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The disease

  • Tetanus is an acute disease caused by the action of tetanus toxin, released following infection by the bacterium Clostridium tetani
  • Tetanus spores are present in soil or manure and may be introduced into the body through a puncture wound, burn, or scratch—which may go unnoticed
  • Neonatal tetanus is due to infection of the baby’s umbilical stump. The bacteria grow anaerobically at the site of the injury and have an incubation period of between 4 and 21 days (most commonly about 10 days)
  • The disease is characterised by generalised rigidity and spasms of skeletal muscles. The muscle stiffness usually involves the jaw (lockjaw) and neck and then becomes generalised
  • Tetanus can never be eradicated because the spores are commonly present in the environment, including soil
  • Tetanus is not spread from person to person

The tetanus vaccination

  • The vaccine is made from a cell-free purified toxin extracted from a strain of C. tetani. This is treated with formaldehyde that converts it into tetanus toxoid. This is adsorbed onto an adjuvant, either aluminium phosphate or aluminium hydroxide, to improve its immunogenicity
  • Tetanus vaccines contain more than 20 international units (IU) of tetanus toxoid
  • The tetanus vaccine is only given as part of combined products: 
    • diphtheria/tetanus/acellular pertussis/inactivated polio vaccine/Haemophilus influenzae type b (DTaP/IPV/Hib)
    • diphtheria/tetanus/acellular pertussis/inactivated polio vaccine (DTaP/IPV or dTaP/IPV)
    • tetanus/diphtheria/inactivated polio vaccine (Td/IPV)
  • The above vaccines are thiomersal-free. They are inactivated, do not contain live organisms, and cannot cause the diseases against which they protect
  • Td/IPV vaccine should be used where protection is required against tetanus, diphtheria, or polio in order to provide comprehensive, long-term protection against all three diseases

Storage

  • Vaccines should be stored in the original packaging at +2˚C–+8˚C and protected from light. All vaccines are sensitive to some extent to heat and cold
  • Heat speeds up the decline in potency of most vaccines, thus reducing their shelf life. Effectiveness cannot be guaranteed for vaccines unless they have been stored at the correct temperature
  • Freezing may cause increased reactogenicity and loss of potency for some vaccines. It can also cause hairline cracks in the container, leading to contamination of the contents

Presentation

  • Tetanus vaccine should only be used as part of combined products. It is supplied as a cloudy white suspension either in a single dose ampoule or in a pre-filled syringe. The suspension may sediment during storage and should be shaken to distribute the suspension uniformly before administration

Administration

  • Vaccines are routinely given intramuscularly into the upper arm or anterolateral thigh. This is to reduce the risk of localised reactions, which are more common when vaccines are given subcutaneously
  • For individuals with a bleeding disorder, vaccines should be given by deep subcutaneous injection to reduce the risk of bleeding
  • Tetanus-containing vaccines can be given at the same time as other vaccines such as MMR, MenC, and hepatitis B
  • The vaccines should be given at a separate site, preferably in a different limb. If given in the same limb, they should be given at least 2.5 cm apart
  • The site at which each vaccine was given should be noted in the child’s records

Dosage and schedule

  • First dose of 0.5 ml of a tetanus-containing vaccine
  • Second dose of 0.5 ml, 1 month after the first dose
  • Third dose of 0.5 ml, 1 month after the second dose
  • Fourth and fifth doses of 0.5 ml should be given at the recommended intervals (see below)

Disposal

  • Equipment used for vaccination, including used vials or ampoules, should be disposed of at the end of a session by sealing in a proper, puncture-resistant ‘sharps’ box (UN-approved, BS 7320)

Recommendations for the use of the vaccine

  • The objective of the immunisation programme is to provide a minimum of five doses of tetanus-containing vaccine at appropriate intervals for all individuals
  • In most circumstances, a total of five doses of vaccine at the appropriate intervals are considered to give satisfactory long-term protection
  • To fulfil this objective, the appropriate vaccine for each age group is determined also by the need to protect individuals against diphtheria, pertussis, Hib, and polio

Primary immunisation

Infants and children under 10 years of age

  • The primary course of tetanus vaccination consists of three doses of a tetanus-containing vaccine with an interval of 1 month between each dose
  • DTaP/IPV/Hib is recommended to be given at 2, 3, and 4 months of age but can be given at any stage from 2 months up to 10 years of age
  • If the primary course is interrupted it should be resumed but not repeated, allowing an interval of 1 month between the remaining doses

Children aged 10 years or over, and adults

  • The primary course of tetanus vaccination consists of three doses of a tetanus-containing vaccine with an interval of 1 month between each dose
  • Td/IPV is recommended for all individuals aged 10 years or over
  • If the primary course is interrupted it should be resumed but not repeated, allowing an interval of 1 month between the remaining doses

Reinforcing immunisation

  • Children under 10 years should receive the first tetanus booster combined with diphtheria, pertussis, and polio vaccines
  • The first booster of a tetanus-containing vaccine should ideally be given 3 years after completion of the primary course, normally between 3.5 and 5 years of age
  • When primary vaccination has been delayed, this first booster dose may be given at the scheduled visit provided it is 1 year since the third primary dose. This will re-establish the child on the routine schedule
  • DTaP/IPV or dTaP/IPV should be used in this age group
  • Td/IPV should not be used routinely for this purpose in this age group because it has been shown not to give equivalent diphtheria antitoxin response when compared with other recommended preparations
  • Individuals aged 10 years or over who have only had three doses of a tetanus-containing vaccine, with the last dose at least 5 years ago, should receive the first tetanus booster combined with diphtheria and polio vaccines (Td/IPV)
  • The second booster dose of Td/IPV should be given to all individuals ideally 10 years after the first booster dose
  • When the previous doses have been delayed, the second booster should be given at the school session or scheduled appointment provided a minimum of 5 years have lapsed between the first and second boosters. This will be the last scheduled opportunity to ensure long-term protection
  • If a person attends for a routine booster dose and has a history of receiving a vaccine following a tetanus-prone wound, attempts should be made to identify which vaccine was given
  • If the vaccine given at the time of the injury was the same as that due at the current visit and was given after an appropriate interval, then the routine booster dose is not required. Otherwise, the dose given at the time of injury should be discounted as it may not provide long-term protection against all antigens, and the scheduled immunisation should be given. Such additional doses are unlikely to produce an unacceptable rate of reactions
  • Intravenous drug users are at greater risk of tetanus. Every opportunity should be taken to ensure that they are fully protected against tetanus. Booster doses should be given if there is any doubt about their immunisation status

Vaccination of children with unknown or incomplete immunisation status

  • Where a child born in the UK presents with an inadequate immunisation history, every effort should be made to clarify what immunisations they may have had (see Chapter 11  on vaccination schedules)
  • A child who has not completed the primary course should have the outstanding doses at monthly intervals
  • Children may receive the first booster dose as early as 1 year after the third primary dose to re-establish them on the routine schedule
  • The second booster should be given at the time of leaving school to ensure long-term protection by this time, provided a minimum of 5 years is left between the first and second boosters
  • Children coming to the UK who have a history of completing immunisation in their country of origin may not have been offered protection against all the antigens currently used in the UK. They will probably have received tetanus-containing vaccines in their country of origin
  • Children coming from developing countries, from areas of conflict, or from hard-to-reach population groups may not have been fully immunised. Where there is no reliable history of previous immunisation, it should be assumed that they are unimmunised, and the full UK recommendations should be followed (see Chapter 11 )
  • Children coming to the UK may have had a fourth dose of a tetanus-containing vaccine that is given at around 18 months in some countries. This dose should be discounted as it may not provide satisfactory protection until the time of the teenage booster. The routine pre-school and subsequent boosters should be given according to the UK schedule

Travellers and those going to reside abroad

  • All travellers should ensure that they are fully immunised according to the UK schedule (see above). Additional doses of vaccines may be required according to the destination and the nature of travel intended
  • For travellers to areas where medical attention may not be accessible and whose last dose of a tetanus-containing vaccine was more than 10 years previously, a booster dose should be given prior to travelling, even if the individual has received five doses of vaccine previously. This is a precautionary measure in case immunoglobulin is not available to the individual should a tetanus-prone injury occur
  • Where tetanus, diphtheria, or polio protection is required and the final dose of the relevant antigen was received more than 10 years ago, Td/IPV should be given

Tetanus vaccination in laboratory workers

  • Individuals who may be exposed to tetanus in the course of their work, in microbiology laboratories, are at risk and must be protected (see Chapter 12 )

Contraindications

  • There are very few individuals who cannot receive tetanus-containing vaccines. When there is doubt, appropriate advice should be sought from a consultant paediatrician, immunisation co-ordinator, or consultant in communicable disease control rather than withholding the vaccine
  • The vaccines should not be given to those who have had:
    • a confirmed anaphylactic reaction to a previous dose of a tetanus-containing vaccine, or
    • a confirmed anaphylactic reaction to neomycin, streptomycin, or polymyxin B (which may be present in trace amounts)
  • Confirmed anaphylaxis occurs extremely rarely. Data from the UK, Canada, and the US point to rates of 0.65 to 3 anaphylaxis events per million doses of vaccine given
  • Other allergic conditions may occur more commonly and are not contraindications to further immunisation. A careful history of the event will often distinguish between anaphylaxis and other events that either are not due to the vaccine or are not life-threatening. In the latter circumstance, it may be possible to continue the immunisation course. Specialist advice must be sought on the vaccines and circumstances in which they could be given. The risk to the individual of not being immunised must be taken into account

Precautions

  • Minor illnesses without fever or systemic upset are not valid reasons to postpone immunisation
  • If an individual is acutely unwell, immunisation should be postponed until they have fully recovered. This is to avoid wrongly attributing any new symptom or the progression of symptoms to the vaccine

Systemic and local reactions following a previous immunisation

  • This section gives advice on the immunisation of children with a history of a severe or mild systemic or local reaction within 72 hours of a preceding vaccine. Immunisation with tetanus-containing vaccine should continue following a history of:
    • fever, irrespective of its severity
    • hypotonic-hyporesponsive episodes (HHE)
    • persistent crying or screaming for more than 3 hours
    • severe local reaction, irrespective of extent

Pregnancy and breast-feeding

  • Tetanus-containing vaccines may be given to pregnant women when protection is required without delay

Premature infants

  • It is important that premature infants have their immunisations at the appropriate chronological age, according to the schedule. The occurrence of apnoea following vaccination is especially increased in infants who were born very prematurely
  • The potential risk of apnoea and the need for respiratory monitoring for 48–72 hours should be considered when administering the primary immunisation series to infants who were born very prematurely (born ≤ 28 weeks of gestation) and particularly for those with a previous history of respiratory immaturity
  • The first immunisation of a child born very prematurely should be administered in hospital. If the child reacts to the first immunisation, they should return to hospital for their second immunisation
  • As the benefit of vaccination is high in this group of infants, vaccination should not be withheld or delayed

Immunosuppression and HIV infection

  • Individuals with immunosuppression or HIV infection (regardless of CD4 count) should be given tetanus-containing vaccines in accordance with the recommendations above. These individuals may not make a full antibody response. Re-immunisation should be considered after treatment is finished and recovery has occurred. Specialist advice may be required

Neurological conditions

Pre-existing neurological conditions

    • The presence of a neurological condition is not a contraindication to immunisation. Where there is evidence of a neurological condition in a child, the advice given in figure 1 should be followed
    • If a child has a stable, pre-existing neurological abnormality such as spina bifida, congenital abnormality of the brain, or perinatal hypoxic ischaemic encephalopathy, they should be immunised according to the recommended schedule. When there has been a documented history of cerebral damage in the neonatal period, immunisation should be carried out unless there is evidence of an evolving neurological abnormality
    • If there is evidence of current neurological deterioration, including poorly controlled epilepsy, immunisation should be deferred and the child should be referred to a child specialist for investigation to see if an underlying cause can be identified. If a cause is not identified, immunisation should be deferred until the condition has stabilised. If a cause is identified, immunisation should proceed as normal
    • A family history of seizures is not a contraindication to immunisation. When there is a personal or family history of febrile seizures, there is an increased risk of these occurring after any fever, including that caused by immunisation
    • Seizures associated with fever are rare in the first 6 months of life and most common in the second year of life. After this age, the frequency falls and they are rare after 5 years of age
    • When a child has had a seizure associated with fever in the past, with no evidence of neurological deterioration, immunisation should proceed as recommended. Advice on the prevention and management of fever should be given before immunisation
    • When a child has had a seizure that is not associated with fever, and there is no evidence of neurological deterioration, immunisation should proceed as recommended

Figure 1: Flow chart for evidence of a neurological condition before immunisation

algorithm for evidence of a neurological condition before tetanus immunisation

Deferral of immunisation

  • There will be very few occasions when deferral of immunisation is required. Deferral leaves the child unprotected; the period of deferral should be minimised so that immunisation can commence as soon as possible
  • If a specialist recommends deferral this should be clearly communicated to the general practitioner, who must be informed as soon as the child is fit for immunisation

Adverse reactions

    • Pain, swelling, or redness at the injection site are common and may occur more frequently following subsequent doses. A small painless nodule may form at the injection site; this usually disappears and is of no consequence
    • Fever, convulsions, high-pitched screaming, and episodes of pallor, cyanosis, and limpness (HHE) occur with equal frequency after both DTaP and DT vaccines
    • Confirmed anaphylaxis occurs extremely rarely
    • Other allergic conditions may occur more commonly and are not contraindications to further immunisation
    • All suspected adverse reactions to vaccines occurring in children, or in individuals of any age to vaccines labelled with a black triangle (▼), should be reported to the Commission on Human Medicines through the Yellow Card scheme. Serious suspected adverse reactions to vaccines in adults should be reported through the Yellow Card scheme
View related immunisation content

full guidelines from…

www.gov.uk/government/uploads/system/uploads/attachment_data/file/148506/Green-Book-Chapter-30-dh_103982.pdf 

Public Health England. Tetanus: the green book, chapter 30. (updated April 2013).