Antitetanus immunisation in the elderly
Date First Published:
March 7, 2003
Last Updated:
September 22, 2004
Report by:
Kevin Mackway-Jones, Consultant (Manchester Royal Infirmary)
Three-Part Question:
In [adult patients who have had a course of ATT and one or two subsequent booster doses] are [further booster doses] [beneficial or detrimental]?
Clinical Scenario:
A 76 year old patient attends the Emergency Department following a fall in the street. She has a wound over her left lower leg that can be treated with steristrips. You enquire about her tetanus immunisation state and discover that she has had a full course of ATT and two booster doses. The last was 15 to 20 years ago. You are sure you have read somewhere that not only should this provide lifelong immunity but also that booster doses may cause severe local side effects in such individuals. You wonder whether this is correct.
Search Strategy:
Medline 1966- week 3/09/04 using the OVID interface.
Search Details:
[[{(exp tetanus OR tetanus.mp) AND (vaccine$.mp OR exp vaccines)} OR exp tetanus antitoxin OR exp tetanus toxin OR exp tetanus toxoid] AND [age.mp OR exp age factors]] NOT [exp child OR children OR exp pediatrics OR exp infant/ OR exp adolescent/ pediatric$.mp OR paediatric$.mp] LIMIT to human AND English.
Outcome:
Altogether 123 papers were found, of which 2 were directly relevant to the question.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Tetanus immunity in an older Australian population. Heath TC, Smith W, Capon AG et al. 1996, Australia | 430 randomly selected adults (49 years or older) | Survey | Protected against tetanus (tetanus antitoxin >0.15 IU/ml) | 52% (47-57%) | Awaiting paper |
| Prevalence of immunity with increasing age | Significant decline (P=0.036) | ||||
| Association of immunity with self reported history of vaccination <10 years | Associated but neither sensitive nor specific | ||||
| Tetanus immunisation in the elderly population. Reid PM, Brown D, Coni N et al. 1996, UK | 111 elderly patients attending ED or inpatient (mean age 79.9 range 67-95 years) | Survey | Protected against tetanus | 50% | |
| Immunisation history | Uncertain and unreliable |
Author Commentary:
There are no studies that answer the exact question posed, however some inferences can be drawn from the studies found. It is difficult to generalise from studies carried out in different conditions since immunisation regimes and programmes were locally determined. This is a particular problem when considering elderly patients as the date for the introduction of primary vaccination in childhood was variable. No evidence relating to the incidence of local side effects in the elderly was found.
Bottom Line:
The majority of elderly patients will have inadequate tetanus immunity. ATT should be given if there is no clear history of vaccination within the preceeding 10 years.
References:
- Heath TC, Smith W, Capon AG et al.. Tetanus immunity in an older Australian population.
- Reid PM, Brown D, Coni N et al.. Tetanus immunisation in the elderly population.