For information from CDR weekly the magazine for microbiologists!
Ray McGlone
Lancaster A&E
Two recent cases of severe tetanus
Two cases of severe tetanus in women aged 61 years with histories of
incomplete vaccination were
notified in April, the first cases reported so far this year.
The first case from West Yorkshire developed symptoms eight days after
sustaining a head injury from
a fall down stairs. Neither tetanus toxoid nor immunoglobulin was given at
the time of her injury,
which required stitches. She was admitted to intensive care four days later
with respiratory and cardiac
arrest, and severe trismus, and died two and a half weeks later. Only one
dose of tetanus toxoid given
eight years ago was shown in her medical records.
The second case from Suffolk presented to her general practitioner (GP) with
classical symptoms of
jaw stiffness and facial spasms. Three days prior to this she suffered a
deep scratch on her forearm
while gardening. The patient reported that she had suffered a mild episode
of tetanus as a teenager, over
40 years ago, and her symptoms with this episode were so similar that she
had correctly self-diagnosed
tetanus before seeing her GP. Following admission to intensive care she had
protracted muscular
spasms and autonomic symptoms, and required repeated intravenous infusions
of tetanus
immunoglobulin. Tetanus antitoxin levels were tested in an admission blood
sample at the PHLS
Respiratory and Systemic Infection Laboratory, and were below protective
levels. Cultures of swabs
taken from the wound grew Clostridium tetani were confirmed by the Anaerobe
Reference Unit in
Cardiff.
Following the first infection the patient had received one vaccination in
the mid-1970s, but had a mild
adverse reaction to the vaccination and so had not received further doses.
The patient is now improving
and, as the only contraindication to vaccination against tetanus is
anaphylaxis, has been started on a
primary course of vaccination.
Immunity does not necessarily develop following tetanus disease and so the
only protection against
future infections is by vaccination. Patients who have had tetanus should be
vaccinated when they have
recovered sufficiently.
Herd immunity plays no part in tetanus control. High vaccination coverage in
the childhood vaccination
programme and opportunistic vaccination of those with histories of
incomplete vaccination are required
to ensure high levels of immunity in the whole population (1). Opportunistic
vaccination should include
groups such as those born before vaccination programmes were implemented and
new arrivals with
uncertain or incomplete vaccination histories. Tetanus vaccination coverage
in most European Union
member states including the UK, is good. Five doses of tetanus
toxoid-containing vaccine are thought
to give life-long protection - routine ten-yearly boosters are no longer
recommended in the UK. Prompt
and appropriate post-exposure prophylaxis is an important control measure.
Doctors working in
accident and emergency medicine need to maintain systems for providing
post-exposure prophylaxis
for tetanus and should preferably provide a vaccine that also includes an
appropriate dose of diphtheria
toxoid. Attendance at accident and emergency offers a good opportunity to
check vaccination status:
liaison with GPs will be required to ensure the completion of a vaccination
course in unvaccinated
individuals. This should be a good topic for audit of local practice.
Since 1930, most tetanus cases in the UK have occurred in older people,
mainly women, who had never
been vaccinated (2-4). Between two and seven tetanus cases per year occur in
England and Wales.
Family doctors should ensure that all their patients are fully vaccinated,
targeting those born before
1961.
1. Department of Health. Immunisation against infectious disease. London:
HMSO, 1996.
2. PHLS CDSC. Tetanus surveillance: England and Wales, 1981-3. BMJ 1985;
290: 696-7.
3. Galbraith NS, Forbes P, Tillett H. National surveillance of tetanus in
England and Wales 1930-79. J Infect 1981; 3: 181-
91.
4. CDSC. Tetanus surveillance in England and Wales. Commun Dis Rep CDR Wkly
1982; (07): 3-5.
----- Original Message -----
From: "Helen Deborah Vecht" <[log in to unmask]>
To: <[log in to unmask]>
Sent: Wednesday, May 15, 2002 10:42 AM
Subject: Re: Replacement of tetanus booster for adults
> The message <[log in to unmask]>
> from Rowley Cottingham <[log in to unmask]> contains
> these words:
>
>
> > It has been around for some time; I have not given tetanus boosters to
> > the over 5 and under 15 population for about 4 years now, as they
> > receive
> > Diftavax, the combined vaccine, at 15 anyway. In general terms it is
> > nothing to do with us, and tetanus immunisation used to be given with
> > every
> > scratch. With an ageing population we would do more good
> > opportunistically checking blood pressure.
>
> There is some merit in that argument *except* that tetanus immunisation
> only became routine in 1961. Many (in the list and outside it) were born
> before then and might not have had primary immunisation as babies. (I
> had mine as a 'catch up' at the age of 15.)
>
> Tetanus immunisation is not routine in Denmark and I have no idea of
> immunisation schedules in other countries. *Many* of the patients I see
> were not born in the UK.
>
> The generation of men who had tetanus immunisation in the Army is
> passing on and many older patients cannot recall *ever* having a tetanus
> injection. I still start/boost tetanus immunisation in these, if they
> have open wounds.
>
> My view is that tetanus immunity is still an issue, especially in older
women.
>
> --
> Helen D. Vecht: [log in to unmask]
> Edgware.
>
|