Routine Boosting Against Tetanus and Diphtheria in Adults: A Time to Reconsider
September 15, 2025 3 minutes read
By Stan Deresinski, MD, FIDSA
Synopsis: Slifka and colleagues make a strong argument against the routine booster vaccination of adults against tetanus and diphtheria as recommended by the Centers for Disease Control and Prevention.
Source: Slifka MK, Thomas A, Gao L, et al. Lessons learned from successful implementation of tetanus and diphtheria vaccination programs. Clin Microbiol Rev. 2025; Jul 15:e0003125. doi: 10.1128/cmr.00031-25. [Online ahead of print].
The U.S. Centers for Disease Control and Prevention (CDC) recommends routine immunization of children against tetanus and diphtheria. They also recommend regular routine booster immunizations in adults.1 Thus, since 1966 it has been recommended that adults receive a tetanus booster every 10 years. This recommendation contrasts with the lack of such a recommendation by the World Health Organization (WHO) and some European countries.
In 2019 in the United States, the incidence of tetanus was 0.008 per 100,000 (less than one per 10 million), having decreased from 0.41 per million in 1948. Over 37 years, there was only one known death in a fully vaccinated individual. The number of cases of respiratory diphtheria decreased from 206,939 in 1921 to 41 in the 16 years from 1980-1995. A comparison with the pre-vaccination era concluded that the availability of the vaccines was associated with a greater than 95% reduction in tetanus and greater than 99.99% reduction in diphtheria cases. The United Kingdom, despite not routinely providing booster vaccination to adults, has rates of both infections comparable to those in the United States. The fact that protective levels of serum antibody against both infections persist into older age supports a lack of benefit to routine boosters in adults.
The authors conclude that adult tetanus and diphtheria vaccinations are not necessary for maintenance of protective population immunity. They also calculate that discontinuation of the adult vaccination program would result in $1 billion annual savings.
Commentary
The evidence is consistent with the current high level of immunity to these infections in the U.S. population being dependent on maintenance of high levels of vaccination in childhood, not on routine boosting in adults. The persistence of protective antibody levels in adults in the absence of further vaccine doses, as demonstrated in countries without routine boosting policies, is consistent with ongoing boosting being unnecessary. However, at the individual level, certain circumstances must be considered.
Thus, the CDC recommends that a single dose of tetanus, diphtheria, and acellular pertussis vaccine (Tdap) should be given, preferably at weeks 27-36, during each pregnancy. In addition, tetanus-diphtheria vaccine (Td) or Tdap should be administered as a part of wound care. Also, booster doses of diphtheria vaccine may be considered for individuals traveling to communities in which this disease is endemic. The recent surge of diphtheria in migrant populations in Europe indicates a need for continued alertness.2,3
Although routine boosters in adults appear to be unnecessary, it must be remembered that virtually all the recorded U.S. fatalities have occurred in unimmunized individuals, indicating a need to maintain immunity levels, something which is accomplished by high rates of complete childhood vaccination, including in members of underserved and low-resource populations. In the current climate, this must be achieved despite the increasing denial of science and associated vaccine hesitancy in portions of the population.
Stan Deresinski, MD, FACP, FIDSA, is Clinical Professor of Medicine, Stanford University.
References
- Centers for Disease Control and Prevention. Adult Immunization Schedule by Age (Addendum updated August 7, 2025). https://www.cdc.gov/vaccines/hcp/imz-schedules/adult-age.html
- Deresinski S. Diphtheria surge in Europe. Infectious Disease Alert. 2025;44:10-11.
- Hoefer A, Seth-Smith H, Palma F, et al; 2022 European Diphtheria Consortium. Corynebacterium diphtheriae outbreak in migrant populations in Europe. N Engl J Med. 2025;392:2334-2345.
Slifka and colleagues make a strong argument against the routine booster vaccination of adults against tetanus and diphtheria as recommended by the Centers for Disease Control and Prevention.
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