Paediatric Clinical Guideline
Emergency 1.5 Tetanus Prophylaxis
Short Title:
Tetanus Prophylaxis
Full Title:
Date of production/Last revision:
Guideline for the management of a tetanus prophylaxis in children
and young people
January 2007
Explicit definition of patient group to which it
applies:
This guideline applies to all children and young people under the age
of 19 years.
Name of contact author
Dr Leonie Wong
Paediatric Specialist Registrar
Dr Stephanie Smith
Consultant Emergency Paediatrician Ext 64042
Revision Date
January 2010
This guideline has been registered with the Trust. However, clinical guidelines are 'guidelines' only. The interpretation
and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a
senior colleague or expert. Caution is advised when using guidelines after the review date.
Tetanus Prophylaxis in Children
Introduction
Tetanus is caused by the action of tetanus toxin following infection by Clostridium tetani. C.
tetani is transmitted by soil or faecal contamination of wounds and has an incubation period of
between 4 and 21 days (commonly 10).
Tetanus is characterised by generalised skeletal muscle rigidity and spasms usually affecting
the neck and jaw.
There were 198 cases of tetanus reported in England and Wales between 1984 and 2004.
The elderly are at highest risk. There were no reported cases in children under 5 years.
Tetanus immunisation was introduced nationally as part of the primary immunisation
programme in 1961. Most children receive their primary immunisations at 2, 3 and 4 months,
with boosters at 4 years and 14-15 years. These are administered via their General
Practitioner, community clinic or school.
Leonie Wong
Page 1 of 5
January 2007
Paediatric Clinical Guideline
Emergency 1.5 Tetanus Prophylaxis
Management of Tetanus Prone Wounds
1. Check the child’s tetanus immunisation status
The normal schedule is
 3 doses of DTaP/IPV/HiB given at 2, 3 and 4 months as part of primary immunisations
 Reinforcing (booster) doses at
 3.5-5yrs of age
 13-15yrs of age
It is essential to check the immune and vaccination status of any patient presenting to
the hospital (via A&E or direct transfer) with ANY wound or burn, however trivial at any
interval.
2. Consider is this a tetanus prone wound?
The following are considered tetanus-prone wounds:
 Wounds / burns requiring surgical intervention that is delayed for > 6hours
 Significant degree of devitalised tissue
 Wounds where there has been contact with soil or manure
 Puncture-type injury
 Compound fractures
 Wounds containing foreign bodies
 Wounds / burns in patients with systemic sepsis
3. Wound toilet, dressing and antibiotics as required
Thorough surgical toilet of the wound is essential irrespective of the immunisation history of
the patient and appropriate antibiotics should be prescribed.
4. Use the table to determine whether immunisation or human tetanus immunoglobulin
is required?
Immunisation Status
Fully immunised1
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 / uncertain3
Clean Wound
Vaccine
Not required
Not required
Reinforcing dose and
further doses to
complete
recommended
schedule
Immediate dose of
vaccine followed by
completion of full 5dose course
Tetanus-prone Wound
Vaccine
HTIG
Not required
Only if high
risk2
Not required
Only if high
risk2
Reinforcing dose and
further doses to
complete
recommended
schedule
Immediate dose of
vaccine followed by
completion of full 5dose course
Yes (given at
different site to
vaccine)
Yes (given at
different site to
vaccine)
Notes
1. Fully immunised: Has received total of 5 doses of vaccine at appropriate intervals
2. High Risk: Heavy contamination with material likely to contain tetanus spores and/or extensive
devitalised tissue
3. Immunosuppressed patients presenting with a tetanus prone wound should always be managed
as if they were incompletely immunised. Please refer to the RCPCH guidance on Immunisation of
the Immunocompromised Child
Leonie Wong
Page 2 of 5
January 2007
Paediatric Clinical Guideline
Emergency 1.5 Tetanus Prophylaxis
5. Ensure patient receives tetanus immunisation where indicated
Patients requiring a tetanus booster should have it administered in the department.
Patients who have not received primary immunisation:
 Contact GP and arrange appointment for primary immunisation
 If appointment not available within 36 hours, give adsorbed vaccine as required in the
department and refer to GP to complete the primary course.
If parents refuse immunisation, inform GP and record your actions in the notes.
Human Tetanus Immunoglobulin
Indications
 Treatment of clinically suspected cases of tetanus (a notifiable disease)
 Prevention of tetanus in high risk tetanus prone wounds (see table and note above)
Dose
Available in 1ml ampoules containing 250IU
Prevention Dose
Treatment Dose
250IU by IM injection
or
500IU by IM injection if >24 hours since injury
/ risk of heavy contamination / burns
5000 – 10000IU by IV infusion
Or
150IU/kg by IM injection (given in multiple
sites) if IV preparation unavailable
Contraindications
 Confirmed anaphylactic reaction to tetanus containing vaccine
 Confirmed anaphylactic reaction to neomycin, streptomycin or polymyxin B
Adverse Reactions
Local
Pain, erythema, induration (Arthus type reaction)
General
Pyrexia, hypotonic-hyporesponsive episode, persistent crying
Confirmed anaphylaxis is very rare (0.65 – 3 events per million doses)
All suspected adverse reactions should be reported to the Committee on Human Medicines
using the Yellow Card scheme.
Leonie Wong
Page 3 of 5
January 2007
Paediatric Clinical Guideline
Emergency 1.5 Tetanus Prophylaxis
Tetanus Vaccine
Tetanus vaccine is only available in combination with other vaccines. When a reinforcing dose
is required the choice of the vaccine will depend on the age of the child and their
immunisation status.
Children <10yrs
Children >10 yrs of age
Leonie Wong
Incomplete/delayed
primary vaccination
The primary course is three
doses of a tetanus-containing
vaccine (DTaP/IPV/Hib) with
an interval of one month
between doses
This can be given at any
stage from 2 months-10yrs
If the primary course is
interrupted it should be
resumed but not repeated
Three doses of 0.5mls
Td/IPV with one month
between doses
Page 4 of 5
Incomplete/delayed
reinforcing doses
Give a single dose of 0.5mls
DTaP/IPV or dTaP/IPV im
This will re-establish the child
on the routine schedule
A single dose of 0.5mls
Td/IPV
This will re-establish the child
on the routine schedule
January 2007
Paediatric Clinical Guideline
Emergency 1.5 Tetanus Prophylaxis
References
Immunisation against Infectious Disease, 3rd edition, Department of Health, 2006. – The
Green Book
Immunisation of the Immunocompromised Child. Best Practice Statement. RCPCH. 2002
Title
Tetanus Prophylaxis
Guideline Number
1.5
Version
Final
Distribution
All wards QMC and CHN
Author
Dr Leonie Wong
Paediatric Specialist Registrar
Dr Stephanie Smith
Consultant Emergency Paediatrician
Document Derivation
Immunisation against
Infectious Disease, 3rd
edition, Department of
Health, 2006. – The Green
Book
Immunisation of the
Immunocompromised Child.
Best Practice Statement.
RCPCH. 2002
First Issued
November 1997
Latest Version Date
January 2007
Review Date
January 2010
Ratified By
Paediatric Clinical Guidelines Meeting
Date
January 2007
Audit
Amendments
Leonie Wong
Induction Programme
Page 5 of 5
January 2007