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

ABSTRACT

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.

Introduction

Tetanus is a life-threatening condition caused by the neurotoxin produced by Clostridium tetani.¹ China has maintained high childhood vaccination coverage through its National Immunization Programme. However, tetanus antibody levels decline over time,² and China has not established a routine booster program for adults.³ Consequently, the management of traumatic wounds remains the primary defense against non-neonatal tetanus. Clinicians must assess wound characteristics and vaccination history accurately to provide appropriate post-exposure prophylaxis after trauma.⁴ Current Chinese guidelines⁵ and international guidelines⁶ recommend a risk-based approach.

However, evidence suggests a substantial gap between guideline recommendations and clinical practice. Healthcare workers frequently rely excessively on passive immunization (e.g., tetanus antitoxin), often disregarding patients’ documented vaccination histories.^7–9 Healthcare providers play a central role in translating immunization guidelines into clinical practice. Evidence from several countries shows that their knowledge and attitudes influence their vaccination recommendations.^10,11 These recommendations are a key determinant of patient vaccination uptake. Within the Knowledge-Attitude-Practice (KAP) framework, inadequate knowledge can lead to inconsistent decision-making. It may also reduce adherence to evidence-based immunization strategies.¹² Previous national surveys have examined awareness among emergency department physicians.⁸ However, data on staff working in dog bite clinics remain scarce, despite their frequent exposure to infected wounds and their central role in immunization decision-making.

This study aimed to evaluate the knowledge structure regarding active and passive tetanus immunization among healthcare workers (HCWs) in emergency departments and dog bite clinics in Quzhou, China, and to identify the potential individual and institutional factors influencing their knowledge levels. By identifying specific areas of knowledge deficiency, this study seeks to provide an empirical basis for designing targeted professional training programs and optimizing clinical post-exposure prophylaxis practices.

Methods

Study design

A questionnaire-based cross-sectional survey was conducted among healthcare professionals in Accident and Emergency departments and dog bite treatment clinics across hospitals in Quzhou City. Its aim was to assess their current knowledge of tetanus and the use of immunological preparations. Between 13 and 25 December 2025, investigators visited all 22 accident and emergency departments and 39 dog bite treatment clinics within Quzhou City. They distributed questionnaires on site and collected anonymous, voluntary responses.

To contextualize the knowledge assessment, it is important to note the routine training schedule for vaccination-related practices in the municipality. Typically, standard immunization training is organized annually by the municipal and county-level Centers for Disease Control and Prevention. However, these comprehensive sessions primarily target public health staff in standard vaccination clinics. For frontline clinical staff in emergency departments and dog bite clinics, the training mainly focuses on acute wound management and rabies post-exposure prophylaxis. Information specifically detailing the latest expert consensus on tetanus active vaccination, the adult booster schedule, and long-term immunological memory is often briefly covered during these routine clinical training sessions.

To ensure adequate statistical power and representative recruitment across institutional strata, we calculated the minimum sample size using the single-population proportion formula for a finite population:

$$n_{\mathit{adj}}=\frac{n}{1+\frac{\mathit{n}-1}{N}}$$

where $\mathit{n}=\frac{Z^2\cdot \mathit{p}\left(1-\mathit{p}\right)}{d^2}$ represents the sample size for an infinite population. In this formula, the standard normal deviate (Z) was set at 1.96, corresponding to a 95% confidence interval. The margin of error (d) was set at 5%. The expected proportion of adequate tetanus knowledge among healthcare workers (p) was conservatively assumed to be 50%, which yields the maximum required sample size. The total target population (N) comprised approximately 420 frontline clinicians working across 22 emergency departments and 39 dog bite clinics in Quzhou. After applying the finite population correction, the minimum required sample size was 201. To ensure the validity and clinical relevance of the survey, we applied strict eligibility criteria when defining healthcare professionals. The inclusion criteria were as follows: (1) licensed medical doctors, including resident doctors, attending physicians and consultants, or registered nurses actively working in emergency departments or standardized dog bite clinics; and (2) individuals who were informed of the study purpose and voluntarily agreed to participate. The exclusion criteria were: (1) nonprofessional healthcare staff, including nursing orderlies, hospital porters, medical secretaries, or administrative personnel, who were not directly involved in clinical decision-making or vaccine administration; and (2) healthcare students or interns without independent practising licenses. To account for the distinct institutional strata of emergency departments and dog bite clinics and to ensure representative recruitment, we employed a comprehensive cluster recruitment strategy. Instead of arbitrary convenience sampling, all 22 secondary / tertiary hospitals with emergency departments and all 39 standardized dog bite clinics within the municipality were mapped. All eligible frontline clinicians on duty during the study period were invited to participate. This total-population approach effectively preserved the natural, proportional distribution of healthcare providers across the two clinical strata in the real-world setting, minimizing selection bias at the recruitment stage. To prevent self-reporting bias, the classification of whether a healthcare institution provided tetanus vaccination services was objectively determined. This was achieved by querying the official vaccine procurement records on the provincial centralized Government Procurement Cloud (Zhengcaiyun) system, which is overseen by the municipal Center for Disease Control and Prevention. Institutions with active procurement and stocking records during the study period were classified as ‘vaccine available.’ Ultimately, 354 paper questionnaires were distributed, of which 348 were returned. After collection, the survey team conducted a preliminary review of the questionnaires. During data entry, we excluded questionnaires if key information, such as occupational category or years of work experience, was missing or illegible. We also excluded questionnaires that showed obvious response patterns, such as selecting ‘A’ for all items, or contained major logical inconsistencies. Ultimately, 343 valid questionnaires were included in the analysis, giving a response rate of 96.89% (343/354). This substantially exceeded the minimum required sample size.

This study strictly adhered to the principles of the Declaration of Helsinki. The research protocol was reviewed and approved by the expert panel of the Quzhou Center for Disease Control and Prevention and the relevant regulatory authorities. As the survey was conducted anonymously, did not involve biological sampling, and posed no risk to participants, written informed consent was waived. The study protocol was reviewed and approved by the Ethics Committee of Quzhou Center for Disease Control and Prevention (Approval No. 2025023). Prior to participation, all respondents were informed of the study purpose, the intended use of the data, and the principle of anonymity. Verbal informed consent was obtained from all participants.

Survey tools and quality control

Questionnaire design and content

The questionnaire was developed in accordance with the Expert consensus on the use of tetanus vaccines for the high-risk group of post-traumatic tetanus,⁴ the Expert consensus on preventive management of post-traumatic tetanus and establishment of vaccination clinic practice standards.¹³ It was adapted to reflect the local context and service delivery characteristics of Quzhou City. The questionnaire comprised three sections. The first section collected basic demographic information, including department, professional title and years of work, among other characteristics. The second assessed knowledge of post-traumatic tetanus and included 10 items on fundamental disease knowledge, with a total score of 26 points, and 19 items on the use of tetanus vaccines and passive immunization products, with a total score of 28 points, giving a maximum overall score of 54 points. The third section explored sources of relevant knowledge and training needs. Further details are provided in Supplementary Table S1.

Questionnaire reliability and validity assessment

Prior to formal implementation, the questionnaire underwent several rounds of expert review and was revised accordingly on the basis of feedback from preliminary pilot surveys. First, five experts in tetanus prevention and immunization programs conducted a formal content validity assessment. The item-level content validity index for each question exceeded 0.80, indicating good expert agreement and satisfactory content representativeness. Subsequently, a pilot survey involving 30 healthcare workers yielded Cronbach’s α coefficients of 0.81 for the ‘knowledge of tetanus’ dimension and 0.83 for the ‘knowledge of tetanus vaccines and passive immunization agents’ dimension, indicating good internal consistency of the questionnaire.

Statistical analysis

Statistical analyses were performed using R version 4.4.2. Differences in awareness rates between participants from hospitals offering tetanus vaccination services and those from hospitals not offering such services were compared using the chi-square test or Fisher’s exact test, as appropriate. Knowledge scores were not normally distributed and are therefore presented as median (M) and interquartile range (IQR, P25–P75). For univariate analyses, the Mann–Whitney U test or the Kruskal–Wallis H test was used, as appropriate.

For multivariable analysis, knowledge scores were categorized into four ordered levels based on quartiles: <P25, P25–M, M–P75, and ≥P75. An ordered logistic regression model (proportional odds model) was applied to examine factors independently associated with higher knowledge levels. Variables with P < .10 in univariate analysis and those considered theoretically or clinically relevant were included in the multivariable model. Multicollinearity among independent variables was assessed using variance inflation factors (VIFs) prior to model fitting. The proportional odds assumption was evaluated using the Brant test. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) were reported. A two-sided P value < .05 was considered statistically significant.

To address potential confounding and test the robustness of the association between institutional vaccine availability and knowledge levels, a sensitivity analysis was conducted using propensity score matching (PSM). Propensity scores for working in a vaccine-available institution were estimated using a multivariable logistic regression model incorporating baseline demographic and professional covariates (including institution type, hospital level, sex, job position, age, education level, professional title, clinical experience, and relevant training). A 1:1 nearest-neighbor matching algorithm without replacement was applied, using a caliper width of 0.05 standard deviations of the logit of the propensity score. Covariate balance before and after matching was evaluated using standardized mean differences (SMD), with an absolute SMD < 0.10 indicating an optimal balance. The ordered logistic regression model was then re-estimated on the propensity-score-matched cohort. Furthermore, to quantify the potential impact of residual unmeasured confounding (e.g., specific institutional size or unmeasured geographical variances), we calculated the E-value, which defines the minimum strength of association that an unmeasured confounder would need to have with both the exposure and the outcome to fully explain away the observed association.

To assess the stability and robustness of the parameter estimates in the ordered logistic regression model, we performed bootstrap validation with 1,000 resamples. This analysis was particularly important for variables with relatively small subgroup sample sizes, such as educational attainment. The bootstrap-derived odds ratios (ORs) and their corresponding 95% percentile confidence intervals (CIs) were calculated to verify the reliability of our primary regression analysis.

Results

Participant characteristics and overall knowledge levels

A total of 343 healthcare professionals were included in the analysis. The overall median total knowledge score was 40 (IQR: 35–45). The median score for tetanus-related disease knowledge was 20 (IQR: 16–23), and for vaccination and passive immunization knowledge was 21 (IQR: 18–23).

Recognition of classical clinical manifestations was consistently high, with awareness rates for trismus, difficulty opening the mouth, muscle spasm, opisthotonus, and risus sardonicus ranging from 94.75% (325/343) to 97.67% (335/343) (Table 1).

Table 1.

Awareness of post-traumatic tetanus among medical staff in dog bite clinics in Quzhou, 2025.

Relevant knowledge	Total		Vaccine not available at the hospital		Vaccination available at the hospital		$\mathit{\chi }$2	P
	N	Awareness (%)	N	Awareness (%)	N	Awareness (%)
Tetanus-related knowledge
Incubation period	148	43.15	65	41.14	83	44.86	0.48	.487
Case fatality rate	132	38.48	58	36.71	74	40.00	0.39	.532
Primary pathogenic agent	215	62.68	98	62.03	117	63.24	0.05	.816
A history of trauma is not a prerequisite for tetanus diagnosis	114	33.24	41	25.95	73	39.46	7.01	.008
Tetanus is not transmitted between humans	260	75.80	105	66.46	155	83.78	13.95	<.001
Cause of infection
Trauma	340	99.13	157	99.37	183	98.92	—	1.000*
Burn injury	265	76.38	114	72.15	151	81.62	4.35	.037
Neonates delivered under unhygienic conditions	290	84.55	132	83.54	158	85.41	0.23	.635
Perianal abscess	190	55.39	83	52.53	107	57.84	0.97	.324
Colonic perforation	185	53.94	80	50.63	105	56.76	1.29	.257
Animal-inflicted injury	305	88.92	130	82.28	175	94.59	13.12	<.001
Clinical manifestations
Fever	255	74.34	114	72.15	141	76.22	0.74	.390
Difficulty opening the mouth	332	96.79	153	96.84	179	96.76	0.00	.967
Lockjaw (trismus)	335	97.67	154	97.47	181	97.84	—	1.000*
Opisthotonus	328	95.63	149	94.30	179	96.76	1.23	.268
Muscle spasm	330	96.21	151	95.57	179	96.76	0.33	.566
Risus sardonicus	325	94.75	149	94.30	176	95.14	0.12	.731
Movement disorder	260	75.80	116	73.42	144	77.84	0.91	.341
Convulsion	295	86.01	132	83.54	163	88.11	1.48	.225
Facial flushing	175	51.02	76	48.10	99	53.51	1.00	.318
Apnoea	235	68.51	102	64.56	133	71.89	2.13	.145
Asphyxia	268	78.13	118	74.68	150	81.08	2.04	.153
Cardiac arrest	205	59.77	95	60.13	110	59.46	0.02	.900
Knowledge of tetanus vaccination and passive immunisation
Tetanus vaccination constitutes active immunisation	238	69.39	108	68.35	130	70.27	0.15	.701
Tetanus antitoxin injection constitutes passive immunisation	230	67.06	98	62.03	132	71.35	3.36	.067
Recovery from tetanus does not induce immunological memory	108	31.49	52	32.91	56	30.27	0.28	.600
Tetanus vaccination is safe for pregnant women	220	64.14	82	51.90	138	74.59	19.09	<.001
Tetanus vaccination schedule	213	62.10	85	53.80	128	69.19	8.58	.003
Protective antibody levels are typically reached two weeks after tetanus vaccination	58	16.91	26	16.46	32	17.30	0.04	.836
Children aged 0–6 y require five doses of tetanus-containing vaccines	42	12.24	18	11.39	24	12.97	0.20	.656
A single booster dose of tetanus vaccine is recommended for adults every 10 y	122	35.57	50	31.65	72	38.92	1.97	.161

*Note: Fisher’s exact test.

Conversely, knowledge of epidemiological and immunological characteristics was markedly lower. Less than half of the participants correctly identified the incubation period (43.15%, 148/343) or the case fatality rate (38.48%, 132/343), and only a minority recognized that a history of trauma is not a prerequisite for diagnosis (33.24%, 114/343) or that recovery does not confer lasting immunity (31.49%, 108/343). Substantial gaps were also observed in vaccination-related knowledge; awareness rates for the protective antibody timeline, the five-dose childhood schedule, and the 10 y adult booster interval were 16.91% (58/343), 12.24% (42/343), and 35.57% (122/343), respectively (Table 1).

Differences by institutional vaccine availability

Participants working in institutions providing tetanus vaccination services demonstrated significantly higher awareness across multiple domains. Specifically, they showed significantly better recognition regarding non-human transmission (P < .001), animal-inflicted injuries as an infection cause (P < .001), and vaccine safety during pregnancy (P < .001). Furthermore, awareness of the recommended vaccination schedule (P = .003) and the fact that tetanus can occur without a clear trauma history (P = .008) was also significantly higher among staff in vaccine-available institutions (Table 1).

Factors associated with tetanus-related knowledge scores

As shown in Table 2, univariate analysis demonstrated that institution type, hospital level, vaccine availability, sex, age, job position, educational attainment, professional title, clinical experience, and relevant training were all significantly associated with knowledge scores (all P < .05). After adjusting for confounding factors in the multivariable ordered logistic regression model, several factors remained independently associated with lower knowledge levels: working in an emergency department (OR = 0.45, 95% CI: 0.27–0.74, P = .002), absence of institutional vaccine availability (OR = 0.58, 95% CI: 0.34–0.82, P = .005), being a nurse (OR = 0.39, 95% CI: 0.23–0.60, P < .001), holding a junior college education or below (OR = 0.32, 95% CI: 0.12–0.85, P = .022), and lacking relevant training (OR = 0.51, 95% CI: 0.26–0.96, P = .028). The corresponding forest plot visualizing the adjusted odds ratios is available in Supplementary Figure S1. Furthermore, internal bootstrap validation (1,000 replications) confirmed the stability of the multivariable ordered logistic regression model. The bootstrap-derived ORs and 95% CIs for the educational categories aligned closely with those from the primary model, indicating that the wide confidence interval observed in the junior college group did not compromise the overall stability of the regression estimates (Supplementary Table S2).

Table 2.

Univariate and multivariable analysis of factors associated with tetanus-related knowledge scores among healthcare professionals (N = 343).

Variable	N	Total Score Median (IQR)	Univariate Analysis		Multivariable Analysis
			H/Z	P	OR (95% CI)	P
Institution type
Dog Bite Clinic	190	42 (36–46)	−4.32	<.001	1.00 (Reference)
Emergency Department	153	38 (33–43)			0.45 (0.27–0.74)	.002
Hospital level
Secondary hospitals	210	41 (35–45)	−2.31	.021	1.00 (Reference)
Tertiary hospitals	133	39 (33–44)			0.85 (0.45–1.60)	.621
Tetanus vaccine available
Yes	185	42 (36–46)	−4.15	<.001	1.00 (Reference)
No	158	38 (33–43)			0.58 (0.34–0.82)	.005
Sex
Man	135	42 (37–45)	−4.75	<.001	1.00 (Reference)
Female	208	38 (34–43)			1.15 (0.68–1.95)	.593
Age (years)
<31	105	38 (33–42)	6.01	.049	1.00 (Reference)	—
31 ~ 40	170	41 (36–45)			1.08 (0.55–2.10)	.825
>40	68	42 (37–46)			1.25 (0.58–2.70)	.567
Job position
Doctor	152	44 (39–47)	−7.01	<.001	1.00 (Reference)	—
Nurse	191	37 (31–41)			0.39(0.23–0.60)	<.001
Years of work experience
<3	40	38 (31–41)	3.61	.306	—	—
3 ~ 5	72	39 (34–43)			—	—
6 ~ 10	95	39 (36–44)			—	—
>10	136	41 (36–45)			—	—
Education level
Master’s degree or above	33	45 (41–48)	13.91	.001	1.00 (Reference)	—
Bachelor’s degree	275	41 (35–45)			0.56 (0.29–1.05)	.071
Junior college or below	35	35 (30–39)			0.32 (0.12–0.85)	.022
Professional title
Junior or below	182	38 (33–43)	17.88	<.001	1.00 (Reference)	—
Intermediate	130	42 (37–46)			1.30 (0.73–2.28)	.353
Senior	31	44 (40–47)			1.45 (0.65–3.22)	.368
Clinical experience
Yes	138	42 (37–46)	−3.15	.002	1.00 (Reference)	—
No	205	38 (33–43)			0.92 (0.53–1.74)	.781
Relevant training
Yes	298	41 (36–45)	−3.88	<.001	1.00 (Reference)	—
No	45	36 (30–40)			0.51 (0.26–0.96)	.028
Total	343	40 (35–45)

Subgroup analysis: impact of vaccine availability on physicians

To determine whether the association between institutional vaccine availability and knowledge scores varied by professional role, we conducted a subgroup analysis restricted to physicians (n = 152). Physicians in institutions with vaccine availability had significantly higher median knowledge scores than those in institutions without vaccine availability (45, IQR 40–48 vs. 41, IQR 36–45; P = .008).

Knowledge structure among staff with clinical tetanus experience

Among healthcare workers with prior clinical tetanus experience (n = 78), a distinct procedural–preventive knowledge imbalance was observed (Supplementary Table S3). Awareness of clinical wound management and passive immunization was generally high, particularly regarding the principles of debridement, the role of tetanus neurotoxin, and the classification of passive agents. In sharp contrast, their understanding of active immunization and long-term prevention strategies remained remarkably low; specifically, the awareness rates for the timeline for antibody production, the childhood schedule, and the adult booster interval were 17.95% (14/78), 14.10% (11/78), and 39.74% (31/78), respectively (Supplementary Table S3).

Sensitivity analysis using propensity score matching and E-value

Prior to matching, substantial baseline differences existed between healthcare workers in institutions with and without vaccine availability. Using 1:1 PSM, we successfully matched 120 participants from vaccine-available institutions with 120 participants from institutions without vaccines, resulting in a well-balanced matched cohort of 240 individuals. After matching, all baseline characteristics (including institution type, hospital level, sex, age, job position, education level, professional title, clinical experience, and training history) achieved an optimal balance with all SMDs markedly reduced to <0.10 (Supplementary Table S4).

A direct comparison within the matched cohort revealed that a significantly higher proportion of healthcare workers in vaccine-available institutions achieved higher knowledge scores (top quartiles) compared to their matched counterparts (58.33%, 70/120 vs. 31.67%, 38/120). When the ordered logistic regression was repeated on this balanced matched cohort, the primary findings remained highly consistent. The absence of institutional vaccine availability remained independently associated with poorer knowledge profiles, demonstrating a robust effect size (Adjusted OR = 0.62, 95% CI: 0.38–0.91, P = .015).

Additionally, to rigorously evaluate the potential threat of residual unmeasured confounding, the E-value was calculated for this primary finding. For the observed association (inverted OR = 1.61), the E-value was calculated to be 2.60 (with a lower confidence bound of 1.44). This indicates that an unmeasured confounder would need to be associated with both institutional vaccine supply and healthcare workers’ knowledge scores by an odds ratio of at least 2.60-fold to negate the observed effect. The existence of such a powerful unmeasured confounder in this clinical setting is highly unlikely, thereby reinforcing the stability of our primary conclusions.

Discussion

This study demonstrates a significant discrepancy in tetanus-related knowledge among healthcare professionals working in hospital A&E departments and dog bite clinics. Participants showed good knowledge of typical clinical manifestations and wound management principles. However, their understanding of active immunization strategies was limited. This included recommended vaccination schedules, booster intervals, and the time required for protective antibodies to develop. Multivariate analysis showed that institutional vaccine supply, professional role, educational attainment and prior professional training were independently associated with knowledge levels. The observed gap was not random, but followed a consistent structural pattern that uncovers a distinct procedural-preventive knowledge imbalance. This pattern underscores that the functional stratification of tetanus knowledge is strongly shaped by both individual clinical roles and broader systemic determinants, such as institutional vaccine availability.

The asymmetry observed in this study likely reflects routine clinical practice in A&E departments and dog bite clinics. Clinicians often prioritize immediate wound care and passive immunization. This interpretation is consistent with findings from other studies.^14,15 The emergency management of contaminated wounds relies on established protocols. Daily clinical practice reinforces these procedures. By contrast, clinicians may pay less attention to the principles of active immunization. This is particularly true for long-term booster strategies. Continuing education and routine practice may not emphasize these aspects.^8,16 Consequently, healthcare professionals may demonstrate strong skills in reactive clinical management. However, they may lack a comprehensive understanding of preventive immunization frameworks. This imbalance does not appear to resolve through clinical experience alone. In the subgroup with prior experience of managing tetanus cases, knowledge of trauma management and passive immunization remained high. However, awareness of active immunization remained inadequate.^8,9 These findings suggest that exposure to individual cases cannot bridge gaps in program-level immunization knowledge. The notably low awareness rate (12.24%) of the five-dose childhood vaccination schedule requires careful interpretation. In China, routine childhood immunizations are entirely managed by public health practitioners at primary care facilities. Frontline clinicians in emergency departments and dog bite clinics work within a separate clinical system that focuses primarily on acute wound management. Furthermore, this knowledge gap may be compounded by confusion over vaccine terminology, as the childhood schedule delivers tetanus antigens through combination vaccines such as Diphtheria, Tetanus, and acellular Pertussis vaccine (DTaP) and Diphtheria and Tetanus toxoid vaccine (DT) rather than monovalent tetanus vaccines. Consequently, although clinicians are generally aware that younger patients have baseline immunity, many are unable to recall the exact number of recommended doses when surveyed.⁹ This finding further highlights the imbalance between procedural and preventive knowledge among frontline healthcare workers.¹⁷ It also underscores the need for continuous medical education to strengthen the integration of emergency care practice with routine public health guidelines. Current practice appears to prioritize acute management over sustained immunoprophylaxis.

From a theoretical perspective, These findings can be interpreted through the KAP framework. The KAP model emphasizes that knowledge is a prerequisite for behavioral change.¹⁸ However, when knowledge is structurally biased, behavioral pathways may also be selectively reinforced. This process can perpetuate acute response behaviors. In contrast, long-term immunization decision-making may lack consistent support. Previous studies have shown that the absence of advice from healthcare professionals and limited access to relevant information are the main reasons why adults remain unvaccinated.^19,20 Healthcare professionals are therefore not only recipients of knowledge. They also play a central role in shaping the public’s vaccination decisions. Healthcare professionals’ understanding of vaccine efficacy and safety directly influences patients’ willingness to receive vaccination.^21–23 In many healthcare systems, clinicians administer tetanus booster doses opportunistically when patients present with injuries. If clinicians do not clearly understand the booster schedule or antibody kinetics, they may miss the optimal opportunity to vaccinate. Consequently, even when vaccine supplies are adequate, gaps in healthcare workers’ knowledge may reduce adult uptake of booster doses.

Globally, adult booster vaccination has long been relatively neglected.²⁴ The World Health Organization has repeatedly emphasized the importance of tetanus booster vaccinations across the life course. However, adult vaccination uptake remains generally low.²⁵ Studies from both high- and middle-income countries have shown that older adults experience waning immunity and often lack awareness of booster vaccination recommendations.^26,27 In this context, guidance from healthcare professionals is among the strongest predictors of adult vaccination uptake. Therefore, strengthening healthcare workers’ knowledge may be a key entry point for improving population-level protection.

One of the most notable findings of this study is the independent association between institutional vaccine supply and knowledge levels. This suggests that knowledge acquisition depends not only on individual willingness to learn but also on the organizational context in which clinicians operate.²⁸ Including institution type as an independent predictor highlights how the specific clinical environment influences healthcare workers’ knowledge structures. Our findings showed that staff in dog bite clinics had higher levels of knowledge than those working in emergency departments. This difference likely reflects the specialized role of dog bite clinics in Quzhou, where staff manage animal-inflicted injuries daily–wounds that are traditionally high-risk and require both rabies and tetanus prophylaxis. This repetitive clinical exposure likely reinforces guideline adherence and risk assessment specific to wound-related immunization. By contrast, emergency departments manage a wide and varied range of acute conditions, where urgent surgical or life-support interventions often take priority over long-term immunoprophylaxis education.²⁹ This institutional variation suggests that training interventions should not follow a uniform approach. Instead, targeted programs are needed to address the specific knowledge gaps among emergency department personnel and reduce the disparity between clinical settings.³⁰ Conversely, in settings without vaccination services, clinical focus may be restricted to wound management and passive immunization. This can further fragment preventive care. This finding underscores the importance of systemic determinants. Educational attainment and occupational roles are individual factors, while institutional vaccine supply represents structural capacity. The observed associations support the view that knowledge acquisition is embedded in the organizational context. Strengthening vaccination capacity may therefore enhance service access while also increasing healthcare professionals’ awareness.^31,32 Notably, our subgroup analysis demonstrated that even physicians, who are traditionally expected to maintain comprehensive medical knowledge, were susceptible to this institutional effect. This suggests that without the environmental reinforcement provided by active vaccine administration, preventive immunization knowledge may atrophy even among core clinical decision-makers.

In this study, the nursing group scored significantly lower than doctors. This finding is consistent with a study conducted in Somalia.³³ This may be related to the fact that nurses primarily carry out doctors’ orders and have limited involvement in decisions regarding immunization strategies. Preventive education is also often underemphasized in their departments. In many wound care settings, nurses play a major role in triage, debridement, and patient counseling. It is therefore especially important to provide nursing staff with targeted training on immunization. Addressing knowledge gaps within multidisciplinary teams can improve consistency in promoting tetanus prevention. Educational attainment directly influences the depth of understanding of fundamental medical theory. Healthcare professionals with a college diploma or lower scored significantly lower on knowledge assessments than those holding a master’s degree or higher. Individuals with higher education generally have stronger self-learning abilities and a more systematic understanding of disease prevention and control.³⁴ This enables them to comprehend the fundamental differences between active and passive immunity more accurately. This study shows a positive correlation between prior training experience and knowledge levels, highlighting the crucial role of continuing professional development in closing knowledge gaps. Furthermore, the specific schedule and information provided in current municipal training programs largely explain the observed knowledge asymmetry. Routine training for emergency and dog bite clinic staff is heavily skewed toward acute trauma protocols and passive immunization administration. Comprehensive information regarding the active five-dose childhood schedule or the 10 y adult booster interval is rarely prioritized in these targeted clinical sessions. Consequently, while clinicians receive sufficient information to master wound debridement and tetanus antitoxin use, they lack the systemic educational reinforcement needed to understand long-term active immunization strategies.^9,17 This finding is consistent with a nationwide survey conducted by Gao et al .⁸ This finding underscores the effectiveness of structured educational interventions. Training programs should reinforce wound management protocols while also emphasizing active immunization schedules, booster intervals, and the principles of sustained antibody protection. Integrating vaccination education into routine professional development may help reduce the current over-reliance on passive treatment.

Although this study was conducted in a specific region, its findings may have broader relevance for tetanus prevention in similar wound care settings. Maintaining sufficient population immunity remains the cornerstone of tetanus prevention.³⁵ Although post-exposure prophylaxis remains crucial, it cannot replace systematic immunization. Overemphasis on passive immunity and neglect of long-term immunization strategies may cause patients to miss important opportunities for prevention. Consequently, enhancing institutional vaccination capacity and professional training may help shift practice from reactive treatment to proactive prevention.

This study has several limitations. First, the cross-sectional design restricts causal inference. We cannot entirely rule out reverse causality, as highly knowledgeable professionals might self-select into institutions that supply vaccines. Unmeasured factors, such as institutional size, might also introduce residual confounding. However, propensity score matching and E-value analyses show that our primary conclusions remain highly robust against these potential selection biases. Second, we relied on self-administered questionnaires to map knowledge structures. This approach did not directly measure actual clinical behaviors, such as the inappropriate use of passive immunization or routine booster recommendations. Extensive literature on the ‘knowledge-behavior gap’ in healthcare indicates that clinical decision-making is complex and not solely determined by theoretical knowledge.^36,37 It is strongly influenced by entrenched institutional practices, defensive medicine, and perceived legal risks in wound management.³⁸ Therefore, our findings reflect cognitive preparedness rather than real-world clinical practice. Third, we conducted this study exclusively in Quzhou, a socioeconomically developed region in eastern China. These findings might not fully generalize to inland provinces or resource-constrained rural primary care settings, where vaccine accessibility and training opportunities differ. Nonetheless, detecting a stark procedural-preventive knowledge imbalance in an affluent area suggests that these systemic gaps may be even more pronounced in less developed regions. Fourth, the professional training variable was captured only as a binary indicator (‘yes’ vs. ‘no’), lacking granular details on training content, duration, format, or assessment. While we qualitatively noted that local routine sessions heavily favor acute trauma over active immunization frameworks, this simplified quantitative measure restricts our ability to model which specific educational components are most effective. Consequently, this limits the formulation of highly tailored blueprints for future intervention design. Fifth, the relatively small sample sizes in the ‘junior college or below’ (n = 35) and ‘master’s degree or above’ (n = 33) subgroups led to wide confidence intervals. Although bootstrap sensitivity analyses confirmed the stability of these estimates, readers should interpret the exact magnitude of these specific subgroup effects with caution. Finally, we acknowledge that the use of self-administered questionnaires may have introduced social desirability bias. Participants might have been inclined to select responses they perceived as ‘correct’ based on clinical guidelines, particularly regarding recommended immunization schedules, which may have led to an overestimation of their actual knowledge. Future research should consider incorporating objective assessments, such as case-based simulations or clinical record audits, to validate these findings and better reflect real-world clinical competence.

Conclusion

Frontline healthcare workers show strong understanding of clinical manifestations and wound care. However, significant gaps remain in their knowledge of active immunization. Institution type, vaccine availability within healthcare settings, professional role, educational attainment, and specialist training are all independently associated with knowledge levels. Addressing these gaps through system-wide improvements and targeted continuing professional development can help align clinical practice with long-term tetanus prevention strategies and increase adult booster vaccination coverage.

Biographies

Guoping Cao, Male, postgraduate degree holder and Associate Chief Physician, currently serving as Head of the Department of Infectious Disease Control at the Quzhou Centre for Disease Control and Prevention. He has extensive experience in the prevention and control of acute infectious diseases, public health surveillance, and emergency response, and has published more than 10 academic papers.

Zhiying Yin, she is the deputy director of Quzhou Center for Disease Control and Prevention, a member of the Standing Committee of Quzhou Science and Technology Association, a chief physician and a master’s tutor. She has been engaged in work related to immunisation planning for 20 y and is a new talent in medical field in Zhejiang Province and 115 talents in the city. She has participated in the writing and publication of 30 SCI papers, of which 20 were published by the first or corresponding authors. She has published many academic papers in Chinese core journals, including ‘Analysis of Varicella Epidemic Characteristics and Varicella Vaccine Immunisation Effect in Quzhou City, Zhejiang Province, 2006-2014’, which has been selected as one of the top academic papers in China’s top quality Science and Technology Journals, ‘Leader 5000’, by China Institute of Science and Technology Information (Certificate No. G452201604010). She has presided over a number of provincial and municipal science and technology projects.

Funding Statement

This study was supported by the Zhejiang Provincial Society of Preventive Medicine through the research project on the application of immunization program technologies and related policies [2026-B-04].

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

All data can be available upon request from the corresponding author.

Supplementary material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/21645515.2026.2694172