Missed Opportunities for Tetanus Postexposure Prophylaxis — California, January 2008–March 2014

Cynthia Yen, MPH; Erin Murray, PhD; Jennifer Zipprich, PhD; Kathleen Winter, MPH; Kathleen Harriman, PhD

Morbidity and Mortality Weekly Report. 2015;64(9):243-246.

Discussion

Although rates of tetanus have declined, sporadic cases continue to occur, particularly in adults who are not up-to-date with TT. Vaccination coverage among children is higher; in 2012, an estimated 82.5% of U.S. children aged 19–35 months and 84.6% of U.S. children aged 13–17 years had received ≥4 doses of diphtheria toxoid-tetanus toxoid-acellular pertussis vaccine (DTaP) and ≥1 dose of tetanus, diphtheria, acellular pertussis vaccine (Tdap), respectively.^[5,6] In contrast, only 62% of adults aged ≥19 years had received TT during the preceding 10 years; coverage for adults aged ≥65 years was 55%.^[7] All of the tetanus patients reported in California during January 2008–March 2014 were adults aged ≥21 years. Among the 12 patients with verified vaccination histories, none recalled receiving TT during the preceding 10 years. Health care providers should assess patient vaccination status during routine visits to determine whether TT is needed. ACIP recommends that after receiving a primary childhood series, a tetanus and diphtheria vaccine (Td) dose should be given during adolescence and every 10 years thereafter. For added protection against pertussis, one of the Td booster doses should be Tdap if it was not previously administered.^[2,3]

Even minor wounds or abrasions can result in tetanus, highlighting the importance of ensuring that patients are up to date for TT.^[8,9] Providers should assess vaccination status in patients with wounds and in particular older adults, injection-drug users, patients with diabetes, and those with chronic wounds, all of whom are considered at increased risk for tetanus.^[1] Patients who have completed the 3-dose primary TT series need a booster dose as part of wound management if they have a clean, minor wound and received their last TT dose more than 10 years prior to injury, or if they have any other type of wound and received their last TT dose more than 5 years prior to injury.^[2] ACIP recommends that persons with unknown or incomplete histories receive TT as part of routine wound management; patients with wounds that are neither clean nor minor should receive TIG in addition to TT. Although the dosage of TIG for PEP is not specified in the recommendations, dosage information is provided in the product insert.^§

In this analysis, only nine of 16 patients with acute injuries had sought medical care before their tetanus illness onset and diagnosis, and only two of the nine received PEP with TT or TT plus TIG as recommended.^[2–4] Health care providers might fail to provide TIG PEP because of a lack of knowledge about current recommendations or because the assessment of wound severity and whether a patient should be managed with TIG according to ACIP recommendations can be subjective.^[2,10] All tetanus patients required considerable and costly medical care, including hospitalization, and almost all (90%) were admitted to intensive care. Among patients who received TIG as treatment, there was variability in the dose administered. In the United States, 3,000–6,000 U, given in a single intramuscular dose with part of the dose infiltrated around the wound if it can be identified, is generally recommended for treatment. However, the optimal therapeutic dose has not been established, and some experts contend that a dose of 500 U, as recommended by the World Health Organization,^¶ is as effective as higher doses and causes less discomfort.^[4] It is also possible that some providers treating tetanus patients inadvertently prescribed the PEP dosage of TIG rather than the treatment dosage. Among five treated patients who received <3,000 U of TIG as treatment, three survived and two died. Among 10 treated patients who received ≥3,000 U of TIG, seven survived, and three died.

The findings in this report are subject to at least three limitations. First, although California health care providers are required to report tetanus cases, surveillance is passive, and underreporting is likely. Second, because there is no laboratory testing for tetanus and case identification depends solely on clinical assessment, some cases might be misclassified. Finally, some of the case reports were incomplete, particularly with regard to TT history.

Although significant progress has been made in reducing the morbidity and mortality caused by tetanus, cases of this vaccine-preventable disease continue to be reported. Health care providers should assess the tetanus vaccination status of their patients during routine visits. All providers who provide care for patients with wounds should have protocols for tetanus PEP and ensure that appropriate PEP is provided for such patients.

^§Additional information available at https://www.talecris-pi.info/inserts/BayTet.pdf.
^¶Additional information available at https://www.who.int/diseasecontrol_emergencies/who_hse_gar_dce_2010_en.pdf.

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Acknowledgments
Celia Bird, MS, Mark Foster, Carol Glaser, DVM, MD, James Watt, MD, California Department of Public Health. Staff members in the Contra Costa, Fresno, Imperial, Los Angeles, Merced, Orange, Sacramento, San Bernardino, San Diego, San Mateo, Santa Barbara, Santa Clara, Sonoma, Stanislaus and Ventura county health departments.

Table 1. Number of tetanus cases (N = 21), by selected characteristics and outcome — California, January 2008–March 2014
Characteristic	Died		Survived		Total
Characteristic	No.	(%)	No.	(%)	No.	(%)
Sex
Male	3	(60)	12	(75)	15	(71)
Female	2	(40)	4	(25)	6	(29)
Age group (yrs)
21–49	2	(40)	8	(50)	10	(48)
50–64	0	—	5	(31)	5	(24)
≥65	3	(60)	3	(19)	6	(29)
Clinical course
Hospitalized	5	(100)	16	(100)	21	(100)
Admitted to ICU	5	(100)	14	(88)	19	(90)
Median no. of days hospitalized (range)	19 (4–38)		17 (2–65)		17 (2–65)
Underlying conditions
Diabetes	1	(33)	3	(19)	4	(19)
Injection drug user	0	—	3	(19)	3	(14)
Tetanus vaccination history
Zero doses	2	(40)	1	(6)	3	(14)
At least one dose*	1	(20)	8	(50)	9	(43)
Unknown	2	(40)	7	(44)	9	(43)
Injury history
Acute injury before illness	5	(100)	11	(69)	16	(76)
Puncture	2	(40)	5	(45)	7	(44)
Abrasion	1	(20)	3	(27)	4	(25)
Linear laceration	1	(20)	2	(18)	3	(19)
Compound fracture	1	(20)	0	—	1	(6)
Animal bite	0	—	1	(9)	1	(6)
Sought medical care for acute injury	5	(100)	4	(36)	9	(56)
Received recommended postexposure prophylaxis	1	(20)	1	(25)	2	(22)

*Of patients who had received at least one dose of TT-containing vaccine, none recalled receiving a dose in the preceding 10 years.

Table 2. Therapeutic treatment of tetanus patients (n = 9) with an acute wound who had sought medical care before illness and diagnosis — California, January 2008–March 2014
Patient No.	Age	Sex	TT history	When last dose received	Wound type	Received TT	Received appropriate PEP	Units of therapeutic TIG received	Outcome
1	48	Female	Unknown	Unknown	Abrasion	Yes	Yes	5,000	Survived
2	38	Male	Zero doses	N/A	Linear laceration	Yes	Yes	5,000	Died
3	73	Male	At least one dose	Unknown	Compound fracture	No*	No	1,000	Died
4	45	Male	Unknown	Unknown	Puncture	No	No	250	Died
5	47	Female	Unknown	Unknown	Animal bite	No	No	500	Survived
6	68	Male	Unknown	Unknown	Puncture	No	No	Unknown	Survived
7	71	Male	At least one dose	50 years ago	Abrasion	No	No	Unknown	Survived
8	86	Female	Zero doses	N/A	Puncture	No	No	3,000	Died
9	89	Female	Unknown	Unknown	Abrasion (contaminated)	Yes	No	5,000	Died

Abbreviations: TT = tetanus toxoid; TIG = tetanus immune globulin; N/A = not applicable.
* Patient reported allergy to TT.

Table 3. Recommended management of tetanus wounds — Advisory Committee on Immunization Practices
Vaccination history	Clean, minor wounds		All other wounds
Vaccination history	Administer Td*	Administer TIG	Administer Td*	Administer TIG
Unknown or <3 doses	Yes	No	Yes	Yes
≥3 doses	No^†	No	No^§	No

Abbreviations: Td = tetanus and diphtheria vaccine; TIG = tetanus immune globulin.
Sources: CDC. Preventing tetanus, diphtheria, and pertussis among adults: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine (Tdap). Recommendations of the Advisory Committee on Immunization Practices (ACIP) and recommendations of ACIP, supported by the Healthcare Infection Control Practices Advisory Committee (HICPAC), for use of Tdap among health-care personnel. MMWR Recomm Rep 2006;55(No. RR-17).
CDC. Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine in adults aged 65 years and older—Advisory Committee on Immunization Practices (ACIP), 2012. MMWR Morb Mortal Wkly Rep 2012;61:468–70.
*Tdap (tetanus, diphtheria, acellular pertussis vaccine) may be substituted for Td if the person has not previously received Tdap and is aged ≥10 years.
^†Yes, if >10 years since last dose.
^§Yes, if >5 years since last dose.