Tetanus
Vaccination
A course of vaccine consists of three injections, with an interval of four weeks
between each dose. A booster dose ten years after the primary course and again ten
years later maintains a satisfactory level of protection, probably lifelong.When an
adult has received a total of five doses of tetanus (e.g. primary course plus two
boosters), no further boosters are recommended except for the treatment of tetanus
prone wounds.
The following are considered to be tetanus prone wounds:
a. Wound or burn sustained more than 6 hours before surgical treatment of same
b. Wound or burn which at any interval after injury shows one or more of the
following characteristics:
1. Significant degree of devitalised tissue
2. Puncture type wound
3. Contact with soil or manure
4. Clinical evidence of sepsis
Thorough surgical toilet of the wound is essential, whatever the tetanus
immunisation of the patient.
The single antigen tetanus vaccine has now been replaced by the combined
tetanus/low dose diphtheria vaccine for adults and adolescents for all routine uses in
these age groups. The change was on the advice of the Joint Committee on
Vaccination and Immunisation, generated by concern at the low levels of immunity to
diphtheria in older people in the UK. It brings us into line with recommendations
from the World Health Organisation.
For tetanus prone wounds, human tetanus immunoglobulin is also used. It is important
that it is administered at a different site to the vaccine to avoid interaction. The dose,
for most uses, is 250iu by intramuscular injection. If more than 24 hours have elapsed
since injury or there is a risk of heavy contamination or following burns, the dose is
500iu.
Disease
There are 20-60 cases of tetanus annually in the UK. It is rare but the organism
(Clostridium tetani) is widespread. The elderly are more vulnerable, although it can
also occur in sports players. Signs include painful muscle stiffness, commonly starting
in the masseters and neck extensors and later spreading to the trunk and limbs. If the
time taken from the first symptom to the establishment of spasms is less than 24
hours, severe disease is likely. Management includes placing the patient in a quiet
environment as any external stimuli can trigger spasms. Unnecessary interventions
should be avoided. The patient will usually need to be admitted to ICU for intubation
and ventilation. Antibiotics are controversial but Penicillin and Metronidazole
(Tetracycline in penicillin allergy) may benefit. Diazepam should be used to control
spasms and human immunoglobulin should be given.
Tetanus Immunisation following Injuries
Immunisation
status
Fully immunised,
i.e. has received a
total of 5 doses at
appropriate
intervals as single
antigen or in a
combined vaccine
Primary
immunisation
complete, boosters
incomplete but up
to date
Primary
immunisation
incomplete or
boosters not up to
date
Not immunised or
immunisation
status not known or
uncertain
Clean wound
Vaccine
Tetanus prone
wound
Vaccine
None required
None required
None required
(unless next dose
due soon and
convenient to give
it now)
A reinforcing dose
of combined
tetanus/diphtheria
vaccine and further
doses as required to
complete the
recommended
schedule (to ensure
future immunity)
An immediate dose
of vaccine
followed, if records
confirm this is
needed, by
completion of a full
3 dose course of
combined
tetanus/diphtheria
vaccine to ensure
future immunity
None required
(unless next dose
due soon and
convenient to give
it now)
A reinforcing dose
of combined
tetanus/diphtheria
vaccine and further
doses as required to
complete the
recommended
schedule (to ensure
future immunity)
An immediate dose
of vaccine
followed, if records
confirm this is
needed, by
completion of a full
3 dose course of
combined
tetanus/diphtheria
vaccine to ensure
future immunity
Human tetanus
immunoglobulin
Only if risk
especially high
(e.g. contaminated
with stable manure
Only if risk
especially high (see
above)
Yes: one dose of
human tetanus
immunoglobulin in
a different site
Yes: one dose of
human tetanus
immunoglobulin in
a different site