TETANUS IMMUNIZATION

Ov erv ie w care for their wounds. All medical professionals must

be cognizant of these factors when providing care to
injured patients.

T
etanus is a potentially fatal noncommunicable Tetanus immunization depends on the patient’s
disease caused by the toxin (tetanospasmin). previous immunization status and the tetanus-prone
It is produced by the spore-forming bacteria nature of the wound. The following guidelines are
Clostridium tetani, an anaerobic Gram-positive bacillus. adapted from the literature, and information is available
The spores are hardy, resistant to heat and antiseptics, from the Centers for Disease Control and Prevention
and found ubiquitously in the soil and feces of humans (CDC). Because this information is continuously
and animals. Successful treatment depends on proper reviewed and updated as new data become available,
care and treatment of wounds and traumatic injuries and the American College of Surgeons Committee on
prevention through appropriate tetanus immunization. Trauma recommends contacting the CDC for the most
Worldwide, tetanus still accounts for 1 million current information and detailed guidelines related
hospital admissions. Most of these cases are in Africa to tetanus prophylaxis and immunization for injured
and Southeast Asia, but they are decreasing with patients. National guidelines may vary.
immunization initiatives directed to these areas. In
2012, tetanus caused 213,000 deaths worldwide. Most
of these deaths occurred in developing countries, and Pathoph ysiolo g y
one-half were in neonates. Mortality in these areas
remains high (30% to 70%). In industrialized countries,
mortality from tetanus is lower. The CDC reports case Clostridium tetani spores are found in the soil and in
fatality of 13.2% in the United States. the feces of animals and humans. The spores access
Tetanus is almost entirely preventable with adequate the body through breaks in the skin and grow under
immunization. The disease has been central to the World low oxygen conditions. Wounds that tend to propagate
Health Organization (WHO) Expanded Programme on spore development are typically puncture wounds
Immunization since 1974. The incidence of tetanus and wounds with significant tissue destruction.
decreases when immunization programs are in place. Tetanospasmin causes tetanus by blocking inhibitory
Unfortunately, under-immunized populations exist pathways (gamma-aminobutyric acid), producing
even in high-income countries. During the surveillance sustained excitatory nervous impulses that give rise
period of 2001–2008 in the United States, 233 cases to the typical clinical symptoms. Once the spores
associated with 26 deaths were reported. Individuals gain access to the body through an open wound, they
over the age of 50 represented one-half of those cases, undergo an incubation period of from 1 to 2 days and
and individuals over 65 represented 30% of the cases. as long as 7 to 21 days. The diagnosis is usually clinical,
Death was five times more likely in people older than and the treatment is supportive. Prevention is the
65. Older women are particularly at risk, because most mainstay of treatment.
of those over age 55 do not have protective levels of Types of wounds likely to encourage the growth of
tetanus antibody. Diabetics and injection drug users tetanus organisms include
are other high-risk groups. Tetanus can occur in non-
•• Open fractures
acute wounds, and 1 of 6 cases surveyed was associated
with non-acute wounds. •• Deep penetrating wounds (> 1 cm)
Inadequate tetanus toxoid vaccination and
•• Stellate or avulsion configuration
inadequate wound prophylaxis are the most important
factors associated with the development of tetanus. •• Wounds containing devascularized tissue
Tetanus surveillance data have demonstrated two •• Wounds resulting from a missile (gunshot
interesting findings: Fewer than 4% of those with acute
wound)
wounds who sought treatment received appropriate
prophylaxis. Only 36.5% sought immediate medical •• Wounds from burns or frostbite

21
­22 TETANUS IMMUNIZATION

•• Wounds containing foreign bodies (especially the risk for tetanus infection in soft-tissue wounds
wood splinters) are detailed in n TABLE 1. However, clinicians should
consider all wounds to be at risk for the development
•• Wounds complicated by pyogenic infections
of tetanus.
•• Wounds with extensive tissue damage (e.g.,
contusions or burns)
•• Any wound obviously contaminated with soil,
Prevention
dust, or horse manure (especially if topical Active immunization is the mainstay of therapy for
disinfection is delayed more than 4 hours) this disease. The following general principles for
•• Reimplantation of an avulsed tooth (because doctors who treat trauma patients concern surgical
the tooth receives minimal washing and wound care and passive immunization. Studies
cleaning to increase the likelihood of successful demonstrate that relying on patients to recall their
reimplantation) immunity status may be unreliable, resulting in both
over- and under-administration of tetanus boosters.
•• Wounds or burns requiring surgical Over-administration of tetanus prophylaxis may
intervention that is delayed more than 6 hours diminish serologic response and increase cost of care,
•• Wounds or burns associated with sepsis whereas under-treatment exposes patients to the risk
of developing the disease and risking mortality and
Wounds must be cleaned, disinfected, and treated morbidity. Serologic testing is available to determine
surgically if appropriate. antibody levels. n BOX 1 lists potential adverse reactions
from tetanus immunization.

Clinical Signs and Course

Passive Immunization
The excitatory impulses lead to sustained muscular Passive immunization with 250 units of human tetanus
contractions, which can be localized or generalized. immune globulin (TIG), administered intramuscularly,
Contractions may begin in the muscles surrounding must be considered for each patient. Double the dose
the wounded area. Lockjaw (severe contraction of if the wound is older than 12 hours, there is heavy
the masseter muscle) is characteristic of generalized contamination, or the patient weighs more than 90 kg.
tetanus. Pain, headache and muscle rigidity are seen in TIG provides longer protection than antitoxin of animal
generalized tetanus (80% of cases). Respiratory failure origin and causes few adverse reactions. Characteristics
caused by laryngeal obstruction and chest wall rigidity of the wound, the conditions under which it occurred,
is the most common direct cause of death. Autonomic wound age, TIG treatment, and the patient’s previous
dysfunction can be seen as well with accompanying active immunization status must all be considered.
fever, diaphoresis, hypertension, arrhythmias, Due to concerns about herd immunity to both
and hypermetabolism. The spasms and autonomic pertussis and diphtheria, and recent outbreaks of both,
instability persist for weeks, and the muscular rigidity
is present for months.
box 1 adverse reactions from
tetanus immunization
Tr e atment Pr inc iple s • Pain
• Palpable lump

Surgical Wound Care • Swelling

• Erythema at the injection site occurring in up to 20%
Regardless of a patient’s active immunization status, he • Type II hypersensitivity reaction with severe swelling
or she must immediately receive meticulous surgical and erythema of the injected arm within 2 to 8 hours of
care—including removal of all devitalized tissue and the injection. (It usually resolves without sequelae.)
foreign bodies—for all wounds. If the adequacy of • General symptoms of malaise fever headache are
wound debridement is in question or a puncture injury uncommon; dyspnea, urticaria, angioedema, and
is present, leave the wound open and do not suture. neurologic reactions are rare.
Such care is essential as part of the prophylaxis against • Anaphylaxis 0.6 to 3 per million doses
tetanus. Traditional clinical features that influence
 TETANUS IMMUNIZATION 23
Dr. Henry: Please add title to the table

table 1 title

ALL OTHER
AGE (YEARS) VACCINATION HISTORY CLEAN, MINOR WOUNDS WOUNDS

0 through 6 Unknown or not up-to-date on DTaP DTaP DTaP

series based on age TIG

Up-to-date on DTaP series based on age No indication No indication

7 through 10 Unknown or incomplete DTaP series Tdap and recommend catch-up Tdap and recommend
vaccination catch-up vaccination
TIG

Completed DTaP series AND <5 years No indication No indication

since last dose

Completed DTaP series AND ≥ 5 years No indication Td, but Tdap preferred
since last dose if child is 10 years of age

11 and older Unknown or <3 doses of tetanus Tdap and recommend catch-up Tdap and recommend
toxoid containing vaccine vaccination catch-up vaccination
(*if pregnant, TIG
see footnote)
3 or more doses of tetanus toxoid No indication No indication
containing vaccine AND <5 years since
last dose

3 or more doses of tetanus toxoid No indication Tdap preferred (if not

containing vaccine AND 5-10 years yet received) or Td
since last dose

3 or more doses of tetanus toxoid Tdap preferred (if not yet Tdap preferred (if not
containing vaccine AND >10 years since received) or Td yet received) or Td
last dose

Dr. Henry:
*Pregnant Women: As part of standard wound management care to prevent tetanus, a vaccine containing tetanus toxoid might be
Please add
recommended for wound management in a pregnant woman if 5 years or more have elapsed since the previous Td booster. If a Td booster is
source
recommended for a pregnant woman, health care providers should administer Tdap.
information.

Tdap (tetanus, diphtheria, and pertussis) is preferred considering vaccination history and wound type,
to Td (tetanus and diphtheria) for adults who have and n FIGURE 1 provides a summary guide of tetanus
never received Tdap. Td is preferred to TT (tetanus prophylaxis in routine wound management.
toxoid) for adults who received Tdap previously or
when Tdap is not available. If TT and TIG are both Dr. Henry: is this the appropriate
given, administer tetanus toxoid adsorbed rather than Bibliography place to cite the table and figure?
tetanus toxoid for booster use only (fluid vaccine).
When tetanus toxoid and TIG are given concurrently,
use separate syringes and separate sites. If the patient 1. Advisory Committee on Immunization Practices.
has ever received a series of three injections of toxoid, Preventing tetanus, diphtheria, and pertussis
TIG is not indicated, unless the wound is judged to be among adults: use of tetanus toxoid, reduced
tetanus-prone and is more than 24 hours old. Table 1 diphtheria toxoid and acellular pertussis
outlines age-based recommendations for vaccination vaccine recommendations of the Advisory
­24 TETANUS IMMUNIZATION

Summary Guide to Tetanus Prophylaxis

in Routine Wound Management
ASSESS WOUND

All other wounds (contaminated with dirt, feces, saliva,

A clean, minor wound soil; puncture wounds; avulsions; wounds resulting from
flying or crushing objects, animal bites, burns, frostbite)

Has patient completed a primary Has patient completed a primary

tetanus diphtheria series?1,7 tetanus diphtheria series?1,7

No/Unknown Yes No/Unknown Yes

Administer vaccine today. 2,3,4 Was the most recent Administer vaccine and Was the most recent
Instruct patient to complete dose within the past tetanus immune gobulin dose within the past
series per age-appropriate 10 years? (TIG) now.2,4,5,6,7 5 years?7
vaccine schedule.

No Yes No Yes

Administer vaccine today.2,4 Vaccine not needed today. Administer vaccine today.2,4 Vaccine not needed today.
Patient should receive next Patient should receive next Patient should receive next Patient should receive next
dose per age-appropriate dose at 10-year interval after dose per age-appropriate dose at 10-year interval after
schedule. last dose. schedule. last dose.

4
1
A primary series consists of a minimum of 3 doses of tetanus- and diphtheria- Tdap* is preferred for persons 10 through 64 years of age if using Adacel1 or 10
containing vaccine (DTaP/DTP/Tdap/DT/Td). years of age and older if using Boostrix1 who have never received Tdap.
2
Age-appropriate vaccine: Td is preferred to tetanus toxoid (TT) for persons 7 through 9 years of age, or ≥65
DTaP for infants and children 6 weeks up to 7 years of age (or DT pediatric if years of age if only Adacel1 is available, or those who have received a Tdap
pertussis vaccine is contraindicated); previously. If TT is administered, an adsorbed TT product is preferred to fluid TT.
Tetanus-diphtheria (Td) toxoid for persons 7 through 9 years of age; and ≥65 (All DTaP/DTP/Tdap/DT/Td products contain adsorbed tetanus toxoid.)
5
years of age; Give TIG 250 U IM for all ages. It can and should be given simultaneously with the
Tdap for persons 10 through 64 years of age if using Adacel1 or 10 years of age tetanus-containing vaccine.
6
and older if using Boostrix1, unless the person has received a prior dose of Tdap.* For infants <6 weeks of age, TIG (without vaccine) is recommended for “dirty”
3
No vaccine or TIG is recommended for infants <6 weeks of age with clean, minor wounds (wounds other than clean, minor).
7
wounds. (And no vaccine is licensed for infants <6 weeks of age.) Persons who are HIV positive should receive TIG regardless of tetanus
immunization history.
*Tdap vaccines: Immunization Program
Adacel (Sanofi) is licensed for persons 11 through 64 years of age. P.O. Box 64975
Boostrix (GSK) is licensed for persons 10 years of age and older. St. Paul, MN 55164-0975
1
Brand names are used for the purpose of clarifying product characteristics and are not in 651-201-5414, 1-877-676-5414
any way an endorsement of either product. www.health.state.mn.us/immunize (9/12) IC# 141-0332

n FIGURE 1 Summary Guide to Tetanus Prophylaxis in Routine Wound Management. Reprinted from Minnesota Department of Health
Immunization Program.

Committee on Immunization Practices (ACIP) 5. CDC. Updated recommendations for use of

and recommendation of ACIP, supported by the tetanus toxoid, reduced diphtheria toxoid, and
Healthcare Infection Control Practices Advisory acellular pertussis (Tdap) vaccine in adults aged
Committee (HICPAC), for use of Tdap among 65 years and older—Advisory Committee on
health-care personnel. MMWR 2006;December Immunization Practices (ACIP), 2012. MMWR
15;55(RR-17):1–37. 2012;61:468–470.
2. Bakole I, Danesi M, Oluwasdamilola O, et 6. CDC. Updated recommendations for the use of
al. Characteristic and outcome of tetanus tetanus toxoid, reduced diphtheria toxoid, and
in adolescent and adult patients admitted acellular pertussis vaccine (Tdap) in pregnant
to the Lagos University Teaching Hospital women—Advisory Committee on Immunization
between 2000 and 2009. J Neurol Sci 2012;323: Practices (ACIP), 2012. MMWR 2013;62:131–135.
201–204. 7. Collins S, White J, Ramsay M, et al. The
3. Centers for Disease Control (CDC). Tetanus importance of tetanus risk assessment during
surveillance—United States, 2001–2009. MMWR wound management. ID Case Rep 2015;2:3–5.
2011;60:365–396. 8. Laurichesse H, Zimmermann U, Galtier F, et
4. CDC. Updated recommendations for use of al. Immunogenicity and safety results from
tetanus toxoid reduced diphtheria toxoid and a randomized multicenter trial comparing a
acellular pertussis (Tdap) vaccine from the Tdap-IPV vaccine (REPEVAX®) and a tetanus
Advisory Committee on Immunization Practices, monovalent vaccine in healthy adults: new
2010. MMWR 2011;60:13–15. considerations for the management of
 TETANUS IMMUNIZATION 25

patients with tetanus-prone injuries. Human 10. Rhee P, Nunley MK, Demetriades D, et al. Tetanus
Vaccines & Immunotherapeutics 2012;8:12: and trauma: a review and recommendation. J
1875–1881. Trauma 2005;58:1082–1088.
9. McVicar, J. Should we test for tetanus 11. U.S. Department of Health and Human Services,
immunity in all emergency department Centers for Disease Control and Prevention.
patients with wounds? Emerg Med J 2013;30: Tetanus. https://www.cdc.gov/vaccines/vpd/
177–179. tetanus/index.html