Tetanus vaccination in children

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)
1^st booster (4^th dose) - ideally 3 years after primary course, usually at age 3 ½ - 5 years old or can be given 1 year post 3^rd dose of primary immunisation course if delayed
2^nd booster (5^th dose) - 10 years after 1^st booster or can be given minimum 5 years after 1^st 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 1^st 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

Assess if wound is tetanus prone or high-risk tetanus prone (table 1)
Assess immunisation status (Table 2)
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
Puncture-type injuries in a contaminated environment e.g. gardening injuries	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/scratches (e.g. animal routing in soil, or pet/animal living in agricultural setting)
Wounds or burns with systemic sepsis

Note: individual risk assessment is required and this list is not exhaustive e.g. a wound from a discarded needle found in a park may a tetanus-prone injury but a needle stick injury in a medical environment is not.

Table 2

Immunisation Status	Immediate Treatment			Later Treatment
Immunisation Status	Clean wound	Tetanus prone	Tetanus prone + high risk	Later Treatment
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 3^rd dose within the last 10 years	None	None	None	Further doses of vaccine as per usual recommended schedule
Age 5-10 with primary course, but no preschool booster Adequate priming course^**, but last dose >10 years ago	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

Public Health England (2013) Immunisation against infectious disease, the Green Book: tetanus chapter 30 [last updated Jan 2020]
Public Health England.(2018) Tetanus: information for health professionals

Editorial Information

Last reviewed: 31 January 2022

Next review: 31 January 2025

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

Co-Author(s): Correspondence author: Dr Steve Foster, Consultant in Paediatric Emergency Medicine, RHCG. Review author: Dr Jordan Fitzpatrick, Paediatric Emergency Doctor, RHCG.

Approved By: Paediatric Emergency Department

NHSGGC Guidelines