Paediatric Clinical Guideline

Emergency 1.5 Tetanus Prophylaxis

Short Title: / Tetanus Prophylaxis
Full Title: / Guideline for the management of a tetanus prophylaxis in children and young people
Date of production/Last revision: / January 2007
Explicit definition of patient group to which it applies: / This guideline applies to all children and young people under the age of 19 years.
Name of contact author / Dr Leonie Wong
Paediatric Specialist Registrar
Dr Stephanie Smith
Consultant Emergency Paediatrician Ext 64042
Revision Date / January 2010
This guideline has been registered with the Trust. However, clinical guidelines are 'guidelines' only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date.

Tetanus Prophylaxis in Children

Introduction

Tetanus is caused by the action of tetanus toxin following infection by Clostridium tetani. C. tetani is transmitted by soil or faecal contamination of wounds and has an incubation period of between 4 and 21 days (commonly 10).

Tetanus is characterised by generalised skeletal muscle rigidity and spasms usually affecting the neck and jaw.

There were 198 cases of tetanus reported in England and Wales between 1984 and 2004. The elderly are at highest risk. There were no reported cases in children under 5 years.

Tetanus immunisation was introduced nationally as part of the primary immunisation programme in 1961. Most children receive their primary immunisations at 2, 3 and 4 months, with boosters at 4 years and 14-15 years. These are administered via their General Practitioner, community clinic or school.

Management of Tetanus Prone Wounds

  1. Check the child’s tetanus immunisation status

The normal schedule is

  • 3 doses of DTaP/IPV/HiB given at 2, 3 and 4 months as part of primary immunisations
  • Reinforcing (booster) doses at
  • 3.5-5yrs of age
  • 13-15yrs of age

It is essential to check the immune and vaccination status of any patient presenting to the hospital (via A&E or direct transfer) with ANY wound or burn, however trivial at any interval.

2. Consider is this a tetanus prone wound?

The following are considered tetanus-prone wounds:

  • Wounds / burns requiring surgical intervention that is delayed for > 6hours
  • Significant degree of devitalised tissue
  • Wounds where there has been contact with soil or manure
  • Puncture-type injury
  • Compound fractures
  • Wounds containing foreign bodies
  • Wounds / burns in patients with systemic sepsis

3. Wound toilet, dressing and antibiotics as required

Thorough surgical toilet of the wound is essential irrespective of the immunisation history of the patient and appropriate antibiotics should be prescribed.

4. Use the table to determine whether immunisation or human tetanus immunoglobulin is required?

Immunisation Status / Clean Wound / Tetanus-prone Wound
Vaccine / Vaccine / HTIG
Fully immunised1 / Not required / Not required / Only if high risk2
Primary immunisation complete, boosters incomplete but up to date / Not required / Not required / Only if high risk2
Primary immunisation incomplete or boosters not up to date / Reinforcing dose and further doses to complete recommended schedule / Reinforcing dose and further doses to complete recommended schedule / Yes (given at different site to vaccine)
Not immunised or immunisation status not known / uncertain3 / Immediate dose of vaccine followed by completion of full 5-dose course / Immediate dose of vaccine followed by completion of full 5-dose course / Yes (given at different site to vaccine)
Notes
  1. Fully immunised: Has received total of 5 doses of vaccine at appropriate intervals
  2. High Risk: Heavy contamination with material likely to contain tetanus spores and/or extensive devitalised tissue
  3. Immunosuppressed patients presenting with a tetanus prone wound should always be managed as if they were incompletely immunised. Please refer to the RCPCH guidance on Immunisation of the Immunocompromised Child

5. Ensure patient receives tetanus immunisation where indicated

Patients requiring a tetanus booster should have it administered in the department.

Patients who have not received primary immunisation:

  • Contact GP and arrange appointment for primary immunisation
  • If appointment not available within 36 hours, give adsorbed vaccine as required in the department and refer to GP to complete the primary course.

If parents refuse immunisation, inform GP and record your actions in the notes.

Human Tetanus Immunoglobulin

Indications

  • Treatment of clinically suspected cases of tetanus (a notifiable disease)
  • Prevention of tetanus in high risk tetanus prone wounds (see table and note above)

Dose

Available in 1ml ampoules containing 250IU

Prevention Dose / Treatment Dose
250IU by IM injection
or
500IU by IM injection if >24 hours since injury / risk of heavy contamination / burns / 5000 – 10000IU by IV infusion
Or
150IU/kg by IM injection (given in multiple sites) if IV preparation unavailable

Contraindications

  • Confirmed anaphylactic reaction to tetanus containing vaccine
  • Confirmed anaphylactic reaction to neomycin, streptomycin or polymyxin B

Adverse Reactions

LocalPain, erythema, induration (Arthus type reaction)

GeneralPyrexia, hypotonic-hyporesponsive episode, persistent crying

Confirmed anaphylaxis is very rare (0.65 – 3 events per million doses)

All suspected adverse reactions should be reported to the Committee on Human Medicines using the Yellow Card scheme.

Tetanus Vaccine

Tetanus vaccine is only available in combination with other vaccines. When a reinforcing dose is required the choice of the vaccine will depend on the age of the child and their immunisation status.

Incomplete/delayed primary vaccination / Incomplete/delayed reinforcing doses
Children <10yrs / The primary course is three doses of a tetanus-containing vaccine (DTaP/IPV/Hib) with an interval of one month between doses
This can be given at any stage from 2 months-10yrs
If the primary course is interrupted it should be resumed but not repeated / Give a single dose of 0.5mls DTaP/IPV or dTaP/IPV im
This will re-establish the child on the routine schedule
Children >10 yrs of age / Three doses of 0.5mls Td/IPV with one month between doses / A single dose of 0.5mls Td/IPV
This will re-establish the child on the routine schedule

References

Immunisation against Infectious Disease, 3rd edition, Department of Health, 2006. – The Green Book

Immunisation of the Immunocompromised Child. Best Practice Statement. RCPCH. 2002

Title
Tetanus Prophylaxis
Guideline Number / Version / Distribution
1.5 / Final / All wards QMC and CHN
Author / Document Derivation
Dr Leonie Wong
Paediatric Specialist Registrar
Dr Stephanie Smith
Consultant Emergency Paediatrician / Immunisation against Infectious Disease, 3rd edition, Department of Health, 2006. – The Green Book
Immunisation of the Immunocompromised Child. Best Practice Statement. RCPCH. 2002
First Issued / Latest Version Date / Review Date
November 1997 / January 2007 / January 2010
Ratified By / Date
Paediatric Clinical Guidelines Meeting / January 2007
Audit / Induction Programme / Amendments

Leonie WongPage 1 of 5January 2007