Tetanus Preventin, Prphylaxis and Wund/Injury Management Standard Sectin 8: Immunizatin f Special Ppulatins Standard #: 08.400 Created by: Apprved by: Prvince-wide Immunizatin Prgram, Standards and Quality Dr. Gerry Predy, Senir Medical Officer f Health, Apprval Date: Revised: Preamble (AHS) Prvince-wide Immunizatin Prgram Standards and Quality, Divisin prvides Public Health and ther partners wh administer prvincially funded vaccines with nging and timely infrmatin relating t prvince-wide immunizatin prgram standards and quality. These standards are based n currently available evidence based infrmatin, Alberta Health (AH) plicy, and prvincial and natinal guidelines. Immunizers must be knwledgeable abut the specific vaccines they administer. Backgrund Tetanus disease in humans is caused by a ptent neurtxin released by the gram-psitive, sprefrming, anaerbic, rd-shaped bacterium, Clstridium tetani. The rganism is sensitive t heat and cannt survive in the presence f xygen, but the spres are very resistant t heat and antiseptics. C. tetani bacilli live in the bwels f humans and animals, and the spre frm is excreted in feces. These spres are hardy and survive fr many years in sil and dust, wrldwide. When a wund is cntaminated with sil, dust, r feces, the spres enter the bdy and begin t germinate if the envirnment is sufficiently anaerbic. As the bacteria in the tissues cntinue t multiply and die, an extxin is prduced which travels t nervus tissue thrugh the bld r t the central nervus system alng peripheral mtr nerves. Tetanus is nt transmitted persn t persn, and therefre. herd immunity plays n rle in its preventin (Centers fr Disease Cntrl and Preventin, 2012). The incubatin perid fr tetanus disease is generally 3 t 21 days but can range frm 1 day t several mnths, with an average f 10 days (nenatal tetanus - average 6 days with range f 3 t 28 days). Symptms include acute nset f severe, painful muscle spasms usually beginning in the jaw (lckjaw) and neck muscles. As the disease prgresses, generalized rigidity and spasms can cause serius cmplicatins such as difficulty breathing due t spasms f the respiratry muscles, fractures, aspiratin and pneumnia. The diagnsis is usually a clinical ne, as labratry cnfirmatin f tetanus frm culture f wunds is rare. The case fatality rate in unimmunized individuals varies frm 10% t ver 80% and is highest in infants and the elderly. Recvery frm disease des nt result in prtectin (Wrld Health Organizatin, 2006). Wrldwide, tetanus disease causes hundreds f thusands f deaths annually (Heymann, 2015). It is mre cmmn in agricultural regins and in underdevelped areas where immunizatin may nt be adequate and there is increased cntact with animal feces. Nenatal tetanus, arising frm cntaminatin f the umbilical crd, accunts fr apprximately 50% f all tetanus deaths in develping cuntries. It generally ccurs when there is a lack f passive immunity due t inadequate immunizatin f the mther (Alberta Health, 2011). Immunizatin with tetanus vaccine began in Alberta in 1947. Tetanus is rare in industrial cuntries nw that tetanus immunizatin is widespread. Between 1990 and 2010, the average number f cases Page 1 f 6
in Canada was 4 per year (Natinal Advisry Cmmittee n Immunizatin, 2012). Persns 60 years and lder accunted fr 48% f the cases and 59% were male (Natinal Advisry Cmmittee n Immunizatin, 2012). Purpse The purpse f this standard is t prmte tetanus preventin fllwing a tetanus prne wund r injury thrugh prper initial wund care accurate identificatin f tetanus prne wunds, assessment f immunizatin histry and recmmendatins fr tetanus pst-expsure prphylaxis. Applicability This standard applies t all health care prviders assessing wunds (acute r chrnic) fr risk f tetanus disease and t thse prviding, r recmmending prvincially funded tetanus-cntaining vaccines and/r tetanus immune glbulin (TIG). Definitins: Tetanus disease (cmmnly referred t as lckjaw ): Characterized by muscle spasms, usually in a descending pattern beginning in the jaw muscles. As the disease prgresses, prlnged frequent spasms may ccur cntributing t serius cmplicatins and death unless treatment is prvided. Tetanus prne wund / injury (Alberta Health, 2015): Any wund that is significantly cntaminated with material likely t cntain tetanus spres and/r that demnstrates the presence f necrtic tissue. Tetanus Immune Glbulin (TIG): TIG is a bld prduct fr IM administratin prepared frm pled human plasma f screened dnrs immunized with tetanus txid. TIG prvides immediate passive prtectin until an expsed persn munts an immune respnse t the tetanus txid administered cncurrently with TIG. Cmpetency In Nvember 2008 the Public Health Agency f Canada published Immunizatin Cmpetencies fr Health Prfessinals with a gal f prmting safe and cmpetent practices fr immunizatin prviders. The fllwing cmpetency is applicable t this standard: Administratin f Immunizing Agents: Names the resurces that are used t guide the immunizatin administratin prcess and decisin making Ppulatins Requiring Special Cnsideratins: Apprpriately refer t expert prfessinals / resurces when required t address the immunizatin needs f certain ppulatins. Sectin 1: Pre-Expsure Tetanus Preventin Opprtunities shuld be taken t educate the public abut tetanus and that the disease is vaccinepreventable. It is als imprtant t emphasize prper wund care. After three dses f apprpriately spaced tetanus-cntaining vaccine (a primary series), mre than 99% f immunized individuals develp prtective antibdies against the effects f the neurtxin. Cmplete immunizatin with tetanus-cntaining vaccine is the key t preventing tetanus disease and is strngly recmmended fr all individuals in whm there is n cntraindicatin t the vaccine. Cmplete prtectin cnsists f a primary series alng with bster dses every 10 years, r earlier if a tetanus-prne wund has ccurred (see sectin 3). The number f dses and type f tetanuscntaining vaccine varies accrding t age. Cmplete recmmendatins are utlined in the Standard fr Recmmended Immunizatin Schedules and tetanus-cntaining vaccine bilgical pages. Page 2 f 6
Imprtant Immunizatin Opprtunities Althugh pprtunities shuld be taken t assess immunizatin status during each cntact with a healthcare prvider, special mentin is warranted with the fllwing grups due t an increased risk f unassessed r unrecgnized tetanus-prne wunds, and/r an increased risk f incmplete immunizatin. Health prgrams targeting these grups shuld ffer immunizatin with tetanuscntaining vaccine and/r prmte and facilitate access t prvincial immunizatin prgrams. Individuals brn befre immunizatin prgrams were implemented Includes, but is nt limited t, patients and/r residents in health care institutins, including hme care clients, especially thse with abscesses, cellulitis, chrnic ulcers, and ther wunds. Immigrants with uncertain r incmplete immunizatin histries Individuals wh inject nnprescriptin drugs Sectin 2: Identificatin f a Tetanus Prne Wund A tetanus-prne wund is any wund (ther than a clean, minr wund) that is significantly cntaminated with material likely t cntain tetanus spres and/r demnstrates the presence f necrtic tissue; including, but nt limited t: Wunds cntaminated with dirt, feces, sil and saliva; animal bites; puncture wunds; avulsins; and wunds resulting frm missiles (gunshts), crushing, burns and frstbite. Wunds with devitalized tissue. Abscesses, cellulitis, chrnic ulcers and ther wunds in patients with diabetes mellitus r illicit injectin drug use. Wunds sustained mre than six hurs befre surgical treatment f the wund / burn. Clinical evidence f sepsis. Sectin 3: Guide T Tetanus Pst-Expsure Prphylaxis Once a tetanus-prne wund has been identified, the mst imprtant gals f tetanus pst-expsure prphylaxis are: Remve the surce f txin prductin by timely, thrugh cleansing f the wund Neutralize any txin which may have been released with high circulating cncentratins f tetanus txin neutralizing antibdy. Effective levels f neutralizing antibdy cncentratins are achieved by either prir cmpletin f tetanus-cntaining vaccine series r the immediate administratin f TIG t ensure prtectin during the usual incubatin perid f tetanus (3 t 21 days; range ne day t several mnths). In keeping with these gals, the fllwing steps shuld be cmpleted as sn as pssible after a tetanus prne wund ccurs: 1. Wund Cleansing Apprpriate cleansing and debridement f the wund is imperative. In situatins where a client with a tetanus prne wund presents directly t public health, the Public Health Nurse (PHN) shuld refer t a physician as necessary if further assessment r wund care is needed. Use f antibitics fr ther ptential rganisms may be cnsidered by the attending physician. 2. Assess Histry f Tetanus-Cntaining Vaccine When a tetanus-prne wund ccurs, it is imprtant that an adequate assessment f the individual s immunizatin histry is cmpleted. This is t determine: Whether the individual has received at least 3 previus dses f tetanus-cntaining vaccine at the apprpriate intervals (primary series) Date f last dse f tetanus-cntaining vaccine Previus reactins t tetanus-cntaining vaccines and/r TIG Page 3 f 6
Electrnic immunizatin recrds may be accessible in (AHS) facilities and shuld be reviewed t ascertain whether immunizatin dcumentatin is available fr the client at the time f presentatin with a tetanus-prne wund. The client may als have their wn recrd f immunizatin. Hwever, if dcumentatin f immunizatin is nt immediately available, tetanus pstexpsure prphylaxis shuld nt be delayed in rder t request and wait fr immunizatin recrds frm anther zne/prvince/cuntry. The assessment shuld be dne at the time the individual presents t the health care system with the infrmatin that is available. Adequate dcumentatin is the nly way t be certain f immunizatin histry and is ptimal when a tetanus prne wund has ccurred. Fr mre infrmatin regarding the definitin f adequate immunizatin dcumentatin, refer t the Standard fr Individuals Presenting with Inadequate Immunizatin Dcumentatin. Hwever, dcumentatin is nt always available. In the absence f adequate dcumentatin, the decisin t cnsider a client previusly immunized, r nt, is made tgether with the client. Cunselling abut this decisin shuld include a discussin with the client abut: Risk f disease Factrs that are assciated with lack f immunity t tetanus (including but nt limited t): Increasing age Birth utside Canada Absence f immunizatin recrds Awareness that parents refused immunizatins N recall f having received previus immunizatins Based n the abve discussin, If the client is nt certain that they have received at least 3 previus dses f tetanus-cntaining vaccine, and adequate dcumentatin is nt available, the client shuld be cnsidered unimmunized r incmpletely immunized and ffered TIG and tetanus-cntaining vaccine as per Table 1 and Table 2. A referral shuld als be made t Public Health t cmplete the primary series. If the client is certain at least 3 previus dses f tetanus-cntaining vaccine were received, the discussin shuld be well dcumented and a bster dse ffered if indicated as per Table 1 and Table 2. 3. Administratin f Immunizing Agents Based n the immunizatin histry, TIG and/r tetanus cntaining vaccine shuld be ffered as summarized in the fllwing table: Table 1: Guide t Tetanus Prphylaxis in Wund Management Histry f tetanus immunizatin Unknwn r less than 3 dses in vaccine series 3 r mre dses in a vaccine series and less than 5 years since last bster dse 3 r mre dses in a vaccine series and 5 years but less than 10 years since last bster dse 3 r mre dses in a vaccine series and 10 years r mre since last bster dse Clean minr wunds Tetanuscntaining vaccine 1 TIG 2 All ther wunds Tetanuscntaining vaccine 1 TIG 2 Yes 1 N Yes 1,3 Yes 3 N N N 1,4 N 4 N N Yes 1 N 4 Yes 1 N Yes 1 N 4 Page 4 f 6
1 2 3 4 See Table 2: Age Apprpriate Tetanus-cntaining Vaccine. If the age-apprpriate vaccine is nt available at the lcatin where the client presents (e.g., ED), the client shuld be referred t Public Health as sn as practical, ideally within 24 hrs. If it will be mre than 72 hurs befre the client will be seen by Public Health, Td r dtap vaccine shuld be given, r cntact with Public Health made after hurs as per znespecific prcesses. Fllw zne-specific prcesses fr accessing TIG. Administer at different injectin sites using separate needles/syringes. Yes, if knwn t have an immune cmprmising cnditin, especially a humral immune deficiency (e.g., HIV infectin, agammaglbulinemia r hypgammaglbulinemia). Vaccine shuld be administered as well, regardless f the time elapsed since the last dse t tetanus-cntaining vaccine. Table 2: Age Apprpriate Tetanus-cntaining Vaccine Age Age Apprpriate Tetanus-cntaining Vaccine* 2 mnths up t and including 6 years f age 7 years up t and including 17 years f age DTaP-IPV-Hib, DTaP-IPV, r dtap-ipv dtap r dtap-ipv 18 years f age and lder Td, dtap, r Td-P *Refer t Immunizatin Schedules fr cmplete recmmendatins. When immunizatin is prvided in the Emergency Department (ED), Urgent Care Centre, and physician ffices, znes shuld wrk twards prcesses where immunizatin infrmatin is sent t Public Health fr dcumentatin in the Zne immunizatin system. Ideally TIG shuld be given within 24 hurs after a tetanus prne wund has ccurred. In rare circumstances where TIG is nt available r there is a delay in the client reprting r presenting fr fllw up, it can be given up t 21 days after sustaining injury, based n the incubatin perid f 3 t 21 days. If mre than 21 days r if a tetanus-cntaining vaccine was given prir t TIG, cnsult the MOH/MOH designate. There are few, if any, frmal recmmendatins available abut timelines fr tetanus PEP fllwing a tetanus prne wund r injury. In general, tetanus PEP shuld ccur as sn as pssible after the injury, especially fr puncture wunds. The zne MOH shuld be cnsulted abut any cases where tetanus PEP may be delayed. Cnsideratins fr delay shuld be based n the nature f the injury and likelihd that the injured persn is susceptible t tetanus. The mre likely the persn is t be susceptible t tetanus (cmpletely r partially), the mre quickly that tetanus prphylaxis shuld be administered. Fr example, a persn with a tetanus-prne injury and n histry f tetanus immunizatin must be immunized and given tetanus immune glbulin (TIG) as sn as pssible. A persn with a dcumented series f at least three tetanus-cntaining vaccine dses, with a bster dse within the last 10 years is less likely t be susceptible t tetanus, and the need fr a bster dse is nt as urgent, particularly if the wund is thrughly cleaned (Immunizatin Actin Calitin, 2015). Whenever pssible the age apprpriate tetanus immunizatin shuld be given at the same time as TIG using a separate syringe/needle and a different anatmical site. Cmplete the primary series f tetanus cntaining vaccine in persns never immunized r partially immunized. When age apprpriate immunizatin cannt be given at the same time as TIG, r within 3 days f administratin f TIG, Td/dTap vaccine may be cnsidered at the time f the wund assessment and in cnsultatin with the MOH/MOH designate. Page 5 f 6
Sectin 4: Referrals between Emergency Departments and Public Health In Alberta, the prvincially-funded tetanus-cntaining vaccines supplied t Emergency Departments are Td (tetanus/diphtheria) and/r dtap (diphtheria, tetanus, acellular pertussis). Because alternate vaccines r schedules are recmmended fr children up t and including 6 years f age, a referral t Public Health is necessary if tetanus-cntaining vaccine is indicated fr these individuals. A referral t Public Health is als required fr anyne needing fllw-up dses f vaccine t cmplete a primary series. Depending n the zne, TIG may be available in EDs, r cnsultatin with the zne MOH/designate may be necessary t access it thrugh Public Health. In rder t ensure that tetanus prphylaxis is timely, zne specific prcesses must be in place t ensure that the client has timely access t TIG and tetanus-cntaining vaccine either in the ED r thrugh Public Health. If a referral is being made t Public Health, the client shuld be made aware f this in the ED. References Alberta Health. (2011, August). Tetanus. Alberta Health, Public Health Ntifiable Disease Management Guidelines. Alberta Health. (2015, February 10). Alberta Immunizatin Plicy. Appendix 11: Tetanus Pstexpsure Prphylaxis in Injury/Wund Management. Alberta Health, Health System Accuntability and Perfrmance Divisin. Centers fr Disease Cntrl and Preventin. (2012). Epidemilgy and Preventin f Vaccine- Preventable Diseases: The Pink Bk (12th Editin Secnd Printing ed.). May. Heymann, D. L. (Ed.). (2015). Cntrl f Cmmunicable Diseases Manual (20th ed.). Washingtn, DC: American Public Health Assciatin. Immunizatin Actin Calitin. (2015, May 19). Ask the Experts: Diseases and Vaccines. Retrieved December 11, 2015, frm Immunizatin Actin Calitin: http://www.immunize.rg/askexperts/experts_tet.asp#wund Natinal Advisry Cmmittee n Immunizatin. (2012). Canadian Immunizatin Guide (Evergreen Editin). Ottawa, ON: Public Health Agency f Canada. Prfessinal Educatin Wrking Grup f the Canadian Immunizatin Cmmittee. (2015, Octber 14). Immunizatin Cmpetencies fr Health Prfessinals. Retrieved December 11, 2015, frm Gvernment f Canada: http://healthycanadians.gc.ca/publicatins/healthy-living-viesaine/immunizatin-cmpetencies-cmpetences-immunisatin/index-eng.php Wrld Health Organizatin. (2006). Tetanus vaccine: WHO Psitin Paper. Weekly epidemilgical recrd, 20, 197-208. Page 6 f 6