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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.
[[{(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.

Search Outcome

Altogether 123 papers were found, of which 2 were directly relevant to the question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Heath TC 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
Reid PM 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

Comment(s)

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.

Clinical 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

1. Heath TC, Smith W, Capon AG et al. Tetanus immunity in an older Australian population. Med J Aust 1996;164:593-6.
2. Reid PM, Brown D, Coni N et al. Tetanus immunisation in the elderly population. J Accid Emerg Med 1996;13:184-5.