TETANUS

GENERAL INFORMATION

Disease

Tetanus ("lockjaw") is an acute, often fatal neuromuscular disease characterized by progressive stiffness, rigidity, and spasm of skeletal muscle, initially involving the jaw and neck. The disease is caused by an exotoxin produced by Clostridium tetani, an anaerobic, gram-positive, spore-forming bacillus.

• These bacilli are widely distributed in the intestines and feces of animals and humans, in soil (especially if manure treated), and in street dust; spores can be also be found on skin surfaces and in contaminated street drugs.

The incubation period is typically 7-10 days, although it can range from 3 days to 3 weeks.

Transmission typically occurs via contamination of wounds, burns, and punctures; in developing countries, neonatal transmission often occurs as a result of the use of unsterile instruments to cut the umbilical cord or subsequent contamination of the unhealed umbilical stump.

• Tetanus is not contagious.

Tetanus is a global health problem, but incidence is highest in densely populated regions with warm, damp climates and rich, organic soil.

Tetanus occurs almost exclusively in unimmunized or inadequately immunized persons.

• Per CDC, in the USA during 1995-97, 60% of tetanus cases occurred in persons 20-59 years of age, 35% occurred in persons age 60 years or older, and 5% occurred in persons younger than 20 years of age.

o        The case-fatality ratio was greatest in those older than 60 years of age.

o        ACIP recommends a routine vaccination assessment at age 50 years,

Treatment:

Wound care will help decrease the risk

Administration of Pen G or Doxycycline, metronidazole.

Control of muscle spasm –Supportive intensive care.

Vaccine

Tetanus vaccine is one of the oldest and safest immunizations. Three vaccines are currently available in the USA:

• Tetanus and Diphtheria Toxoid, Adsorbed, Adult Formulation (Td) is licensed for the primary and booster immunization of adults and of children aged > 7 years.
  • It contains less diphtheria toxoid than the pediatric preparation.
  • Td is recommended over tetanus toxoid because adults in need of tetanus immunization are also considered susceptible to diphtheria.
• Tetanus Toxoid, Adsorbed
  • In cases where immunization with diphtheria toxoid is contraindicated, use of the adsorbed tetanus toxoid product is generally preferred over the fluid because the former induces longer-lasting immunity.
• Tetanus Toxoid, Fluid

Tetanus Immune Globulin (BayTet^®) is a special immune globulin formulation used in postexposure treatment of injured persons whose tetanus immunization is incomplete or uncertain.

• This immunoglobulin is prepared from large pools of plasma. It contains thimerosal.
• Administer intramuscularly.

Indications for Vaccination

Td is recommended for the routine immunization of persons 7 years of age and older.

Td is routinely indicated for susceptible pregnant women (see "Pregnancy").

Per AAP, tetanus immunization is indicated for persons recovering from tetanus or diphtheria, as these diseases do not typically confer immunity.

Td is indicated for wound management.

ADMINISTRATION: TD VACCINE

Pediatric < 7 years

Use DTaP or DT as appropriate (see "Diphtheria, Tetanus, & Pertussis" ).

Tetanus and Diphtheria Toxoids Adsorbed, for Adult Use USP; Tetanus Toxoid, Adsorbed; and Tetanus Toxoid, Fluid are not recommended for children younger than age 7.

Adult & Pediatric > 7 Years

Dose/Route

0.5 mL, intramuscular - tetanus & diphtheria toxoid, adsorbed, for adult use (Td).

Schedule

(Unimmunized adults and children > 7 years of age:

Primary: Give first 2 doses 4-8 weeks apart and third dose 6-12 months later.

• A prolonged interval between primary doses does not necessitate reinitiation of the primary series.
• Tetanus Toxoid, Adsorbed and Tetanus Toxoid, Fluid are not indicated for primary immunization.

Booster: Give first booster dose of Td at age 11-12 years (age range of 11-16 years is acceptable), provided at least 5 years have passed since last primary dose of DTaP, DTP, or DT (see Table 1). Thereafter, routinely boost at 10-year intervals.

• Exceptions:
  • For children who completed primary immunization with Td prior to age 12 years, the recommended timing for routine administration of the first Td booster is age 12-16 years, maintaining an interval of at least 5 years since the last dose of Td. Thereafter, routinely boost at 10-year intervals.
  • Per AAP, if more than 5 years have elapsed since the last dose, a Td booster should be considered for persons going on wilderness expeditions in remote areas where tetanus boosters may not be readily available.

If an interim dose is given for travel or for wound management (see Table 11 "Tetanus Prophylaxis" ), administer the next routine booster 10 years later, as increased rates and severity of local or systemic reactions may occur if tetanus doses are administered too frequently.

SIDE EFFECTS

Common local reactions include redness and induration at the injection site, with or without tenderness; occasionally a nodule may be palpable at the injection site of an adsorbed product for several weeks or a sterile abscess may occur.

Exaggerated local (Arthus-type) reactions, with painful swelling from shoulder to elbow, may occur 2-8 hours after injection with tetanus toxoid vaccines or tetanus and diphtheria toxoid.

Fever and other systemic symptoms are uncommon.

Severe systemic reactions (e.g., generalized urticaria, anaphylaxis) are rare.

CDC notes that recent evidence favors a causal relationship between tetanus toxoid and both brachial neuritis and Guillain-Barré syndrome in adult vaccinees, although these reactions are very rare

.

PRECAUTIONS AND CONTRAINDICATIONS

General

The only other contraindication is an immediate anaphylactic reaction to any toxoid-containing vaccine (DTaP, DTP, DT, or Td).

• Anaphylactic reaction to a vaccine constituent contraindicates the use of vaccines containing that substance.
  • Td contains thimerosal.
    • Most patients do not develop reactions to the thimerosal component of vaccines, even when patch or intradermal tests indicate thimerosal hypersensitivity.
    • When postvaccination thimerosal reactions are reported, they are typically the delayed, localized type.

If a contraindication to tetanus toxoid-containing preparations exists in a person who has not completed the primary series, only passive immunization with tetanus immune globulin (TIG) should be given for wound

Persons who have experienced Arthus-type hypersensitivity reactions or temperature > 39.4°C (103°F) following a prior dose of tetanus toxoid should not be given doses of Td more frequently than every 10 years, even for wound management.

Bleeding Disorders

This is an IM injection and as such may pose a risk for persons with bleeding disorders (e.g., thrombocytopenia, hemophilia or other coagulation disorders).

Compromised Immunity

Immune deficiency disorders and immunosuppressive therapies (including irradiation, antimetabolics, alkylating agents, cytotoxic drugs, and corticosteroids used in greater than physiologic doses) may reduce the immune response.

Pregnancy

Td is routinely indicated for susceptible pregnant women.

• Partially immunized pregnant women should complete the 3-dose series.
• Pregnant women immunized more than 10 years previously should receive a booster.

• Waiting until the second trimester is a reasonable precaution for minimizing any concern about the possibility of teratogenic effects.

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