5.3 Prevention of tetanus following injuryTop

Following injury, it is essential that all wounds be adequately cleaned and devitalised tissue removed. Further treatment depends on the circumstances of each case.

If the injury is considered to be tetanus-prone and there is any doubt about the adequacy of previous tetanus immunisation, the individual must have tetanus immunoglobulin (TIG) and the recommended primary course of three doses of a tetanus toxoid-containing vaccine (Td or Tdap – the latter is not funded for adults aged 18 years and older).

The definition of a tetanus-prone injury is not straightforward, because tetanus can occur after apparently trivial injury, such as from a rose thorn, or with no history of injury. However, there are certain types of wounds likely to favour the growth of tetanus organisms. These include:

General measures for the treatment of tetanus-prone wounds

Wounds or injuries should be classified as tetanus-prone or non-tetanus-prone as follows (see Table 19.2):

Immunised individuals respond rapidly to a booster injection of tetanus toxoid-containing vaccine, even after a prolonged interval. Tetanus toxoid-containing vaccine and TIG should be given at the same time, but into different limbs and using separate syringes.

Table 19.2: Guide to tetanus prophylaxis in wound management

History of tetanus vaccination Time since last dose Type of wound Td or Tdap as appropriatea,b TIGe
≥3 doses <5 years Tetanus-prone wounds No No
≥3 doses 5–10 years Clean minor wounds No No
≥3 doses 5–10 years Tetanus-prone wounds Booster dosec No
≥3 doses >10 years Tetanus-prone wounds Booster dosec No
≥3 doses >10 years Clean minor wounds Booster dosec No
<3 doses or uncertain   Clean minor wounds Complete the coursed No
<3 doses or uncertain   Tetanus-prone wounds Complete the coursed Yes
a See Appendix 2 for catch-up schedules for previously unimmunised children. DTaP-containing vaccine may be used in children aged under 10 years.
b Td is funded; Tdap may be given to, but is not funded for, individuals aged 18 years and older.
c If appropriate, this may count as the age 45 or 65 years booster dose.
d To complete the 3-dose primary immunisation course, give 1 to 3 doses at not less than 4-weekly intervals.
e TIG = tetanus immunoglobulin. The recommended dose is 250 IU given by IM injection as soon as practicable after injury. If more than 24 hours has elapsed, 500 IU is recommended.

See also the Immunisation Advisory Centre factsheet: Guidelines for the management of tetanus-prone wounds (http://www.immune.org.nz/sites/default/files/resources/AdministrationTetanusFlowChartImac20160505V01Final.pdf).

Tetanus immunoglobulin (TIG) availability and storage

TIG is issued in ampoules, each containing 250 IU. (Ampoules of 2000 IU are used for treatment and not for prophylaxis.) These should be protected from light and stored in a refrigerator at +2oC to +8oC. They must never be frozen. TIG is given intramuscularly.

TIG dose

The recommended dose to prevent tetanus is 250 IU of TIG for recent injuries, but this should be increased to 500 IU if more than 24 hours has elapsed since injury, or if there is a risk of heavy contamination or following burns.

There is no need to test the patient’s sensitivity before administering TIG, but caution is necessary if the patient is known to suffer complete immunoglobulin A (IgA) deficiency. In this situation, specialist help should be sought (see section 4.3).

Patients with impaired immunity who suffer a tetanus-prone wound may have failed to respond to prior vaccination and may therefore require TIG.

19.5.4 (Re-)vaccinationTop

Tetanus-containing vaccines are funded for (re-)vaccination of eligible patients, as follows.

​DTaP-IPV-HepB/Hib (Infanrix-hexa; for children aged under 10 years), DTaP-IPV (Infanrix-IPV) and Tdap (Boostrix) are funded for patients:

  • post-haematopoietic stem cell transplant (HSCT) or chemotherapy 
  • pre- or post-splenectomy
  • pre- or post-solid organ transplant
  • undergoing renal dialysis
  • with other severely immunosuppressive regimens.

​Td (ADT Booster) is funded for patients following immunosuppression.

See also sections 4.2 and 4.3.