Infectious Disease
Tetanus immunity and physician compliance with tetanus prophylaxis practices among emergency department patients presenting with wounds

https://doi.org/10.1016/j.annemergmed.2003.09.017Get rights and content

Abstract

Study objective

We determine tetanus seroprotection rates and physician compliance with tetanus prophylaxis recommendations among patients presenting with wounds.

Methods

A prospective observational study of patients aged 18 years or older who presented to 5 university-affiliated emergency departments (EDs) because of wounds was conducted between March 1999 and August 2000. Serum antitoxin levels were measured by enzyme immunoassay with seroprotection defined as more than 0.15 IU/mL. Seroprotection rates, risk factors for lack of seroprotection, and rates of physician compliance with tetanus prophylaxis recommendations by the Advisory Committee on Immunization Practices were determined.

Results

The seroprotection rate among 1,988 patients was 90.2% (95% confidence interval 88.8% to 91.5%). Groups with significantly lower seroprotection rates were persons aged 70 years or older, 59.5% (risk ratio [RR] 5.2); immigrants from outside North America or Western Europe, 75.3% (RR 3.7); persons with a history of inadequate immunization, 86.3% (RR 2.9); and persons without education beyond grade school, 76.5% (RR 2.5). Despite a history of adequate immunization, 18% of immigrants lacked seroprotection. Overall, 60.9% of patients required tetanus immunization, of whom 57.6% did not receive indicated immunization. Among patients with tetanus-prone wounds, appropriate prophylaxis (ie, tetanus immunoglobulin and toxoid) was provided to none of 504 patients who gave a history of inadequate primary immunization (of whom 15.1% had nonprotective antibody titers) and to 218 (79%) of 276 patients who required only a toxoid booster.

Conclusion

Although seroprotection rates are generally high in the United States, the risk of tetanus persists in the elderly, immigrants, and persons without education beyond grade school. There is substantial underimmunization in the ED (particularly with regard to use of tetanus immunoglobulin), leaving many patients, especially those from high-risk groups, unprotected. Better awareness of tetanus prophylaxis recommendations is necessary, and future tetanus prophylaxis recommendations may be more effective if they are also based on demographic risk factors.

Introduction

Tetanus continues to occur in the United States despite the widespread availability of a safe and effective vaccine. Between 1995 and 1997, 124 cases were reported, with a case fatality rate of 11%, and it is believed there is significant underreporting.1

Clinical tetanus in the United States has predominantly been limited to the elderly who were born before childhood immunization became routine.1, 2 Previous seroprevalence studies have found high rates of underprotection among the elderly and immigrants.3, 4 However, no seroprevalence data exist among emergency department (ED) patients seeking wound care. Recently, however, the epidemiology of tetanus has shifted to younger populations that include parenteral drug users.1, 2, 5 Seroprotection rates among these patients, who often seek ED care, are also unknown.

Many patients seeking wound care have not received adequate tetanus immunizations.6 In this circumstance, tetanus can be potentially prevented by episodic administration of tetanus toxoid either alone or with tetanus immunoglobulin, as dictated by recommendations of the Advisory Committee on Immunization Practices (Appendix).7 However, to the best of our knowledge, no information exists about the extent to which these recommendations are followed in ED practice.

To evaluate the effectiveness of current tetanus prophylaxis recommendations, it is important to establish an understanding of the degree of tetanus risk among ED patients presenting with wounds and the extent to which episodic tetanus prophylaxis is appropriately administered.

The purpose of this study was to determine tetanus antitoxin levels among ED patients treated for wounds. We also evaluated physician compliance with Advisory Committee on Immunization Practices immunization recommendations for these patients and examined the frequency with which patients who did not receive adequate prophylaxis were unprotected based on their serology. We hypothesized that there continue to exist at-risk groups with substantial underprotection and practices that result in substantial underimmunization.

Section snippets

Study design and setting

This was a prospective observational case series conducted at 5 urban university-affiliated EDs in collaboration with the US Centers for Disease Control and Prevention (CDC) and EMERGEncy ID NET, a CDC-supported, ED-based network that conducts research on emerging infectious diseases. Each investigative site's institutional review board approved the study.

Selection of participants

Patients selected were a convenience sample aged 18 years or older and presenting for wound-related complaints between March 1999 and August

Results

Among 2,134 patients enrolled, 146 (6.8%) were excluded from serology evaluation because of a lack of specimen, and 210 (9.8%) were excluded from evaluation of tetanus immunization because their accompanying data sheet lacked documentation of tetanus immunization history (Figure). Twenty-three attending physicians completed a survey after the completion of the study to determine their knowledge of the study's purpose. Most had either no idea (52%) or low certainty (48%) of the study's specific

Limitations

In this study, compliance with Advisory Committee on Immunization Practices recommendations was used as the criterion standard for judging the appropriateness of tetanus prophylaxis practices. However, these recommendations have not been validated as the optimally effective strategy. The number of reported tetanus cases in the United States presently is low compared with that observed before the institution of routine and episodic immunization policies. It is beyond the scope of this research

Discussion

A 1995 editorial commenting on the low rates of tetanus seroprotection and continued observation of tetanus cases in the United States stated that “a case of tetanus reflects the failure of our health care delivery system to provide immunization.”11 Previous studies have found that approximately 30% of persons older than 6 years lack protective tetanus immunity, with rates as high as 60% among Mexican-born Americans and the elderly.3, 4 Not surprisingly, past tetanus cases and tetanus-related

Acknowledgements

We wish to acknowledge Stewart Geboff, Gina Pulido, John DeHart, Chris King, the study assistants, and medical and nursing staff at the participating centers for their assistance with this project.

References (15)

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Author contributions: DAT, GJM, KA, BRT, CVP, MTS, LMD, RSW, and SMO conceived and designed the study. FMA, KA, BRT, CVP, MTS, and LMD acquired the data. WRM, DAT, and FMA analyzed and interpreted the data. DAT and FMA drafted the manuscript. WRM and FMA conducted the statistical analysis. MDB conducted the serologic testing. DAT obtained funding. DAT, KA, BRT, CVP, MTS, LMD, RSW, and SMO provided administrative, technical, and material support. DAT, FMA, KA, BRT, CVP, MTS and LMD supervised the study. All authors take responsibility for the paper as a whole.

Supported by a research grant from Bayer Biological Products, Research Triangle Park, NC.

Dr. Talan, Dr. Abrahamian, Dr. Moran, and Dr. Alagappan have received speaking honoraria and research grants from Bayer. Dr. Dunbar has received research grants from Bayer.

Reprints not available from the authors.

1

Dr. Pollack is currently affiliated with the Pennsylvania Hospital, University of Pennsylvania Health System, Philadelphia, PA.

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