Johns Hopkins ABX Guide
Tetanus vaccines
VACCINE TYPE
- DT (tetanus + diphtheria toxoids)
- Discontinued in 2022; no longer available in the U.S.
- Td (tetanus toxoid+ reduced-dose diphtheria toxoid)
- DTaP (diphtheria and tetanus toxoids + acellular pertussis)
- Used routinely in children <7 years.
- Tdap (tetanus toxoid + reduced-dose diphtheria toxoid + acellular pertussis)
- Tdap and Td: used in persons ≥7 years.
- For other combinations, see formulations.
INDICATIONS
ACIP RECOMMENDATIONS
- Children <7 years, routine series:
- All children should receive 5 doses of DTaP.
- DTaP: 5-dose series at ages 2, 4, 6, and 15–18 months and 4–6 years.
- All children should receive 5 doses of DTaP.
- All adolescents between the ages of 11 and 12 should receive a single dose of Tdap.
- A pregnant adolescent should get a Tdap during each pregnancy (as early as possible within the 27th-36th week window).
- Catch-up immunization:
- Children < 7 years, utilizing DTaP:
- Minimum intervals: dose 1→2, 4 weeks; dose 2→3, 4 weeks; dose 3→4, 6 months; dose 4→5, 6 months.
- Dose 5 is unnecessary if dose 4 was given at age ≥4 years and ≥6 months after dose 3.
- For more information, see the ACIP immunization schedule
- Minimum intervals: dose 1→2, 4 weeks; dose 2→3, 4 weeks; dose 3→4, 6 months; dose 4→5, 6 months.
- Children and adolescents aged 7–18 years:
- Schedule depends on prior vaccination; see ACIP immunization schedule
- Tdap given at ages 7–9 years does not replace the routine 11–12-year dose, while a Tdap given at age 10 years does.
- Inadvertent DTaP at ages ≥7 years; see ACIP immunization schedule
- Children < 7 years, utilizing DTaP:
- Adults (≥19 yrs):
- Td (or Tdap) booster every 10 years (either product is acceptable for the booster)
- Adults who have never received Tdap:
- Give 1 dose of Tdap, regardless of the interval since the last Td-containing vaccine; thereafter, Td or Tdap every 10 years
- Pregnant persons should get a Tdap during each pregnancy (as early as possible within the 27th-36th week window).
FORMS
brand name | preparation | manufacturer | route | form | dosage | cost* |
ADACEL | Tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine adsorbed (Tdap) | Sanofi Pasteur | IM | vial, syringe | 0.5 mL | $48.20 |
BOOSTRIX | Tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine adsorbed (Tdap) | GlaxoSmithKline | IM | vial, syringe | 0.5 mL | $48.71 |
DAPTACEL | Diphtheria and tetanus toxoids and acellular pertussis vaccine adsorbed (DTaP) | Sanofi Pasteur | IM | vial | 0.5 mL | $28.17 |
TDVAX (generic) | Diphtheria and tetanus toxoids (Td) | Mass Biologics | IM | vial | 0.5 mL | $26.34 |
DT | Diphtheria and tetanus toxoids (DT) | Sanofi Pasteur | IM | vial | 0.5 mL | N/A in US |
INFANRIX | Diphtheria and tetanus toxoids and acellular pertussis vaccine adsorbed (DTaP) | GlaxoSmithKline | IM | vial, syringe | 0.5 mL | $29.83 |
KINRIX | Diphtheria and tetanus toxoids and acellular pertussis adsorbed and inactivated poliovirus vaccine (DTaP-IPV) | GlaxoSmithKline | IM | vial, syringe | 0.5 mL | $63.35 |
PEDIARIX | Diphtheria and tetanus toxoids and acellular pertussis adsorbed, Hepatitis B (recombinant) and inactivated poliovirus vaccine (DTaP-HBV-IPV) | GlaxoSmithKline | IM | syringe | 0.5 mL | $107.98 |
PENTACEL | Diphtheria and tetanus toxoids and acellular Pertussis adsorbed, and inactivated poliovirus vaccine, and Haemophilus b conjugate vaccine (DTaP-IPV-Hib) | Sanofi Pasteur | IM | KIT | 0.5 mL | $115.52 |
TENIVAC | Tetanus and diphtheria toxoids adsorbed (Td) | Sanofi Pasteur | IM | vial, syringe | 0.5 mL | $40.91 |
QUADRACEL | Diphtheria and tetanus toxoids and acellular pertussis adsorbed and inactivated poliovirus vaccine (DTaP-IPV) | Sanofi Pasteur | IM | vial | 0.5 mL | $59.68 |
VAXELIS | Diphtheria and tetanus toxoids and acellular pertussis adsorbed, inactivated poliovirus, Haemophilus b conjugate, and hepatitis B (recombinant) vaccine (DTaP-IPV-Hib-HepB) | Merck/Sanofi Pasteur | IM | syringe | 0.5 mL | $146.36 |
*Prices represent cost per unit specified and are representative of "Average Wholesale Price" (AWP).
PATHOGEN DIRECTED PROTECTION
- Clostridium tetani(Tetanus)
DOSE/ADMINISTRATION
Adult PRIMARY SERIES
- Unvaccinated/incompletely vaccinated adults:
- Complete a 3-dose series with Tdap as the first dose, Td or Tdap ≥4 weeks later, and Td or Tdap 6–12 months after dose 2.
Adult BOOSTER
- Ensure ≥1 Tdap dose; thereafter, Td or Tdap every 10 years.
- Tdap can also be used whenever a tetanus booster is indicated.
Pediatric PRIMARY SERIES
- INFANRIX or DAPTACEL (DTaP): 0.5 mL IM dose at each of the following ages: 2, 4, 6, and 15-18 months and 4-6 years for 5 total doses
- For a child <7 years with a true contraindication to the pertussis component, Td is now used off-label in place of remaining DTaP doses, since DT was discontinued in the US in 2022.
- VAXELIS (DTaP-IPV-Hib-HepB): 0.5 mL IM as a 3-dose series at 2, 4, and 6 months of age in children 6 weeks through 4 years.
- Vaxelis is used for DTaP doses 1–3 and should not be used for doses 4 or 5.
- Complete the DTaP series with an age-appropriate DTaP-containing vaccine.
- Vaxelis is used for DTaP doses 1–3 and should not be used for doses 4 or 5.
- Other combination vaccines exist that include components and can be substituted for DTaP as appropriate.
Pediatric BOOSTER
- INFANRIX or DAPTACEL (DTaP): 0.5 mL IM given according to ACIP primary schedule or catch-up schedule
- For children <7 years with a true contraindication to the pertussis component, use Td off-label according to the DTaP schedule.
- Tdap (ADACEL or BOOSTRIX): single 0.5 mL IM at age 11-12 years. It may be administered to children 7 years and older according to the ACIP catch-up schedule.
WARNINGS/CONTRAINDICATIONS
- Severe allergic reaction (eg, anaphylaxis) after a previous dose or to a vaccine component is a contraindication.
- Encephalopathy not attributable to another identifiable cause within 7 days after a pertussis-containing vaccine is a contraindication to additional DTaP/Tdap.
- Precautions include GBS within 6 weeks after a tetanus-toxoid–containing vaccine, moderate/severe acute illness, and, for DTaP/Tdap, progressive or unstable neurologic disease until stabilized.
- Arthus hypersensitivity reaction
- Requires deferral of tetanus/diphtheria-toxoid vaccination for at least 10 years.
ADVERSE DRUG REACTIONS
GENERAL
- Generally well tolerated.
COMMON
- Tdap
- Pain and tenderness at the injection site; rate increases with more doses
- Headache
- Fatigue
- DTaP
- Fussiness
- Loss of appetite
- Fever
- Injection site reactions
OCCASIONAL
- Arthralgia
- Tdap
- Fever
RARE
- Anaphylaxis
- Arthus reaction (severe pain, swelling, induration, edema, hemorrhage, and occasional local necrosis)
- Requires deferral of tetanus/diphtheria-toxoid vaccination for at least 10 years.
VACCINE/DRUG INTERACTIONS
- Tetanus-containing vaccines may generally be administered concomitantly with other indicated vaccines at different anatomic sites.
- Immunosuppressive therapy may reduce vaccine immune responses.
- If vaccine and TIG are given simultaneously, use separate sites.
IMMUNE RESPONSE
- Tetanus: A complete tetanus toxoid–containing vaccine series has inferred clinical efficacy approaching 100%.
- Efficacy is established largely from protective antitoxin levels rather than randomized placebo-controlled trials.
- Pertussis protection is less durable and wanes substantially after DTaP/Tdap.
CLINICAL EFFICACY
- During 2009–2023, 402 tetanus cases and 37 deaths were reported in the U.S. (mean, 26.8 cases/year; range, 17–37); incidence was highest among adults aged ≥80 years.
- Among cases with known vaccination history, 43.9% had received no tetanus-toxoid–containing vaccine, and no deaths were reported among persons documented to have received ≥3 doses.
- Global tetanus deaths fell approximately 88% between 1990 and 2019, but non-neonatal tetanus deaths have since plateaued. Tetanus does not confer natural immunity, so all patients who recover from tetanus require a full immunization course.
WOUND MANAGEMENT
- See Tetanus module for additional details.
- Wounds
- Clean/minor wound → booster only if ≥10 years.
- Dirty/major wound → booster if ≥5 years.
- Unknown/incomplete vaccination → vaccinate for either wound type.
- TIG (tetanus immune globulin): administer if <3 doses of a tetanus toxoid–containing vaccine or unknown + contaminated wound (dirt, stool, saliva, soil), crush, burn, or frostbite. Also administer in persons with HIV or severe immunodeficiency regardless of vaccine history.
- Prophylaxis: 250 IU IM
- Active tetanus: TIG 500 IU IM once
- Tetanus does not confer immunity; initiate or complete age-appropriate tetanus vaccination during recovery.
OTHER INFORMATION
- Tetanus seroprotection remains high in the U.S. but declines with age.
- NHANES 2015–2016 found protective antibody levels in 84% of adults aged 70–79 years and 76% of those aged ≥80 years.[12]
- ADACEL contains the same tetanus toxoid, diphtheria toxoid, and five pertussis antigens as those in DAPTACEL (pediatric DTaP), but ADACEL is formulated with reduced quantities of diphtheria toxoid and detoxified pertussis toxin.
- Use in HIV-positive patients
- Tdap and Td are inactivated vaccines and are safe at any CD4 count.
- Follow the same vaccination schedule as for persons without HIV.
- Antibody responses to tetanus and diphtheria may be attenuated with advanced HIV; tetanus antibody responses are similar to those in the general population when the CD4 count is >300 cells/mm³.
Basis for recommendation
- Havers FP, Moro PL, Hunter P, et al. Use of Tetanus Toxoid, Reduced Diphtheria Toxoid, and Acellular Pertussis Vaccines: Updated Recommendations of the Advisory Committee on Immunization Practices - United States, 2019. MMWR Morb Mortal Wkly Rep. 2020;69(3):77-83. [PMID:31971933]
Comment: ACIP recommendations have been updated to allow either tetanus and diphtheria toxoids (Td) vaccine or Tdap to be used for the decennial Td booster, tetanus prophylaxis for wound management, and for additional required doses in the catch-up immunization schedule if a person has received at least 1 Tdap dose.
- Liang JL, Tiwari T, Moro P, et al. Prevention of Pertussis, Tetanus, and Diphtheria with Vaccines in the United States: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2018;67(2):1-44. [PMID:29702631]
Comment: Compiled, updated recommendations that serve as the basis for recommended schedules as well as booster needs.
References
- American College of Obstetricians & Gynecologistsߣ Immunization, Infectious Disease, and Public Health Preparedness Expert Work Group. Maternal Immunizations. Obstet Gynecol. 2026;147(5):e123-e128. [PMID:41701970]
Comment: Current ACOG recommendations for immunizations during pregnancy.
- Cornia PB, Lipsky BA. Pertussis Infection in Adults. JAMA. 2026;335(12):1084-1085. [PMID:41706481]
Comment: This JAMA Insights article discusses the epidemiology, transmission, and risk factors for pertussis in adults.
- Hughes MM, Amin AB, Rubis AB. Tetanus Surveillance - United States, 2009-2023. MMWR Surveill Summ. 2026;75(1):1-11. [PMID:41980046]
Comment: Current U.S. tetanus surveillance: 402 cases and 37 deaths were reported during 2009–2023. The disease predominantly affected adults and persons who were unvaccinated or under-vaccinated, and recommended wound post-exposure prophylaxis was frequently missed.
- Hsiao A, Bartlett J, Fireman B, et al. Effectiveness of 5-pertussis-component tetanus, diphtheria, and acellular pertussis (Tdap5) vaccination in pregnancy at preventing infant pertussis. Am J Obstet Gynecol. 2026;234(4):1172-1182. [PMID:41276201]
Comment: A large retrospective cohort study of 263,809 infants found maternal Tdap5 vaccination to be 96% effective against infant pertussis during the first 2 months of life and 56% effective through the first year.
- Liu M, Zhou X, Guan L, et al. Diphtheria-tetanus-acellular pertussis vaccine safety in children under 7 years: a post-marketing analysis of the U.S. vaccine adverse event reporting system. Front Cell Infect Microbiol. 2026;16:1733777. [PMID:41704959]
Comment: Postmarketing VAERS analysis of DTaP reports in children <7 years through May 2025. Most reported events were nonserious and occurred within 30 days; disproportionality analyses identified multiple reporting signals. Interpretation is limited by the passive, hypothesis-generating nature of VAERS data.
- Issa AN, Wodi AP, Moser CA, et al. Advisory Committee on Immunization Practices Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger - United States, 2025. MMWR Morb Mortal Wkly Rep. 2025;74(2):26-29. [PMID:39819853]
Comment: ACIP schedule summarizing current routine and catch-up vaccination recommendations for children and adolescents, including DTaP and Tdap/Td schedules.
- Wodi AP, Issa AN, Moser CA, et al. Advisory Committee on Immunization Practices Recommended Immunization Schedule for Adults Aged 19 Years or Older - United States, 2025. MMWR Morb Mortal Wkly Rep. 2025;74(2):30-33. [PMID:39820474]
Comment: ACIP schedule summarizing adult Tdap/Td primary vaccination, decennial boosters, pregnancy, and other special-situation recommendations.
- Sudarshan R, Sayo AR, Renner DR, et al. Tetanus: recognition and management. Lancet Infect Dis. 2025;25(11):e645-e657. [PMID:40543524]
Comment: A state-of-the-art summary of global tetanus epidemiology, its clinical features and differential diagnosis, principles of management, and prognosis.
- Jones CE, Yusuf N, Ahmed B, et al. Progress Toward Achieving and Sustaining Maternal and Neonatal Tetanus Elimination - Worldwide, 2000-2022. MMWR Morb Mortal Wkly Rep. 2024;73(28):614-621. [PMID:39024183]
Comment: Global assessment of maternal and neonatal tetanus elimination: from 2000–2022, 47 of 59 priority countries achieved elimination. Reported neonatal tetanus cases declined by 89%, and estimated neonatal tetanus deaths declined by 84%.
- Bampoe VD, Brown N, Deng L, et al. Serologic Immunity to Tetanus in the United States, National Health and Nutrition Examination Survey, 2015-2016. Clin Infect Dis. 2024;78(2):470-475. [PMID:37787062]
Comment: U.S. serosurvey found protective tetanus antibody levels in 93.8% of persons aged ≥6 years, with seroprotection declining with age to 75.8% among persons aged ≥80 years.
- Li J, Liu Z, Yu C, et al. Global epidemiology and burden of tetanus from 1990 to 2019: A systematic analysis for the Global Burden of Disease Study 2019. Int J Infect Dis. 2023;132:118-126. [PMID:37086867]
Comment: Global Burden of Disease analysis documenting the marked decline in tetanus morbidity and mortality since 1990 while demonstrating persistent disease burden in resource-limited settings.
- Gidengil C, Goetz MB, Newberry S, et al. Safety of vaccines used for routine immunization in the United States: An updated systematic review and meta-analysis. Vaccine. 2021;39(28):3696-3716. [PMID:34049735]
Comment: Analysis of existing studies found no evidence of increased risk (varied SoE) for key adverse events among pregnant women following tetanus, diphtheria, and acellular pertussis vaccine, including stillbirth (moderate SoE).
- Panel on Guidelines for the Prevention and Treatment of Opportunistic Infections in Adults and Adolescents With HIV. Immunizations for Preventable Diseases in Adults and Adolescents With HIV. NIH/CDC/HIVMA/IDSA. Updated May 27, 2026.
Comment: Current guidance on vaccination in people with HIV: Tdap/Td are safe at any CD4 count; routine schedules are used, and tetanus/diphtheria antibody responses may be attenuated with advanced HIV.
