Jane Chiodini explains the importance of tetanus immunisation and describes how to set up a patient group direction for administering the vaccine

Tetanus is induced by the toxin of tetanus bacillus, Clostridium tetani which is harboured in the intestine of many vertebrates, including man. The spores are also widely distributed in the environment, particularly in the soil.

Infection usually results when spores are introduced into a wound at the time of an injury, often through a puncture wound but also through burns and superficial cuts.

Neonatal tetanus, caused by infection of the baby's umbilical stump, is the cause of many deaths in Asia and Africa.

The invading toxin grows anaerobically and the acute disease is characterised by muscular rigidity with superimposed agonising contractions. The incubation period is between 4 and 21 days.

Management involves administering human tetanus immunoglobulins and benzylpenicillin. Recovery may take several weeks, but severe cases will require intensive nursing care, assisted ventilation and muscle relaxants. Patients are at risk of dying even in the later stages of the illness.1-2

Tetanus immunisation became part of the UK national routine childhood programme in 1961. Members of the British armed forces have received tetanus immunisation since 1938.1

The World Health Organization target of 95% coverage for tetanus immunisation has been achieved in the UK for the past 8 years, and of the few cases that occur, most are in older people who have never been immunised.

In England and Wales there were four cases of tetanus in 1999 and two in 2000, resulting in two deaths. One was an unimmunised man in his 90s who had injured himself on a rose bush, and the other was a 50-year-old farmer who developed tetanus following an injury at work. He had received a booster dose of tetanus toxoid but his primary vaccination history was not known.3

Current guidance recommends that tetanus be given as part of the national programme.1 The primary course consists of three doses starting at 2 months old with an interval of one month between each dose.

A booster should be given at least 3 years after the final dose of the primary course, and a further reinforcing dose is recommended approximately 10 years later. (This is usually combined with low dose diphtheria-Td vaccine.)

Figure 1: Sample patient group direction for absorbed tetanus vaccine, BP
Figure 1 (continued): Sample patient group direction for absorbed tetanus vaccine, BP
Figure 1(continued): Sample patient group direction for absorbed tetanus vaccine, BP

Drawing up a PGD

Patient group directions (PGDs) have been a legal requirement throughout the UK since 9 August 2000. National guidance is now available in England,4 Wales5 and Scotland.6

PGDs should be in place for the administration of these prescription only medicines (POM) to groups of patients who may not be individually identified before presentation at the surgery.

Nurses administering these vaccines must only do so 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.4-5-6

To work in accordance with a PGD the nurse administering the POM must be named in the document and must sign it, as must the senior doctor giving his or her authorisation for the nurse to work within the PGD.

To do this, however, the senior doctor in the practice must be satisfied that the nurse has adequate knowledge and is competent to administer the immunisation in line with the Nursing and Midwifery Council (NMC) Code of Professional Conduct7 and NMC Standards for the Administration of Medicines.8

It is essential to have access to the Summary of Product Characteristics (SPCs) for the vaccine, which is available directly from the drug manufacturer or on the internet. SPCs for the tetanus vaccines can be obtained from http://emc.vhn.net/. It is advisable to gather all the information required before commencing work on a PGD, which 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 follow up action necessary and the circumstances
  • A statement of the records to be kept for audit purposes.

For those who have received five doses of tetanus vaccine, booster doses are not recommended other than at the time of a tetanus-prone injury, because they have been shown to be unnecessary and can cause considerable local reaction.1

However, travellers may need additional boosters if they are going to countries where specific tetanus immunoglobulin, which is used for treatment, is not available and tetanus-prone injuries are likely to occur.2 Pre-travel assessment is important to evaluate this risk to enable both the healthcare professional and the traveller to decide on a suitable course of action.


  1. Department of Health. Immunisation Against Infectious Disease. London: HMSO, 1996.
  2. Scottish Centre for Infection and Environmental Health. Tetanus factsheet. http://www.travax.scot.nhs.uk/
  3. 1999/2000 Review of Communicable Diseases, England and Wales. Chapter 4: Vaccine Preventable Diseases. http://www.phls.org.uk/publications/Annual%20Review/ReviewIndex.htm
  4. NHS Executive. Patient Group Directions (England Only). HSC 2000/026. Leeds: NHSE, 2000.
  5. 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). COCNO CDOCSOCPhA-SALEMED3. 22 December 2000
  6. Scottish Executive Health Department. NHS HDL (2001)7. Patient Group Directions. January 2001. www.show.scot.nhs.uk/sehd/mels/hdl2001_07.htm
  7. Nursing and Midwifery Council. Code of Professional Conduct. London: NMC, 2002. www.nmc-uk.org
  8. Nursing and Midwifery Council. Standards for the Administration of Medicines. London: NMC, 2002. www.nmc-uk.org