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Tetanus Prophylaxis

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An acute, often fatal disease caused by the toxin produced by Clostridium tetani bacilli, which grow anaerobically at the site of an injury.  It can affect people of any age, and neonatal tetanus is a frequent cause of death in Asia, Africa and South America.

Tetanus spores are widespread in the environment and wound contamination can occur very easily.

Presentation is delayed, with muscle rigidity and painful spasms occurring after an incubation period of 4-21 days (usually 7-10 days).  Death (still ~10% in advanced nations) is due to respiratory failure, hypotension and cardiac arrhythmias.

Wounds Which Favour the Growth of Tetanus Organisms Include:

  • Compound fractures
  • Penetrating wounds
  • Wounds containing foreign material
  • Wounds with extensive tissue damage (e.g. major burns)
  • Superficial wounds contaminated with soil, horse manure
  • Wounds complicated by pyogenic infection

Tetanus can follow trivial or even unnoticed wounds. Vaccination generates an immune response against the tetanus toxin, not to the bacteria itself. Active immunisation is the only way of providing effective protection.

The Tetanus vaccine only provides protection of the vaccinated individual - there is no herd immunity. It is a killed, cell free preparation. There is no monovalent Tetanus vaccine available in New Zealand.

The following are our tetanus containing vaccines:

  • ADT - contains Tetanus 20 IU and Diptheria. Recommended as a booster only.
  • Boostrix - contains Tetanus 20 IU, Diptheria and Pertussis. Recommended for children 7 years old and over
  • Infanrix-IPV (4 Year old child vaccination) - Tetanus 40 IU, Diptheria, Pertussis and Polio. Recommended for children up to 7 years old.
  • Infanrix - hexa (6w, 3m and 5m old vaccination) - Tetanus 40 IU, Diptheria, Pertussis, Polio, Haemophillus, Hepatitis B. Recommended for children 6 weeks to 5 years old. 

Primary immunisation against tetanus requires 3 injections at intervals of not less than one month. Standard childhood primary immunisation is achieved by doses of Infanrix-hexa at 6 weeks, 3 months and 5 months of age.  Boosters are given at age 4 and 11 years of age. Adults are recommended to get boosters at ages 45 and 65, or sooner if sustaining an inury more than 5 years from last booster.  Tetanus antibodies cross the placenta, and can provide protection for young infants

Side Effects and Adverse Reactions of Tetanus Immunisation

  • Common - mild discomfort or pain at injection site lasting one or two days.  May also occur 10 days or so after injection.
  • Rare - headache, myalgia, fever, malaise.
  • Very rare - acute anaphylaxis, urticaria, peripheral neuropathy.

Precautions/Contraindications To Tetanus Vaccine
Anaphylaxis to a previous dose is the only absolute contraindication.  If a previous severe reaction has occurred,  other measures such as the use of tetanus immune globulin should be considered.

Human tetanus immune globulin (TIG)
TIG should be given for tetanus prone wounds when primary immunisation is incomplete or doubtful.  250 iu of human tetanus immune globulin is given IM as soon as possible after the injury.  If the presentation is delayed by more than 24 hrs, 500 iu should be given.  At the same time, 0.5ml of Booxtrix or ADT (age > 7yrs) or Infanrix-hexa/IPV (age < 7yrs) is given into a different limb. TIG is not normally given for clean wounds.

  • non-tetanus-prone wounds - clean, minor wounds that are less than six hours old, non-penetrating and with negligible tissue damange
  • tetanus-prone wounds - all wounds that may be contaminated and/or infected, and are penetrating, more than six hours old and with tissue damage.

Local debridement & cleaning is crucial in the management of tetanus prone wounds.

Summary of Tetanus Prophylaxis in Wound Management  

  Clean minor wounds Other wounds
Immunisation history Tetanus vaccine TIG Tetanus vaccine TIG
Fully Immunised
(3 Doses or more)
Only if due for routine booster NO Yes if > 5 years since last booster NO
Uncertain or less than 3 doses YES NO YES YES
  • In children up to 7 years of age, use the Infanrix-hexa/Infanrix-IPV vaccine appropriate to the immunisation schedule.  Use ADT vaccine if the child has a contraindication to the use of Pertussis vaccine (anaphylaxis or encephalopathy within 7 days of previous dose are now the only general contraindications to Pertussis vaccine).
  • In children older than 7 yrs, use Boostrix or ADT vaccine.

Children with incomplete vaccination status should be provided with a letter for their GP documenting the dose given on this occasion. As incubation can be as long as a month, and vaccination is against the toxin produced and not the bacteria, parents must be informed of the need to attend the GP to receive a full course of 3 injections to reduce risk of infection.

To achieve tetanus immunity a primary course of 3 vaccinations is needed.
If Boostrix or ADT are used (containing 20 IU active ingredient), these vaccines may be less effective than those that contain 40 IU. However to date, for children 7 years and over that have received the 20 IU of tetanus toxoid, there has anecdotally been no increase in tetanus cases where this has been used as their primary course. The Ministry of Health guidelines say ADT and Boostrix may be used as the primary course of vaccinations for children 7 years and over

For children aged 6 weeks to 7 years Infanrix hexa/Infanrix-IPV is recommended as the primary course.

When parents decline full vaccination and pertussis protection?
ADT has not been clinically tested in children under 5, although there are not likely to be any safety issues, there are no data to support this. It should be emphasised to parents that the vaccine contains less active ingredient (20 IU) than the Infanrix-hexa and Infanrix-IPV (40 IU), so for under 5 year olds there may still be a risk of incomplete immunisation and an increased risk of contracting tetanus following exposure.

Information for Families

Factsheet on Tetanus and Immunisation from IMAC (http://www.immune.org.nz/diseases/tetanus)

References

Infanrix-hexa http://www.medsafe.govt.nz/profs/datasheet/I/Infanrixhexainj.pdf

Infanrix-IPV http://www.medsafe.govt.nz/profs/datasheet/i/InfanrixIPVinj.pdf

Boostrix http://www.medsafe.govt.nz/profs/datasheet/b/Boostrixinj.pdf

ADT http://www.medsafe.govt.nz/profs/datasheet/a/ADTBoosterinj.pdf 

http://www.immune.org.nz/sites/default/files/MoH/2014/AdministrationTetanusFlowChartImac20140828V01Final.pdf

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Document Control

  • Date last published: 20 December 2015
  • Document type: Clinical Guideline
  • Services responsible: Children’s Emergency Department
  • Owner: Tony Bell
  • Editor: Greg Williams
  • Review frequency: 2 years

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