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From the Centers for Disease Control and Prevention
June 13, 2001

Deferral of Routine Booster Doses of Tetanus and Diphtheria Toxoids for Adolescents and Adults

JAMA. 2001;285(22):2849-2850. doi:10.1001/jama.285.22.2849-JWR0613-2-1

MMWR. 2001;50:418-427

A shortage of tetanus and diphtheria toxoids (Td) and tetanus toxoid (TT) in the United States has resulted because one of two manufacturers discontinued production of tetanus toxoid–containing products.1 Aventis Pasteur (Swiftwater, Pennsylvania) is the only major manufacturer of tetanus and Td in the United States. In response to the shortage, Aventis Pasteur has increased production of Td to meet national needs; however, because 11 months are required for vaccine production, the shortage is expected to last for the remainder of 2001.

To assure vaccine availability for priority indications,2 all routine Td boosters in adolescents and adults should be delayed until 2002. Td use should follow existing recommendations for all other indications, which include (1) persons traveling to a country where the risk for diphtheria is high*; (2) persons requiring tetanus vaccination for prophylaxis in wound management; (3) persons who have received <3 doses of any vaccine containing Td; and (4) pregnant women who have not been vaccinated with Td during the preceding 10 years.

CDC recommends that health-care providers, including clinic personnel, record the names of patients whose booster dose is delayed during the shortage. When Td supplies are restored, these patients should be notified to return to their health-care provider for vaccination. According to Aventis Pasteur, sufficient vaccine will be available in early 2002 to supply the national demand.

Health-care providers using Td for wound management should follow recommendations from the Advisory Committee on Immunization Practices for wound management.3 All wound patients should receive Td if they have received <3 tetanus-containing vaccines or if vaccination history is uncertain. These patients also should receive tetanus immune globulin for wounds that are contaminated with dirt, feces, soil or saliva, puncture wounds, and avulsions and wounds resulting from missiles, crushing, burns or frostbite.3 For persons with ≥3 doses of TT-containing vaccine and severe or contaminated wounds, Td should be given only if >5 years have passed since the last dose of tetanus-containing vaccine. For clean and minor wounds, Td should be given only if the patient has not received a tetanus-containing vaccine during the preceding 10 years. Health-care providers should inquire from patients presenting for wound management about the timing of their last tetanus-containing vaccine to avoid unnecessary vaccination.

Pediatric formulations of diphtheria and tetanus toxoids (DT) and diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP) should not be used for persons aged ≥7 years. Although TT might be considered a substitute for Td in wound management when Td is not available, TT is not available for national distribution. Existing stocks of TT are extremely limited and are mainly reserved for production of tetanus immune globulin and other special circumstances.

Health-care providers and institutions requiring Td for priority indications should contact Aventis Pasteur, telephone (800) 822-2463 or (800) VACCINE. Institutions should place orders for their anticipated needs for priority indications only. Limiting quantities of vaccine in each order is necessary to assure the widest possible distribution of available vaccine. For emergency situations (e.g., natural disasters) requiring increased use of Td, Aventis Pasteur can provide vaccine within 24 hours.

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*Travelers to certain countries may be at substantial risk for exposure to toxigenic strains of C. diphtheriae, especially with prolonged travel, extensive contact with children, or exposure to poor hygiene. Based on surveillance data and consultation with the World Health Organization, countries at highest risk are: Africa = Algeria, Egypt, and sub-Saharan Africa; Americas = Brazil, Dominican Republic, Ecuador, and Haiti; Asia/Oceania = Afghanistan, Bangladesh, Cambodia, China, India, Indonesia, Iran, Iraq, Laos, Mongolia, Myanmar, Nepal, Pakistan, Philippines, Syria, Thailand, Turkey, Vietnam, and Yemen; Europe = Albania and all countries of the former Soviet Union.3
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