Tetanus Status Research Articles

First Contact Management of Traumatic Hand Injuries

Performing a comprehensive history and physical examination is the first stage in treating any hand injury. This includes finding out the mechanism and timing of the injury, hand dominance, tetanus status, the patient's occupation, and baseline function. It is critical that the primary care physician oversee initial care in order to promote prompt healing and reduce long-term morbidity. It's crucial to identify injuries that need to be sent to hand surgeons as away. To enable prompt therapy of such an accident, direct phone communication between the on-call hand surgeon and the primary care physician is crucial.

Frostbite in the Pediatric Population: A Comprehensive Review and a Prospective Canadian Survey.

Frostbite in the pediatric population, where skeletal maturity has not been achieved, can have important repercussions on subsequent growth. Yet, the optimal management of frostbite injuries in children remains vague. This review aims to summarize the current evidence for frostbite management in children and understand Canadian practice trends on this topic. A review using Medline, Scopus, Web of Science, and gray literature was performed to identify relevant literature on the clinical manifestations, diagnostic methods, and treatment options in pediatric frostbite. An online survey was sent to plastic surgeons through the Canadian Society of Plastic Surgeons (CSPS) mailing list to further identify national practices and trends for pediatric frostbite management. A total of 109 articles were reviewed. No article provided a specific algorithm for pediatric frostbite, with existing recommendations suggesting the use of adult guidelines for treating children. Our survey yielded 9 responses and highlighted the rarity of pediatric frostbite cases, with no responder treating more than 10 cases per year. Most (55.6%) do not use a pediatric-specific treatment algorithm, whereas 30% apply adult guidelines. A conservative approach focusing on rewarming (55.6%), limb elevation (50%), and tetanus status verification (66.7%) was predominant. Imaging and surgical interventions seem to be reserved for severe cases. The current literature for pediatric frostbite management lacks specificity. Canadian practices vary, with a trend toward a conservative approach. The limited evidence and rarity of experience highlight the need for further research, ideally in a collaborative multicentric manner, to create a consensus for pediatric frostbite care.

Management of bloodborne pathogen exposures in primary care: A quality improvement project

Background Exposure to bloodborne pathogens poses a serious risk to healthcare workers. As more primary care providers are being asked to perform occupational health services, the evaluation and treatment of bloodborne pathogen (BBP) exposures can be overwhelming. Lack of knowledge about how to handle these encounters can lead to poor outcomes, including conversion to human immunodeficiency virus (HIV) and hepatitis B virus if not handled properly. To assist providers with understanding best practices for the management of exposures, a detailed protocol and targeted education were developed. The protocol addressed the importance of evaluating the source patient for HIV, hepatitis B virus, and hepatitis C virus; injured workers were assessed for the same items, tetanus status, and the need for post-exposure prophylaxis (PEP). Methods A retrospective chart review for 12 months before the implementation of the protocol and eight months after implementation was completed to assess compliance with five evidence-based criteria and the appropriate use of PEP when indicated. Findings Variables of interest included (a) correct identification of the source patient, (b) accuracy of source patient labs, (c) completion of same-day employee labs, (d) accuracy of employee labs, and (e) evaluation of the employee's tetanus status. The rate of completion of these categories ranged from 14% to 43% in pre-protocol cases ( n = 7), and 100% in post-protocol cases ( n = 7). Conclusions The combination of targeted education and a detailed protocol for evaluating and treating BBP exposures resulted in increased compliance with best-practice care; the project also improved employee satisfaction.

Need for improving immunization status and preventive care in diabetes mellitus patients.

The incidence and the comorbidities, such as infectious diseases (e.g. pneumonia or influenza) of diabetes mellitus are increasing. Therefore, the purpose of this study is to investigate immunization status and preventive care in diabetes mellitus patients. Two groups from the Austrian health interview survey 2014 were identified, acohort of diabetes mellitus (DM) individuals (n = 678) and anon-diabetes mellitus (non-DM) cohort (n = 15,093). The frequencies of doctors' visits, preventive care and immunization status were compared. Furthermore, the study population was divided by age (> 50years, < 50years) and differences between > 50years old DM with < 50years old DM and the > 50years old DM and > 50years old Non-DM cohort were investigated. In the DM cohort ahigher frequency of influenza immunization (13.3% vs. 7.1%, p < 0.001), doctor visits (89.4% vs. 75.4%, p < 0.001), and preventive care, such as colonoscopy (11.2% vs. 6.8%, p < 0.001) and hemoccult tests (32.6% vs. 22.1%, p < 0.001) was observed. Even though older DM individuals have ahigher risk for complications, the > 50 years DM cohort has similar frequencies of colonoscopy, hemoccult test and immunization against influenza and TBE (tick-borne encephalitis) compared to > 50 years Non-DM. Although the > 50 years old DM cohort had ahigher frequency of doctors' visits, they still had lower frequencies of mammography and dentists' visits compared to > 50 years old Non-DM. In comparison to the < 50 years old DM cohort, the > 50 years DM cohort was related to lower intact immunization status of tetanus, diphtheria, Polio and TBE. Still a higher frequency of intact immunization of pneumococcus, influenza and doctors' visits in the > 50years old DM cohort compared to the < 50years old DM cohort can be reported. Preventive care and immunization status in the DM cohort just differ slightly from the general cohort but still should be improved.

High-Risk Patients with Infected Puncture Wounds and Appropriate Tetanus Prophylaxis.

We sought to evaluate clinicians' compliance with national guidelines for tetanus vaccination prophylaxis in patients with high-risk feet. We retrospectively evaluated 114 consecutive patients between June 1, 2011, and March 31, 2019, who presented to the emergency department with a foot infection resulting from a puncture injury. Eighty-three patients had diabetes mellitus and 31 patients did not have diabetes mellitus. Electronic medical records were used to collect a broad range of study data on patient demographics, medical history, tetanus immunization history and tetanus status on presentation to the emergency department, peripheral arterial disease, sensory neuropathy, laboratory values, and clinical/surgical outcomes. Of the 114 patients who presented to the emergency department with a puncture wound, 53 (46.5%) did not have up-to-date tetanus immunization. Of those patients, 79.2% received a tetanus-containing vaccine booster, 3.8% received intramuscular tetanus immunoglobulin, 3.8% received both a tetanus-containing vaccine booster and tetanus immunoglobulins, and 20.8% received no form of tetanus prophylaxis. Comparing data between patients with and without diabetes mellitus, there were no statistically significant differences in tetanus prophylaxis. Guidelines for tetanus prophylaxis among high-risk podiatric medical patients in this study center are not followed in all patients. Patients with diabetes mellitus are at high risk for exposure to tetanus; therefore, we recommend that physicians take a detailed tetanus immunization history and vaccinate patients if the tetanus history is unclear.

Maternal Self-Report of Tetanus Diphtheria Pertussis Vaccination during Pregnancy Correlates with Patient-Specific Electronic Medical Records

To evaluate the concordance between maternal report of antepartum tetanus, diphtheria, pertussis (Tdap) vaccination and vaccination status documented in the electronic medical record (EMR), as well as factors associated with discordance. A survey was completed by a convenience sample of postpartum patients in a New York metropolitan hospital. The survey collected patients' demographic information, health beliefs, and whether they received Tdap vaccine during this pregnancy. The patient's Tdap vaccination status was abstracted from the EMR, a combination of data gathered from the obstetrician and patient's hospital record. Kappa statistics measured the agreement between maternal report and EMR on antepartum Tdap vaccination. Univariate and multivariable logistic regression analyses were performed to identify maternal characteristics associated with discordance. Of the 1571 patients with Tdap status available in the EMR, 1549 patients (92%) reported on receipt status for Tdap vaccination during pregnancy; 1328 maternal reports (86%) agreed with the EMR for Tdap status (kappa=0.72, 95% CI 0.68-0.75). Several factors were statistically significant in multivariable analyses: lower income was associated with greater discordance (ie, overreporting; P=.02), as well as certain health beliefs including "Pregnant women should be concerned about the possibility of pertussis in their babies" (aOR 2.86, 95% CI 1.02-8.04) and "My friends would probably think getting a Tdap vaccine is a good idea" (aOR 2.36, 95% CI 1.11-4.99). Maternal recall of Tdap vaccination during pregnancy is consistent with the EMR. This supports the value of maternal report in determining Tdap vaccination status, which is especially important when vaccination records are not available.

Rabies post-exposure prophylaxis in Germany − What are the challenges?

Rabies post-exposure prophylaxis (R-PEP) including wound treatment, vaccination and application of rabies immunoglobulin (RIG) is essential in preventing rabies mortality. Today, Germany is officially declared free from terrestrial rabies and rabies is only found in bats. However, physicians in A&E Departments are frequently consulted on the need for R-PEP. We retrospectively analysed patients who received R-PEP at the A&E Department of the University Hospital Bonn between 01.01.2013 and 30.06.2019. Demographic data, travel history, clinical and laboratory findings, previous rabies vaccinations and R-PEP vaccination regimen were recorded. During the study period, 90 patients received R-PEP at the University Hospital Bonn, in 10 cases without indication for R-PEP. Altogether, we found deviations from R-PEP guidelines in 51% (n = 41/80). Infiltration of RIG was missed in 12 patients and incorrectly administrated in 24 patients. Furthermore, vaccination scheme was incorrect in 11 patients. Correct wound washing and documentation of tetanus status was missing in 14% and 63% of patients, respectively. Despite rabies elimination in Germany patients frequently seek advice for R-PEP, the majority returning from foreign travel. Our data show that there is a high need for education on indication for R-PEP before and after travel and for implementation of precise R-PEP guidelines in daily clinical practice.

Using an Online Vaccination Registry to Confirm Tetanus Status in Children with Tetanus-prone Wounds.

IntroductionTetanus vaccination status is an important consideration for emergency physicians managing patients with tetanus-prone wounds. Physicians must identify at-risk patients, but vaccination histories are often unknown and commonly lack documentation. The study objective was to determine the potential impact of an online immunization registry (Florida SHOTS – State Health Online Tracking System) on the appropriate administration of tetanus prophylaxis for pediatric patients managed in the emergency department (ED).MethodsWe conducted a retrospective review of all patients less than 18 years old who received ED tetanus prophylaxis at two separate sites between January 2011–May 2015. The Florida SHOTS database was accessed to determine vaccination status for each patient in the study group at the time of the encounter. We compared vaccination status for each patient, as documented in the electronic health record (EHR), with Florida SHOTS data to determine whether tetanus prophylaxis was indicated. The proportion of patients receiving tetanus prophylaxis in the ED, who were subsequently identified as up to date with tetanus vaccination per Florida SHOTS, was determined.ResultsWe identified 743 patients who received ED tetanus prophylaxis. Forty-three (6%) were listed as “up to date” on the EHR and 656 (93%) were listed as “not up to date.” In comparison, 209 (30%) of the study group were identified as “up to date” via Florida SHOTS, and 477 (70%) were not. We accessed the Florida SHOTS record retrospectively to determine whether the vaccine was required. It was determined that 174 (25%) of the patients received tetanus prophylaxis unnecessarily as they were already up to date per Florida SHOTS documentation.ConclusionTwenty-five percent of patients vaccinated for tetanus in the ED could have been spared if Florida SHOTS data had been used by providers at the time of the encounter. Access to Florida SHOTS provides valuable information regarding vaccination status that impacts patient care and resource utilization in the ED.

A survey investigating the current practice of French health professionals regarding infection risk after monkey bites.

International tourism is steadily increasing, with 15% of travellers reporting health problems when they come back. Animal bites represent 2% of consulting causes, of which 20% are due to monkey bites. The Monkey B virus (Macacine alphaherpesvirus 1) is an alphaherpesvirus (Herpesviridae, genus Simplexvirus) enzootic in macaques (Genus Macaca). Zoonotic infections with the Monkey B virus following exposure to macaques are exceptionally rare, but can cause fatal encephalomyelitis in humans. An observational survey was undertaken in 2018 to assess the practice of French health professionals regarding infection risk after monkey bites. French health professionals practicing in vaccination and rabies centres were specifically targeted for this study. Standardized questionnaires were sent by email to a sample of French health professionals. They were asked to participate on a voluntary and anonymous basis. The questionnaires requested epidemiological details and included multiple-choice questions about the infection management of monkey bites. The response rate was 33.5%. The frequency of monkey bites in 2017 was variable with a minority of centres managing more than 6 per year (12%), 46% managing 1-5 monkey bites and 42% none. Most of the monkey bites were described as occurring in South Asia at tourist sites, on naked upper limbs, shortly after the travellers arrived at their destination. Tetanus status verification, rabies post-exposure prophylaxis and antibiotic therapy were said to be prescribed in most cases. Knowledge about the Monkey B virus was reported as scarce for 38% of the participants. The number of monkey bites managed per year per centre varied greatly but practices regarding infectious risk after monkey bites were generally homogeneous. The risk of Monkey B virus transmission did not readily come to mind in the differential diagnosis of infection risk for many French health professionals.

1646. Education Level is Associated with Tetanus Vaccine Coverage: Results from the 2016 BRFSS

BackgroundVaccination coverage among US adults for tetanus, a potentially fatal disease, continues to be lower than the national goals. Education has been considered to have positive impact on vaccination coverage. However, recently there have been outbreaks of vaccine preventable conditions in areas with high college completion rates. This study aims to assess the relationship between education and vaccination coverage. Specifically, we looked at the association between education level and tetanus vaccination status of the US adults.MethodsData from the 2016 Behavioral Risk Factor Surveillance System, a self-reported annual survey for non-institutionalized adults in the United States from the Centers for Disease Control, were analyzed. The outcome was up-to-date tetanus coverage (within the last 10 years) defined by the response to: have you received tetanus vaccine since 2005? Education was stratified into four categories: (1) grade 11 or less, (2) grade 12/GED, 3) college 1–3 years, and (4) college 4 or more years. Bivariate analyses and multivariable logistic regression were conducted on the analytic sample (n = 417,473) using Stata 15, accounting for weighting and the complex survey design of the BRFSS.ResultsThis study identified that 59.9% of US adults are up-to-date on the tetanus vaccine status (Table 1). Higher education level was found to be associated with increased odds of up to date tetanus vaccination. The highest odds were for those with 4 or more years of college education [aOR = 1.31; 95% CI: 1.26–1.35)] while the lowest odds were for those less than grade 11 education, when compared with those with a high school degree [aOR = 0.93; 95% CI: 0.88–0.98] (Figure 1). Other covariates identified as negatively associated with up-to-date tetanus status were race/ethnicity, female sex, unemployment, not being married, not having insurance or a personal healthcare provider, and being above 45 years of age (Figure 1).ConclusionThis study identified a positive association between up-to-date tetanus status and higher education level. Introducing community-specific vaccination education programs for those without tertiary education, especially for those above age 45 and without insurance, may help increase the overall vaccination status in the United States. Disclosures All authors: No reported disclosures.

Management and treatment of animal bites.

Animal bites account for 1% of ED visits and more than $50 million in healthcare costs annually in the United States. Managing bite wounds can be challenging and providers must consider the patient's tetanus status, species of animal inflicting the bite, and infection risk. This article describes treatment and care of bites and when rabies prophylaxis is indicated.

A New Proposal for Management of Severe Frostbite in the Austere Environment

Despite advances in outdoor clothing and medical management of frostbite, individuals still experience catastrophic amputations. This is a particular risk for those in austere environments, due to resource limitations and delayed definitive treatment. The emerging best therapies for severe frostbite are thrombolytics and iloprost. However, they must be started within 24 hours after rewarming for recombinant tissue plasminogen activator (rt-PA) and within 48 hours for iloprost. Evacuation of individuals experiencing frostbite from remote environments within 24 to 48 hours is often impossible. To date, use of these agents has been confined to hospitals, thus depriving most individuals in the austere environment of the best treatment. We propose that thrombolytics and iloprost be considered for field treatment to maximize chances for recovery and reduce amputations. Given the small but potentially serious risk of complications, rt-PA should only be used for grade 4 frostbite where amputation is inevitable, and within 24 hours of rewarming. Prostacyclin has less risk and can be used for grades 2 to 4 frostbite within 48 hours of rewarming. Until more field experience is reported with these agents, their use should probably be restricted to experienced physicians. Other modalities, such as local nerve blocks and improving oxygenation at high altitude may also be considered. We submit that it remains possible to improve frostbite outcomes despite delayed evacuation using resource-limited treatment strategies. We present 2 cases of frostbite treated with rt-PA at K2 basecamp to illustrate feasibility and important considerations.

April 15, 2013

April 15, 2013

Tetanus seropositive prevalence and perceived protection from emergency admissions.

BackgroundEmergency physicians see many people who present to the emergency department stating that they are immunized against tetanus, when in fact, they are not. The patient history is not dependable for determining true tetanus status and simple patient surveys do not provide actual prevalence. The objective of this study was to determine the prevalence of tetanus status by antibody titer seropositivity and quantify such status among patients reporting tetanus protection.MethodsThis study is a single center prospective convenience sample of patients presenting to the emergency department 12 years of age or older. Patients deemed study candidates and willing to be in the study filled out an eight-question questionnaire that included the question ‘is your tetanus shot up to date’. A blood sample was then drawn for tetanus antibody titer and quantified according to a pre-determined cutoff for protection.ResultsA total of 163 patients were enrolled. Of patients responding yes to the query ‘is your tetanus shot up to date’ 12.8% (N=5) of them were not seropositive. Of the 26 people who were seronegative in the study all had been to a doctor in the past year and 88.5% (N=23) had been to their family physician.ConclusionThe study suggests that it may be difficult to trust the tetanus immunization history given by patients presenting to the emergency room. The study also observed that a large percentage of patients who were serenegative were seen by a primary care physician and not had a necessary tetanus immunization.

Tetanus in patients with chronic wounds – are we aware?

The incidence of tetanus in patients with wounds is unknown; however, recently concern has been raised over the proportion of tetanus cases in which a chronic wound is the portal of entry for Clostridium tetani. Varicose ulcers, dermatosis and necrosed tumours are estimated to be the point of entry for C. tetani spores in 11-14% of three cases. Of diabetic patients in the USA who contracted tetanus, a diabetic foot ulcer was responsible in 25% of cases despite this chronic wounds have yet to be considered as a risk factor for tetanus. An audit was undertaken and a survey devised to form the basis of the data collection to assess if patients with chronic wounds are up-to-date in accordance with the tetanus immunisation programme. Over a 5-day period, the data were prospectively collected and the tetanus status of a 100 patients retrospectively analysed. The status was then compared with general practitioner (GP) records via telephone follow-up. One hundred patients (n = 100) were available in the audit period, with the majority being male (n = 51). The age range was 22-91 years old (median 70 years). Nearly half of the samples (n = 48) were diabetic, with the majority of patients (n = 35) having venous leg ulcers. Only 15% had a biopsy of their wound. The duration of wounds varied from 1 to 480 months. Patients were asked to confirm their tetanus status. Almost half of the patients were unsure of their tetanus status 48% (n = 48), almost a third 30% (n = 30) thought they were not covered and 22% (n = 22) thought they were up-to-date. After confirming with the GP records, the results were as follows: almost half of the patients, 43% (n = 43) were not covered, 33% (n = 33) were up-to-date, 13% had no immunisation records available at the GPs, 10% had no GP contact details and 1% no contact was possible. Currently, tetanus prophylaxis is given based on the vaccination history of the patient but as identified that this can prove to be unreliable. With the burden of chronic wound and ageing population set to increase, levels of protection amplify the risk of tetanus faced by those suffering from chronic wounds. Strict caution should be taken in those patients who were born before the national childhood vaccination programme, implemented in 1961. Moreover, every effort should be made to ensure that such individuals complete their primary course. By ensuring each patient is actively immunised, protection against tetanus, a potential killer, is provided.

Study of enteral nutrition on patients with severe tetanus

Objective To study the effect of enteral nutrition on patients with severe tetanus. Methods The patients totaled 60 cases were divided into two groups with 30 cases in each. The patients in EN group were treated with enteral nutrition on basis of routine treatment, control group was treated with total parenteral nutrition (TPN). The indicators values of BMI, TSF, MAMC, TP, PAm, m, ALB and Hb were tested on the day before nutrition supports and after nutrition supports 10 days later in two groups. Adverse reaction and the treatment effect were observed simultaneously. Results With nutritional supports 10 days later, two groups had no obvious decline in BMI, TSF and MAMC. TP, PA, ALB and Hb of EN group were higher than those of control group (P＜0.05) . Complication rate of EN group was lower than that of control group, there was significant differences (P＜0.05) . Conclusions Early EN may improve protein metabo lism in patients with severe tetanus and nutritional status. Key words: Severe tetanus; Enteral nutrition; Total parenteral nutrition; Nutritional support

Lizard Bites of the Head and Neck

BackgroundAs the ownership of lizards becomes more prevalent in the United States, injuries from these exotic pets will increase. Emergency and primary care physicians must be familiar with the proper management of lizard bites to the head and neck. ObjectivesThe aim of this case report is to discuss the potential complications and proper management of lizard bites to the head and neck. Case ReportA 47-year-old man presented to the emergency department 3h after his 5-foot iguana bit his face. The wounds were irrigated and primarily closed. Tetanus prophylaxis was administered. He was given oral amoxicillin/clavulanate potassium for 7 days. Sutures were removed 1 week after the repair. ConclusionsTopical antiseptic care, verification of tetanus status, primary wound closure, and careful monitoring of non-venomous lizard bites is recommended for lizard bites to the head and neck. Wounds at risk for infection should be treated with a quinolone or other antibiotics covering Salmonella as well as human skin flora. Venomous lizard (e.g., Gila monster and Mexican Beaded Lizard) bites require prompt attention due to potentially significant morbidities including anaphylaxis, disseminated intravascular coagulation, and acute myocardial infarction.

Emergency nurse practitioner management of tetanus status and tetanus-prone wounds

The aim of this paper is to address the management of tetanus-prone wounds and the use of tetanus prophylaxis within the remit of the emergency nurse practitioner (ENP) to ensure safe and effective management of patients who present to the Emergency Department (ED) with tetanus-prone wounds. The paper will also provide the reader with an overview of the epidemiology of tetanus along with the signs and symptoms of tetanus. Practicalities of tetanus vaccine storage and injection will also be discussed. The paper will also discuss Protetanus which is a single step immunoassay for the determination of anti-tetanus immune status; this product has the potential to reduce over immunisation with tetanus and can provide the clinician with a tetanus antibody status in patients who are unaware of their own immunisation status.

Seroprevalence and immunization history of selected vaccine preventable diseases in medical students

To evaluate protection against vaccine-preventable diseases in medical students, we obtained data on immunization status and history of diphtheria, tetanus, pertussis, poliomyelitis, measles, mumps, rubella, varicella and hepatitis B from students with elective periods in our institution. Further, serum antibodies against measles, mumps, rubella and varicella-zoster virus (VZV) and hepatitis B surface (HBs) antigen were determined on a voluntary basis. For students with incomplete immunization status or lack of protective antibodies, vaccination was offered for free. Success of catch-up immunizations was serologically confirmed 4 weeks later. From May 1999 to April 2003, 170 students were enrolled; their mean age was 26 years with a median of 25 years (range 22–48 years). Immunization records were complete in 148 (87%), incomplete in 11 (6.5%) and missing in 11 (6.5%) students. Only 26% of the cohort had a complete and up-to-date immunization status. Seroprevalence of IgG antibodies against measles, mumps, rubella, VZV and HBs (≥10 IU/l) in 149 students were 85, 85, 92, 97 and 90%, respectively. Indications for ≥1 catch-up immunization were found in 125 (74%) students and were accepted by 97 of them (78%). Sixty two (99%) of 63 immunized students available for follow-up demonstrated an adequate serological response. In conclusion, the great majority of medical students had immunization gaps. Systematic immunization programmes for medical students should be implemented.

Neonatal tetanus in the State of Minas Gerais: a contribution to understand the problem

This study aimed at investigating the status of neonatal tetanus in the state of Minas Gerais from 1989 to 1996. Data were collected from the Investigation Forms of the Epidemiological Surveillance Office. Of the 70 confirmed cases, 48 developed to death, which represents a mortality rate of 68.6% for the period under study. The cases occurred in very poor rural and urban areas with a greater deficit in the distribution of local health resources. Of the total number of cases, 59.4% originated in the rural area, 72.1% were children of multiparae, 68.6% used inadequate substances on the umbilical cord stump, among which olive oil and tobacco, whether isolated or not, were distinguished. Most of the deliveries (65.3%) occurred at home and 60.8% were assisted by an unqualified professional. Comparatively, the chances of children from rural areas dying of tetanus were 3.9 times higher than those of children from urban areas.