ACIP recommends a single dose of tetanus immune globulin (TIG) for treatment of persons with tetanus. Although the optimal therapeutic dose has not been established, experts recommend 500 international units (IU), which appears to be as effective as higher doses ranging from 3,000 to 6,000 IU and causes less discomfort. Available preparations must be administered intramuscularly; TIG preparations available in the United States are not licensed or formulated for intrathecal or intravenous use. Infiltration of part of the dose locally around the wound is usually recommended if feasible, although the efficacy of this approach has not been proven. If TIG is not available, intravenous immune globulin (IGIV) can be used at a dose of 200 to 400 milligrams per kilogram (mg/kg). However, the Food and Drug Administration (FDA) has not approved IGIV for this use. In addition, anti-tetanus antibody content varies from lot to lot. See www.cdc.gov/tetanus/clinicians.html for more information on this issue.
Ask the Experts: Tetanus: Wound Management
Children age 7–10 years should receive Tdap if they are not fully vaccinated for prevention of pertussis. Otherwise they may receive Td or Tdap. If additional doses are necessary for full tetanus protection, they may be administered as Td or Tdap. Adolescents, and adults age 11 years and older should receive a single dose of Tdap, if they have not received a dose of Tdap after the 11th birthday, otherwise they may receive Td or Tdap. If additional doses are necessary for full tetanus protection, they may be administered as Td or Tdap.
ACIP has not addressed this issue specifically. Puncture wounds, however, should be attended to as soon as possible. The decision to delay a booster dose of tetanus toxoid-containing vaccine following an injury should be based on the nature of the injury and likelihood that the injured person is susceptible to tetanus. The more likely the person is to be susceptible, the more quickly that tetanus prophylaxis should be administered. A person with a tetanus-prone wound (e.g., punctures, wounds contaminated with soil or fecal material) and who has no history of tetanus immunization must be vaccinated and given tetanus immune globulin (TIG) as soon as possible. A person with a documented series of at least three tetanus toxoid-containing products, with a booster dose within the previous 10 years ago is less likely to be susceptible to tetanus, and the need for a booster dose is not as urgent, particularly if the wound can be thoroughly cleaned. The more likely a person is to be completely susceptible to tetanus (i.e., unvaccinated or incompletely vaccinated), the sooner that TIG and Td/Tdap should be administered, even if it means a trip to the emergency department.
One dose of tetanus toxoid-containing vaccine (Tdap or Td) provides little or no protection. That is why tetanus immune globulin (TIG) is also recommended in this situation. See the Tetanus Prophylaxis for Wound Management section of the current ACIP statement, available at www.cdc.gov/mmwr/volumes/67/rr/pdfs/rr6702a1-H.pdf, pages 27–28. As far as timing, the toxoid and TIG should be given as soon as possible.
TIG is recommended for any wound other than a clean minor wound if the person’s vaccination history is either unknown, or the person has not had a full series of 3 doses of tetanus-containing vaccine. People with HIV infection or severe immunodeficiency who have contaminated wounds (including minor wounds) should also receive TIG, regardless of their history of tetanus immunizations. TIG should be given as soon as possible after the injury. The dose is 250 IU administered intramuscularly. See CDC’s web page for details: www.cdc.gov/tetanus/clinicians.html#wound-management.
The incubation period of tetanus ranges from 3 to 21 days, averaging about 10 days. In general, the further the injury site is from the central nervous system, the longer the incubation period. In the opinion of the tetanus experts at the CDC, for a person who has been vaccinated but is not up to date, there is probably little benefit in giving TIG more than a week or so after the injury. For a person believed to be completely unvaccinated, it is suggested to increase this interval to 3 weeks (i.e., up to day 21 post injury). Td or Tdap should be given concurrently with TIG.