Tetanus prophylaxis in the emergency department

Abstract

Tetanus is now so rare in the United States that few physicians encounter a case in the course of their careers. The 96% reduction in the incidence of reported tetanus cases and elimination of neonatal tetanus since the late 1940s can be attributed to the effectiveness of widespread vaccination with tetanus toxoid–containing vaccines, as well as improved wound care and delivery practices.1 Despite its rarity, tetanus continues to be of concern because of the clinical severity, high mortality, and associated high costs of the disease. In 1991 to 2000, the median hospital stay for tetanus cases reported to the US Centers for Disease Control and Prevention (CDC) was 16 days, with more than half of cases requiring mechanical ventilation. The overall case fatality rate was 19% (Centers for Disease Control and Prevention, unpublished data, 2003). The vast majority of reported cases and nearly all deaths occur in individuals who are unvaccinated or inadequately vaccinated and thus were potentially preventable.1-3 In this issue of Annals, Talan et al4 report the results of a study measuring the prevalence of protective antitetanus antibody levels in approximately 2,000 adults presenting for wound care in 5 academic emergency departments (EDs) and the frequency with which they received appropriate tetanus prophylaxis. Histories and physical examinations were performed on participants at the time of presentation. A standardized data collection form was used to record information about the immune status and wound characteristics of enrolled patients but not their history of prior tetanus toxoid immunization in order to disguise the purpose of the study from the treating physicians. Serum was obtained for determination of tetanus antitoxin levels; wound care was performed as clinically indicated. A systematic history of tetanus immunization was subsequently obtained by research associates when patients returned for follow-up care 5 to 7 days after presentation. At that time, a second serum sample for tetanus antitoxin determination was collected from those who received tetanus toxoid and not tetanus immunoglobulin at their initial visit. Patient charts from the initial ED visit were reviewed for documentation of tetanus vaccination histories. Appropriate tetanus prophylaxis was defined as that given in accordance with the recommendations of the Advisory Committee on Immunization Practices.5 The most striking finding of this study was that only 57% of patients presenting with wounds were provided appropriate tetanus prophylaxis; 35% failed to receive indicated tetanus vaccination, or vaccination and tetanus immunoglobulin, and 8% received unnecessary measures. Ironically, none of the 504 (26%) patients most in need of prophylaxis (ie, those without a history of primary immunization who presented with tetanus-prone wounds) were treated correctly. The lack of appreciation of the importance of a primary tetanus immunization series when assessing and managing tetanus risk was also suggested by the absence of recorded information about primary vaccination in 80% of medical records.4 Since the study by Talan et al4 was conducted in teaching hospitals, the apparent lack of familiarity and compliance with recommendations that have been in place for more than a decade and endorsed by most medical societies, including the American College of Emergency Physicians, is noteworthy. It is also likely that attention to tetanus prophylaxis was at least modestly enhanced during the course of the study, because 12% of participating attending physicians who were surveyed suspected that tetanus prophylaxis was a possible focus of the study and an additional 48% may have had some suspicion.4 Had the study been conducted in a representative sample of institutions providing emergency care, adherence to tetanus prophylactic guideI N F E C T I O U S D I S E A S E / E D I T O R I A L