Tetanus immunoglobulin, rather than vaccine, should be administered to boost immunity following a high-risk tetanus-prone injury, explains Jane Chiodini

Tetanus is contracted by exposure to the spores of Clostridium tetani, which are present in soil. Bacteria enter the body via a wound and produce a potent neurotoxin in devitalised tissue.

The first symptoms of tetanus are spasms in the muscles of mastication causing trismus or ïlockjawÍ. Trismus can be followed by sustained spasm of the back muscles (opisthotonus) and other muscle spasms. Involvement of the facial muscles results in the characteristic ïsmileÍ of risus sardonicus. Finally, mild external stimuli may trigger generalised tetanic seizures which contribute to serious complications, including dysphagia and aspiration pneumonia, and are fatal unless the patient receives rapid supportive treatment.1

Tetanus immunisation was introduced nationally in the UK in 1961 and in May 2002 the Department of Health announced a change from the use of single antigen tetanus vaccine to combined tetanus and low dose diphtheria vaccine (Td) for adults and adolescents.2 A total of five doses of vaccine at the appropriate intervals is considered to give lifelong immunity.3

Vaccine given at the time of injury may not boost tetanus immunity early enough to give additional protection during the incubation period. Therefore it is now recommended that no further doses of vaccine should be given following a tetanus-prone injury if the individual has received a full five-dose course of tetanus vaccine at the recommended intervals.

If the risk of tetanus is especially high (for example if the wound is contaminated with manure), tetanus immunoglobulin should be given to provide immediate additional protection.3 This advice replaces guidance available in the current ïGreen BookÍ, Immunisation Against Infectious Disease 1996.4

A tetanus-prone wound is considered to be:

  • Any wound or burn if there is a delay of more than 6 hours before it is surgically treated
  • Any wound or burn at any interval after injury that shows one or more of the following characteristics:
    • significant degree of devitalised tissue
    • a puncture-type wound
    • contact with soil or manure likely to harbour tetanus organisms
    • clinical evidence of sepsis.

In patients whose vaccinations are not up to date or whose status is not known, a reinforcing dose of Td as well as tetanus immunoglobulin should be given at the time an injury is treated. The full schedule is described in Table 1(below).

Table 1: Tetanus immunisation following injuries 3

Immunisation status

Clean wound

Tetanus-prone wound

  Vaccine Vaccine Human tetanus immunoglobulin
Fully immunised i.e. has
received a total of 5 doses of tetanus vaccine at appropriate
intervals as single antigen or
in a combined vaccine
None required None required Only if risk especially high (e.g. contaminated with stable manure)
Primary immunisation complete, boosters incomplete but up to date None required (unless next dose due soon and convenient to give now) None required (unless next dose due soon and convenient to give now) Only if risk especially high (see above)
Primary immunisation incomplete or boosters not up to date A reinforcing dose of combined tetanus/diptheria vaccine and further doses as required to complete the recommended schedule (to ensure future immunity) A reinforcing dose of combined tetanus/diptheria vaccine and further doses as required to complete the recommended schedule (to ensure future immunity) Yes: one dose of human tetanus immunoglobulin in a different site
Not immunised or immunisation status not known or uncertain An immediate dose of vaccine followed, if records confirm this is needed, by completion of a full 3 dose course of combined tetanus/diptheria vaccine to ensure future immunity An immediate dose of vaccine followed, if records confirm this is needed, by completion of a full 3 dose course of combined tetanus/diptheria vaccine to ensure future immunity Yes: one dose of human tetanus immunoglobulin in a different site

Until now, stocks of immunoglobulin have been kept in accident and emergency departments but not generally in primary care. In view of the new advice, however, practices should consider keeping a small quantity in stock.

Patient Group Directions (PGDs) have been a legal requirement throughout the UK since 9 August 2000. National guidance is now available in England,5 Wales 6 and Scotland.7 PGDs should be in place for the administration of prescription only medicines (POM) to groups of patients who may not be individually identified before presentation at the surgery. Therefore nurses administering these vaccines must do so only if there is an appropriate PGD in place. To do otherwise, would be to act illegally and could result in a criminal prosecution under the Medicines Act.5,6,7,

To work in accordance with a PGD, the nurse administering the POM must be named within the document and must sign it, as must the senior doctor giving his/her authorisation for the nurse to work within the PGD. To do this however, the senior doctor within the practice must be satisfied that this nurse has adequate knowledge and is competent to administer the immunisation in line with the Nursing and Midwifery Council (NMC) Professional Code of Conduct 8 and NMC Standards for the Administration of Medicines.9

It is useful to gather together all the information you need before starting work on a PGD, and it is essential to have access to the Summary of Product Characteristics (SPC) for the vaccine. SPCs are available directly from the drug manufacturers and on the internet at http://emc.vhn.net/.

Figure 1: Sample patient group direction for tetanus immunoglobulin, Tetabulin®
Figure 1 (continued): Sample patient group direction for tetanus immunoglobulin, Tetabulin®
Figure 1 (continued): Sample patient group direction for tetanus immunoglobulin, Tetabulin®

The PGD should include:

  • The name of the business to which the direction applies
  • The date the direction comes into force and the date it expires
  • A description of the medicine(s) to which the direction applies
  • Class of health professional who may supply or administer the vaccine
  • Signature of a senior doctor or dentist and a pharmacist
  • Signature of an appropriate health organisation
  • The clinical condition or situation to which the direction applies
  • A description of those patients excluded from treatment under the direction
  • A description of the circumstances in which further advice should be sought from a doctor (or dentist, as appropriate) and arrangements for referral
  • Details of the appropriate dosage and maximum total dosage, quantity, pharmaceutical form and strength, route and frequency of administration and minimum or maximum period over which the medicine should be administered
  • Relevant warnings including potential side-effects
  • Details of any necessary follow up action and the circumstances
  • A statement of the records to be kept for audit purposes.

Tetanus immunoglobulin may not be readily available abroad and it is now recommended that individuals travelling to areas where medical facilities may not be accessible should be given a booster dose of Td if they have not been vaccinated against tetanus in the past 10 years.3

  1. World Health Organization. International Travel and Health - Vaccination Requirements and Health Advice. Geneva: WHO, 2002.
  2. Department of Health. Replacement of single antigen tetanus vaccine by combined tetanus/ low dose diphtheria vaccine for adults and adolescents. London: DoH, 16 May 2002 (Letter).
  3. Department of Health. Replacement of single antigen tetanus vaccine (T) by combined tetanus/diphtheria vaccine for adult and adolescents (Td) and advice for tetanus immunisation following injuries. Update on Immunisation Issues. PL/CMO/2002/4, PL/CNO/2002/4, PL/CPHO/2002/2 www.doh.gov.uk/cmo/index.htm
  4. Department of Health. Immunisation Against Infectious Disease 1996. London: DoH, 1996.
  5. NHS Executive. Patient Group Directions (England Only). HSC 2000/026. Leeds: NHSE, 2000.
  6. The National Welsh Assembly. Review of Prescribing, Supply and Administration of Medicines - Sale, Supply and Administration of Medicines by Health Professionals Under Patient Group Directions (PGD). COCNOCDOC SOCPhA-SALEMED3. 22 December 2000.
  7. Scottish Executive Health Department. NHS HDL (2001)7. Patient Group Directions. January 2001. www.show.scot.nhs.uk/sehd/mels/hdl2001_07.htm
  8. Nursing and Midwifery Council. Code of Professional Conduct. London: NMC, 2002. www.nmc-uk.org
  9. Nursing and Midwifery Council. Standards for the Administration of Medicines. London: NMC, 2002. www.nmc-uk.org

Guidelines in Practice, January 2003, Volume 6(1)
© 2003 MGP Ltd
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