Although tetanus is rare in the U.S., it is associated with high mortality rates. Tetanus infections occur primarily after a cut or a penetrating injury in people who have not been properly immunized. In the U.S., tetanus is primarily a disease of older adults. In surveillance data on 99 patients with tetanus, 68% were 50 years of age or older.
Serosurveys show that many American adults lack the protective antibody to tetanus. A study published in 2002 noted that only 60% of Americans six years of age or older had fully protective levels of diphtheria antibody and that 72% had protective levels of the tetanus antibody. As the age of the group increased, the percentage of people with protective antibodies declined. Among those 70 years of age and older, only 29.5% had protective antibodies against diphtheria and 31.0% had protection against tetanus. These results agree with those of older studies showing older adults to be largely unprotected from tetanus and diphtheria.
Another barrier to adequate immunity among the elderly is the fact that 81% of patients with tetanus who visited a health care provider for treatment did not receive prophylaxis, as recommended by ACIP guidelines.
Tetanus toxoid is available in combination with diphtheria toxoid and acellular pertussis vaccine (DTaP), in combination with diphtheria toxoid only (Td, TD) or as tetanus toxoid (TT) alone. DTaP is used primarily to immunize children. The vaccine provides active immunity against all three represented antigens.
The dose of diphtheria toxoid that is contained in both DTaP and TD is greater than that contained in Td. This larger dose is intended to elicit a primary immune response in recipients who have not previously completed a series of diphtheria immunizations (e.g., children receiving their first series of immunizations). Tetanus toxoid should be used only for patients who cannot tolerate diphtheria toxoid. All other adults should receive Td as a booster when needed.
The ACIP has issued the following recommendations for tetanus and diphtheria immunization in adults:
- Adults with an uncertain history of a complete primary vaccination series should receive a primary series using the combined Td toxoid.
- Booster doses of Td should be given every 10 years.
Patients who sustain injuries should be assessed for a history of tetanus immunization. Although tetanus rarely occurs in people who have documentation of having received a primary series of toxoid injections, some patients may need a booster dose of Td to ensure proper immunity to tetanus. The ACIP has issued the following guidelines for immunization of patients who have sustained a wound:
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- Patients with an unknown or an uncertain history of previous vaccination should be considered as having received no previous tetanus toxoid doses.
- Patients who have received a primary immunization series for tetanus need only a booster dose every 10 years if they have sustained a minor and uncontaminated wound.
- For patients who have sustained any other type of wound, a booster injection is appropriate if no tetanus toxoid has been administered within the preceding five years.
Some patients may experience adverse reactions following a tetanus injection. Many health care providers have misconceptions about these reactions and consider these events as contraindications to further immunization against tetanus, and some health care providers inappropriately consider certain conditions or circumstances as primary contraindications to DTaP vaccination. The following situations should not preclude the administration of tetanus and diphtheria toxoids:
- soreness, redness, or swelling at the DTaP vaccination site
- a fever below 40.5°C (105°F)
- mild, acute illness with low-grade fever or mild diarrhea that is affecting an otherwise healthy child
- current antimicrobial therapy
- the convalescent phase of an acute illness
- recent exposure of the patient to an infectious disease
- premature birth (the appropriate age for initiating vaccination among prematurely born infants is the usual chronological age from birth using full doses of vaccine—0.5 ml)
- a history of allergies or having relatives with allergies
- a family history of convulsions
- a family history of sudden infant death syndrome (SIDS)
- a family history of an adverse event following a DTaP vaccination
Patients should not receive further immunization with Td if they have a history of a neurological or severe hypersensitivity reaction following a previous dose. Intradermal skin testing should be considered for patients thought to have a hyper-sensitivity reaction to tetanus toxoid.
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In one study, most patients with a reported hypersensitivity reaction to tetanus toxoid had a negative skin test. For patients who have true contraindications to tetanus immunization, tetanus immune globulin can be considered for treatment of wounds that are neither clean nor minor. In patients requiring passive immunity because of an incomplete immunization history, separate syringes and separate injection sites can be used to administer tetanus toxoid at the same visit.
Several other vaccines are important, particularly those designed to protect against measles-mumps-rubella (MMR), varicella, and hepatitis B. Patients who were born before 1957 are considered immune to MMR and varicella if they had these diseases in childhood. Hepatitis B vaccine can be considered in adults over age 65, especially health care workers and sexually active homosexual men. Routine use of hepatitis B vaccine is not warranted in other elderly populations.