Tetanus vaccine, also known as tetanus toxoid (TT), is an inactive vaccine used to prevent tetanus.[1] During childhood, five doses are recommended, with a sixth given during adolescence.[1] Additional doses every ten years are recommended.[2] After three doses, almost everyone is initially immune.[1] In those who are not up to date on their tetanus immunization, a booster should be given within 48 hours of an injury.[3] In those with high-risk injuries who are not fully immunized, tetanus antitoxin may also be recommended.[1] Making sure pregnant women are up to date on their tetanus immunization can prevent neonatal tetanus.[1]
Tetanus vaccine
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Tetanus vaccination is often administered via combination DPT vaccines
Vaccine description
Target disease
Tetanus
Type
Toxoid
Clinical data
MedlinePlus
a682198
License data
US DailyMed: Tetanus
ATC code
J07AM01 (WHO)
Legal status
Legal status
US: ℞-only
Identifiers
ChemSpider
none
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The vaccine is very safe, including during pregnancy and in those with HIV/AIDS.[1] Redness and pain at the site of injection occur in between 25% and 85% of people.[1] Fever, feeling tired, and minor muscle pain occurs in less than 10% of people.[1] Severe allergic reactions occur in less than one in 100,000 people.[1]
A number of vaccine combinations include the tetanus vaccine, such as DTaP and Tdap, which contain diphtheria, tetanus, and pertussis vaccines, and DT and Td, which contain diphtheria and tetanus vaccines.[4] DTaP and DT are given to children less than seven years old, while Tdap and Td are given to those seven years old and older.[4][5] The lowercase d and p denote lower strengths of diphtheria and pertussis vaccines.[4]
Tetanus antiserum was developed in 1890, with its protective effects lasting a few weeks.[6][7] The tetanus toxoid vaccine was developed in 1924, and came into common use for soldiers in World War II.[1][8] Its use resulted in a 95% decrease in the rate of tetanus.[1] It is on the World Health Organization's List of Essential Medicines, the safest and most effective medicines needed in a health system.[9] The wholesale cost in the developing world is between 0.17 and 0.65 USD per dose as of 2014.[10] In the United States, a course of tetanus vaccine is between 25 and 50 USD.[11][12]
Medical uses Edit
Effectiveness Edit
Decrease in tetanus deaths by age group between 1990 and 2017[13]
Following vaccination, 95% of people are protected from diphtheria, 80% to 85% from pertussis, and 100% from tetanus.[14] Globally deaths from tetanus in newborns decreased 787,000 in 1988 to 58,000 in 2010, and 34,000 deaths in 2015 (a 96% decrease from 1988).[2][15]
In the 1940s, before the vaccine, there was about 550 cases of tetanus per year in the United States which has decreased to about 30 cases per year in the 2000s.[2] Nearly all cases are among those who have never received a vaccine, or adults who don't stay up to date on their 10-year booster shots.[16]
Pregnancy Edit
Guidelines on prenatal care in the United States specify that women should receive a dose of the Tdap vaccine during each pregnancy, preferably between weeks 27 and 36, to allow antibody transfer to the fetus.[17][18] All postpartum women who have not previously received the Tdap vaccine are recommended to get it prior to discharge after delivery.[19] It is recommended for pregnant women who have never received the tetanus vaccine (i.e., neither DTP or DTaP, nor DT as a child or Td or TT as an adult) to receive a series of three Td vaccinations starting during pregnancy to ensure protection against maternal and neonatal tetanus. In such cases, Tdap is recommended to be substituted for one dose of Td, again preferably between 27 and 36 weeks of gestation, and then the series completed with Td.[17][18]
Specific types Edit
The first vaccine is given in infancy. The baby is injected with the DTaP vaccine, which is three inactive toxins in one injection. DTaP protects against diphtheria, pertussis, and tetanus. This vaccine is safer than the previously used DTP.[4] Another option is DT, which is a combination of diphtheria and tetanus vaccines. This is given as an alternative to infants who have conflicts with the DTaP vaccine.[14] Quadrivalent, pentavalent, and hexavalent formulations contain DTaP with one or more of the additional vaccines: inactivated polio virus vaccine (IPV), Haemophilus influenzae type b conjugate, Hepatitis B, with the availability varying in different countries.[20][21][22]
For the every ten-year booster Td or Tdap may be used, though Tdap is more expensive.[18]
Schedule Edit
Because DTaP and DT are administered to children less than a year old, the recommended location for injection is the anterolateral thigh muscle.[medical citation needed] However, these vaccines can be injected into the deltoid muscle if necessary.[medical citation needed]
The World Health Organization (WHO) recommends six doses in childhood starting at six weeks of age.[1] Four doses of DTaP are to be given in early childhood.[14] The first dose should be around two months of age, the second at four months, the third at six, and the fourth from fifteen to eighteen months of age. There is a recommended fifth dose to be administered to four- to six-year-olds.[14]
Td and Tdap are for older children, adolescents, and adults and can be injected into the deltoid muscle.[14] These are boosters and are recommended every ten years. It is safe to have shorter intervals between a single dose of Tdap and a dose of the Td booster.[23]
Additional doses Edit
Booster shots are important because lymphocyte production (antibodies) is not at a constant high rate of activity. This is because after the introduction of the vaccine when lymphocyte production is high, the production activity of white blood cells will start to decline. The decline in activity of the T-helper cells means that there must be a booster to help keep the white blood cells active.[24]
Td and Tdap are the booster shots given every ten years to maintain immunity for adults nineteen years of age to sixty-five years of age.[4][18]
Tdap is given as a one-time, first-time-only dose that includes the tetanus, diphtheria, and acellular pertussis vaccinations.[4] This should not be administered to those who are under the age of eleven or over the age of sixty-five.[medical citation needed]
Td is the booster shot given to people over the age of seven and includes the tetanus and diphtheria toxoids. However, Td has less of the diphtheria toxoid, which is why the "d" is lowercase and the "T" is capitalized.[4]
It is important to understand that booster shots should be administered before the age of sixty-five and that one of these booster shots should be Tdap while the rest are Td.[14]
In 2020, the US Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP) recommended that either tetanus and diphtheria toxoids (Td) vaccine or Tdap to be used for the decennial Td booster, tetanus prevention during wound management, and for additional required doses in the catch-up immunization schedule if a person has received at least one Tdap dose.[18]
Side effects Edit
A bump resulting from a tetanus vaccine injection
Common side effects of the tetanus vaccine include fever, redness, and swelling with soreness or tenderness around the injection site (one of five people have redness or swelling). Body aches and tiredness have been reported following Tdap. Td / Tdap can cause painful swelling of the entire arm in one of 500 people.[14][25] Tetanus toxoid containing vaccines (DTaP, DTP, Tdap, Td, DT) may cause brachial neuritis at a rate of one out of every 100,000 to 200,000 doses.[2][26]
Mechanism of action Edit
The type of vaccination for this disease is called artificial active immunity. This type of immunity is generated when a dead or weakened version of the disease enters the body, causing an immune response which includes the production of antibodies. This is beneficial because it means that if the disease is ever introduced into the body, the immune system will recognize the antigen and produce antibodies more rapidly.[27]
CHAPTER 5 DIPHTHERIA, TETANUS, PERTUSSIS VACCINE Introduction Diphtheria is a potentially acute disease caused by exotoxin- producing Corynebacterium diphtheriae. Morbidity and mortality result from the bacterial toxin that may cause obstructive pseudo-membranes in the upper respiratory tract or damage to myocardium and other tissues. Devastating diphtheria epidemics affecting mainly children have been described from many countries throughout history. Diphtheria toxoid is one of the oldest vaccines in current use. Tetanus is an infectious bacterial disease caused by Clostridium tetani. Under favourable anaerobic conditions it may produce tetanospasmin, an extremely potent neurotoxin. The disease may affect any age group and protection against tetanus is antibody-dependent and can be achieved only through active (tetanus vaccine) or passive (tetanusspecific immunoglobulin) immunization. The immunized mother passes antitoxin via the placenta to her fetus, thereby preventing neonatal tetanus. Pertussis (whooping cough) caused by Bordetella pertussis is an important public health concern even in countries with high vaccination coverage. The clinical outcome of pertussis depends on factors such as age and vaccination status. Although most cases of clinically recognizable pertussis occur in older children, adolescents and adults, pertussis is often unrecognized because of its frequent atypical course. However, older age groups represent an important source of infection for susceptible infants. The main aim of pertussis vaccination is to reduce the risk of severe pertussis in infancy. Types of Diphtheria, Tetanus, Pertussis (DTP) Vaccines DTP vaccines are available in various formulations and are given in 0.5 mL doses. The five most common formulations are DTwP, DTaP, Tdap, DT, and aTd. Of these vaccines, three (DTwP, DTaP and DT)
are given to children younger than 7 years of age, and two (Tdap and aTd) are given to individuals 7 years or older1. As indicated by the lower case “d” and “p”, the concentration of diphtheria and pertussis toxoids has been reduced in these “adult” formulations to prevent adverse effects, while the “a” in “ap” indicates that the acellular vaccine contains purified components of Bordetella pertussis1. All DTP vaccines are adjuvanted with aluminium compounds such as aluminium phosphate or aluminium hydroxide.WHO requirements for potency of each component per single human dose of Diphtheria-Tetanus-Pertussis vaccine formulations2
DTaP-HepB vaccine (Please see Chapter 8 for more details) DTwP-Hib vaccine (Please see Chapter 6 for more details) DTwP-HepB-Hib (pentavalent vaccine) (Please see Chapters 6 & 8 for more details) DTaP-HepB-IPV-Hib (hexavalent vaccine) Each 0.5 mL dose of hexavalent vaccine contains diphtheria toxoid ≥ 20 IU, tetanus toxoid ≥ 40 IU and B. pertussis toxoid 25 µg, FHA 25 µg, inactivated polio virus type 1 (40 D antigen units); type 2 (8 D antigen units); type 3 (32 D antigen units), hepatitis B surface antigen (rDNA) 10 µg and conjugated H. influenzae type b 12 µg. It also contains adsorbed aluminium hydroxide. The vaccine may contain traces of neomycin, streptomycin and polymixin B. Combined triple diphtheria, tetanus and pertussis vaccines (DTwP), has been part of the immunization programme of Sri Lanka from 1961 and in 2008, combined pentavalent DTwP-HepB-Hib vaccine was introduced4. Efficacy Three doses of DTP vaccine, starting as early as 2 months of age and given at least 8 weeks apart at the age of 4 and 6 months are recommended for primary immunization of infants.
The protection following primary DTP vaccination wanes after 6–12 years due to lack of natural boosting. Therefore, the primary vaccination series of 3 doses should be extended by at least 1 booster dose. The optimal timing for and the number of such booster doses should be based on epidemiological surveillance as well as on immunological and programmatic considerations. Boosting at the age of 18 months (with DTwP), at school entry (with DT) and at 10 to 12 years of age (aTd) is recommended in Sri Lanka. Pertussis component is not included in school entry and older school age groups, because of its high reactogenicity in those age groups. High-efficacy levels can be obtained with both wP and aP containing vaccines5. However, the best aP vaccines have higher efficacy than low-efficacy wP vaccines, but they may be less efficacious than the highest-efficacy wP vaccines in preventing pertussis5. Available limited data on the interchangeability of pertussis vaccines shows that changing among or within the wP and aP vaccine groups is unlikely to interfere with the safety or immunogenicity of these vaccines5. Revaccination of adults against diphtheria and tetanus every 10 years may be necessary to sustain immunity in some epidemiological settings6,7. In order to minimize reactogenicity to the protein of diphtheria toxoid, the quantity of the toxoid has been markedly reduced in these adult vaccines. Indications (i) Adsorbed diphtheria, tetanus and pertussis vaccine (DTwP, DTaP) • Primary course of immunization against diphtheria, tetanus and pertussis is recommended for all infants on completion of 2, 4 and 6 months of age, unless there is a contraindication. If the primary course is interrupted it should be resumed but not repeated, allowing appropriate intervals (minimum of 6-8 weeks) between the remaining doses. The booster dose is recommended at 18 months of age. • There is no contraindication to vaccination of unimmunized older children up to the age of 7 years1.
(ii) Adsorbed diphtheria and tetanus vaccine (DT) • It is recommended for children immediately before school entry, preferably after at least 3 years from the last dose of the primary course or booster dose. • When immunization against pertussis antigen containing vaccine (DTP) is contraindicated, DT can be used for primary immunization. (iii) Diphtheria and tetanus vaccine adsorbed for adults and adolescents (aTd) • For primary vaccination and re-vaccination of adults and adolescents • In the National Immunization Programme (NIP) of Sri Lanka, aTd is given at the age of 10-12 years (iv) Reduced antigen tetanus, diphtheria & acellular pertussis vaccine (Tdap) • For booster vaccination against diphtheria, tetanus and pertussis of individuals from age seven years onwards1. (v) (vi) DTaP-HepB vaccine • This is an optional DTP containing vaccine for primary course of immunization against diphtheria, tetanus, pertussis and hepatitis B; recommended for all infants on completion of 2, 4 and 6 months of age, unless there is a contraindication. DTwP-Hib vaccine • This is an optional DTP containing vaccine for primary course of immunization against diphtheria, tetanus, pertussis and Hemophilus influenzae type b; recommended for all infants on completion of 2, 4 and 6 months of age, unless there is a contraindication.
(vii) DTwP-HepB-Hib (pentavalent vaccine) • Primary course of immunization against diphtheria, tetanus, pertussis, hepatitis B and H. influenzae type b is recommended for all infants on completion of 2, 4 and 6 months of age, unless there is a contraindication • In the NIP of Sri Lanka this vaccine is used for primary course of immunization for all infants. (viii) DTaP-HepB-IPV-Hib (hexavalent vaccine) • This is an optional DTP containing vaccine for primary course of immunization against diphtheria, tetanus, pertussis, hepatitis B, inactivated polio and H. influenzae type b; recommended for all infants on completion of 2, 4 and 6 months of age, unless there is a contraindication Dosage and Administration For all DTP or DTP containing vaccines, the standard dose is 0.5 mL. DTP vaccine should be administered deep intramuscularly in the antero-lateral thigh in infants or in the deltoid muscle in older age groups Contraindications for DTwP This vaccine should not be given to persons who developed a severe reaction to previous doses of DTwP vaccine. These reactions are mainly due to the wP component in the DTP. • an extensive area of redness and swelling which becomes indurated and involves most of the antero-lateral surface of the thigh or a major part of the circumference of the upper arm • bronchospasm, laryngeal oedema • encephalopathy within 7 days of administration of a previous dose of DTwP and not attributable to another identifiable cause
• prolonged inconsolable crying/screaming lasting more than 3 hours • convulsions occurring within 72 hours • progressive neurological disorders These reactions may increase in severity with each subsequent injection. DT or DTaP should be used for subsequent vaccinations. Contraindications for DTaP • anaphylaxis to previous dose of DTaP • anaphylactic reaction to any component of the vaccine which may be present even in trace amounts (such as neomycin, polymyxin B) In the case of encephalopathy within 7 days of administration of a previous dose of DTwP/DTaP which is not attributable to another identifiable cause, subsequent immunization is recommended with DT vaccine.8 Personal or family history of allergy or non-progressive neurological conditions such as cerebral palsy or spina–bifida are not contraindications for immunization with DTP. Precautions There are certain groups of children to whom the administration of pertussis vaccine requires special consideration. Appropriate advice should be obtained from a specialist before a decision is made to administer the vaccine to them. • Temperature of 40.5° C or higher within 48 hours after vaccination with a previous dose of DTwP/DTaP • Collapse or hypotonic hyporesponsive episode (HHE) within 48 hours after receiving a previous dose of DTwP/DTaP
• Convulsions within 72 hours after receiving a previous dose of DTaP • Children with a documented history of cerebral damage in the neonatal period • Children with a history of convulsions Acute illness is not a contraindication. Vaccination should be postponed until child has recovered. Adverse Reactions Both DTaP and DTwP vaccines have high level of safety. Mild adverse reactions are relatively common with DTwP vaccine5. Whole-cell pertussis vaccines are not recommended for use in adolescents and adults due to high reactogenicity. Therefore, a vaccine containing acellular pertussis antigen is recommended. Vaccines containing lower dose of diphtheria toxoid (aTd, Tdap) are recommended for adolescents and adults to provide satisfactory immune response with lower risk of reactions. DTP Vaccine •Localreactions Pain, redness and swelling at the injection site may occur and persist for several days. Persistent nodules at the injection site may arise if the injection is not given deep enough. •Systemicreactions Headache, lethargy, malaise, myalgia and pyrexia may occur. Anaphylactic reactions and urticaria may occur occasionally and rarely peripheral neuropathy The common, non-specific reactions such as crying, screaming and fever may occur for the pertussis component in DTP vaccine. These reactions may also occur after vaccines which do not contain the
pertussis component. Attacks of high pitched screaming, episodes of pallor, cyanosis, limpness, and convulsions as well as local and general reactions have been reported. Neurological events including convulsions and encephalopathy may rarely occur after the pertussis component. Although encephalopathy is included as a rare adverse reaction to DTP vaccine, it is not certain whether DTP vaccines in fact cause encephalopathy1, 9. DT Vaccine •Localreactions Reactions are generally mild and confined to the site of injection. Occasionally a painless nodule may develop at the site of injection but usually disappears without sequelae. •Systemicreactions Transient fever, headache, malaise and irritability. Anaphylactic reactions are rare. Neurological reactions have been reported occasionally. Storage The vaccine should be stored in a dry place and stored and transported at 2°C - 8°C. Vaccines should not be frozen or come into direct contact with ice or ice packs during transport or storage. DTP vaccines can be irreversibly damaged by either inadvertent freezing or heat. WHO recommended Open Vial Policy is practiced for multidose vials for all DTP containing vaccines.
History Edit
The first vaccine for passive immunology was discovered by a group of German scientists under the leadership of Emil von Behring in 1890. The first inactive tetanus toxoid was discovered and produced in 1924. A more effective adsorbed version of the vaccine, created in 1938, was proven to be successful when it was used to prevent tetanus in the military during World War II.[14] DTP (which is the combined vaccine for diphtheria, tetanus, and pertussis) was first used in 1948, and was continued until 1991, when it was replaced with an acellular form of the pertussis vaccine due to safety concerns.[28] Half of those who received the DTP vaccine had redness, swelling, and pain around the injection site[14], which convinced researchers to find a replacement vaccine.
Two new vaccines were launched in 1992. These combined tetanus and diphtheria with acellular pertussis (TDaP or DTaP), which could be given to adolescents and adults (as opposed to previously when the vaccine was only given to children).[14]