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It is recommended that five doses of tetanus toxoid provide lifelong immunity and 10 yearly doses are not required beyond this.1 National immunisation against tetanus began in 1961, providing five doses (three in infancy, one preschool and one on leaving school).2 Coverage is high, with uptake over 90% since 1990.2 Therefore, the majority of the population under the age of 40 are fully immunised against tetanus.
Td (tetanus toxoid/low dose diphtheria) vaccine is often administered in the Emergency Department (ED) following a wound or burn based upon the patient’s recollection of their immunisation history. Many patients and staff may believe that doses should still be given every 10 years.
During summer 2004, an audit of tetanus immunisation was carried out at our department. The records of 103 patients who had received Td in the ED were scrutinised and a questionnaire was sent to the patient’s GP requesting information about the patient’s tetanus immunisation history before the dose given in the ED. Information was received in 99 patients (96% response). In 34/99 primary care records showed the patient was fully immunised before the dose given in the ED. One patient had received eight doses before the ED dose and two patients had been immunised less than 1 year before the ED dose. In 35/99 records suggested that the patient was not fully immunised. However, in this group few records were held before the early 1990’s and it is possible some may have had five previous doses. In 30/99 there were no tetanus immunisation records. In 80/99 no features suggesting the wound was tetanus prone were recorded.
These findings have caused us to feel that some doses of Td are unnecessary. Patient’s recollections of their immunisation history may be unreliable. We have recommended that during working hours, the patient’s general practice should be contacted to check immunisation records. Out of hours, if the patient is under the age of 40 and the wound is not tetanus prone (as defined in DoH Guidance1), the general practice should be contacted as soon as possible and the immunisation history checked before administering Td.
However, we would like to emphasize that wound management is paramount, and that where tetanus is a risk in a patient who is not fully immunised, a tetanus booster will not provide effective protection against tetanus. In these instances, tetanus immunoglobulin (TIG) also needs to be considered (and is essential for tetanus prone wounds). In the elderly and other high-risk groups—for example, intravenous drug abusers—the need for a primary course of immunisation against tetanus should be considered not just a single dose and follow up with the general practice is therefore needed.
The poor state of many primary care immunisation records is a concern and this may argue in favour of centralised immunisation records or a patient electronic record to protect patients against unnecessary immunisations as well as tetanus.
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