Public Health England Guideline

Guidance on the management of suspected tetanus cases and on the assessment and management of tetanus-prone wounds

Tetanus disease

Tetanus is caused by a neurotoxin produced by Clostridium tetani, an anaerobic spore forming bacillus.

Generalised tetanus is characterised by trismus (lockjaw), tonic contractions and muscle spasms (painful muscular contractions of trunk muscles, dysphagia, opisthotonus, rigid abdomen).

Localised tetanus involves rigidity and spasms confined to site of infection.

Tetanus is primarily a clinical diagnosis.

Tetanus is a notifiable disease.

Vaccine schedule

Vaccine is given as a combined preparation containing adsorbed tetanus toxoid vaccine (cell-free purified toxin of Clostridium tetani).
Adult Combined preparation (Td/IPV): tetanus, low-dose diphtheria, inactivated polio
Children combined preparation: 6-in-1 vaccine : diphtheria, tetanus, pertussis, inactivated polio, Haemophilus influenzae type b, hepatitis B)

Children
Age<1y: three doses, at age 2m, 3m, 4m (DTaP/IPV/Hib/HepB) = primary course
Age 4y/pre-school entry: one booster dose (DTaP/IPV) = 1st booster (4th dose)
Age 13-18y/School leaving: one booster dose (Td/IPV) = 2nd booster (5th dose)

Adults
3 doses of Td/IPV one month apart = primary course
+ 5yr later Td/IPV = 1st booster (4th dose)
+10yr later Td/IPV = 2nd booster (5th dose)

In most cases, 5 doses of tetanus vaccine is considered sufficient for long-term protection.

Tetanus-prone wound

Any of the following:

• Sustained more than 6 hours before surgical treatment

• Puncture-type (particularly if contaminated with soil or manure, gardening injury)

• Devitalised tissue

• Septic or are compound fractures

• Contain foreign bodies (such as wound splinters)

• Certain animal bites and scratches

Very rarely, tetanus has developed after abdominal surgery or parenteral drug abuse.

Action for tetanus prone wound

1. Wound debridement and cleansing

2. Any doubt of vaccination status, then administer tetanus booster and further vaccination following recovery

3. Intramuscular tetanus specific immunoglobulin (IM-TIg), given at a different site, if the risk of infection is especially high (e.g. contamination with manure).

4. Antibacterial prophylaxis (with benzylpenicillin, co-amoxiclav, or metronidazole)

If suspected tetanus infection (generalised or localised) then add in the following to the above regimen:

1. Human intravenous immunoglobulin (IVIG) based on weight e.g. octagam 5%, vigam 5%, gammaplex 5%

2. Supportive care (benzodiazepines for muscle spasms, treatment of autonomic dysfunction, maintenance of ventilation)

3. Full course of tetanus booster and further tetanus vaccination following recovery to ensure tetanus immunity

Clean wounds

For clean wounds, fully immunised individuals (those who have received a total of 5 doses of a tetanus-containing vaccine at appropriate intervals) and those whose primary immunisation is complete (with boosters up to date), do not require tetanus vaccine.