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Tetanus in a Child with Improper Medical Exemption from Immunization -- Florida

In June 1984, a 12-year-old male was brought to a Florida emergency room for an inflamed splinter wound on the foot. The injury had occurred 14 days previously and had been treated with herbal remedies. The child was given tetanus toxoid and intramuscular penicillin and was sent home. Later that day, he developed neck stiffness, interscapular pain, and spasms. He returned to the emergency room, where generalized stiffness and difficulty opening the jaw were noted. A small splinter was removed from his foot, and some pus was expressed. He was admitted to an intensive-care unit, placed on high-dose penicillin, and given 7,000 units of tetanus immune globulin (TIG) over a 5-day period. Diazepam was begun to control increasingly frequent muscle spasms lasting 1-2 minutes. Episodic periods of tachycardia, hypertension, and diaphoresis occurred. Respiratory function remained stable, and on the ninth day of hospitalization, the child was transferred to the pediatric ward. He recovered and was discharged on day 12 of hospitalization.

Investigation revealed that the child had received a dose of oral polio vaccine at about 18 months of age but had received no other immunizations. In the school record was a form granting him permanent medical exemption to all vaccines. The form, signed by a health-care provider, gave the reason for exemption as "due to recent medical literature." The provider later stated that the literature referred to "cytotoxic allergies secondary to immunization," but cited no specific references. Review of immunization records in the child's school revealed two other children with similar exemptions granted by this same provider. Reported by JJ Witte, HT Janowski, JJ Sacks, MD, Acting State Epidemiologist, Florida Dept of Health and Rehabilitative Svcs; Div of Field Svcs, Epidemiology Program Office, Surveillance, Investigations, and Research Br, Div of Immunization, Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: This case illustrates several important points: (1) a thorough attempt should be made to determine the tetanus immunization status of persons with wounds treated in emergency rooms; (2) appropriate antitetanus wound prophylaxis should reflect the patient's immunization status and type of wound (1); (3) even with a school immunization law in place, proper immunization of a school-aged child cannot be assumed; and (4) granting of medical exemptions should not be given indiscriminately.

A recent study of antitetanus prophylaxis in emergency rooms found that 23% of patients with wounds were treated incorrectly (6% undertreated, 17% overtreated). Moreover, only 27% of patients at highest risk of acquiring tetanus, i.e., those with contaminated puncture wounds or other serious wounds and/or fewer than three previous doses of tetanus toxoid, received appropriate prophylaxis against tetanus (2). In this particular instance, little could have been done to prevent tetanus at the time the patient presented to the emergency room because so much time had elapsed since the wound occurred. A summary guide to tetanus prophylaxis in routine wound management is presented in Table 1.

Tetanus toxoid is generally well tolerated, even in individuals with histories of presumed adverse reactions to tetanus toxoid. In one study, 94 of 95 persons giving histories of anaphylactic symptoms following a previous tetanus toxoid dose were nonreactive following intradermal testing and tolerated a further tetanus toxoid challenge without a reaction (3). Booster doses are routinely recommended every 10 years. More frequent boosters are not indicated and may result in an increased occurrence and severity of adverse reactions, particularly the Arthus-type hypersensitivity reaction (4).

Adults are less likely than children to be adequately immunized or adequately protected against tetanus and diphtheria (5-7). The routine use of tetanus and diphtheria toxoids (Td) in all medical settings is, therefore, recommended; emergency room visits by adults may be the best opportunity to boost immunity to both tetanus and diphtheria.

At least four doses of a tetanus toxoid-containing preparation are required for entering kindergarten in Florida. Exemptions from immunization in Florida are allowed for religious or medical reasons but only a very small proportion (0.1%) of Florida schoolchildren have such exemptions. To maintain the current high levels of immunization in the school system and to avoid incidents such as the one described here, medical exemptions should be carefully evaluated. For example, a contraindication (e.g., immune deficiency) to live virus vaccines does not mean inactivated vaccines are necessarily contraindicated as well. Blanket medical exemptions for all vaccines are rarely indicated.


  1. ACIP. Diphtheria, tetanus, pertussis: guidelines for vaccine prophylaxis and other preventive measures. MMWR 1985;34:405-14, 419-26.

  2. Brand DA, Acampora D, Gottlieb LD, Glancy KE, Frazier WH. Adequacy of antitetanus prophylaxis in six hospital emergency rooms. N Engl J Med 1983;309:636-40.

  3. Jacobs RL, Lowe RS, Lanier BQ. Adverse reactions to tetanus toxoid. JAMA 1982;247:40-2.

  4. Edsall G, Elliot MW, Peebles TC, et al. Excessive use of tetanus toxoid boosters. JAMA 1967;202:111-3.

  5. Mullooly JP. Tetanus immunization of adult members of an HMO. Am J Public Health 1984;74:841-2.

  6. Ruben FL, Nagel J, Firemen P. Antitoxin responses in the elderly to tetanus-diphtheria (TD) immunization. Am J Epidemiol 1978;108:145-9.

  7. Crossley K, Irvine P, Warren JB, Lee BK, Mead K. Tetanus and diphtheria immunity in urban Minnesota adults. JAMA 1979;242:2298-3000.

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