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Tetanus Surveillance -- United States, 1995-1997

Barbara Bardenheier, M.P.H (1,2) D. Rebecca Prevots, Ph.D., M.P.H. (1) Nino Khetsuriani, Ph.D., M.D. (1) Melinda Wharton, M.D., M.P.H. (1)

(1) Epidemiology and Surveillance Division

National Immunization Program (2) Dyntel Corporation

Abstract

Problem/Conditions: Despite widespread availability of a safe and effective vaccine against tetanus, 124 cases of the disease were reported during 1995-1997. Only 13% of patients reported having received a primary series of tetanus toxoid (TT) before disease onset. Of patients with known illness outcome, the case-fatality ratio was 11%.

Reporting Period Covered: 1995-1997.

Description of System: Physician-diagnosed cases of tetanus are reported by state and local health departments to CDC's National Notifiable Diseases Surveillance System. In addition, since 1965, supplemental clinical and epidemiologic information for cases has been provided to CDC's National Immunization Program.

Results: From 1995 through 1997, a total of 124 cases of tetanus were reported from 33 states and the District of Columbia, accounting for an average annual incidence of 0.15 cases per 1,000,000 population. Sixty percent of patients were aged 20-59 years; 35% were aged greater than or equal to 60 years; and 5% were aged less than 20 years, including one case of neonatal tetanus. For adults aged greater than or equal to 60 years, the increased risk for tetanus was nearly sevenfold that for persons aged 5-19 years and twofold that for persons aged 20-59 years. The case-fatality ratio varied from 2.3% for persons aged 20-39 years to 16% for persons aged 40-59 years and to 18% for persons aged greater than or equal to 60 years. Only 13% of patients reported having received a primary series of TT before disease onset. Previous vaccination status was directly related to severity of disease, with the case-fatality ratio ranging from 6% for patients who had received one to two doses to 15% for patients who were unvaccinated. No deaths occurred among the 16 patients who previously had received three or more doses. Tetanus occurred following an acute injury in 77% of patients, but only 41% sought medical care for their injury. All patients who sought care were eligible for TT as part of wound prophylaxis, but only 39% received it. Tetanus in injecting-drug users (IDUs) with no known acute injury comprised 11% of all cases, compared with 3.6% during 1991-1994. None of the IDU-associated tetanus cases occurred among persons who were known to have been vaccinated. Sixty-nine percent of IDU-associated tetanus cases were reported from California, and 77% of these cases occurred in heroin users.

Interpretation: Tetanus remains a severe disease that primarily affects unvaccinated or inadequately vaccinated persons. Adults aged greater than or equal to 60 years continue to be at highest risk for tetanus and for severe disease. However, the overall incidence of tetanus has decreased slightly since the late 1980s and early 1990s, from 0.20 to 0.15, a result primarily of a decreased incidence among persons aged greater than or equal to 60 and less than 20 years.

Actions Taken: Tetanus is preventable through both routine vaccination and appropriate wound management. In addition to decennial booster doses of diphtheria and tetanus toxoids during adult life, the Advisory Committee on Immunization Practices (ACIP) recommends vaccination visits for adolescents at age 11-12 years and for adults at age 50 years to enable health-care providers to review vaccination histories and administer any needed vaccine. Every contact with the health-care system, particularly among older adults and IDUs, should be used to review and update vaccination status as needed.

INTRODUCTION

The reported incidence of tetanus morbidity and mortality in the United States has declined substantially since the mid-1940s, when tetanus toxoid became universally available (1). This decline has resulted from a) widespread use of tetanus toxoid-containing vaccines (TT) for vaccination of infants and children (e.g., as diphtheria and tetanus toxoids and pertussis vaccine {DTP} or as diphtheria and tetanus toxoids for adult use {Td}), b) use of TT and tetanus immune globulin (TIG) for postexposure prophylaxis in wound treatment, and c) improved wound care management. In addition, increased rural to urban migration (2), with consequent decreased exposure to tetanus spores, may have contributed to the decline in tetanus mortality noted during the first half of the century.

Vaccination coverage with TT among school-aged children has improved substantially with the adoption and implementation of state immunization requirements. Forty-nine of the 50 states and the District of Columbia have passed legislation requiring that children be vaccinated for tetanus before admission to school (3), and greater than 96% of school-aged children have received three or more doses of DTP by the time they begin school (4). In addition, among children aged 19-35 months, national vaccination coverage with three or more doses of DTP has increased significantly (p less than 0.05), from 83% in 1992 to 95% in 1996 (5).

National surveillance for tetanus is conducted to monitor the epidemiology of the disease and to identify high-risk populations. In this report, we describe the epidemiology of tetanus in the United States from 1995 through 1997 and update tetanus morbidity and mortality trends from 1947 to 1997.

METHODS

Tetanus Surveillance

National tetanus surveillance relies on reporting of physician-diagnosed cases to state and local health departments. The diagnosis of tetanus is based on the clinical judgment of the attending physician because a laboratory test for definitive diagnosis of tetanus is not routinely available. In 1990, the Council of State and Territorial Epidemiologists and CDC adopted the following clinical case definition for public health surveillance for tetanus: "Acute onset of hypertonia and/or painful muscular contractions (usually of the muscles of the jaw and neck) and generalized muscle spasms without other apparent medical cause (as reported by a health professional)" (6).

State health departments report cases of tetanus on a weekly basis to CDC's National Notifiable Diseases Surveillance System (NNDSS). CDC publishes the number of tetanus cases reported by each state to NNDSS on a weekly basis and in an annual summary (1). In addition, since 1965, state health departments have reported supplemental clinical and epidemiologic information for cases to CDC's National Immunization Program. This supplemental reporting system provides CDC with information about the clinical history, presence and nature of any associated risk factors, vaccination status of the patient, wound care, and clinical management for each tetanus case (7). A summary of this additional information is published approximately every 2-4 years (8-12).

RESULTS

Long-Term Trends

During 1995-1997, a total of 124 tetanus cases with onset during this period (i.e., 40 * cases in 1995, 36 in 1996, and 48 in 1997) were reported to NNDSS. The annual average for this period was 41 cases, which is the lowest annual average ever reported since national tetanus surveillance began in 1947 (Figure_1) and is lower than the average of 50 cases reported from 1991 through 1994 (12). The incidence rate of 0.15 cases per million population represents a slight decline from the rate of 0.2 cases per million population reported from 1987 through 1994 (8-12) and a 96% decrease from the 3.9 cases per million population reported for 1947. The overall case-fatality ratio also has declined, from 91% in 1947 to 24% during 1989-1994 and to 11% during 1995-1997.

Epidemiology

At least one case of tetanus was reported by each of 33 states, the District of Columbia, and New York City during 1995-1997 (Figure_2), and tetanus cases were reported all 3 years by 10 states (California, Colorado, Florida, Illinois, Louisiana, Minnesota, New York, Pennsylvania, Tennessee, and Texas). Of the 17 states with no reported cases, seven (41%) were located in the Rocky Mountain and West North Central regions. Tetanus incidence in these regions has historically been low (8-12). An additional five states with no reported cases (29%) were located in New England.

Data on age were reported for all 124 patients. Of these, 44 (35%) were aged greater than or equal to 60 years; 74 (60%) were aged 20-59 years; and six (5%) were aged less than 20 years, including one case of neonatal tetanus and four patients aged 1-14 years (Figure_3). In contrast, during 1991-1994, 54% were aged greater than or equal to 60 years (an annual average of 25 cases) (12), and 41% were aged 20-59 years. During 1995-1997, the average annual incidence among persons aged greater than or equal to 60 years was 0.33 cases per million population, a more than 12-fold increased risk compared with that for persons aged 5-19 years (0.026 cases per million population), and a nearly twofold increased risk compared with that for persons aged 20-59 years (0.17 cases per million population) (Figure_3).

Data on sex were reported for all 124 patients; data on race and ethnicity were reported for 120 (97%) of the 124 patients. Of the 124 cases, 74 (60%) were male. The female-to-male ratio among patients aged 20-59 years was 0.42; among patients aged greater than or equal to 60 years, the ratio was 1.75. For persons aged 20-59 years, the incidence among males (0.24 cases per million population) was 2.4 times greater than that among females (0.10 cases per million population). For persons aged greater than or equal to 60 years, incidence among males (0.28 cases per million population) was similar to that among females (0.37 cases per million population). Incidence among whites was 0.15 cases per million population; among Hispanics, 0.27; and among blacks, 0.09.

Supplemental clinical and epidemiologic information was provided for 123 (99%) of the 124 reported tetanus cases. One case of neonatal tetanus was reported in an infant who was delivered in 1995 in a hospital where standard aseptic practices were used. The mother had immigrated from Mexico 8 years before delivery and had previously received only one tetanus vaccination in Mexico at age 12 years. Since moving to the United States in 1987, she had given birth to two other children in a hospital, and the index pregnancy included five routine visits for prenatal care during the 6 weeks before delivery. The family's home in the United States was near a pasture where cattle grazed. The infant recovered fully after a 2-month hospitalization (13).

The youngest non-neonatal tetanus case occurred in an unvaccinated boy aged 3-1/2 years who had been stung by an insect. Because of their religious beliefs, his parents initially refused medical care for the tetanus and treated the child with herbal tea and carrot juice. The child had generalized tetanus that required mechanical ventilation; he recovered after a 24-day hospitalization.

Previous Vaccination Status

Sixteen (13%) of the 122 non-neonatal patients with supplemental data were reported to have received at least a primary series (i.e., three or more doses) of TT before onset of illness (Table_1), including two (40%) of the five non-neonatal patients aged less than 20 years. Three (60%) of the non-neonatal patients aged less than 20 years were unvaccinated because of their parents' religious objections. The fourth case occurred in a boy aged 14 years who was bitten by a dog and who had received his last dose 2 years previously. This patient did not seek medical care for his injury and was later hospitalized with tetanus for 2 days. He did not require mechanical ventilation and subsequently recovered. The fifth case occurred in a boy aged 15 years who was in a moped crash; the interval since his last dose was 11 years. The patient sought medical attention and received TT within 6 hours of his injury; he was hospitalized 4 days and recovered without sequelae.

Of the 14 (11%) patients aged greater than or equal to 20 years who were known to have received a primary series, six reported receipt of the last booster dose less than or equal to 10 years before onset of illness and two within 5 years before onset of illness.

Case-Fatality Ratio

Fourteen deaths occurred among 122 patients with known outcome, representing a case-fatality ratio of 11%. All tetanus-related deaths occurred among patients aged greater than or equal to 25 years. The case-fatality ratio varied from 2.3% among patients aged 20-39 years to 16% among patients aged 40-59 years and to 18% among patients aged greater than or equal to 60 years. Previous vaccination status was directly related to disease severity: the case-fatality ratio ranged from 6% for patients who had received one to two doses of TT to 15% for patients who were unvaccinated. No deaths occurred among the 16 patients who previously had received three or more doses (Table_1), and only one patient required mechanical ventilation. Of these 16 patients, nine had generalized tetanus, four had localized tetanus, and one had cephalic tetanus. For two cases, the type of tetanus was unknown.

Type of Injury, Wound Treatment, and Prophylaxis

An acute injury sustained before onset of illness was identified for 93 (77%) of the 120 tetanus cases with known injury status. Of these cases, 46 (49%) occurred after puncture wounds, the most frequent type of injury. Of the 33 patients for whom the circumstance of the puncture wound was known, 13 (39%) had stepped on a nail. Other puncture wounds resulted from self-performed body piercing (one case), self-performed tattooing (one case), animal bites, and splinters. The case associated with body piercing occurred in a woman aged 27 years who pierced her umbilicus at home with a sterile 16-gauge needle. The other most frequently reported types of acute injury were 20 (22%) lacerations and 11 (12%) abrasions. Nine (10%) of the 93 patients with an acute injury also reported injecting-drug use (IDU). An additional three patients had an acute injury related to surgery performed 4-8 days before onset of illness; none of these patients were known to have been vaccinated for tetanus. These patients included a woman aged 63 years who underwent a hemorrhoidal banding procedure, a man aged 41 years who had an implant inserted in his back, and a man aged 32 years who had knee surgery. All three patients were administered TIG therapeutically and recovered.

The site of the antecedent acute injury was a lower extremity in 43 (46%) patients, an upper extremity in 33 (35%) patients, and the head or trunk in 11 (12%) patients. The injury site was not specified for six patients. The environment in which the antecedent injury occurred was reported for 85 patients. Of these patients, 20 (24%) were injured while at home; 13 (15%) while indoors, other than at home; 33 (39%) while performing outdoor farming or gardening activities; and 19 (22%) while engaged in other outdoor activities. The median incubation period was 6 days (range: 0-73 days) for the 92 non-neonatal cases with an acute injury for which dates of injury and illness onset were known. For 90 (98%) of these cases, the incubation period was less than or equal to 30 days.

Information regarding medical care was reported for 88 patients who became ill with tetanus after sustaining an acute injury. Of these patients, 36 (41%) obtained medical care for their injury, and all were eligible to receive Td prophylaxis for wound management. TT was administered as prophylaxis to only 14 patients (i.e., 39% of those who obtained medical care), 10 (71%) of whom received toxoid within 24 hours after the injury. The remaining 22 patients were eligible for Td prophylaxis but did not receive it as recommended by the Advisory Committee on Immunization Practices (ACIP). Of the 13 (43%) patients who sought medical care and whose wounds were debrided, only three received the TIG indicated as part of wound prophylaxis.

Twenty-nine non-neonatal cases unrelated to acute injury were associated with underlying medical conditions, including chronic wounds or IDU. Two patients had breast tissue necrosis secondary to breast cancer. Three patients had diabetes, two of whom were insulin-dependent. Thirteen (43%) of the patients without an acute injury were known to be IDUs (one of whom also had insulin-dependent diabetes), representing 11% of all tetanus cases. The median age of patients with IDU-associated tetanus was 43 years (range: 24-60 years); 11 (85%) were male. Vaccination history was known for three (23%) of the 13 IDU-associated patients, all of whom were unvaccinated. The overall case-fatality ratio among IDU-associated cases was 15%. Nine (69%) of the 13 IDU-associated cases were reported from California. Of these cases, eight (89%) were Hispanic, seven (78%) were male, and three (33%) were aged 20-29 years. Although information on the types of drugs used is not routinely collected on IDU-associated tetanus cases, seven of the patients with tetanus from California were identified as heroin users (14).

Clinical Features and Treatment

The type of tetanus was reported for 100 (82%) of the 123 cases with supplemental information. Of these cases, 81 (81%) were generalized; 13 (13%), localized; and six (6%), cephalic. Therapeutic TIG administration for treatment of clinical tetanus was reported for 108 (88%) patients, and the exact dosage of TIG was specified for 80 (74%) patients. The median TIG dosage used therapeutically was 3,000 IU; 75% of the patients received 1,000-4,000 IU of TIG. The interval between onset of illness and TIG administration was known for 102 (94%) of the patients who received TIG; TIG was administered to 35 (34%) of these patients less than 24 hours after onset of illness and to 40 (40%) patients 1-4 days after onset. The case-fatality ratio for patients who received therapeutic treatment within 24 hours was 9%, compared with 10% for those who received treatment greater than 1 day after onset of illness. Information about illness outcome was reported for 107 (99%) patients who received TIG; 11 (10%) of these patients died. Two (20%) of the 10 patients who did not receive TIG died.

Length of hospitalization was reported for 98 (79%) patients; the median duration was 11 days (range: 0-79 days). Of the 96 patients for whom the use of assisted ventilation was reported, 46 (48%) received ventilation. Eighteen percent of those who required ventilation died, compared with 6% of those who did not require ventilation.

DISCUSSION

Tetanus remains a severe disease occurring primarily among persons who are unvaccinated or inadequately vaccinated. Adults aged greater than or equal to 60 years continue to be at highest risk for tetanus and for severe disease. However, the overall incidence of tetanus has decreased slightly since the late 1980s and early 1990s, from 0.20 to 0.15 cases per million, a result primarily of a decreased incidence among persons aged greater than or equal to 60 and less than 20 years. In addition, for the first time since 1973 (15), patients aged 20-59 years have accounted for a greater proportion of cases (60%) than those aged greater than or equal to 60 years, with most (52%) of these cases in the 20-49 year age group. This change in age distribution has resulted from both an increase in the average annual number of cases among persons aged 20-59 years and a decrease in the average annual number of cases among persons aged greater than or equal to 60 and less than 20 years (12).

Older adults are at highest risk for tetanus because of the low prevalence of immunity to tetanus in this population. Data obtained from a national population-based serologic survey conducted during 1988-1991 indicate that the prevalence of immunity to tetanus in the United States is lower in older age groups, from greater than 80% among persons aged 6-39 years to 28% among persons aged greater than or equal to 70 years (16). The decreased incidence among older adults during the 1990s may be in part related to increases in tetanus vaccination among persons aged greater than or equal to 60 years. The National Health Interview Survey, a national probability sample, ascertained a moderate increase in tetanus vaccination rates among older adults; in 1991, 27% of persons aged greater than or equal to 65 years reported that they had received a tetanus vaccination during the preceding 10 years. By 1995, this figure had increased to 36% (CDC, unpublished data). Although this increase in tetanus vaccination does not entirely explain the twofold decreased incidence in adults aged greater than or equal to 70 years, it suggests increased compliance with current tetanus vaccination recommendations for adults (17). Nonetheless, to further reduce the tetanus burden among older adults, improved compliance with these recommendations is needed to increase population immunity.

The disproportionate number of tetanus cases in the 20-59 year age group is in part related to an increased number of cases among IDUs, particularly among Hispanics in California. Among patients aged 20-59 years, IDUs comprised 27% of cases and 14% of cases with no acute injury. Overall, IDUs comprised 18% of all cases; IDUs with no acute injury comprised 11% of all cases. In contrast, from 1982 through 1994, the overall proportion of IDU-associated cases ranged from 2.1% to 4.5% (8-12) **. The increase in the number of IDU-associated tetanus cases is related to an increase in cases reported from California; although California has reported most (59%) of these cases in the United States since 1987, the number of IDU-associated cases reported from California has increased steadily since the 1990s, particularly in recent years (14). A disproportionate number of IDU-associated cases was last observed in the United States among cases reported during 1970-1971 (18).

IDUs, particularly heroin users, have previously been reported to be at high risk for tetanus both in the United States and elsewhere (19-24). The high risk among IDUs is related to both increased exposure and susceptibility, including: a) the high prevalence of abscesses, which favor anaerobic conditions for bacterial growth, secondary to nonsterile injection practices (25); b) subcutaneous injection ("skin popping") (19,20,22); c) contamination of the drug supply (20,21); and d) low prevalence of immunity (19,24). The increased number of cases among Hispanic IDUs may be related to both low prevalence of immunity to tetanus and exposure to contaminated heroin. A national population-based seroprevalence survey conducted during 1988-1991 identified ethnic differences in tetanus immunity. Only 58% of Mexican-Americans (the predominant Hispanic population in the Western region {26}) had protective levels of tetanus antibodies, compared with 73% of non-Hispanic whites and 68% of non- Hispanic blacks (16).

Most of the heroin supplied to the Southwest is available in the resinous form called "black tar" (27,28); the use of black tar heroin may be increasing in this region (29). A recent increase in cases of wound botulism (an anaerobic bacterial infection caused by Clostridium botulinum) associated with injecting black tar heroin has also been reported among drug users in California (29). Whether the disproportionate number of IDU-associated cases from California is because of an increase in black tar heroin use remains unclear and requires further investigation (14). Among IDUs for whom drug cessation strategies have not been successful, strategies to prevent cases of tetanus among IDUs, include a) use of clean needles and sterile injection technique (30) and b) assessment and updating of vaccination status as needed during every contact with the medical-care system. ACIP recognizes that IDUs are at increased risk for tetanus and recommends that they be kept up-to-date with Td vaccinations (31).

The case of neonatal tetanus reported in 1995 was the first reported since 1989 (32). Although nearly all tetanus cases in the United States occur in adults, most reported tetanus cases worldwide occur in neonates, with an estimated 490,000 deaths worldwide attributed to neonatal tetanus in 1994 (33). The goal of worldwide neonatal tetanus elimination was adopted by the World Health Assembly in 1989 (34). This goal has been defined as less than one case per 1,000 live births in the presence of a functional surveillance system. The key strategies are a) achievement and maintenance of high vaccination coverage levels among women of childbearing age in high-risk areas and b) promotion of clean delivery and cord-care practices (35). The two most recent neonatal tetanus cases in the United States occurred among infants born to immigrants in the United States in 1989 (32) and 1995 (13). The elimination of neonatal tetanus in the United States can ultimately only be achieved through improved worldwide coverage with at least two doses of TT among girls and women of childbearing age.

National health objectives for the year 2000 include a disease-elimination objective of no tetanus cases among persons aged less than 25 years. Three of the 12 cases among persons aged less than 25 years were among children who had received no vaccines because their parents had religious or philosophic objections to vaccination. Tetanus is not a communicable disease, and the organism is ubiquitous in the environment; unlike other vaccine-preventable diseases, there is no herd immunity to tetanus. As long as any child remains susceptible to tetanus, cases of tetanus among children in the United States can continue to occur.

The number of cases derived from passive reporting by physicians to local and state health departments underestimates the true incidence of tetanus in the United States. Completeness of reporting for tetanus mortality has been estimated at 40%, while completeness of reporting for tetanus morbidity may be lower (36). Although tetanus mortality reporting is incomplete, reported tetanus deaths are representative of all tetanus deaths (36). Because fatal cases are more likely to be reported than nonfatal ones, possible changes in reporting practices do not appear to explain the decreased number of reported cases among older adults, who are more likely to have severe disease.

Tetanus remains a clinical diagnosis because confirmatory laboratory tests are not available for routine use. Isolation of the organism from wounds is neither sensitive nor specific: anaerobic cultures of tissues or aspirates usually are not positive, and the organism might be grown from wounds in the absence of clinical signs and symptoms of disease (37-39).

Tetanus is preventable through both routine vaccination and appropriate wound management. Vaccination with a primary series of three doses of TT-containing vaccine and booster doses of Td every 10 years are highly effective in preventing tetanus (40). During 1995-1997, only 13% of patients were known to have completed a primary series with TT before onset of tetanus, and only 47% of these had been vaccinated during the 10 years preceding onset of tetanus. In addition, nearly two thirds of patients who sought medical care following their injury did not receive prophylaxis as recommended by ACIP (Table_2).

ACIP recommends that persons be routinely scheduled for a vaccination visit at age 11-12 years (41) and age 50 years (42). Such visits enable health-care providers to a) review the patient's vaccination status, b) administer Td as indicated, and c) determine whether a patient needs other vaccinations (e.g., influenza and pneumococcal vaccinations). Because many patients with tetanus did not have an acute injury and only 41% of those who did have an acute injury sought medical care, every contact with the health-care system, particularly among the elderly and IDUs, should be used to review and update vaccination status as needed.

Acknowledgments

The authors thank Evelyn L. Finch and Barry I. Sirotkin for data management and statistical support and Peter M. Strebel and Roland W. Sutter (all four with CDC's National Immunization Program, Atlanta, GA) for their critical review of the manuscript; Cynthia D. O'Malley (California Department of Health Services, Berkeley, CA) for her assistance with surveillance data; and all reporting state and local health departments for their efforts in conducting tetanus surveillance.

References

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* One case with onset in 1994 was reported in 1995; this case was included in a previous surveillance summary (12).

** During 1991-1994, although six of the seven IDU-associated cases were initially reported as having an acute injury, further investigation revealed that the only known injury was ongoing drug use.



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Table_1
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TABLE 1. Tetanus toxoid vaccination status and deaths among persons with reported
tetanus, by vaccination status -- United States, 1995-1997
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                                           No.
Vaccination status     No.        (%)     deaths
------------------------------------------------
Unknown                 66    ( 53.7)        9
0 doses                 27    ( 21.5)        4
1 dose                  11    (  9.1)        0
2 doses                  4    (  3.3)        1
3 doses                  4    (  3.3)        0
>=4 doses               12    (  9.1)        0

Total                  124 *  (100.0)       14
------------------------------------------------
*Outcome was unknown for two patients.
====================================================================================

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Table_2
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TABLE 2. Summarized recommendations for the use of tetanus prophylaxis in routine
wound management -- Advisory Committee on Immunization Practices (ACIP), 1991 (17)
===================================================================================================
                       Clean, minor wounds    All other wounds *
History of adsorbed    -------------------    ------------------
  tetanus toxoid          Td +      TIG &        Td       TIG
----------------------------------------------------------------
Unknown or <3 doses       Yes        No          Yes      Yes
>=3 doses @               No **      No          No ++    No
----------------------------------------------------------------
 * Such as, but not limited to, wounds contaminated with dirt, feces, soil, or saliva; puncture
   wounds; avulsions; and wounds resulting from missiles, crushing, burns, or frostbite.
 + For children aged <7 years the diphtheria and tetanus toxoids and acellular pertussis
   vaccines (DTaP) or the diphtheria and tetanus toxoids and whole-cell pertussis vaccines
   (DTP) -- or pediatric diphtheria and tetanus toxoids (DT), if pertussis vaccine is
   contraindicated -- is preferred to tetanus toxoid (TT) alone. For persons aged >= 7 years, the
   tetanus and diphtheria toxoids (Td) for adults is preferred to TT alone.
 & TIG=tetanus immune globulin.
 @ If only three doses of fluid toxoid have been received, a fourth dose of toxoid -- preferably
   an adsorbed toxoid -- should be administered.
** Yes, if >10 years have elapsed since the last dose.
++ Yes, if >5 years have elapsed since the last dose. More frequent boosters are not needed
   and can accentuate side effects.
===================================================================================================

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