Tetanus Prophylaxis Background Tetanus is caused by tetanus toxin, which is released after infection by Clostridium tetani. Patients suffer rigidity and spasms of skeletal muscle – normally starting with jaw and neck, then becoming generalised. Tetanus spores are found in soil and manure. They can enter the skin via wounds and burns. Neonates are at risk via the umbilical stump. There is usually an incubation period of around 10 days (range 4 – 21) before symptoms develop. Fatality rates in developed countries for non-neonatal tetanus are low as a result of good supportive care. Tetanus is very rare in the UK (around 3 cases per year in Scotland) – however there have been clusters of UK cases in intravenous drug users

Management Summary **As of November 2018 there has been a significant change to the Department of** **Health Green Book tetanus immunisation and prophylaxis advice** **For all but clean wounds it is a return to a 10 year booster rule**

SUMMARY OF CHANGES

 We should no longer consider someone who has had five doses of vaccine at appropriate intervals as ‘fully immunised for life’  Now consider patients to have had an ‘adequate priming course’ – at least 3 doses of vaccine – and booster within 10 years as ‘fully immunised’  A patient who has had an ‘adequate priming course’ but last dose more than 10 years ago is not fully immunised and would now require a tetanus booster for a tetanus prone wound

 The intention is that we tr eat a fully immunised person as someone who has ‘received an adequate priming course’ and then give a booster or not depending on whether their last dose of vaccine was more than 10 years ago  This change reflects waning antibody levels following priming and / or booster doses. It cannot be assumed, in the context of a tetanus prone injury, that someone who received 5 doses where the last dose is more than 10 years ago, has sufficient levels of antibody to protect.

Assess all wounds and burns for tetanus inoculation risk by asking 3 questions:

1) Is the wound/burn clean, tetanus prone, or high risk? 2) What is the patient’s tetanus immunisation status?

3) When was the patient’s last tetanus booster?

 Ensure that all wounds are thoroughly cleaned

Full Guidance Available here - [Also Contains info on management of clinical tetanus] https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/754976/Tetan us_information_for_health_professionals.pdf

DOH Green Book here - https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/759133/Green book_chapter_30_Tetanus_.pdf

ED Guidance Ref Tetanus Prophylaxis Date of Issue May 2019 Version 2.0 Date of Review May 2022 Prepared by Mike Rennie Authorised by Raigmore ED Consultants

Is my patient immunised against tetanus?

National vaccination program introduced to UK in 1961 so patients born after this date have usually been fully immunised against tetanus. However immunity is felt to diminish 10 years after last dose.

Current tetanus vaccine schedule in Scotland (see http://www.immunisationscotland.org.uk/when-to- immunise/immunisation-schedule.aspx)

 Primary course of 3 doses ‘6-in-1 Vaccine’ given at 2,3, and 4 months of age o = diphtheria, tetanus, pertussis, polio, and haemophilus influenza b & Hep B o THIS IS THE ‘ADEQUATE PRIMING COURSE’  Preschool booster (4-in-1 Vaccine) between 3.5 and 5 years old  Further booster between 12 – 18 years (usually given at school at around 15 years)

SEE THE NEXT PAGE TO EVALUATE IF SOMEONE IS ADEQUATELY IMMUNISED OR WILL NEED A BOOSTER AND OR IMMUNOGLOBULIN

What is the risk of tetanus inoculation from this burn / wound?

Classify the wound or burn into clean / tetanus prone / high risk, as follows:

1. Clean Wounds

2. Tetanus Prone Wounds  Puncture-type injuries acquired in a contaminated environment and likely therefore to contain tetanus spores e.g. gardening injuries  Wounds containing foreign bodies  Compound (open) fractures  Wounds or burns with systemic sepsis  certain animal bites and scratches - although smaller bites from domestic pets are generally puncture injuries animal saliva should not contain tetanus spores unless the animal has been routing in soil or lives in an agricultural setting

3. High Risk Wounds – any of the above with  heavy contamination with material likely to contain tetanus spores e.g. soil, manure  wounds or burns that show extensive devitalised tissue  wounds or burns that require surgical intervention that is delayed for more than six hours are high risk even if the contamination was not initially heavy

ED Guidance Ref Tetanus Prophylaxis Date of Issue May 2019 Version 2.0 Date of Review May 2022 Prepared by Mike Rennie Authorised by Raigmore ED Consultants

What Tetanus Prophylaxis is Required?

ED Guidance Ref Tetanus Prophylaxis Date of Issue May 2019 Version 2.0 Date of Review May 2022 Prepared by Mike Rennie Authorised by Raigmore ED Consultants

Tetanus Immunoglobulin Prescribing Dose is 250 units irrespective of age given IM  Give into a different arm if vaccine also prescribed simultaneously  Helps to rapidly raise antibody levels (especially important if insufficiently immunised) Dose is 500 units if  >24 hours since injury  Risk of heavy contamination  Following burns

Tetanus Vaccine Prescribing

Tetanus vaccine is only available in compound preparations. Check Highland Formulary on TAM site for updates but at time of writing guidance is as follows:

All patients > 10 years old  Revaxis 0.5ml IM – either for boosting or primary immunisation

Children under 10 years old

1. Child has not had primary course, or there is no reliable Hx (therefore assume patient unimmunised)  Give Infanrix-Hexa  Ensure GP follow up as child will need 2 further doses at 1 month intervals

2. Primary course incomplete: course should be resumed but not repeated  Give Infanrix-Hexa  Ensure GP follow up if any further doses required

3. Booster dose in child 3.5 yrs to 10 yrs:  Only give booster if child hasn’t already received their first preschool booster  Give Repevax or Infanrix-IPV

Tetanus Vaccine Information

All current tetanus vaccine preparations are fully inactivated and also thiomersal free

No single component tetanus vaccines are available in the UK

Tetanus vaccine considered safe in pregnancy and during breast feeding

Confirmed anaphylaxis to previous tetanus containing vaccine is a contraindication to further doses – however this is very rare (< 3 cases per million doses)  Previous local reaction is NOT a contraindication

ED Guidance Ref Tetanus Prophylaxis Date of Issue May 2019 Version 2.0 Date of Review May 2022 Prepared by Mike Rennie Authorised by Raigmore ED Consultants