Adult Seroprotection Gaps Against Diphtheria and Tetanus in Urban China: Repeated Cross-Sectional Serosurveillance in Pudong, Shanghai, 2017-2025.
Cheng Wanran W, Li Juan J, Yang Tian T, Bai Yu Y et al.
Background: Adult susceptibility to diphtheria and tetanus may increase as vaccine-induced immunity wanes, yet repeated population-based serosurveillance data in China are limited. Methods: We analyzed annual serosurveys conducted in Pudong New Area, Shanghai, China, from 2017 to 2025 among healthy adults aged 20-49 years. Diphtheria and tetanus IgG concentrations were measured by ELISA. Seroprotection was defined as antibody concentration ≥0.1 IU/mL. Antibody concentrations were further categorized as <0.01, 0.01-<0.1, 0.1-<1.0, and ≥1.0 IU/mL, and geometric mean concentrations (GMCs) were calculated. Multivariable logistic regression models were fitted to assess factors associated with non-protection, including survey year, age group, and household registration. Sensitivity analyses excluding the 2018 survey year were conducted. Results: A total of 2376 serum samples were included. Overall seroprotection was 21.46% for diphtheria and 13.80% for tetanus. The proportion protected against both antigens was 9.05%, while 73.78% showed concurrent non-protection against both antigens. The overall GMC was 0.032 IU/mL (95% CI: 0.030-0.034) for diphtheria and 0.018 IU/mL (95% CI: 0.017-0.019) for tetanus. Concentrations ≥1.0 IU/mL were uncommon for both antigens. Adults aged 40-49 years had higher odds of non-protection than those aged 20-29 years for diphtheria (OR: 2.43, 95% CI: 1.85-3.21) and tetanus (OR: 2.94, 95% CI: 2.11-4.13). Non-local residents also had higher odds of non-protection than local residents for diphtheria (OR: 1.55, 95% CI: 1.24-1.93) and tetanus (OR: 2.81, 95% CI: 2.15-3.69). Seroprotection varied across survey years, with a marked nadir in 2018. Sensitivity analyses excluding 2018 attenuated most year-specific associations, whereas age- and residence-related differences persisted. Conclusions: Healthy adults aged 20-49 years in Pudong showed low seroprotection and low GMCs against both diphtheria and tetanus, with a high proportion concurrently non-protected against both antigens. These findings highlight a persistent adult immunity gap and support further evaluation of adult booster strategies and enhanced serosurveillance.