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BACKGROUND: Most
individuals in developed countries including Ireland have an underlying
level of immunity to tetanus. While this general trend is positive the
level of immunisation at various stages of life is variable from place to
place. Whereas very high percentages of patients receive their tetanus
prophylaxis systematically at the appropriate age in the UK the situation is
not quite so good in Ireland. Recently a national initiative has been
commenced to have GPs responsible for childhood immunisation and to
encourage same although so far this has been patchy.
There is a balance between ensuring that the patient is adequately protected
against tetanus and at the same time ensuring that patients do not receive
additional tetanus boosters needlessly. Such patients may develop
significant local reactions which are both painful and distressing. There
is also the potential that needless and thoughtless administration of a
tetanus toxoid booster could be regarded as negligent should a patient
suffer an untoward reaction. Immunisation advice has changed recently and
many are unaware of the implications of same.
NORMAL PATTERN OF IMMUNISATION:
Infants receive either DTP (Diphtheria, Tetanus, Pertussis vaccine) or DT
(Diphtheria, Tetanus vaccine) if Pertussis vaccine is contraindicated.
Normally in the North West the injections are given in a sequence of 3 at
2, 4 & 6 months of age.
Normally a further booster injection of DT is given in the 4-6 age
group. There is a misconception that a further booster is given as a
teenager; this is not the case in Ireland although it does occur in the
U.K. The approximate estimate for uptake rates for the various vaccination
milestones are as follows:
Infant immunisation 70-80%
4-6 year old immunisation 40-50%
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It is important therefore to ask about immunisation history when dealing
with children and young adults and not make assumptions that due
vaccination has been given. |
PRINCIPLES
OF TETANUS PREVENTION:
The tetanus vaccine is a toxoid which has been inactivated. After a
primary course of 3 injections then by a further booster at 10 yearly
intervals it is hoped that immunity can be preserved against tetanus which
is a potentially fatal disease if contracted. Tetanus is most likely to be
a complicating feature of wounds in which there is a significant degree of
contamination with soil and animal excrement or where there is a significant
amount of devitalised tissue.
It is important to remember that the most efficient way of preventing
tetanus is by appropriate and thorough wound management.
Dead and devitalised tissue and dirt must be rigorously debrided and a
cleansed wound produced. If necessary this will have to be done under
general anaesthetic. Antibiotics, tetanus toxoid or tetanus immunoglobulin
are not substitutes for proper wound care.
TETANUS IMMUNOGLOBULIN (TIG):
In situations where the risk of tetanus is very significant and the
underlying level of immunity is poor TIG may be required. This is a
preparation of specific anti-tetanus antibody which is commercially
produced. Unlike antiserum that was used in the past which was extracted
from horses and therefore a highly antigenic foreign protein, modern TIG is
much safer and much more specific.
Revised advice from the National Immunisation Advisory Committee of the
Royal College of Physicians in Ireland was issued in June 2002 and the
following is based on that advice.
SUGGESTED SCHEME FOR TETANUS PROPHYLAXIS:
For practical purposes wounds can be divided into 2 groups.
a) "Normal" wounds.
b) Tetanus prone wounds.
NORMAL WOUNDS:
These are the regular wounds which turn up in Accident and Emergency
Departments including simple lacerations, clean abrasions etc.
TETANUS PRONE WOUNDS:
These essentially are wounds in which the likelihood of contracting tetanus
is significantly greater. These include -
1) Wounds contaminated with obvious dirt, faeces, soil or saliva.
NB. Human and animal bites.
2) Wounds with a significant amount of devitalised tissue ie. those
resulting from missiles eg. gunshots, burns, frostbite and where there is a
significant crushing component.
3) Deep puncture wounds or wounds which have involved avulsion of
significant amounts of tissue.
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History of dsorbed
Tetanus Toxoid |
Years Since
Last Dose |
Normal Wounds
Toxoid TIG |
Tetanus Prone Wounds
Toxoid TIG |
|
Unknown or
£
2 |
- |
YES* NO
(Course) |
YES* YES
(Course) |
|
³
3
|
<5 |
NO NO |
NO NO |
|
³
3 |
5-10 |
NO NO |
YES NO
(Booster) |
|
³
3 |
>10 |
YES NO
(Booster) |
YES NO
(Booster) |
* A course of three tetanus injections should be started. These should be
given on the day of presentation, 6 weeks later and 6 months later. The
latter two injections should be given by the patients General Practitioner.
Note
-
For children <7 years of age DTP is used or DT if Pertussis vaccine is
contraindicated.
-
If the child is aged from 7-10yrs DT is preferred to tetanus toxoid alone.
-
Subsequent booster doses in patients >10yrs of age should be with Td
(Adsorbed tetanus toxoid plus adult diphtheria).
This is a change from previous guidelines.
Tetanus Toxoid is a highly effective vaccine. Protective antibody levels
are generally maintained for at least 10 years.
- The standard dose of Tetanus Toxoid is 0.5ml to be given
either IM or SC.
- The standard dose of Tetanus Immunoglobulin (TIG) is 250 i.u. to
be given IM.
PRESCRIPTION & ADMINISTRATION OF TETANUS TOXOID:
Tetanus toxoid should be treated the same as any other prescribed drug. It
should be prescribed by the doctor who is seeing the patient and the order
to give it documented in the notes. The nursing staff should administer
tetanus toxoid as prescribed.
It is important that nursing staff continue to question the patient about
their tetanus status and bring this to the attention of the doctor if they
feel tetanus prophylaxis is indicated but has been overlooked by the doctor. |
