TETANUS IMMUNIZATION
Ov erv ie w
T
etanus is a potentially fatal noncommunicable
disease caused by the toxin (tetanospasmin).
It is produced by the spore-forming bacteria
Clostridium tetani, an anaerobic Gram-positive bacillus.
The spores are hardy, resistant to heat and antiseptics,
and found ubiquitously in the soil and feces of humans
and animals. Successful treatment depends on proper
care and treatment of wounds and traumatic injuries and
prevention through appropriate tetanus immunization.
Worldwide, tetanus still accounts for 1 million
hospital admissions. Most of these cases are in Africa
and Southeast Asia, but they are decreasing with
immunization initiatives directed to these areas. In
2012, tetanus caused 213,000 deaths worldwide. Most
of these deaths occurred in developing countries, and
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
fatality of 13.2% in the United States.
Tetanus is almost entirely preventable with adequate
immunization. The disease has been central to the World
Health Organization (WHO) Expanded Programme on
Immunization since 1974. The incidence of tetanus
decreases when immunization programs are in place.
Unfortunately, under-immunized populations exist
even in high-income countries. During the surveillance
period of 2001–2008 in the United States, 233 cases
associated with 26 deaths were reported. Individuals
over the age of 50 represented one-half of those cases,
and individuals over 65 represented 30% of the cases.
Death was five times more likely in people older than
65. Older women are particularly at risk, because most
of those over age 55 do not have protective levels of
tetanus antibody. Diabetics and injection drug users
are other high-risk groups. Tetanus can occur in nonacute wounds, and 1 of 6 cases surveyed was associated
with non-acute wounds.
Inadequate tetanus toxoid vaccination and
inadequate wound prophylaxis are the most important
factors associated with the development of tetanus.
Tetanus surveillance data have demonstrated two
interesting findings: Fewer than 4% of those with acute
wounds who sought treatment received appropriate
prophylaxis. Only 36.5% sought immediate medical
care for their wounds. All medical professionals must
be cognizant of these factors when providing care to
injured patients.
Tetanus immunization depends on the patient’s
previous immunization status and the tetanus-prone
nature of the wound. The following guidelines are
adapted from the literature, and information is available
from the Centers for Disease Control and Prevention
(CDC). Because this information is continuously
reviewed and updated as new data become available,
the American College of Surgeons Committee on
Trauma recommends contacting the CDC for the most
current information and detailed guidelines related
to tetanus prophylaxis and immunization for injured
patients. National guidelines may vary.
Pathoph ysiolo g y
Clostridium tetani spores are found in the soil and in
the feces of animals and humans. The spores access
the body through breaks in the skin and grow under
low oxygen conditions. Wounds that tend to propagate
spore development are typically puncture wounds
and wounds with significant tissue destruction.
Tetanospasmin causes tetanus by blocking inhibitory
pathways (gamma-aminobutyric acid), producing
sustained excitatory nervous impulses that give rise
to the typical clinical symptoms. Once the spores
gain access to the body through an open wound, they
undergo an incubation period of from 1 to 2 days and
as long as 7 to 21 days. The diagnosis is usually clinical,
and the treatment is supportive. Prevention is the
mainstay of treatment.
Types of wounds likely to encourage the growth of
tetanus organisms include
•• Open fractures
•• Deep penetrating wounds (> 1 cm)
•• Stellate or avulsion configuration
•• Wounds containing devascularized tissue
•• Wounds resulting from a missile (gunshot
wound)
•• Wounds from burns or frostbite
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TETANUS IMMUNIZATION
•• Wounds containing foreign bodies (especially
wood splinters)
•• Wounds complicated by pyogenic infections
•• Wounds with extensive tissue damage (e.g.,
contusions or burns)
•• Any wound obviously contaminated with soil,
dust, or horse manure (especially if topical
disinfection is delayed more than 4 hours)
•• Reimplantation of an avulsed tooth (because
the tooth receives minimal washing and
cleaning to increase the likelihood of successful
reimplantation)
•• Wounds or burns requiring surgical
intervention that is delayed more than 6 hours
•• Wounds or burns associated with sepsis
Wounds must be cleaned, disinfected, and treated
surgically if appropriate.
Clinical Signs and Course
The excitatory impulses lead to sustained muscular
contractions, which can be localized or generalized.
Contractions may begin in the muscles surrounding
the wounded area. Lockjaw (severe contraction of
the masseter muscle) is characteristic of generalized
tetanus. Pain, headache and muscle rigidity are seen in
generalized tetanus (80% of cases). Respiratory failure
caused by laryngeal obstruction and chest wall rigidity
is the most common direct cause of death. Autonomic
dysfunction can be seen as well with accompanying
fever, diaphoresis, hypertension, arrhythmias,
and hypermetabolism. The spasms and autonomic
instability persist for weeks, and the muscular rigidity
is present for months.
Tr e atment Pr inc iple s
the risk for tetanus infection in soft-tissue wounds
are detailed in n TABLE 1. However, clinicians should
consider all wounds to be at risk for the development
of tetanus.
Prevention
Active immunization is the mainstay of therapy for
this disease. The following general principles for
doctors who treat trauma patients concern surgical
wound care and passive immunization. Studies
demonstrate that relying on patients to recall their
immunity status may be unreliable, resulting in both
over- and under-administration of tetanus boosters.
Over-administration of tetanus prophylaxis may
diminish serologic response and increase cost of care,
whereas under-treatment exposes patients to the risk
of developing the disease and risking mortality and
morbidity. Serologic testing is available to determine
antibody levels. n BOX 1 lists potential adverse reactions
from tetanus immunization.
Passive Immunization
Passive immunization with 250 units of human tetanus
immune globulin (TIG), administered intramuscularly,
must be considered for each patient. Double the dose
if the wound is older than 12 hours, there is heavy
contamination, or the patient weighs more than 90 kg.
TIG provides longer protection than antitoxin of animal
origin and causes few adverse reactions. Characteristics
of the wound, the conditions under which it occurred,
wound age, TIG treatment, and the patient’s previous
active immunization status must all be considered.
Due to concerns about herd immunity to both
pertussis and diphtheria, and recent outbreaks of both,
box 1 adverse reactions from
tetanus immunization
• Pain
• Palpable lump
Surgical Wound Care
• Swelling
Regardless of a patient’s active immunization status, he
or she must immediately receive meticulous surgical
care—including removal of all devitalized tissue and
foreign bodies—for all wounds. If the adequacy of
wound debridement is in question or a puncture injury
is present, leave the wound open and do not suture.
Such care is essential as part of the prophylaxis against
tetanus. Traditional clinical features that influence
• Type II hypersensitivity reaction with severe swelling
• Erythema at the injection site occurring in up to 20%
and erythema of the injected arm within 2 to 8 hours of
the injection. (It usually resolves without sequelae.)
• General symptoms of malaise fever headache are
uncommon; dyspnea, urticaria, angioedema, and
neurologic reactions are rare.
• Anaphylaxis 0.6 to 3 per million doses
TETANUS IMMUNIZATION
Dr. Henry: Please add title to the table
23
table 1 title
AGE (YEARS)
0 through 6
VACCINATION HISTORY
Unknown or not up-to-date on DTaP
DTaP
DTaP
series based on age
7 through 10
ALL OTHER
WOUNDS
CLEAN, MINOR WOUNDS
TIG
Up-to-date on DTaP series based on age
No indication
No indication
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
No indication
Td, but Tdap preferred
since last dose
Completed DTaP series AND ≥ 5 years
since last dose
11 and older
if child is 10 years of age
Unknown or <3 doses of tetanus
Tdap and recommend catch-up
Tdap and recommend
toxoid containing vaccine
vaccination
catch-up vaccination
TIG
(*if pregnant,
see footnote)
3 or more doses of tetanus toxoid
No indication
No indication
No indication
Tdap preferred (if not
containing vaccine AND <5 years since
last dose
3 or more doses of tetanus toxoid
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:
Please add
source
information.
*Pregnant Women: As part of standard wound management care to prevent tetanus, a vaccine containing tetanus toxoid might be
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
recommended for a pregnant woman, health care providers should administer Tdap.
Tdap (tetanus, diphtheria, and pertussis) is preferred
to Td (tetanus and diphtheria) for adults who have
never received Tdap. Td is preferred to TT (tetanus
toxoid) for adults who received Tdap previously or
when Tdap is not available. If TT and TIG are both
given, administer tetanus toxoid adsorbed rather than
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
has ever received a series of three injections of toxoid,
TIG is not indicated, unless the wound is judged to be
tetanus-prone and is more than 24 hours old. Table 1
outlines age-based recommendations for vaccination
considering vaccination history and wound type,
and n FIGURE 1 provides a summary guide of tetanus
prophylaxis in routine wound management.
Bibliography
Dr. Henry: is this the appropriate
place to cite the table and figure?
1. Advisory Committee on Immunization Practices.
Preventing tetanus, diphtheria, and pertussis
among adults: use of tetanus toxoid, reduced
diphtheria toxoid and acellular pertussis
vaccine recommendations of the Advisory
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TETANUS IMMUNIZATION
Summary Guide to Tetanus Prophylaxis
in Routine Wound Management
ASSESS WOUND
A clean, minor wound
All other wounds (contaminated with dirt, feces, saliva,
soil; puncture wounds; avulsions; wounds resulting from
flying or crushing objects, animal bites, burns, frostbite)
Has patient completed a primary
tetanus diphtheria series?1,7
Has patient completed a primary
tetanus diphtheria series?1,7
Yes
No/Unknown
2,3,4
Administer vaccine today.
Instruct patient to complete
series per age-appropriate
vaccine schedule.
Was the most recent
dose within the past
10 years?
No
Administer vaccine today.2,4
Patient should receive next
dose per age-appropriate
schedule.
1
2
3
Yes
No/Unknown
Yes
No
*Tdap vaccines:
Adacel (Sanofi) is licensed for persons 11 through 64 years of age.
Boostrix (GSK) is licensed for persons 10 years of age and older.
1
Brand names are used for the purpose of clarifying product characteristics and are not in
any way an endorsement of either product.
Yes
Administer vaccine today.2,4
Patient should receive next
dose per age-appropriate
schedule.
Vaccine not needed today.
Patient should receive next
dose at 10-year interval after
last dose.
A primary series consists of a minimum of 3 doses of tetanus- and diphtheriacontaining vaccine (DTaP/DTP/Tdap/DT/Td).
Age-appropriate vaccine:
DTaP for infants and children 6 weeks up to 7 years of age (or DT pediatric if
pertussis vaccine is contraindicated);
Tetanus-diphtheria (Td) toxoid for persons 7 through 9 years of age; and ≥65
years of age;
Tdap for persons 10 through 64 years of age if using Adacel1 or 10 years of age
and older if using Boostrix1, unless the person has received a prior dose of Tdap.*
No vaccine or TIG is recommended for infants <6 weeks of age with clean, minor
wounds. (And no vaccine is licensed for infants <6 weeks of age.)
Was the most recent
dose within the past
5 years?7
Administer vaccine and
tetanus immune gobulin
(TIG) now.2,4,5,6,7
4
5
6
7
Vaccine not needed today.
Patient should receive next
dose at 10-year interval after
last dose.
Tdap* is preferred for persons 10 through 64 years of age if using Adacel1 or 10
years of age and older if using Boostrix1 who have never received Tdap.
Td is preferred to tetanus toxoid (TT) for persons 7 through 9 years of age, or ≥65
years of age if only Adacel1 is available, or those who have received a Tdap
previously. If TT is administered, an adsorbed TT product is preferred to fluid TT.
(All DTaP/DTP/Tdap/DT/Td products contain adsorbed tetanus toxoid.)
Give TIG 250 U IM for all ages. It can and should be given simultaneously with the
tetanus-containing vaccine.
For infants <6 weeks of age, TIG (without vaccine) is recommended for “dirty”
wounds (wounds other than clean, minor).
Persons who are HIV positive should receive TIG regardless of tetanus
immunization history.
Immunization Program
P.O. Box 64975
St. Paul, MN 55164-0975
651-201-5414, 1-877-676-5414
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)
and recommendation of ACIP, supported by the
Healthcare Infection Control Practices Advisory
Committee (HICPAC), for use of Tdap among
health-care personnel. MMWR 2006;December
15;55(RR-17):1–37.
2. Bakole I, Danesi M, Oluwasdamilola O, et
al. Characteristic and outcome of tetanus
in adolescent and adult patients admitted
to the Lagos University Teaching Hospital
between 2000 and 2009. J Neurol Sci 2012;323:
201–204.
3. Centers for Disease Control (CDC). Tetanus
surveillance—United States, 2001–2009. MMWR
2011;60:365–396.
4. CDC. Updated recommendations for use of
tetanus toxoid reduced diphtheria toxoid and
acellular pertussis (Tdap) vaccine from the
Advisory Committee on Immunization Practices,
2010. MMWR 2011;60:13–15.
5. CDC. Updated recommendations for use of
tetanus toxoid, reduced diphtheria toxoid, and
acellular pertussis (Tdap) vaccine in adults aged
65 years and older—Advisory Committee on
Immunization Practices (ACIP), 2012. MMWR
2012;61:468–470.
6. CDC. Updated recommendations for the use of
tetanus toxoid, reduced diphtheria toxoid, and
acellular pertussis vaccine (Tdap) in pregnant
women—Advisory Committee on Immunization
Practices (ACIP), 2012. MMWR 2013;62:131–135.
7. Collins S, White J, Ramsay M, et al. The
importance of tetanus risk assessment during
wound management. ID Case Rep 2015;2:3–5.
8. Laurichesse H, Zimmermann U, Galtier F, et
al. Immunogenicity and safety results from
a randomized multicenter trial comparing a
Tdap-IPV vaccine (REPEVAX®) and a tetanus
monovalent vaccine in healthy adults: new
considerations for the management of
TETANUS IMMUNIZATION
patients with tetanus-prone injuries. Human
Vaccines & Immunotherapeutics 2012;8:12:
1875–1881.
9. McVicar, J. Should we test for tetanus
immunity in all emergency department
patients with wounds? Emerg Med J 2013;30:
177–179.
25
10. Rhee P, Nunley MK, Demetriades D, et al. Tetanus
and trauma: a review and recommendation. J
Trauma 2005;58:1082–1088.
11. U.S. Department of Health and Human Services,
Centers for Disease Control and Prevention.
Tetanus. https://www.cdc.gov/vaccines/vpd/
tetanus/index.html