Thanks Ray for that.
One point though, about post exposure prophylaxis for tetanus, by which I
presume you mean Tetanus immunoglobulin.
I have never given this myself,  not only because it is extremely hard to
come by,   but also because I wouldn't want to have it myself,  weighing up
the risks of tetanus with the risk of other pathogens in this combined human
immunoglobulin, CJD / Hep F-Z etc.  Does anyone else have similar qualms ?

Paul Ransom
SpR A&E Hastings

----- Original Message -----
From: Ray McGlone <[log in to unmask]>
To: <[log in to unmask]>
Sent: Wednesday, May 15, 2002 8:36 PM
Subject: Re: Replacement of tetanus booster for adults


> 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.
> >
>
>