The definitive letter



Ray McGlone

A&E Lancaster






Room 605A


Skipton House


80 London Road


London SE1 6LH




Tel: 020 7972 1526


Fax: 020 7972 5758


[log in to unmask]



16 May 2002





To:        All Immunisation Co-ordinators

            All Pharmacists

            All GPs via Practice Managers



Dear Colleague,



REPLACEMENT OF SINGLE ANTIGEN TETANUS VACCINE BY COMBINED TETANUS/LOW DOSE
DIPHTHERIA VACCINE FOR ADULTS AND ADOLESCENTS



Single antigen Tetanus vaccine (T) is being replaced by the combined
Tetanus/low dose diphtheria vaccine for adults and adolescents (Td) for all
routine uses.



Td vaccine replaced single antigen Tetanus vaccine for the routine booster
immunisation given to school-leavers in 1994.  CMO's Update 5, issued in
March 1995, clarified that Td should now always be given rather than tetanus
(T) alone.



The change was on the advice of the Joint Committee on Vaccination and
Immunisation (JCVI), generated by concern at the low levels of immunity to
diphtheria in older people in the UK. It brings us into line with
recommendations from the World Health Organization.



Td should now be used:



·         For primary immunisation of adults and adolescents previously
unimmunised against tetanus

·         Where booster doses of tetanus are indicated, following a tetanus
prone wound or for the purposes of travel



Please note that for both tetanus and diphtheria a total of 5 doses of
vaccine are considered to give lifelong immunity. These may have been given
either as the primary 3 dose course in childhood followed by school entry
and school leaving doses, OR as a primary course at any time followed by a
booster 10 years later and a further booster 10 years after that.



Booster doses are therefore indicated only:


·         Following a tetanus prone wound,  where the individual has not
received a full 5 dose course and is due a further dose, OR, the
immunisation status is unknown  (if the wound is contaminated, a dose of
human tetanus immunoglobulin should be given);



·         For travellers to areas where medical attention may not be
accessible should a tetanus prone injury occur, and the last dose was more
than 10 years previously.



Single antigen low dose diphtheria vaccine for adults and adolescents (d)
can still be used where diphtheria vaccine is indicated in an individual who
is fully immunised against tetanus. However, from time to time this vaccine
is not available; when this occurs, the combined vaccine can be used.



Adverse reactions


Adverse reactions to the tetanus and diphtheria components are similar, but
are more likely to be due to the 'T' component.



Local reactions such as pain, redness and swelling round the injection site
may occur and may persist for several days. General reactions are uncommon,
but include headache, lethargy, malaise, myalgia and pyrexia. Acute
anaphylactic reactions and urticaria may occasionally occur and, rarely,
peripheral neuropathy or other neurological reactions. Persistant nodules at
the injection site may arise if the injection is not given deeply enough.



Contraindications


The vaccine should not be given to an individual suffering an acute febrile
illness except in the presence of a tetanus prone wound.



Immunisation should not proceed in individuals who have had an anaphylactic
reaction to a previous dose. Otherwise, tetanus containing vaccines can be
given to people who have had previous severe adverse reactions, but in a
setting where full facilities are available to deal with any acute allergic
reaction.



Supplies


The hospital contract for the supplies of combined tetanus and low dose
diphtheria vaccine for adults and adolescents is in place with the
manufacturer Aventis Pasteur MSD. Details of this contract are available
from the NHS Purchasing and Supply Agency (contact Alan White, tel:  0118
980 8785).  Hospitals should continue to use existing stocks of adsorbed
tetanus before changing to the combined vaccine.



Stocks of the combined vaccine can be ordered by Practices from Aventis
Pasteur MSD who are currently the sole manufacturer in the UK.



Many practices will have standing orders or individual agreements with
Aventis Pasteur MSD, Evans Vaccines or Glaxo SmithKline for the supply of
adsorbed tetanus vaccine. These companies will continue to supply tetanus
vaccine until current stocks are exhausted. Practices should continue to use
existing stocks of adsorbed tetanus before changing to the combined vaccine.



Yours sincerely,







Jane Leese FRCP
Senior Medical Officer

Communicable Disease Immunisation Branch

----- Original Message -----
From: "Goat" <[log in to unmask]>
To: <[log in to unmask]>
Sent: Thursday, May 16, 2002 2:40 PM
Subject: Re: Replacement of tetanus booster for adults


> I seem to be out of step with several others (Adrian, Matt, Nick - read
> on). Our little A&E department obviously enjoys very different working
> arrangements from the rest of the world. I agree this thread is rapidly
> drifting away from the list's intended use, so will contribute no more
> on this subject publicly after this. Very happy to entertain more
> discussion off list with any of you who feel strongly about the
> following.
>
> Apologies to Nick Jenkins for any perceived sleight in my email - none
> intended. I obviously misunderstood your email, but having just re-read
> it, I still get the strong impression you are questioning whether it is
> A&E's job to provide opportunistic tet vaccinations, much less
> Diphtheria too. I actually think you are quite right to question this
> and provoke searching questions about what jobs A&E should be involved
> in. I agree that providing routine immunization clinics is not a
> sensible use of A&E services, but I'm not sure that's what's being
> suggested.
>
> Matt Dunn feels that "not my job" is a part of good patient care. I'm
> sorry you feel that way, if only on the grounds that the patient or
> manager hearing this will hear "I could do it, but I'm not going to".
> The difference may be subtle but personally I find that "not my field of
> expertise" or "not something we're equipped to do" leads to much more
> fruitful negotiations with patients and managers alike.
>
>
> In article <003101c1fc64$c1af39e0$79a81e3e@AdrianFogarty>, Adrian
> Fogarty <[log in to unmask]> writes
> >A&E is clearly the dumping ground for just about everyone
> >these days
> You need to get out of London more, Adrian - we have a vacant post!
>
> You'll struggle to find anyone who says their A&E department is
> adequately resourced, but we're not alone in that. Ask any GP round here
> - they will read "GPs are the dumping ground....." in your above quote.
> That's precisely why the "not my job" argument (whether explicit or
> perceived) is unhelpful. The disastrous consequences of pitting social
> services against health should be ample supportive evidence.
>
> Post-exposure HIV prophylaxis and post-coital baby prophylaxis are
> examples of how this department has NOT just accepted "dumping"
> unquestioningly. Perhaps you think that our Department's goodwill is
> being hopelessly abused. All I can say is that if you look at the
> support we have from patients, in-patient teams and GPs locally then
> this approach has worked reasonably well for us.
>
> Having said all that, if we continue to be abused as a surrogate for
> adequate bed provision, I won't want to work here, or any other A&E
> Department for much longer (don't get me started on that one again!).
>
> Best wishes
>
> Gautam
>
> Dr G Ray
> A&E
> Sussex
> Reply to [log in to unmask]
>