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Tetanus Immunisation

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 under10 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

Older Adults

  • May be unimmunised and at particular risk.
  • Try to check their immunisation status opportunitistically (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

  • Immunoglobulin may not be available and a tetanus prone injury is liable to occur.
  • A booster dose of Td/IPV should be given as a precautionary measure if the last dose of a tetanus containing vaccine was more than 10 years previously, even if the individual has received 5 doses of vaccine previously.
Storage

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

Contraindications to Tetanus Vaccination 2,3
  • 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 250iu 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 500iu im is given.

Document References
  1. Department of Health; The Green Book. Immunisation Against Infectious Disease 2006
  2. Summary of Product Characteristics - Revaxis® (Diphtheria, tetanus and poliomyelitis (inactivated) vaccine (adsorbed)); Sanofi Pasteur MSD Limited; Updated May 2005; electronic Medicines Compendium.
  3. British National Formulary; 52nd Edition (September 2006) British Medical Association and Royal Pharmaceutical Society of Great Britain. London (link to current BNF).
Internet and Further Reading AcknowledgementsEMIS is grateful to Dr Colin Tidy for writing this article. The final copy has passed scrutiny by the independent Mentor GP reviewing team. ©EMIS 2007.
DocID: 534
Document Version: 2
DocRef: bgp24824
Last Updated: 11 Oct 2007
Review Date: 10 Oct 2008




















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See also MAKEPOVERTYHISTORY North East for details and links to campaigns against poverty.

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