Tetanus vaccine

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 10 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 women who are pregnant are up to date on their tetanus immunization and, if not, immunizing them can prevent neonatal tetanus.[1]

Tetanus vaccine
Tetanus vaccination is often administered via combination DPT vaccines
Vaccine description
Target diseaseTetanus
TypeToxoid
Clinical data
MedlinePlusa682198
ATC code
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 muscles pains occur 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 vaccine, and DT and Td which contain diphtheria and tetanus vaccine.[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] 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.[5][6] The tetanus toxoid vaccine was developed in 1924 and came into common use for soldiers in World War II.[1][7] 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 most effective and safe medicines needed in a health system.[8] The wholesale cost in the developing world is between 0.17 and 0.65 USD per dose as of 2014.[9] In the United States a course of tetanus vaccine is between 25 and 50 USD.[10]

Medical uses

Since the discovery and productions of the tetanus vaccines, the occurrence of tetanus, diphtheria, and pertussis has decreased. Using US population derived figures, following vaccination, 95% of people are protected from diphtheria, 80% to 85% of people are protected from pertussis, and 100% of people are protected from tetanus.[11] Before the vaccine there was an average of 580 annual cases of tetanus and 472 annual deaths from tetanus. But since the vaccine there is an average of 41 annual cases of tetanus and 4 annual deaths from tetanus. This is a 93% reduction in occurrence of tetanus and a 99% reduction in fatalities resulting from tetanus.[11]

Tetanus has become uncommon in the United States, with an average of 29 reported cases per year from 1996 through 2009. Nearly all cases of tetanus are among those who have never received a tetanus vaccine, or adults who don't stay up to date on their 10-year booster shots.[12]

Pregnancy

Guidelines on prenatal care in the United States state that pregnant 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.[13] All postpartum women who have not previously received Tdap vaccine are recommended to receive Tdap prior to discharge after delivery.[14] It is recommended for pregnant women who have never received the tetanus vaccine (i.e., have never received DTP, DTaP or DT as child or Td or TT as 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.[15]

Specific types

The first vaccine is administered at infancy. The baby is injected with the DTaP vaccine which is 3 inactive toxins in one injection. DTaP protects against diphtheria, pertussis, and tetanus. This vaccine is safer than the previously used DTP.[16]

Another option for infants is DT, which is a vaccine that is a combination of diphtheria and tetanus vaccines. This is given as an alternative to infants who have conflicts with the DTaP vaccine.[11] Quadrivalent, pentavalent, and hexavalent formulations contain DTaP with one or more of the additional vaccines: inactivated poliovirus vaccine (IPV), Haemophilus influenzae type b conjugate, Hepatitis B, with the availability varying in different countries.[17][18][19]

Schedule

Because DTaP and DT are administered to children less than a year old, the recommended location for injection is the anterolateral thigh muscle. However, these vaccines can be injected into the deltoid muscle if necessary.

The WHO recommends 6 doses in childhood starting at 6 weeks of age.[1] Four doses of DTaP are to be given in early childhood.[11] The first dose should be around two months of age, the second at four months age, the third at six months of age, and the fourth from fifteen months of age to eighteen months of age. There is a recommended fifth dose to be administered to four- to six-year-olds.[11]

Td and Tdap are for older children, adolescents, and adults and can be injected into the deltoid muscle.[11] 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.[20]

Additional doses

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 the 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.[21]

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.[16]

Tdap is given as a onetime, first time only dose that includes the tetanus, diphtheria, and acellular pertussis vaccinations.[16] This should not be administered to those who are under the age of eleven or over the age of sixty-five.

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 lower case and the "T" is capitalized.[16]

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.[11]

Side effects

Common side effects include fever, redness and swelling with soreness or tenderness around the injection site (1 of 5 people have redness or swelling). Body aches and tiredness have been reported following Tdap. Td / Tdap can cause painful swelling of entire arm in 1 of 500 people.[11][22] Tetanus toxoid containing vaccines (DTaP, DTP, Tdap Td, DT) may cause brachial neuritis at a rate of 1 out of every 100,000 to 200,000 doses.[23][24]

A bump resulting from a tetanus vaccine injection

Mechanism of action

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 to the body because this means that if the disease is ever introduced into the body, the immune system will recognize the antigen and produce antibodies more rapidly.[25]

History

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.[11] 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 because of safety concerns.[26] Half of those who received the DTP vaccine had redness, swelling, and pain around the injection site[11] 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).[11]

References
  1. "Tetanus vaccines: WHO position paper – February 2017" (PDF). Weekly epidemiological record. 92 (6): 53/76. Nov 6, 2017. Archived (PDF) from the original on 2017-04-21.
  2. Hamborsky, J (2015). "21". Pinkbook Tetanus Epidemiology of Vaccine Preventable Diseases (13 ed.). CDC. Archived from the original on 2017-04-13.
  3. "Puncture wounds: First aid". Mayo Clinic. Feb 4, 2015. Archived from the original on 8 December 2015. Retrieved 6 December 2015.
  4. "Vaccines: VPD-VAC/Tetanus/main page". Centers for Disease Control. Archived from the original on February 12, 2015. Retrieved February 10, 2015.
  5. Gradmann, C.; Simon, J. (2010). Evaluating and Standardizing Therapeutic Agents, 1890-1950. Springer. p. 53. ISBN 9780230285590.
  6. Jones, Bernard R. (2016). Pharmacology for Student and Pupil Nurses and Students in Associated Professions. Elsevier. p. 162. ISBN 9781483141312.
  7. Macera, Caroline (2012). Introduction to Epidemiology: Distribution and Determinants of Disease. Nelson Education. p. 251. ISBN 9781285687148. Archived from the original on 2016-03-05.
  8. "WHO Model List of Essential Medicines (19th List)" (PDF). World Health Organization. April 2015. Archived (PDF) from the original on 13 December 2016. Retrieved 8 December 2016.
  9. "Vaccine, Tetanus Toxoid". International Drug Price Indicator Guide. Retrieved 6 December 2015.
  10. Hamilton, Richart (2015). Tarascon Pocket Pharmacopoeia 2015 Deluxe Lab-Coat Edition. Jones & Bartlett Learning. p. 317. ISBN 9781284057560.
  11. Centers for Disease Control and Preventi (2011). "Tetanus". Epidemiology and Prevention of Vaccine-Preventable Diseases (CDC, Epidemiology and Prevention of Vaccine-Preventable Diseases (pdf). Washington, D.C: Public Health Foundation. ISBN 0-01-706609-3. Archived (PDF) from the original on March 6, 2008. Retrieved January 4, 2016.
  12. "About Tetanus". Archived from the original on 2014-11-11. Retrieved 2014-12-11.
  13. "Updated Recommendations for Use of Tetanus Toxoid, Reduced Diphtheria Toxoid, and Acellular Pertussis Vaccine (Tdap) in Pregnant Women — Advisory Committee on Immunization Practices (ACIP), 2012". www.cdc.gov.
  14. Guidelines for Vaccinating Pregnant Women - section Tetanus, Diphtheria, and Pertussis (Tdap); & Tetanus and Diphtheria (Td).
  15. Updated Recommendations for Use of Tetanus Toxoid, Reduced Diphtheria Toxoid, and Acellular Pertussis Vaccine (Tdap) in Pregnant Women — Advisory Committee on Immunization Practices (ACIP), 2012 - section "Special Situations".
  16. "Vaccines: VPD-VAC/Tetanus/main page". Centers for Disease Control. Archived from the original on 2012-06-16. Retrieved 2012-06-04.
  17. "2016 Binational Immunization Resource Tool for Children from Birth Through 18 Years" (PDF). Centers for Disease Control. Archived (PDF) from the original on 2017-02-11. Retrieved 2016-12-22.
  18. "Licensure of a Diphtheria and Tetanus Toxoids and Acellular Pertussis Adsorbed, Inactivated Poliovirus, and Haemophilus b Conjugate Vaccine and Guidance for Use in Infants and Children". Centers for Disease Control. Archived from the original on 2016-11-07. Retrieved 2016-12-22.
  19. Baldo V, Bonanni P, Castro M, Gabutti G, Franco E, Marchetti F, Prato R, Vitale F (2014). "Combined hexavalent diphtheria-tetanus-acellular pertussis-hepatitis B-inactivated poliovirus-Haemophilus influenzae type B vaccine; Infanrix™ hexa: twelve years of experience in Italy". Hum Vaccin Immunother. 10 (1): 129–37. doi:10.4161/hv.26269. PMC 4181021. PMID 24004825.
  20. Talbot, Elizabeth A (2010). The Safety of Immunizing with Tetanus–diphtheria–acellular Pertussis Vaccine (Tdap) Less than 2 Years following Previous Tetanus Vaccination: Experience during a Mass Vaccination Campaign of Healthcare Personnel during a Respiratory Illness Outbreak. pp. 8001–8007.
  21. Veronesi, R (1981). Tetanus: Important New Concepts. Amsterdam: Excerpta Medica.
  22. "Vaccine Information Statement | Tdap | Tetanus-Diphtheria-Pertussis | VIS | CDC". www.cdc.gov. Archived from the original on 16 December 2016. Retrieved 9 December 2016.
  23. "Pinkbook - Tetanus - Epidemiology of Vaccine Preventable Diseases - CDC". www.cdc.gov. 16 May 2018.
  24. "Update: Vaccine Side Effects, Adverse Reactions, Contraindications, and Precautions Recommendations of the Advisory Committee on Immunization Practices (ACIP)". Centers for Disease Control and Prevention. September 6, 1996. Retrieved December 18, 2018.
  25. "Vaccines & Immunizations". Archived from the original on 2011-12-22. Retrieved 27 Nov 2011.
  26. "Whooping Cough: Vaccine Combined with Tetanus, Diphtheria". Archived from the original on June 6, 2017. Retrieved May 1, 2017.
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