Incidence of Tetanus and Diphtheria in Relation to Adult Vaccination Schedules

Ariel M. Slifka, Byung Park, Lina Gao, Mark K. Slifka

Research output: Contribution to journalArticlepeer-review

23 Scopus citations


Background: The World Health Organization (WHO) does not recommend routine adult booster vaccination for tetanus and diphtheria after completion of the childhood vaccination series. However, many countries continue to implement adult booster vaccinations, leading to the question of whether this is necessary to reduce the incidence of these 2 rare diseases. Methods: We conducted an observational cohort study based on WHO case reports from 2001 through 2016. We compared the incidence of tetanus and diphtheria in 31 North American and European countries that either do or do not recommend adult booster vaccination. Results: Countries that vaccinate adults every 5-20 years (group 1) were compared with countries that do not routinely vaccinate adults for tetanus or diphtheria (group 2). Comparison of group 1 vs group 2 revealed no significant decline in tetanus incidence rates among countries that vaccinate adults (P =. 52; risk ratio [RR] = 0.78; 95% confidence interval [CI],. 36 to 1.70). The risk of contracting diphtheria was increased among countries that vaccinate adults due to inclusion of Latvia, a country that had poor vaccination coverage (P <. 001). However, if Latvia is excluded, there is no difference in diphtheria incidence between countries that do or do not routinely vaccinate adults (P =. 26; RR = 2.46; 95% CI,. 54 to 11.23). Conclusions: Review of >11 billion person-years of incidence data revealed no benefit associated with performing adult booster vaccinations against tetanus or diphtheria. Similar to other vaccines, this analysis supports the WHO position on adult booster vaccination and, if approved by governing health authorities, this may allow more countries to focus healthcare resources on vulnerable and undervaccinated populations.

Original languageEnglish (US)
Pages (from-to)285-292
Number of pages8
JournalClinical Infectious Diseases
Issue number2
StatePublished - Jan 15 2021


  • diphtheria
  • disease incidence
  • immunological memory
  • tetanus

ASJC Scopus subject areas

  • Microbiology (medical)
  • Infectious Diseases


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