Tetanus

Content

Available Vaccines

In this chapter:

Introduction
Post-exposure Prophylaxis and Treatment
Implication for Healthcare Workers (HCWs)
Evidence of Safety & Effectiveness
References

Introduction

Tetanus is caused by Clostridium tetani, a spore-forming bacterium that produces two potent toxins: tetanospasmin (an alpha-neurotoxin responsible for muscle spasms and rigidity) and tetanolysin (an alpha-haemolysin that damages local tissues). Infection usually occurs when spores enter the body through wounds, lacerations, or penetrating injuries.

In Malaysia, tetanus has remained at a consistently low incidence, with only slight year-to-year variation. The case fatality rate is highest among infants and older adults, reaching up to 10–20% even with modern healthcare. Individuals over 60 years of age face greater risk of both infection and mortality, particularly if their immunisation is incomplete or immunity has waned. As tetanus can arise from even minor injuries, active immunisation is crucial for protection. A booster every 10 years is sufficient to maintain long-term immunity, and additional doses are unnecessary after each injury. For wound management, tetanus toxoid or tetanus immunoglobulin should be administered only if vaccination status is incomplete or uncertain, particularly in high-risk or contaminated wounds.

Table 7.1 Vaccines Registered in Malaysia

Table 7.2 High-risk Groups in Malaysia

*in accordance to Malaysian Maternal Immunisation Consensus Guidelines (2024)

Post-exposure Prophylaxis and Treatment

For wound management, the need for active immunisation, with or without passive immunisation, depends on the condition of the wound and the patient’s vaccination history (refer to Table 7.3).

Table 7.3 Guide to Tetanus Prophylaxis in Wound Management

Note:

* The recommended dose for TIG is 250IU, given by IM injection, as soon as practicable after the injury. If more than 24 hours have elapsed, 500IU should be given. Because of its viscosity, TIG should be given to adults using a 21-gauge needle.

† All wounds other than minor clean wounds should be considered ‘tetanus-prone’.

# Individuals with humoral immune deficiency (including HIV-infected persons who have immunodeficiency) should be given TIG if they have received a tetanus-prone injury, regardless of the time since their last dose of tetanus-containing vaccine.

§ Individuals who have no documented history of a primary vaccination course (3 doses) with a tetanus toxoid-containing vaccine should receive all missing doses and must receive TIG.

In summary, for clean and minor wounds, administer Tdap or Td if more than 10 years have passed since the last dose of the tetanus–toxoid–containing vaccine; for all other wounds, administer Tdap or Td if more than 5 years have passed since the last dose of the tetanus–toxoid–containing vaccine. For pregnant women, Tdap is recommended. Tdap is also preferred for persons who have not previously received Tdap or whose Tdap history is unknown. For others who have already received Tdap before, either Td or Tdap can be given.

Implication for Healthcare Workers (HCWs)

A dose of Tdap is recommended to be administered as soon as feasible to all healthcare workers who have not received Tdap previously. Td or Tdap boosters are advocated every 10 years thereafter.

Evidence of Safety & Effectiveness

The tetanus vaccine contains a toxoid that stimulates the production of antitoxin antibodies, providing protection against the toxin produced by Clostridium tetani, though it does not prevent bacterial growth. Complete immunisation (3 primary doses and 2 booster doses) induces protective levels of antitoxin throughout childhood and into adulthood. By middle age, however, immunity may wane in about 50% of individuals. In such cases, a single booster dose reliably induces a rapid and robust anamnestic response.

References

Centers for Disease Control and Prevention. (2025). Tetanus vaccine recommendations. Retrieved July 31, 2025, from https://www.cdc.gov/tetanus/hcp/vaccine-recommendations/index.html
Centers for Disease Control and Prevention. (2023, April 25). Chapter 21: Tetanus. In Epidemiology and Prevention of Vaccine-Preventable Diseases (14th ed.). National Center for Immunization and Respiratory Diseases. Retrieved from https://www.cdc.gov/pinkbook/hcp/table-of-contents/chapter-21-tetanus.html
Havers, F. P., Moro, P. L., Hunter, P., Hariri, S., & Bernstein, H. (2020, January 24). Use of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccines: Updated recommendations of the Advisory Committee on Immunization Practices — United States, 2019. Morbidity and Mortality Weekly Report, 69(3), 77–83. https://doi.org/10.15585/mmwr.mm6903a5
National Pharmaceutical Regulatory Agency (NPRA) Sistem Pendaftaran Produk & Perlesenan.https://quest3plus.bpfk.gov.my/pmo2/index.php
Obstetrical & Gynaecological Society of Malaysia. (2024). Malaysian Maternal Immunisation Consensus Guidelines (1st ed.) [e-book]. Obstetrical & Gynaecological Society of Malaysia. https://ogsm.org.my/docs/Maternal-Immunisation-Guidelines.pdf