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Tetanus vaccination in Children

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Objectives

Guidance for the use of tetanus containing vaccines in children

Scope

Children presenting to hospital (RHC) with a tetanus prone or high-risk injury.

Audience

Medical and nursing staff assessing children presenting with an injury that may be tetanus prone in the ED at RHC.

Tetanus containing vaccines

Tetanus is an acute disease caused by the action of tetanus toxin, released following infection by the bacterium Clostridium tetani.

UK tetanus immunisation Schedule:

  • Primary Immunisation- 3 doses of tetanus containing vaccine at least one month apart (usually at 2, 3, and 4 months of age)
  • 1st booster- at least 3 years after primary course, usually at age 3 ½ - 5 years old or can be given 1 year post 3rd dose of primary immunisation course if delayed
  • 2nd booster- 10 years after 1st booster or can be given minimum 5 years after 1st booster if course delayed

In all wounds other than clean minor wounds, the risk of tetanus should be considered. Children who have received their primary immunisations but not had their 1st booster are fully immunised up until the age of 5. A clean wound is a non-penetrating wound with negligible tissue damage and <6 hours old.

Patients who are severely immunosuppressed may not be adequately protected against tetanus, despite having been fully immunised – All should be discussed with ED senior.

 

Assessment
  1. Assess if wound is tetanus prone or high-risk tetanus prone (table 1)
  2. Assess immunisation status (Table 2)
  3. Is tetanus-containing vaccine and or Tetanus Immunoglobulin (TIG) required? (Table 2)

Table 1

Tetanus prone:

High risk- tetanus prone
any tetanus prone injury with:

Compound fracture

Heavy contamination with soil or manure

Deep penetrating wound/ puncture injury

Wound with extensive tissue damage e.g. contusion or burns

Wound containing foreign body (especially wood splinters)

Wound or burns requiring surgery that is delayed >6 hours

Certain animal bites- agricultural setting

 

Wounds or burns with systemic sepsis

 

 

Table 2

Immunisation Status

Immediate Treatment

Later Treatment

Clean wound

Tetanus prone

Tetanus prone + high risk

FULLY IMMUNISED (defined as):

Under 5s who have had full primary course*

Age 5-10 with primary course* and 1 booster

Over 11 years of age and had ≥ 3 doses**

and 3rd dose within the last 10 years

None

None

None

Further doses of vaccine as per usual recommended schedule

Primary course* UTD but boosters not up to date (includes over 5s with no booster)

Fully immunised but last dose >10 years

None

Vaccine dose “booster”

Vaccine dose “booster” + 1 dose TIG in a different site

Further doses of vaccine as per usual recommended schedule

Not had full primary course*

OR

Immunisation status unknown

Vaccine dose

Vaccine dose + 1 dose TIG in a different site

Vaccine dose “booster” + 1 dose TIG in a different site

Further doses of vaccine as per usual recommended schedule

*  Primary Immunisation – 3 doses of tetanus containing vaccine at least one month apart (usually at 2, 3, and 4 months of age)

**  At least 3 doses of tetanus vaccine at appropriate intervals. This definition of “adequate course” is for the risk assessment of tetanus-prone wounds only. The full UK schedule is five doses of tetanus containing vaccine at appropriate intervals.

Vaccine Booster

If tetanus vaccine “booster” required:

Under 10yrs of age – dTap/IPV (Repevax) or DTaP/IPV (Infarix-IPV)

Over 10yrs of age – Td/IPV (Revaxis)

If not had full primary course or status unknown give:

Under 10yrs of age – DTap/IPV/Hib (Infanrix hexa)

Over 10yrs of age – Td/IPV (Revaxis)

Management

Wounds must be thoroughly cleaned and follow assessment above.

If TIG is required give 250IU IM, or 500IU if more than 24 hours have elapsed since injury or there is a risk of heavy contamination or following burns.

If primary immunisation incomplete or vaccination status unknown refer to GP for f/u and completion of immunisation schedule.

References
  1. Public Health England (2013) Immunisation against infectious disease, the Green Book: tetanus chapter 30 [last updated Nov 2018]
  2. GGC (2016). Immunisation best practice guideline.
  3. Public Health England.(2018) Tetanus: information for health professionals
Editorial Information

Last reviewed: 01 September 2019

Next review: 30 September 2021

Author(s): Dr Laura Clarke, Paediatric Medicine trainee, RHCG

Co-Author(s): Correspondence author: Dr Steve Foster, Consultant in Paediatric Emergency Medicine, RHCG

Approved By: Paediatric Emergency Department