My Father’s 2 year old baby brother died of tetanus in about 1929 after a minor cut to his foot. I’ve read about tetanus but thanks to modern vaccines, I’ve never seen a case. (If you want to read a chilling description of a death from tetanus, read about the death of John A. Roebling in The Great Bridge, which also describes the early history of “caisson disease” or “the bends”.) Tetanus is one of those diseases that has become rare thanks to vaccination, but may be making a comeback as a result of opposition to vaccination.
The post below is by guest blogger and good friend, Harriet Jones, MD, an infectious disease expert and practicing wound care physician.
Tetanus booster recommended for patients with chronic wounds
Since 2005, there have been 3 types of vaccinations against ‘tetanus’. These include: single dose tetanus toxoid; reduced diphtheria toxoid ; and acellular pertussis (Tdap). In October 2019 the Advisory Committee of Immunization Practices (ACIP) updated the recommendation to use Td or Tdap in situations where previously only Td was recommended. After receiving Tdap, booster doses of tetanus and diphtheria toxoids (Td) are recommended every 10 yrs. Recently the ACIP has proposed changes in the immunization schedule for adults that are also relevant to wound management. Summary charts have also been amended to reflect these changes in recommendations for high risk groups of people including persons who have wounds. The FDA has also listed Tetanus prophylaxis for wound management in their table of approved and off-label use of tetanus toxoid, reduced diphtheria toxoid and acelluar pertussis (tdap) products in 2019.
According to the Morbidity and Mortality Weekly Report (MMWR) February 12, 2021 / Vol 70 / No 6, ACIP has recommended giving tetanus toxoid-containing vaccine and tetanus immune globulin (TIG) when indicated as part of standard wound management if more than five years has passed since the last tetanus toxoid-containing vaccine dose.
Here are some specific guidelines:
- When a tetanus toxoid-containing vaccine is indicated for persons aged >/= 11 yrs, Tdap is preferred for those who have not previously received Tdap or whose Tdap history is unknown.
- If a tetanus toxoid-containing vaccine is indicated and Td is unavailable, Tdap may be administered.
- Persons who have completed the 3-dose primary tetanus vaccination series and have received a tetanus toxoid-containing vaccine < 5 years earlier do not require a a tetanus toxoid-containing vaccine or TIG as part of wound management.
- An attempt should be made to determine whether a patient with a wound has completed the 3-dose primary tetanus vaccine series. If it is unknown or uncertain of vaccination histories, the person should be considered to have had no previous tetanus toxoid-containing vaccine.
- Persons who have not completed the primary series might require tetanus toxoid-containing vaccine and passive vaccination with TIG at the time of wound management. When indicated, these products should be administered using separate syringes and at different anatomical sites.
- Persons with HIV or severe immunodeficiency who have contaminated wounds should also receive TIG regardless of their history of tetanus immunizations.
- People who have a history of having had an Arthus reaction following a previous dose of a tetanus toxoid-containing vaccine should not received a tetanus toxoid-containing vaccine until > 10 years after the most recent dose. This interval is recommended regardless of the level of contamination of a wound.
- An Arthus reaction is a type III hypersensitivity reaction that is rare but can occur after tetanus-toxoid or diphtheria toxoid-containing vaccines. Symptoms of Arthus reaction include: onset within a few (4-12) hours of immunization; severe pain; swelling; induration; edema; hemorrhage and occasionally necrosis. As with extensive limb swelling, these reactions usually resolve.
Additional information regarding Tdap and wound management is available at https://www.cdc.gov/mmwr/volumes/67/rr/rr6702a1htm.
–Harriet Jones, MD