Structural asymmetry in knowledge of active and passive tetanus immunization among frontline healthcare workers: Implications for adult booster policy in China

Despite sustained high childhood tetanus vaccination coverage in China, adult booster immunization has not been institutionalized, leaving a substantial immunity gap. Frontline healthcare providers play a critical role in post-exposure prophylaxis decisions; however, their knowledge regarding tetanus immunization remains inadequately characterized We conducted a cross-sectional survey among 343 healthcare professionals working in 22 emergency departments and 39 dog bite clinics in Quzhou, China. A validated questionnaire assessed knowledge of tetanus disease, active immunization schedules, and passive immunization use. Knowledge scores were categorized into quartiles and analyzed using ordered logistic regression. Recognition of key clinical manifestations ranged from 94.75% (325/343) to 97.67% (335/343). In contrast, knowledge regarding active immunization was markedly limited: only 12.24% (42/343) correctly identified the five-dose childhood schedule and 35.57% (122/343) recognized the recommended 10y adult booster interval. Awareness that tetanus may occur without a clear trauma history was 33.24% (114/343). Among respondents with prior clinical experience managing tetanus, knowledge of wound management was high (94.87%, 74/78), whereas understanding of long-term immunization strategies remained low (14.10%, 11/78–39.74%, 31/78), indicating a procedural–preventive knowledge imbalance. Institution type, vaccine availability at the institution, occupational role, educational level, and prior training were independently associated with higher knowledge scores (all P < .05). Frontline providers demonstrated adequate clinical recognition but insufficient understanding of active immunization and adult booster strategies. This imbalance may contribute to inappropriate reliance on passive immunization in trauma settings. Strengthening guideline-based training and improving institutional vaccine accessibility are essential to optimize tetanus prophylaxis practices and support adult immunization policy development.