Tetanus toxoids and wound management

Tetanus toxoid and antitoxin preparations

All adults lacking a complete primary series of diphtheria and tetanus toxoids should complete the series with Td. A primary series for adults is three doses of preparations containing tetanus and diphtheria toxoids, with the first two doses given at least 4 weeks apart and the third dose given 6-12 months after the second. All adults for whom > 10 years have elapsed since completion of their primary series or since their last booster dose should receive a booster dose of Td. Thereafter, a booster dose of Td should be administered every 10 years. Doses need not be repeated if the primary schedule for the series or booster doses is delayed.

Complete and appropriately timed vaccination is nearly 100% effective in preventing tetanus. Td is the preferred preparation for active tetanus immunization of adults because a large proportion of them also lack protective levels of circulating antitoxin against diphtheria.

Wound management

For wound management the need for active immunization, with or without passive immunization, depends on the condition of the wound and the patient's vaccination history. Table 1 represents a summary of the indications for active and passive immunization.

Evidence indicates that complete primary vaccination with tetanus toxoid provides long-lasting protection ( >10 years among most recipients). Consequently, after complete primary tetanus vaccination, boosters are recommended at 10-year intervals. For clean and minor wounds occurring during the 10-year interval, no additional booster is recommended. For other wounds, a booster is appropriate if the patient has not received tetanus toxoid within the preceding 5 years. Antitoxin antibodies develop rapidly in persons who have previously received at least two doses of tetanus toxoid.

Persons who have not completed a full primary series of injections or whose vaccination status is unknown or uncertain may require tetanus toxoid and passive immunization at the time of wound cleaning and debridement. Ascertaining the interval since the most recent toxoid dose is not sufficient. A careful attempt should be made to determine whether a patient has previously completed primary vaccination and, if not, how many doses have been given. Persons with unknown or uncertain previous vaccination histories should be considered to have had no previous tetanus toxoid doses.

In managing the wounds of adults, Td is the preferred preparation for active tetanus immunization. This toxoid preparation is also used to enhance protection against diphtheria, because a large proportion of adults are susceptible. Thus, if advantage is taken of visits for care of acute health problems, such as for wound management, some patients who otherwise would remain susceptible can be protected against both diseases. Primary vaccination should ultimately be completed for persons documented to have received fewer than the recommended number of doses, including doses given as part of wound management.

If passive immunization is needed, human tetanus immune globulin (TIG) is the product of choice. The currently recommended prophylactic dose of TIG for wounds of average severity is 250 units IM. When T or Td and TIG are given concurrently, separate syringes and separate sites should be used. Most experts consider the use of adsorbed toxoid mandatory in this situation.

Toxoid side effects and adverse reactions

Local reactions (usually erythema and induration, with or without tenderness) can occur after Td is administered. Fever and other systemic symptoms are less common.

Arthus-type hypersensitivity reactions starting 2-8 hours after an injection and often associated with fever and malaise may occur, particularly among persons who have received multiple boosters of tetanus toxoid adsorbed (T).

Rarely, severe systemic reactions, such as generalized urticaria, anaphylaxis, or neurologic complications, have been reported after administration of tetanus and diphtheria toxoids. Peripheral neuropathy has been reported rarely after administration of T, although a causal relationship has not been established.

Toxoid precautions and contraindications

Although no evidence suggests that diphtheria and tetanus toxoids are teratogenic, waiting until the second trimester of pregnancy to administer Td is a reasonable precaution.

A history of a neurologic reaction or a severe hypersensitivity reaction (e.g., generalized urticaria or anaphylaxis) after a previous dose is a contraindication to diphtheria and tetanus toxoids. Local side effects alone do not preclude continued use. If a prior systemic

reaction suggests allergic hypersensitivity, appropriate skin testing to document immediate hypersensitivity may be useful before T vaccination is discontinued. Mild, nonspecific skin-test reactivity to T toxoid is common. Most vaccines develop a delayed but inconsequential cutaneous hypersensitivity to the toxoid.

Persons experiencing severe Arthustype hypersensitivity reactions to a dose of T usually have very high serum tetanus antitoxin levels and should not be given even emergency booster doses of Td more frequently than every 10 years.

If a contraindication to using preparations containing T exists in a person who has not completed a primary immunizing course of T and other than a clean minor wound is sustained, only passive immunization should be given using TIG.

Although a minor illness, such as a mild upper respiratory infection, should not be cause for postponing vaccination, a severe febrile illness is reason to defer routine vaccination.