The Tetanus Vaccine (Tetanus Toxoid)

Recommendations of the IAP Committee on Immunisation

Background

Antibodies to tetanus decline over time and hence regular boosting is needed to ensure adequate levels of antibodies during any apparent/inapparent exposure to tetanus bacilli/ toxin.

Vaccine/Toxoid

TT containing 5 Lf of toxoid is one of the most heat stable and commonly used vaccines. The vaccine should be stored between 2 to 8°C and the dose is 0.5 ml intramuscularly. Administration of boosters more frequently than indicated leads to increased frequency and severity of local and systemic reactions as the preformed antitoxin binds with the toxoid and leads to immune complex mediated reactions.

TT in Pregnancy

WHO has evolved exhaustive guidelines for administration of TT in pregnant women and recommends replacement of TT with Td in a phased manner. For pregnant women who have not been previously immunized, two doses of TT atleast one month apart should be given during pregnancy so that protective antibodies in adequate titers are transferred to the newborn for prevention of neonatal tetanus. The first dose should be administered at the time of first contact/as early as possible and the second dose of TT should be administered 1 month later and at least 2 weeks before delivery. A single dose of TT would suffice for subsequent pregnancies that occur in the next 5 years; thereafter, 2 doses of TT would again be necessary.

Women, who have received 5 doses of TT over a period of at least 2.5 years, get lasting protection for their reproductive years. For women who have received 3 primary doses in infancy, two doses during the 1st pregnancy are indicated. The 2nd pregnancy requires 1 more dose and gives lasting protection for the reproductive years. For women who have received three doses and 1 booster in childhood, 1 dose each in the first and second pregnancy provide lasting protection. In women who have received 3 primary doses and the two childhood boosters only 1 dose in the first pregnancy provides lasting protection. For women who have received an additional adolescent booster in addition to the 5 childhood doses no further doses are necessary in pregnancy.

TT in Wound Management

All patients presenting with skin wounds/infections should be evaluated for tetanus prophylaxis. Cleaning of the wound, removal of devitalized tissue, irrigation and drainage is important to prevent anerobic environment which is conducive to tetanus toxin production. The indications for TT and tetanus immunoglobulin (TIG) are as below (Table 1). Again replacement of TT with Td/Tdap is recommended. Table 1: Indications for tetanus and tetanus immunoglobulin

Doses of TT given in past	Clean, minor wounds		All other wounds
	TIG	TT	TIG	TT
Unknown less than three doses, immunodeficient	Yes	Yes	No	Yes
Three doses or more	No	No (a)	No	No (b)

All Other Wounds Including, but not limited to, wounds contaminated with dirt, feces, soil, saliva; puncture wounds; avulsions; and wounds resulting from missiles, crushing, burns, and frostbite. TIG: Tetanus immunoglobulin (250- 500 IU IM) (a): Yes, if more than 10 years since last dose (b): Yes, if more than 5 years since last dose.

Evidence suggests that tetanus is highly unlikely in individuals who have received 3 or more doses of the vaccine in the past and who get a booster dose during wound prophylaxis, hence passive protection with TIG is not indicated in these patients irrespective of wound severity unless the patient is immunocompromised. For children who are completely unimmunized, catch up vaccination should be provided by giving three doses of TT at 0, 1 and 6 months.

For partially immunized children catch up vaccination entails administration of at least 3 doses of TT including previous doses received. Children with unknown/undocumented history should be treated as unimmunized. It is recommended that the TT booster doses administered at the time of wound management and for catch up vaccination be replaced with DTwP/DTaP/Td/Tdap depending on the age of the child and nature of previous doses received for more comprehensive protection.
 
 

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