tetanus

ADT™ Booster

Td

ADT™ Booster is used for primary and booster vaccination of children 7 years of age and over and adults to protect against tetanus and diphtheria. An alternative vaccine called Boostrix®, which protects against tetanus, diphtheria and pertussis (whooping cough), can be substituted for one, two or all three doses of the primary vaccinations in these age groups. Both ADT™ Booster and Boostrix® are licensed as booster vaccines. They are used for primary vaccination out of licensure as there is no alternative primary vaccination strength vaccine available in New Zealand for these age groups. When the vaccine is used for a primary vaccination course, use will be outside of current licensure. No safety concerns are expected with use in these circumstances.

Infanrix®-IPV

DTaP-IPV

Infanrix®-IPV is used for primary and booster vaccination of infants and children to protect against diphtheria, tetanus, pertussis and poliomyelitis. Infanrix®-IPV can also be used for catch-up immunisation for children up to their 10th birthday.

Infanrix®-hexa

DTaP-IPV-HepB/Hib

Infanrix®-hexa is used for primary and booster vaccination of infants and children to protect against diphtheria, tetanus, pertussis, hepatitis B, poliomyelitis and disease caused by Haemophilus influenzae type b. Infanrix®-hexa can also be used for catch-up immunisation for children up to their 10th birthday.

 

Boostrix®

Tdap

Boostrix® is used for booster vaccination of adolescents aged 11 years and pregnant women between 28-38 weeks gestation* to protect against diphtheria, tetanus and pertussis (whooping cough). Boostrix® can also be used for catch-up immunisation for children aged 7 years# to under 18 years.

*After immunisation protection against pertussis takes up to two weeks to develop. Whilst immunisation between 38-40 weeks gestation is still safe for mother and baby later immunisation means the newborn may still be exposed to the disease by their mother on delivery and/or during the first two weeks of life. The PHARMAC decision to limit funded Boostrix® to 28-38 weeks gestation maximises the benefit of immunisation against pertussis whilst being accountable for the use of public funds. Pregnant women can choose to purchase Boostrix® privately after 38 weeks gestation or at any time after delivery.

#Although Boostrix® is not licensed for use in children aged 7 years to under 10 years it has been used in New Zealand and overseas in this age group and there are no safety concerns with off-label use.

Tetanus

Common Name: 
Lockjaw
Parents & Caregivers
Introduction: 

Tetanus, also called lockjaw, is caused by the action of tetanus toxin released by a spore-forming bacillus called Clostridium tetani. The bacillus and spores are found the soil around the world. Many animals, in addition to humans, can carry the bacillus and its spores in their gastrointestinal tract and excrete them in faeces. Tetanus occurs after the bacillus and/or spores are introduced into the body through a wound and release a toxin that affects the nervous system.

A person or animal with tetanus is not infectious. Having tetanus does not usually generate immunity to the disease. 

A brief history: 

The first medical description of tetanus is believed to have been recorded in ancient Egypt. Later tetanus was also described by Hippocrates and other ancient Greeks but the cause was not discovered until 1884. Worldwide at least one million cases of tetanus need hospital treatment each year. In developing countries neonatal tetanus (acquired through the umbilical stump) accounts for approximately half the cases. In developed countries injuries cause approximately 70% of cases.
On a weight basis tetanus toxin is one of the most potent known poisons.
Universal infant immunisation with a tetanus toxoid vaccine began in 1960 in New Zealand. Anyone born before 1960 is less likely to have received a primary series, unless they were in the armed forces.

The current New Zealand situation: 

Almost all the recent cases of tetanus in New Zealand, in both adults and children, occurred in individuals without a documented history of a primary immunisation course of a tetanus-containing vaccine.

Seven cases of tetanus were notified in 2010, the highest number since 1992, and one person died. One case had received a primary course of tetanus vaccines but had not had a booster dose for 15 years. In New Zealand tetanus usually occurs following a minor injury.

Symptoms: 

Initial symptoms include weakness, stiffness or cramps and difficulty chewing or swallowing food. As the disease progresses tetanus is characterised by muscular rigidity and very painful contraction spasms. When severe it is associated with a characteristic facial grimace (risus sardonicus) and arching of the back (opisthotonus).

How do you get it?: 

Animals, including humans, can carry Clostridium tetani in their intestine and excrete the bacillus and/or spores with their faeces into the soil. The bacillus and/or spores can be introduced into the body through any break in the skin (wound), no matter how minor.

Once in the wound bacilli mature, become spores and germinate releasing a chemical that is toxic to the central and autonomic nervous systems (toxin). 

Wounds that are contaminated, have lots of tissue damage or a deep puncture type wounds have the highest risk of containing Clostridium tetani but even minor wounds have caused tetanus.

What are the risks?: 

Approximately 10% of people who get tetanus die, despite the modern intensive care units, machines and medicines.

Those who survive usually have a full recovery after physical rehabilitation.

Who is most at risk?: 

Everyone who has not received a primary course of three tetanus containing vaccines.

Anyone born before 1960 is less likely to have received a primary series, unless they were in the armed forces. Older women appear to be at particular risk.

Treating the symptoms: 

Treatment of tetanus is aimed at preventing further circulating toxin affecting the nervous system (tetanus immunoglobulin), prevent further toxin release from the spores (wound debridement), supportive care e.g., assist breathing, circulation and heart function; low stimulus environment (dimly lit and quiet), anti-spasm medication; pain medication; nutritional support that may include tube or intravenous feeding; prevention of blood clots and skin breakdown; and physical rehabilitation.

Preventing Disease Spread: 

It is not possible to eliminate Clostridium tetani from the environment. All wounds require adequate cleaning and removal of damaged tissue. Additional treatment depends on the circumstances of each case.

A complete primary course of three doses of tetanus containing vaccine and appropriate administration of booster doses provides protection against the toxin released by the spores but will not stop infection with the bacillus and/or spores, their germination or toxin release.

Tetanus immunoglobulin (TIG), derived from human blood donations, must be given to any person who has not completed three doses of vaccine before getting a high tetanus risk wound. The person should also start a course of tetanus containing vaccines or continue their course of tetanus containing vaccines until they have had three doses.

A person who has completed three doses of tetanus containing vaccine before having a high tetanus risk wound may benefit from a booster with a tetanus containing vaccine if they have not had a tetanus containing vaccine in the previous five years.

A person who has completed three doses of tetanus containing vaccine before having a low tetanus risk wound may benefit from a booster with a tetanus containing vaccine if they have not had a tetanus containing vaccine in the previous 10 years.

People in certain occupations and travellers may also benefit from tetanus vaccine booster doses when more than 10 years have elapsed since their previous dose.

Health Professionals
Causative organism: 

Tetanus is caused by toxin released from Clostridium tetani, a gram-positive, spore-forming, anaerobic bacillus. Animals, including humans, can carry Clostridium tetani bacillus and spores in their intestine and excrete them in faeces. Spores are found in soil worldwide and can survive for months to years if not exposed to sunlight. They are resistant to boiling and a variety of disinfecting agents. Sterilisation of equipment at 120°C for 15 to 20 minutes more easily destroys the spores.

Clostridium tetani need an anaerobic (absent oxygen) environment in which to grow, often found in damaged and necrotic tissue, and prefer a growing temperature of 33-37°C. The bacillus becomes a spore that germinates and releases two exotoxins, tetanolysin and tetanospasmin. Of these tetanospasmin is the neurotoxin that causes the symptoms of tetanus. On a weight basis tetanospasmin is one of the most potent known poisons.

Clinical signs, symptoms and complications: 

Incubation of Clostridium tetani ranges from 3-21 days, with the average being around 8-10 days. The distance between the point of bacillus entry (wound) and the central nervous system (CNS) influences the incubation period, with the further the wound is from the CNS the longer the incubation period.

Wounds of the head, neck and trunk typically have the shortest incubation periods. The length of incubation period also influences the severity of the disease, longer incubation (10 days or more) typically results in more mild disease than a shorter incubation period (7 days or less).

Tetanus is diagnosed on clinical grounds. A history of contaminated wound may or may not be present. Laboratory testing e.g., wound cultures, cannot confirm or exclude the diagnosis. Strychnine poisoning mimics tetanus, without a raised body temperature. Other differential diagnoses include dental caries/disease, tonsillitis, parotitis, temporomandibular joint (TMJ) disease, Bell’s palsy, low serum calcium and dystonic reactions to medication.

Tetanospasmin travels to the CNS via the axons and irreversibly binds to the neuromuscular junction nerve terminals, blocking the release of inhibitory neurotransmitters that cause muscle relaxation. Tetanospasmin may also cause autonomic nervous system (ANS) dysfunction.
Localised tetanus is rare in humans; spasms are confined to an area close to the wound, may be mild and may resolve spontaneously over several weeks to months or may progress to generalised tetanus.

Generalised tetanus is characterised by generalised muscular rigidity and prolonged, tonic contraction spasms often triggered by external stimuli. Initial symptoms include weakness, stiffness or cramps, and difficulty chewing or swallowing food progressing to the person’s inability to open their mouth (trismus), a characteristic facial grimace (risus sardonicus) and arching of the back (opisthotonus).

The person with tetanus may cause trauma to their tongue. Muscle spasms can be severe enough to cause fractures of the vertebrae and long bones and can raise the person’s body temperature by 2-4°C.

ANS dysfunction may present as hypertension, hypotension, flushing, sweating, urinary retention, tachycardia and arrhythmias.

A person with tetanus remains conscious and alert, unless they develop upper airway obstruction and become severely hypoxic. Spasm of the glottis can cause immediate death.

Cephalic tetanus is rare and usually associated with a wound on the head. Following a short incubation period, 1-2 days, the person presents with atonic cranial nerve palsies (facial paralysis) involving nerves III, IV, VII, IX, X and XII, singly or in combination. Trismus may be present and cephalic tetanus may progress to generalised tetanus.

Tetanus neonatorum (neonatal tetanus) is the most common presentation of tetanus in developing countries. It is a form of generalised tetanus arising from infection of the umbilical stump. Mortality exceeds 90%. Babies who survive may experience long term consequences including subtle intellectual and behavioural abnormalities, cerebral palsy and severe psychomotor retardation.

The acute clinical course of tetanus varies between 1-4 weeks. Approximately 10% of people who get tetanus die, despite the modern intensive care units, machines and medicines. Those who survive usually have a full recovery after rehabilitation.

Method of transmission: 

Animals, including humans, can carry Clostridium tetani in their intestine and excrete the bacillus and/or spores with their faeces into the soil. The bacillus and/or spores can be introduced into the body through any break in the skin (wound), no matter how minor. Once in the wound bacilli mature, become spores and germinate releasing toxic to the central nervous system (toxin).

A person with tetanus is not infectious to others.

Public health significance: 

It is not possible to eliminate Clostridium tetani from the environment.

A complete primary course of three doses of tetanus containing vaccine and appropriate administration of booster doses provides protection against the toxin released by the spores but will not stop infection with the bacillus and/or spores, their germination or toxin release.

Vaccination against tetanus provides individual protection against tetanus.
Vaccination against tetanus does not create “herd immunity” because the disease is not spread person to person.

All cases of tetanus must be notified immediately on suspicion to the local medical officer of health, who should be provided with as accurate immunisation history as possible.

New Zealand epidemiology: 

Almost all the recent cases of tetanus in New Zealand, in both adults and children, occurred in individuals without a documented history of a primary immunisation course of a tetanus-containing vaccine.

Seven cases of tetanus were notified in 2010, the highest number since 1992. One case aged 1-4 years (unvaccinated); one case 40-49 years (last vaccination 15 years earlier); one case aged 60-69 years (vaccination status unknown; and four cases aged 70 years and older (two unvaccinated, two vaccination status unknown). One of the people aged over 70 years died from tetanus.

The National Serosurvey of Vaccine Preventable Diseases over 2005-2007 found that 85 percent of 6–10-year-olds, 94 percent of 11–15-year-olds, 95 percent of 16–24-year-olds, 95 percent of 25–44-year-olds and 89 percent of ≥ 45-year-olds had presumed protective levels of tetanus antibody.

Prevention: 

Wounds that are contaminated (dirt, faeces, saliva, foreign bodies e.g., wood splinter), have lots of tissue damage (crush injuries, burns), are a deep puncture type wound and/or are more than six hours old have the highest risk of containing Clostridium tetani and causing tetanus,  but even minor wounds have caused tetanus.

All wounds require adequate cleaning and removal of damaged tissue. Additional treatment depends on the circumstances of each case.

Management of high tetanus risk wounds

If a wound is considered to be a high tetanus risk wound and the person has not previously completed a three dose course of tetanus containing vaccine or there is any doubt with regard to the person having already completed a three dose course of tetanus containing vaccine tetanus immunoglobulin (TIG) must be given.

Outside of Auckland, TIG is ordered from the local District Health Board hospital blood bank. Within Auckland TIG is ordered directly from the New Zealand Blood Service.

If less than 24 hours has elapsed since the wound occurred the recommended dose of TIG, to prevent tetanus, is 250 IU administered by intramuscular injection. However, the dose should be increased to 500 IU in cases of severely contaminated wounds, burns and/or when more than 24 hours has elapsed since the wound occurred.

Antibiotics are not currently recommended for prevention of tetanus. However wounds should be observed regularly for signs of infection and antibiotics prescribed when clinically indicated.

People with tetanus do not need to be isolated.

Contacts of a person with tetanus do not need a tetanus booster.

A person who has completed three doses of tetanus containing vaccine before having a high tetanus risk wound may benefit from a booster with a tetanus containing vaccine if they have not had a tetanus containing vaccine in the previous five years.

Management of low tetanus risk wounds

A person who has completed three doses of tetanus containing vaccine before having a low tetanus risk wound may benefit from a booster with a tetanus containing vaccine if they have not had a tetanus containing vaccine in the previous10 years.

Occupational vaccination and travel

People in certain occupations and travellers may benefit from tetanus vaccine booster doses when more than 10 years have elapsed since their previous dose.

Treatment: 

Treatment of tetanus is aimed at preventing further circulating toxin affecting the central nervous system (tetanus immunoglobulin), prevent further toxin release from the spores (wound debridement), supportive care e.g., assist breathing, circulation and heart function; low stimulus environment (dark and quiet), anti-spasm medication; pain medication; tube or intravenous feeding; prevention of blood clots and skin breakdown; and physical rehabilitation.

Prevent circulating toxin affecting the CNS and ANS
Tetanus immunoglobulin (TIG) or normal human immunoglobulin (IVIG) is given at diagnosis of the disease.
Patients should commence, or complete, a course of three tetanus containing vaccinations because the amount of tetanospasmin able to cause disease is very small and not expected to induce immunity. The Clostridium tetani spores are very stable, retaining their ability to germinate and cause disease in the future. Cases of tetanus relapse or recurrence have been reported.

Prevent further toxin release
Wound debridement.
Antibiotics if co-existing wound infection is present.

C​ontrol muscle spasms
Keeping the patient in a dimly lit and quiet environment to avoid sudden stimulus. Medication to reduce spasms and hypertonicity if clinically indicated and pain management e.g., use of beta-blockers and morphine.

Manage respiratory function
Patients with severe spasms that affect breathing may need neuromuscular blockade and mechanical ventilation. A tracheostomy may be required if long term ventilation is anticipated.

Manage autonomic dysfunction
Medication to maintain normal blood pressure, heart rate and rhythm. A pacemaker may be required for persistent bradycardia.

Metabolic/nutritional support
Patients with tetanus usually have high metabolic demands. Parenteral nutrition may be required e.g., nasogastric feeding or total parenteral nutrition (TPN).

Other supportive care

  • Maintain skin integrity by preventing of pressure areas. Active cooling for raised body temperature.
  • Prevention thromboemboli.
  • Rehabilitation.
Disease Effects vs Vaccine Side Effects (Table)
Disease Description: 

Tetanus spores in a wound germinate and release toxin that affects the nervous system.

Effects of disease: 
Initial symptoms include weakness, stiffness or cramps and difficulty chewing or swallowing food.
Symptoms progress to muscle rigidity and very painful contraction spasms with an inability to open the mouth (trismus), a characteristic facial grimace (risus sardonicus) and arching of the back (opisthotonus).
Trauma to the tongue during spasms.
Bone fractures.
Raised body temperature by 2-4°C.
Blood pressure changes.
Heart rate and rhythm changes.
Sweating.
Unable to pass urine.
Throat spasm.
Approximately 10% of people who get tetanus die.
Those who survive usually have a full recovery after rehabilitation.
Common side effects of vaccine: 
Soreness/pain, redness and/or swelling around the injection site.
Fever over 38°C.
Decreased appetite, vomiting and/or diarrhoea.
Irritability, restlessness.
Unusual crying.
Fatigue.
Redness and/or swelling more than 6 cm in size around the injection site. In a small percentage of vaccine recipients the reactions will be severe enough to limit movement of the arm and may last for about a week.
Swelling involving the entire thigh or upper arm occurs in 2–3 percent of children after administration of the fourth and fifth doses of acellular pertussis vaccine. It resolves spontaneously without long term consequences.
Uncommon side effects of vaccine: 
Fever over 39°C.
Muscle or joint stiffness or pain.
Rare/very rare side effects of vaccine: 
High fever over 40°C.
Persistent (> 3 hours) inconsolable screaming.
Hypotonic, hyporesponsive episode (HHE) with 48 hours of immunisation.
Inflammation of the nerve in the arm causing muscle weakness and pain (brachial neuritis) occurs within four weeks of immunisation, 1- 2 times per 200,000 doses.
Urticaria.
Anaphylaxis.
Convulsion within 2 days of immunisation.
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