Integrating non-neonatal tetanus vaccination into an emergency department rabies PEP clinic: Real-world workload, documentation gaps, and VAERS-informed observation priorities

Animal-bite and scratch visits to the emergency department (ED) often require time-sensitive decisions on rabies post-exposure prophylaxis (PEP) alongside tetanus prevention. In China, recent national standards and local implementation programs have framed non-neonatal tetanus prevention as an integrated medical-public health service model, yet integrated workflows and structured documentation remain uncommon in many tertiary hospitals. We reviewed patients presenting for their first recorded exposure to a dedicated ED rabies PEP clinic (8 Oct 2022-31 Oct 2025; n = 3,365) to describe real-world encounter characteristics and quantify implementation-relevant workload. Grade III exposures accounted for 73.6% of presentations, and 93.1% of patients presented on the same day. While grade III encounters form a practical priority subgroup for tetanus management, grade II/III encounters represented 99.4% of visits, indicating that tetanus immunization-history review and wound tetanus-risk documentation would need to be routine steps for nearly all PEP encounters. However, tetanus-related elements (immunization history, Td/Tdap/TT vaccination, tetanus immunoglobulin/antitoxin use) were not captured in structured registry fields, and Td/Tdap/TT vaccination is not routinely available in our ED clinic workflow, highlighting a quality improvement opportunity for standardized implementation. To provide external pharmacovigilance context in the absence of local coadministration safety data, we summarized adult VAERS reports listing both rabies vaccine and Td/Tdap/TT in 2022-2025 (n = 9; serious reports 0/9) and explored predefined disproportionality signals in 2006-2025. In sensitivity analyses, syncope and hypersensitivity showed increased reporting odds in reports listing both vaccines compared with rabies-only reports. These VAERS findings are presented as hypothesis-generating only: they identify potential event categories that may warrant awareness and documentation if multiple vaccines are administered during one encounter, but they do not confirm same-day administration, estimate incidence, or support causal inference.