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Does every injury require Tetanus immunization in children?

Dr Bharat Choudhary Pediatric Emergency Physician Urgent Care

A seven year old boy immunized as per his age brought by father to Urgent Care with complaints of fall while riding bicycle. Child had sustained small laceration over forehead. Child had similar history of fall five months back and had received tetanus vaccine. Does he require repeat dose of tetanus immunization this time? Injuries are very common in childhood. It is one of the common causes of morbidity and mortality throughout the world. Management of injury usually involves pain relieving, care of the wound and preventive measure from tetanus which may include tetanus immunization and or tetanus immunoglobulin. In day to today practice, we often come across situations in which parents worries about tetanus infection and insist on injecting tetanus vaccine after every minor injury. So what are the evidence based guidelines or recommendations for tetanus vaccinations following injury? Do we have to inject Tetanus vaccine after every injury? Tetanus was prevalent in pre vaccination era. But after the introduction of vaccine its incidence has decreased tremendously. Tetanus germs are found in soil which contaminates the wound following injury. In non vaccinated individuals this germ multiplies, releases a toxin known as tetanus toxoid which directly affect nervous system and produce rigidity in the body and difficulty in breathing which may prove fatal. In vaccinated children, preformed antibodies detoxify the toxin and the adverse effects will be avoided so thats why vaccination is important. How many vaccines does child require? Routine primary immunization includes three DPT vaccines within 4 months of life. There after 3 boosters at 18 month, 4and year and at 10 year. Once child had received initially three vaccines he does not require tetanus vaccine after minor injury up to 10 years.

Which vaccine to be given? For children aged <7 years - DTaP (DT, if pertussis vaccine contraindicated) is preferred to tetanus toxoid alone. For children aged 710 years who are not fully vaccinated against pertussis and for whom no contraindication to pertussis vaccine exists, a single dose of Tdap should be given to provide protection against pertussis. If additional doses of tetanus and diphtheria toxoid-containing vaccines are needed, then children aged 710 years should be vaccinated according to catch-up guidance, with Tdap preferred as the fi rst dose. For adolescents and adults aged 1064 years, a single dose of Tdap should be provided in place of one Td booster if the patient has not previously been vaccinated with Tdap. Adults aged 65 years who have or who anticipate having close contact with an infant aged <12 months and who have not previously received Tdap should receive a single dose of Tdap to protect against pertussis and reduce the likelihood of transmission; All other adults 65 years who have not previously received Tdap may be given a single dose of Tdap instead of Td. CDC (Centre for disease control, USA) guidelines for tetanus vaccine following injury
HISTORY OF TETANUS IMMUNIZATION (DOSES) Uncertain or <3 doses 3 doses CLEAN, MINOR WOUNDS ALL OTHER WOUNDS Td* Yes No, unless >5 years since last dose3 TIG# Yes No

Yes No, unless >10 years since last dose

No No

*Td - Tetanus Diptheria vaccine; # TIG Tetanus immunoglobulin

Why to avoid repeated vaccination with tetanus? 1. Frequent tetanus vaccine may produce hypersensitive reactions 2. Tetanus vaccine is painful, so to avoid unnecessary injections specially in children 3. Each vaccine adds to the cost of the treatment.