Download Tetanus assessment and prophylaxis after injury

Regina A. Delahunt Director Greg Stern, M.D. Health Officer
WHATCOM COUNTY Health Department Immunization Program Update
Please distribute to each Physician, NP, PA and Vaccine Coordinator in your office Subject: To: Emergency Medicine, Family Practice, Infectious Disease, Pediatrics, ARNP, Midwife, Naturopaths, Occupational Medicine, and Vaccine Coordinators From: Greg Stern, MD, Health Officer Contact Person: Astrid Newell, MD, Community Health Manager Phone: 676­4593 Date: Wednesday, February 20, 2008 Pages: 2 This update is being sent as a reminder to health care providers about the importance of tetanus assessment and prophylaxis after injury. Background Tetanus is an anaerobic bacteria commonly found in soil and in the intestines and feces of many household and farm animals and humans. Tetanus has a high fatality rate. According to the Washington State Department t of Health Communicable Disease report for 2006, “The case fatality rate ranges from 10% to over 80% and is highest in infants and in the elderly.”
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Tetanus affects unvaccinated persons or older adults who did not receive the initial series of 3 doses or who did not receive booster doses of tetanus toxoid.
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Many types of injuries can allow tetanus bacilli to enter the body, including burns, lacerations, abrasions, crushing injuries, animal bites, splinters, and injection drug use. People can get tetanus after surgery or dental procedures. Tetanus spores can be introduced by a penetrating injury resulting from trauma or during activities such as farm work, gardening, or peeling vegetables grown in soil. In Washington, four cases of tetanus were reported during the past ten years. No cases were reported in 2006. Prevention and management of tetanus risk
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Ensure your staff adequately assess patients for tetanus risk All triage staff should carefully assess the need for Tetanus Immune Globulin (TIG) and/or tetanus vaccine. Persons who have had 0­2 prior doses or an unknown number of doses of vaccine need TIG. Ask about what type of injury occurred and when it happened. Asking only for the date of the most recent tetanus shot is not sufficient assessment.
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Act in a timely manner Tetanus vaccine and/or TIG should be given soon after the injury. The incubation period varies from three to twenty­one days, with an average of eight days. Tetanus has occurred as soon as two days after the injury. Patients should be advised to get a tetanus booster, preferably the same day but no later than 72 hours after the injury.
ADMINISTRATION DISEASE RESPONSE ENVIRONMENTAL HEALTH HUMAN SERVICES 509 Girard Street Bellingham, WA 98225­4005 (360) 676­6724 FAX (360) 676­7646 COMMUNITY HEALTH 1500 North State Street Bellingham, WA 98225­4551 (360) 676­4593 FAX: (360) 676­6772 Arrange for Tetanus Immune Globulin if necessary The following locations carry TIG:
St. Joseph Hospital
Whatcom Occupational Health
Hoagland Pharmacy can order in 3­4 days ·
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Note: Whatcom County Health Department (WCHD) gives routine tetanus vaccine, but does not administer tetanus vaccine after injury. WCHD does not carry TIG.
Follow the Guidelines for Tetanus Prophylaxis ·
Tetanus Guidelines History of adsorbed tetanus toxoid (doses) Unknown or <3 ≥3 Clean, minor wound Tdap or Td † TIG Yes No No § No All other wounds* Tdap or Td † TIG Yes Yes No ¶ No *Such as, but not limited to, wounds contaminated with dirt, feces, soil, and saliva; puncture wounds; avulsions; and wounds resulting from missiles, crushing, burns and frostbite. † Tdap is preferred to Td for adolescents who have never received Tdap. Td is preferred to Tetanus Toxoid (TT) for adolescents who received Tdap previously or when Tdap is not available. If TT and TIG are both used, Tetanus Toxoid Adsorbed rather than Tetanus Toxoid for Booster Use Only [fluid vaccine] should be used. § Yes, if ≥10 years since the last tetanus toxoid­containing vaccine dose. ¶ Yes, if ≥5 years since the last tetanus toxoid­containing vaccine dose (see text for discussion of Arthus reactions). Source: Table 13, MMWR Recommendations and Reports, March 24, 2006, Vol.55, No. RR – 3
Additional Recommendations for Adults
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Tetanus prophylaxis in wound management: Adults aged 19­64 who require a tetanus toxoid­containing vaccine as a part of wound management should receive Tdap instead of Td if they have not previously received Tdap. This recommendation addresses the resurgence of pertussis due to waning immunity in adults. If Tdap is not available or was administered previously, Td should be administered.
Adults age > 65 years: Td should be given. Tdap is not licensed for use among adults aged > 65 years old. ADMINISTRATION DISEASE RESPONSE ENVIRONMENTAL HEALTH HUMAN SERVICES 509 Girard Street Bellingham, WA 98225­4005 (360) 676­6724 FAX (360) 676­7646 COMMUNITY HEALTH 1500 North State Street Bellingham, WA 98225­4551 (360) 676­4593 FAX: (360) 676­6772