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 parent’s 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 that’s 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 ½ 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 7–10 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 7–10 years should be vaccinated according to catch-up guidance, with Tdap preferred as the fi rst dose.

For adolescents and adults aged 10–64 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)	CLEAN, MINOR WOUNDS		ALL OTHER WOUNDS
	Td*	TIG#	Td*	TIG#
Uncertain or <3 doses	Yes	No	Yes	Yes
≥3 doses	No, unless >10 years since last dose	No	No, unless >5 years since last dose3	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.