Past experiences with medical management of wounds and injuries in the aftermath of earthquakes have shown that approximately

2 to 3% of the injured patients might develop tetanus as a complication of their injuries. Tetanus has a worldwide mortality rate of 50%, usually very young, old or unvaccinated persons. Description of Tetanus Tetanus is an acute disease caused by an exotoxin produced by Clostridium tetani. After incubation period of 3 to 21 days, tetanus usually presents with a descending pattern. The first sign is muscle stiffness of the jaw (trismus or lockjaw) followed by stiffness of the neck, difficulty in swallowing, and rigidity of abdominal muscles. Other symptoms include elevated temperature, sweating, elevated blood pressure, and episodic rapid heart rate. Spasms last for several minutes and may occur frequently, continuing for 34 weeks. Complete recovery may take months. Laryngospasm (spasm of the vocal cords) and/or spasm of the muscles of respiration might lead to interference with breathing. Muscle spasms and sustained contractions from tetanus may cause fractures of the spine or long bones. Vaccination of children with unknown or incomplete immunisation status

A child who has not completed the primary course should have the outstanding doses at monthly intervals. Children may receive the first booster dose as early as one year after the third primary dose to re-establish them on the routine schedule. The second booster should be given at the time of leaving school to ensure long-term protection by this time, provided a minimum of five years is left between the first and second boosters. Children coming to the UK, who have a history of completing immunisation in their country of origin, may not have been offered protection against all the antigens currently used in the UK. Where there is no reliable history of previous immunisation, it should be assumed that they are unimmunised, and the full UK recommendations should be followed. Children coming to the UK may have had a fourth dose of a tetanus-containing vaccine that is given at around 18 months in some countries. This dose should be discounted as it may not provide satisfactory protection until the time of the teenage booster. The routine preschool and subsequent boosters should be given according to the UK schedule.

Older adults

May be unimmunised and at particular risk. Try to check their immunisation status opportunistically (e.g. when giving their influenza vaccination), and complete the recommended 5-dose schedule. Td/IPV can be given at the same time as influenza vaccine in a different arm. Intravenous drug users are also a high-risk group.

Travellers to remote areas For travellers to areas where medical attention may not be accessible and whose last dose of a

tetanus-containing vaccine was more than ten years previously, a booster dose should be given prior to travelling, even if the individual has received five doses of vaccine previously. This is in case immunoglobulin is not available to the individual should a tetanus-prone injury occur. Storage Store at 2 to 8C and protect from light. Contra-indications to tetanus vaccination1

Absolute contra-indications are: o Confirmed anaphylactic reaction to previous tetanus vaccine (occurs in 3/million). o Confirmed anaphylactic reaction to neomycin, streptomycin or polymyxin B. Stable neurological conditions, febrile convulsions, and personal or family history of seizures are not contra-indications. Immunisation should be deferred if the child is unwell with fever (vaccinate as soon as possible once child has recovered). Fever, hypotonic-hyporesponsive episodes (HHEs), persistent crying or severe local reaction within 72 hours of previous vaccination are not reasons for not giving subsequent tetanus vaccinations.

Side-effects Report adverse reactions to the Committee on Safety of Medicines (CSM) via the Yellow Card Scheme.

Pain, redness and swelling are common. Transient nodule at injection site. Anaphylaxis is rare (0.65-3 per million).

Tetanus-prone injuries Tetanus-prone wounds are:

Wounds or burn sustained >6 hours before surgical treatment. Any wound or burn with: o A significant degree of devitalised tissue. o Puncture wounds. o Wounds having come in contact with soil or manure likely to harbour tetanus organisms. o Clinical evidence of sepsis.

Management2

Following such a wound, where the individual has received a full 5-dose course of tetanus vaccine at the recommended intervals, or is up-to-date with their tetanus

immunisation schedule: o No further doses of vaccine are recommended (as within the incubation period of tetanus, vaccine given at the time of a tetanus-prone injury may not boost immunity early enough to give additional protection). o If the risk of tetanus is especially high, e.g. the wound is contaminated with stable manure, human tetanus immunoglobulin should be given to give immediate additional protection. If the immunisation schedule is not up-to-date or its status is unknown, a reinforcing dose of Td/IPV should be given at the time of treatment of an injury and further doses given as required to complete the recommended 5-dose schedule. In this situation, immunoglobulin should be given for any injury defined as a tetanus-prone wound (see above). For travellers to areas where medical attention may not be accessible should a tetanusprone injury occur and whose last dose of a tetanus-containing vaccine was more than 10 years previously, a booster dose of Td/IPV should be given, even if the individual has received 5 doses of vaccine previously. This is a precautionary measure in case immunoglobulin is not available to the individual should a tetanus-prone injury occur. The preventative dose of human tetanus immunoglobulin is 250 IU IM in most cases, except if more than 24 hours have elapsed since injury or there is a risk of heavy contamination or following burns, when 500 IU IM is given.

Guide to tetanus prophylaxis in wound management3

Document references 1. Summary of Product Characteristics - Revaxis (Diphtheria, tetanus and poliomyelitis (inactivated) vaccine (adsorbed)); Sanofi Pasteur MSD Limited; Updated May 2008; electronic Medicines Compendium. 2. Department of Health; Immunisation against infectious disease - 'The Green Book' (various dates). 3. The Australian Immunisation handbook 9th edition. Tetanus-prone wounds