Adults Need Tetanus Shots, Too : Part 2

by Food and Drug Administration (FDA)

(Page 2 of 2)

The first case involved an 82-year-old man, hospitalized because of shortness of breath and weakness and difficulty chewing and swallowing. When doctors examined him, they found he had difficulty opening his jaw and noted an abrasion on his right elbow resulting from a fall two days earlier. He had never been vaccinated. Doctors administered both tetanus toxoid and tetanus immune globulin (TIG). (An injection of tetanus toxoid after the injury does not give immediate full immunity. TIG confers temporary immunity to those people who have low or no immunity to tetanus toxin by providing antitoxin directly to the body, ensuring that protective levels of antitoxin are reached quickly rather than waiting for the body's immune response.) In the next few weeks, his body was racked by spasms, followed by respiratory failure and pneumonia, which necessitated the use of a breathing machine. After treatment with antibiotics, diuretics, and neuromuscular blocking agents, he recovered and was discharged a few weeks later.

The second case involved a diabetic 57-year-old man who had stepped on a rusty nail and sought emergency treatment for tetanus that same day. Hospital personnel cleaned the wound and administered tetanus toxoid. Four days later, he returned to the emergency department complaining of severe pain in the foot, as well as chills, fever and vomiting. When he developed pain and a stiff neck, he was hospitalized immediately with a diagnosis of tetanus and received TIG. After a number of life-threatening heart and lung problems, he died following an episode of cardiac arrest. His relatives reported that he had not been previously vaccinated with tetanus toxoid.

The surviving and the deceased tetanus victims each spent about a month in the hospital and ran up medical bills of about $150,000 apiece. At that time, public health clients could have received a tetanus shot for $3.30, while vaccination with a private physician would have cost just a few dollars more.

Tetanus has become a rare disease in the United States as well as in England, with only 36 reported U.S. cases in 1994, though there may be more unreported cases. The disease has become uncommon not because tetanus bacteria have been eliminated from the environment — they're still all around us — but because immunization has provided protection.

Since adults 50 years or older account for 70 percent of tetanus infections, mature people should make certain they have received boosters within the last 10 years. If they don't know whether they were immunized as children, the primary series of shots should be completed.

Childhood Immunizations

Immunization should be postponed if a child has a high fever or a severe infection. However, a minor illness, such as a mild respiratory infection, is no reason to delay immunization. All infants and children 6 to 8 weeks of age and up to 7 years should receive tetanus toxoid as part of their DTP (diphtheria and tetanus toxoids and pertussis vaccine adsorbed) immunization schedule. Those children who cannot tolerate the pertussis vaccine because of adverse reactions should continue, nevertheless, to be immunized with diphtheria and tetanus toxoids for pediatric use, according to the DT immunization schedule.

The Public Health Service's Advisory Committee on Immunization Practices (ACIP) and the American Academy of Pediatrics recommend that children receive five tetanus immunizations by the age of 6:

• three doses of DTP in their first year of life, usually given at 2, 4 and 6 months
• a fourth dose in their second year of life, usually between 15 and 18 months of age
• a fifth dose just before school entry, from 4 to 6 years of age. All 50 states have adopted laws requiring children to receive at least three immunizations before they can be admitted to school.

A recent survey found that one-fifth of older children (10 to 16 years of age) do not have protective antibody levels to tetanus. "The new recommendation," says Roland W. Sutter, M.D., medical epidemiologist, U.S. Centers for Disease Control and Prevention, "is that children aged 11 to 13 also receive a sixth dose with Td [tetanus and diphtheria toxoids for adult use] because immunity levels can fall. It's also a convenient time to check to see if they've received the second dose of measles vaccine and whether they've received hepatitis vaccine at this point."

Children older than 7 years should receive tetanus toxoid as part of the tetanus and diphtheria toxoids (Td) for adult use, both for the primary series and for booster doses every 10 years. ACIP recommends the use of combined diphtheria and tetanus toxoids (Td) rather than tetanus toxoid alone for boosters because adult cases of diphtheria continue to occur both in the United States and in other parts of the world.

Adult Immunizations

Some individuals may be protected for life against tetanus after a properly administered primary series of vaccinations, but in most people antitoxin levels fall with time. Adults should receive booster doses every 10 years, along with diphtheria immunization. "We are now recommending an adult immunization visit at age 50 years," says Roland W. Sutter, M.D., medical epidemiologist, U.S. Centers for Disease Control and Prevention, "when people can check their records to see if they are actually up-to-date with vaccinations, particularly for Td. Quite a number of older persons haven't received the primary series. If they haven't been immunized, this visit serves as an opportunity to initiate the series."

When given to adults, the first two primary doses of Td are administered at least four weeks apart, and the third dose is administered 6 to 12 months after the second.

In some individuals, antibody levels may fall too low to provide protection before 10 years have passed. That's why people who sustain a deep or contaminated wound should receive a booster dose if it has been more than five years since the last dose.

Immunization is especially recommended for:

• adults, especially those 50 years and older, because most of the tetanus cases in recent years have occurred in this age group
• persons who are not sure whether they have received the initial series of tetanus shots or boosters
• travelers, especially to countries with hot, damp climates and soil rich in organic matter
• agricultural workers and others who work with dirt or manure
• persons whose jobs or recreational activities expose them to cuts and scrapes
• those who are recovering from tetanus, because having a case of tetanus does not confer lasting immunity, as is true for some other diseases
• injured persons who may require emergency tetanus treatment depending on their immunization status (primary immunization, boosters) and the type of wound received
• pregnant women who have not been immunized or may be inadequately immunized or who may deliver their infants in unhygienic circumstances. After immunization, antibodies to the disease are passed from the mother to the fetus through the placenta.

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