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Tetanus Immunisation

See also Tetanus.

Because of concern at the low levels of immunity to diphtheria in older people in the UK, and the recent switch to inactivated polio vaccine (IPV), tetanus vaccine is now only given as part of combined products:

  • "Standard " tetanus/diphtheria/inactivated polio vaccine (Td/IPV).
  • Primary course for those aged under 10 years: diphtheria/tetanus/acellular pertussis/inactivated polio vaccine/Haemophilus influenzae type b (DTaP/IPV/Hib).
  • "Preschool booster": diphtheria/tetanus/acellular pertussis/inactivated polio vaccine(DTaP/IPV or dTaP/IPV).

Vaccines are normally given intramuscularly into the upper arm or anterolateral thigh, except if patients have a bleeding disorder (e.g. haemophilia) when deep subcutaneous injection is appropriate.

UK immunisation schedule (amended 2006)1
  • Children:
    • Primary Course: 3 doses of vaccine (usually as combined DTaP/IPV/Hib) at 2, 3 and 4 months of age.
    • 4th dose: At least 3 years after the primary course, usually pre-school entry (as DTaP/IPV).
    • 5th dose: Aged 13-18 years before leaving school (as Td/IPV).
  • Adults:
    • Primary Course: 3 doses of vaccine (as Td/IPV) each one month apart.
    • 4th dose: 10 years after primary course (as Td/IPV).
    • 5th dose: 10 years after 4th dose (as Td/IPV).

DTaP/IPV/Hib = Diphtheria, tetanus, acellular pertussis (whooping cough), inactivated polio and Haemophilus influenzae type B.
d = low dose diphtheria

Vaccination of children with unknown or incomplete immunisation status

  • A child who has not completed the primary course should have the outstanding doses at monthly intervals.
  • Children may receive the first booster dose as early as one year after the third primary dose to re-establish them on the routine schedule.
  • The second booster should be given at the time of leaving school to ensure long term protection by this time, provided a minimum of five years is left between the first and second boosters.
  • Children coming to the UK who have a history of completing immunisation in their country of origin may not have been offered protection against all the antigens currently used in the UK.
  • Where there is no reliable history of previous immunisation, it should be assumed that they are unimmunised, and the full UK recommendations should be followed.
  • Children coming to the UK may have had a fourth dose of a tetanus-containing vaccine that is given at around 18 months in some countries. This dose should be discounted as it may not provide satisfactory protection until the time of the teenage booster. The routine pre-school and subsequent boosters should be given according to the UK schedule.

Older adults

  • May be unimmunised and at particular risk.
  • Try to check their immunisation status opportunistically (e.g. when giving their influenza vaccination), and complete the recommended 5 dose schedule.
  • Td/IPV can be given at the same time as influenza vaccine in a different arm.
  • Intravenous drug users are also a high risk group.

Travellers to remote areas

For travellers to areas where medical attention may not be accessible and whose last dose of a tetanus-containing vaccine was more than ten years previously, a booster dose should be given prior to travelling, even if the individual has received five doses of vaccine previously. This is in case immunoglobulin is not available to the individual should a tetanus-prone injury occur.

Storage

Store at 2 to 8°C and protect from light.

Contraindications to tetanus vaccination2
  • Absolute contraindications are:
    • Confirmed anaphylactic reaction to previous tetanus vaccine (occurs in 3/million).
    • Confirmed anaphylactic reaction to neomycin, streptomycin or polymyxin B.
  • Stable neurological conditions, febrile convulsions, personal or family history of seizures are not contraindications.
  • Immunisation should be deferred if the child is unwell with fever (vaccinate as soon as possible once child has recovered).
  • Fever, hypotonic-hyporesponsive episodes (HHE), persistent crying or severe local reaction within 72 hours of previous vaccination are not reasons for not giving subsequent tetanus vaccinations.
Side effects

Report adverse reactions to CSM via yellow card scheme.

  • Pain, redness and swelling are common.
  • Transient nodule at injection site.
  • Anaphylaxis is rare (0.65-3 per million).
Tetanus prone injuries

Tetanus prone wounds are:

  • Wounds or burn sustained >6 hours before surgical treatment.
  • Any wound or burn with:
    • A significant degree of devitalised tissue.
    • Puncture wounds.
    • Wounds having come in contact with soil or manure likely to harbour tetanus organisms.
    • Clinical evidence of sepsis.

Management1

  • Following such a wound, where the individual has received a full 5 dose course of tetanus vaccine at the recommended intervals, or is up to date with their tetanus immunisation schedule:
    • No further doses of vaccine are recommended (as within the incubation period of tetanus, vaccine given at the time of a tetanus prone injury may not boost immunity early enough to give additional protection).
    • If the risk of tetanus is especially high e.g. the wound is contaminated with stable manure, human tetanus immunoglobulin should be given to give immediate additional protection.
  • If the immunisation schedule is not up to date or whose status is unknown, a reinforcing dose of Td/IPV should be given at the time of treatment of an injury and further doses given as required to complete the recommended 5 dose schedule. In this situation immunoglobulin should be given for any injury defined as a tetanus prone wound (see above).
  • For travellers to areas where medical attention may not be accessible should a tetanus prone injury occur and whose last dose of a tetanus containing vaccine was more than 10 years previously, a booster dose of Td/IPV should be given, even if the individual has received 5 doses of vaccine previously. This is a precautionary measure in case immunoglobulin is not available to the individual should a tetanus prone injury occur.
  • The preventative dose of human tetanus immunoglobulin is 250 iu im in most cases, except if more than 24 hours have elapsed since injury or there is a risk of heavy contamination or following burns, when 500 iu im is given.

Document references
  1. Immunisation against infectious disease - 'The Green Book', Department of Health (various dates)
  2. Summary of Product Characteristics - Revaxis® (Diphtheria, tetanus and poliomyelitis (inactivated) vaccine (adsorbed)); Sanofi Pasteur MSD Limited; Updated May 2008; electronic Medicines Compendium.
Internet and further reading Acknowledgements EMIS is grateful to Dr Colin Tidy for writing this article. The final copy has passed scrutiny by the independent Mentor GP reviewing team. ©EMIS 2008.
DocID: 534
Document Version: 3
DocRef: bgp24824
Last Updated: 28 Oct 2008
Review Date: 28 Oct 2010






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