No 5b - 2015

Changed recommendations for tetanus prophylaxis after wound injury

Tetanus vaccination was introduced into the Danish childhood vaccination programme in 1950. Tetanus is occurs rarely in Denmark because the coverage of the childhood vaccination programme has remained high for many years, and therefore the majority of persons below 65 years of age are fully or partly vaccinated.

Nevertheless, it is important to remain protected throughout life. Therefore, in case of wound injury, the severity of the injury and immunity shall always be assessed. EPI-NEWS 7/04 on recommendations for tetanus prophylaxis after wound injury has been amended, among others because the recommendations on adaptation to the childhood vaccination programme have been changed, EPI-NEWS 5a/15.

Primary and booster vaccination

All persons should receive a primary vaccination series including three tetanus-containing vaccines once in life. The minimum interval between the first and the second vaccine dose is 1 month, and the minimum interval between the second and third dose is 6 months.

Subsequently, booster vaccination is recommended, initially after 4-5 years and then every 10 years.
Infants are protected by maternal antibodies against tetanus for the first 3 months of life, provided the mother has received a booster vaccination within the past 10 years.

Both children and adults are considered to be protected against tetanus when they have received 2 vaccines, and will remain covered until receiving the third vaccine after 6-12 months.

Table 1 presents the available tetanus-containing vaccines from the SSI.



Children below the age of 10 years:
Children normally receive a primary vaccination series consisting of 3 DTaP-IPV/Hib at 3, 5 and 12 months of age and a dTap-IPV booster (DiTeKiPol Booster) at 5 years of age, EPI-NEWS 50/14.

We recommend that children below 10 years of age continue receiving this vaccination regimen. A diagram showing how vaccination after wound injury should be given in this age-group is available for download and printing (pdf version).

Children aged 10 years or older and adults may receive primary vaccination - either full vaccination or conclusion of a previously initiated vaccination series - using a diphtheria low-titre dT-containing vaccine for booster vaccination EPI-NEWS 5a/15. These may therefore receive primary vaccination or conclude a previously initiated vaccination series with the following vaccines:
Tetanus-only vaccine, dT vaccine, dTap vaccine or dTap-IPV vaccine, Table 1.

Children aged 10-17 years:
In children aged 10-17 years who lack vaccination against the remaining childhood diseases, e.g. pertussis and/or polio, it is expedient to complete the primary vaccination series with a vaccine containing the relevant antigen. 
A diagram showing how vaccination after wound injury should be given in this age-group is available for download and printing (pdf version).

Adults aged 18 years and above:
Persons above 17 years of age may receive primary vaccination or complete a previously initiated vaccination series with dT vaccine (dTap vaccine or dTap-IPV if protection against pertussis and/or polio is also wanted).
A diagram showing how vaccination after wound injury should be given in this age-group is available for download and printing (pdf version).

Both the tetanus-only vaccine and the dT/dTap vaccine for booster vaccination may be given to pregnant women following exposure or prior to exposure, if the interval for protection was exceeded, EPI-NEWS 26a/13.

Risk assessment in wound injury

Surgical revision is decisive to minimise the risk of tetanus. All wounds - even very minor ones - may carry a risk of tetanus.
The risk is particularly high in connection with:
- lesions with devitalised tissue - open as well as closed (e.g. hammer stroke) wounds
- perforated lesions (gunshot wounds, stab wounds, bite wounds) and particularly in cases where foreign objects are suspected (wood splinters, thorns, nails)
- lesions caused by 3rd degree burns (particularly caused by fire) and 2nd degree burns covering more than 3% of
the body surface area.
- lesions to the lower extremities (particularly in feet and toes), ulcus cruris
- smooth cut lesions that have become contaminated by dirt, or where an infection has subsequently occurred
- lesions that are more than 5 hours old when the patient arrives for treatment.

Tetanus vaccination and possibly human tetanus immunoglobulin after wound injury

Whether a patient should both receive tetanus vaccination (T) and human tetanus immune globulin (TIG) depends on both the vaccination status of the patient and the degree of tissue injury, Table 2.



Children below 10 years of age, who have initiated a primary vaccination series, should generally not receive a dT booster vaccination as the content of diphtheria antigens is insufficient, and as this group shall also receive vaccination against polio and pertussis. It may therefore be expedient for accident and emergency departments to keep a limited stock of DTaP-IPV/Hib vaccine for primary vaccination and dTap-IPV vaccine for booster vaccination.

Children aged 10 years and above, and adults may, as stated above, react adequately to vaccination with low-dose diphtheria antigen, EPI-NEWS 5a/15, why dT vaccine may be used for primary vaccination (Children and adolescents aged 10-17 years, who lack vaccinations against the remaining childhood diseases, e.g. polio, may also conclude their primary vaccination series with dTap-IPV vaccine for booster vaccination).

In case of wound injury in a completely unvaccinated patient, TIG should be given concurrently with the first tetanus vaccination. This is subsequently supplemented with a total of three tetanus vaccinations after 1, 2 and 12 months, respectively. If the patient has not previously been vaccinated against diphtheria, 3 diphtheria vaccines for primary vaccination should also be given in children aged 10 years or less. These will typically be given as DTaP-IPV/Hib vaccine at primary vaccination, where the Hib component is given depending on the child's age, EPI-NEWS 5a/15.

In un- or partly vaccinated children aged 10 years or above and in adults, diphtheria vaccination may be given concurrently, e.g. as a dT vaccine, EPI-NEWS 5a/15.

For patients who have received primary vaccination against both diphtheria and tetanus, dT vaccine is used for booster vaccination. If the vaccine's protection interval was exceeded, TIG may be given following a specific risk assessment, Table 2.

Vaccination with tetanus-containing vaccine after wound injury shall always be given as soon as possible. Even though it may seem inexpedient to vaccinate a child at an accident and emergency department using a dT vaccine, if the child lacks one or more primary vaccinations, awaiting vaccination cannot generally be recommended.

Examples
1) A 9-day-old child suffers burns to a hand, the mother has not received dT vaccination within the past 10 years: TIG is given and the child then follows the standard childhood vaccination programme, Diagram 1.

2) A 6-month-old child is bitten in the face by a cat. The two first primary vaccinations were given timely: The child is protected against tetanus and shall simply follow the vaccination programme, Diagram 1.

3) A 15-month-old child suffers a 3rd degree burn to the hand. The child has received the first 2 primary vaccinations timely: The child is protected against tetanus, but may be given DTaP-IPV/Hib in the accident and emergency department or with the GP the day after in order to conclude the primary vaccination series, Diagram 1.

4) A 19-month-old child suffers a deep skin abrasion in connection with a fall on a gravel path. The child has only received 2 primary vaccinations, at 4 and 6 months of age: 13 months has passed since the last vaccination and both vaccination (DTaP-IPV/Hib) and TIG shall be given, Diagram 1. As TIG is given, the child shall receive an extra tetanus vaccination for primary vaccination 1 month later. If the accident and emergency department does not stock DTaP-IPV/Hib, the child shall be given a tetanus-only vaccine and TIG, Diagram 1 (link 1). The child shall subsequently be vaccinated with DTaP-IPV/Hib a minimum of 1 month after the visit to the accident and emergency department, and will then have concluded the primary series, Table 2.

5) A child aged 5 years has been bitten in the hand by a dog. The child has received all three primary vaccinations on time, but has not yet received the 5-year dTap-IPV booster. The child is protected against tetanus and may be given the 5-year vaccination at the GP the day after, if the accident and emergency department does not stock vaccine for dTap-IPV booster vaccination, Diagram 1.

6) A child aged 6.5 years has suffered a cut by a clean kitchen knife. The child has received all three childhood vaccinations on time, but has not received the 5-year vaccination: The child is not protected against tetanus. The child does not need TIG, but does need T, preferably in the form of a dTap-IPV booster vaccination, Diagram 1. If this vaccination is not available at the accident and emergency department, the child may be given a dT vaccine, and subsequently an IPV at the GP. In this situation, the child will not have boosted its protection against pertussis, and will be susceptible to pertussis infection.

7) A child aged 6.5 years has a dirty splinter of wood lodged in the hand. The child has received all three primary vaccinations on time, but has not received the 5-year dTap-IPV booster: The child shall receive T and TIG due to considerable risk, Table 2. The vaccine should be given as a dTap-IPV booster, Diagram 1. If a booster is not available, a dT vaccine is given, and subsequently an IPV vaccine. In this situation, the child will not have boosted its protection against pertussis, and will be susceptible to pertussis infection.

8) A 13-year-old child has fallen in the school yard and has deep skin abrasions on both knees. The child has only received 2 primary vaccinations at 4 and 9 months of age and has not received booster vaccination: Both T and TIG shall be given, Table 2. T may be given as a dTap-IPV booster at the accident and emergency department, alternatively as a T vaccine. As TIG is given, an extra tetanus-containing vaccine shall be given after a month, Diagram 2. This vaccine may be given as a tetanus-only vaccine by the GP (If T vaccine was given at the accident and emergency department, the GP gives the third DTaP-IPV/Hib primary vaccination instead). Subsequently, the child shall receive booster vaccination after 4-5 years with dT/dTaP vaccine.

9) A 23-year-old man is involved in a motorbike accident and suffers extensive trauma and a penetrating deep lesion to the femoral muscles with extensive bleeding (transfusion need; 3 blood units). Latest dT vaccination was 17 years ago: Considerable risk of tetanus infection is associated with the lesion, but the blood loss is not extreme. dT vaccine and TIG shall be given due to the considerable risk, Table 2 and Diagram 3.

10) A woman aged 60 years accidentally lodges a thorn deep into her hand. Her vaccination status is unknown. TIG and the first tetanus vaccination shall be given. Subsequently, an additional 3 tetanus vaccines shall be given after 1, 2 and 12 months, respectively (If her diphtheria vaccination status is also unknown, the women should receive diphtheria vaccination concurrently. In this case a dT vaccine with a low diphtheria antigen content (diTeBooster) shall be used rather than a tetanus-only vaccine, Diagram 3  and EPI-NEWS 5a/15).

Commentary

Tetanus prophylaxis after wound injury is considered post-exposure treatment and is defrayed by the relevant Danish Region.
Children aged 18 years or less are comprised by an offer equivalent to the childhood vaccination programme, i.e. three primary vaccinations and the first booster vaccination, normally given at 5 years of age.

Children with no current injury, who have received their first booster vaccination, and persons above 18 years of age who are given a booster vaccination to ensure protection are not comprised by the free vaccination offer.

Tetanus immune globulin (TIG) should be stored at all accident and emergency departments/acute treatment clinics and in general practices with a long driving distance to the nearest emergency department. The shelf life of TIG is approximately 2 years, and it is a preparedness product that may be ordered free of charge from the SSI for post-exposure treatment.
The Consultancy Team, Department of Infectious Disease Epidemiology, H. Nielsen, Department of Infectious Diseases, Aalborg University Hospital)

Link to previous issues of EPI-NEWS

28 January 2015