Obstacles to Immunization in Children with Juvenile Idiopathic Arthritis

Adults Largely Don't Need Tetanus, Diphtheria Vaccine Boosters, Researchers Say

With certain exceptions, US adults could safely forego tetanus and diphtheria booster vaccination—if uptake of childhood vaccines stays high, an Oregon Health & Science University–led research team wrote yesterday in Clinical Microbiology Reviews.

Discontinuing the 10-year doses could save about $1 billion each year, said the researchers, who compared the impact of the tetanus and diphtheria vaccination programs to that of other routine childhood vaccines, reviewed childhood vaccination programs in France and England, and proposed revisions to the adult booster vaccination schedule.

While diphtheria is highly contagious, the community is broadly protected through childhood vaccination, and "Tetanus is unique among vaccine-preventable diseases because it is not transmitted from person to person; therefore, vaccination provides important individual protection but does not impact the risk for a community at large," the study authors wrote. 

'More likely to be struck by lightning' 

The current US vaccination schedule calls for giving children five doses of the Tdap (diphtheria, tetanus, and pertussis [whooping cough]) vaccine by age 7, adolescents one dose at age 11 or 12, and adults one dose every 10 years. Current US childhood vaccine coverage is 95%.

Despite lacking the technological advances of today, these medical interventions represent two of the most successful vaccines ever developed.

Studies the team conducted in 2016 and 2020 suggested that the vaccines generate at least 30 years of immunity against the life-threatening infections, far beyond the current 10-year booster recommendations and previous recommendations for even more frequent boosters (eg, every 3 years in 1955). 

In addition, childhood vaccination against tetanus and diphtheria have achieved roughly 95% and 99.9% reductions in those diseases, similar to those of other routine pediatric vaccines such as measles (99.9%), mumps (97.6%), and rubella (99.9%), the researchers said.

"Despite lacking the technological advances of today, these medical interventions represent two of the most successful vaccines ever developed, as indicated by the incidence of disease falling to less than one case of tetanus per 10 million person-years and approximately one case of diphtheria per 1 billion person-years in the U.S. Population," they wrote.

First author Mark Slifka, PhD, of Oregon Health & Science University, said in a university news release that childhood vaccination has ensured that diphtheria and tetanus are "incredibly rare" today. "In fact, you're 10 to 1,000 times more likely to be struck by lightning than to be diagnosed with tetanus and diphtheria in the United States," he said.

Closer alignment with WHO guidelines

Like the United States, France recommends tetanus and diphtheria booster vaccines for adults. But the United Kingdom hasn't recommended them for anyone older than 14 since the 1950s, except for pregnant women or for those with tetanus-prone wounds.

These findings indicate that after completing the childhood vaccination series, decennial booster vaccinations may no longer be needed to maintain protective immunity in the general population.

Yet the investigators found that the United Kingdom had a slightly lower rate of tetanus and diphtheria infection and that population immunity remained strong even through a 2022 outbreak of 73 imported diphtheria cases among immigrants seeking asylum.

"Remarkably, despite this proportionally large influx of imported diphtheria cases, there was no evidence of transmission reported among other asylum seekers who arrived by other routes or among staff or health care workers," the authors wrote.

The authors caution that adult boosters should still be considered for emergency use in cases involving susceptible wounds, pregnant women, travelers to areas endemic for diphtheria, and anyone who didn't complete the childhood vaccine series.

"These findings indicate that after completing the childhood vaccination series, decennial booster vaccinations may no longer be needed to maintain protective immunity in the general population," the researchers wrote, adding that the move would more closely align US recommendations with the World Health Organization (WHO) guidelines, which haven't recommended adult boosters against tetanus or diphtheria since 2017.

American Adults Could Forgo Tetanus And Diphtheria Boosters, OHSU Scientist Says

Tetanus is a wretched disease. Toxins released by a nasty bacterium afflict the nervous system, causing muscle spasms so severe they can break bones.

But tetanus, also known as lockjaw, is avoidable, thanks to a supremely effective vaccine. In the U.S., the protocol is to get a booster every 10 years. But scientists at Oregon Health & Science University say that might be overkill.

The U.S. Could stop adult boosters for both tetanus and diphtheria, which are given together, saving the strapped U.S. Health care system about $1 billion a year, says Mark Slifka, a professor of microbiology and immunology in the OHSU School of Medicine and lead author of a paper published yesterday in Clinical Microbiology Reviews.

Slifka isn't a vaccine skeptic. He and his colleagues used scientific methods to show that the vaccines for tetanus and diphtheria, usually given together, confer immunity for 30 years, "well beyond the current recommendation of every 10 years for adults from the U.S. Centers for Disease Control and Prevention," OHSU said in a release about the paper.

The recommendation comes at a delicate time in vaccine land. Robert F. Kennedy Jr., secretary of the Health and Human Services Department, has expressed skepticism about vaccines, saying that measles can be treated with cod liver oil. Under his guidance, HHS stopped recommending the COVID vaccine for both children and healthy pregnant women.

Former OHSU resident and health author Casey Means has also expressed skepticism about vaccines. She is President Donald Trump's nominee for U.S. Surgeon general.

Cutting back on boosters might sound like more vaccine skepticism. As recently as 1948, tetanus, also known as lockjaw, killed 91% of its victims. The mortality rate for diphtheria was about 50%. Diphtheria still kills 1 in 10 people who aren't vaccinated.

But now, death from the diseases is almost unknown.

"Thanks to childhood vaccinations, these diseases are incredibly rare," Slifka said in the release. "In fact, you're 10 to 1,000 times more likely to be struck by lightning than to be diagnosed with tetanus and diphtheria in the United States."

Among the evidence for discontinuing boosters in adulthood, OHSU says, is a comparison between the United Kingdom and France. Like the U.S., France recommends boosters for adults. By contrast, the U.K. Has since the 1950s recommended stopping tetanus and diphtheria shots at age 14.

"This represents sort of an experiment of nature," Slifka says. "We have one country with over 60 million people that for decades has continued to vaccinate adults throughout their lifetime and another nearby country that also has over 60 million people, but over the past 50 years, they have never recommended adult booster vaccinations."

Despite decades of adult booster vaccination, the review found that France had "virtually no advantage over the U.K. In the rates of tetanus or diphtheria," OHSU said. "In fact, the review found that the UK had a slightly lower rate overall."

Slifka is also a professor at the Oregon National Primate Research Center, the 200-acre facility in Hillsboro that's home to 5,000 macaques and other monkeys. The center faces cutbacks in funding from the National Institutes of Health by the Trump administration, which is curbing primate research at the Food and Drug Administration and other agencies.

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