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In the UK, tetanus immunization began formally in 1961. Before then a few local programmes existed, and the Armed Forces were immunized from 1938. A sizeable part of the population is thus protected, and this fact should be reflected by limited use of booster doses of tetanus toxoid in accident and emergency departments. The official guideline1 says that, unless there is a tetanus-prone wound, there is little justification for booster doses in patients who have received a full course (five doses) in their lifetime. Behind this advice is the observation that, in the very rare cases where tetanus develops in the fully immunized, the disease is not severe. Of the 175 people who developed tetanus in England and Wales from 1984 to 20002, just 2 had been fully immunized according to their age and both survived (White J, PHLS, Personal communication). An additional reason for restraint is the risk of local reactions when further boosters are given.
Perhaps the guideline needs more publicity. We questioned 40 people (19 doctors, 21 nurses) working in A&E departments in the Northern and Yorkshire regions and either prescribing or administering tetanus toxoid. Just 17 were aware of the guideline; and, of these, only 2 gave the correct answer to a question concerning the need for a booster after five doses. 8 of the 40 gave an answer consistent with the guideline in saying they would not give a booster to a fully immunized 30-year-old with a clean laceration. But, even for those who know it, the guideline does present practical difficulties. In younger patients, decisions for A&E staff will seldom be difficult, but a person born before the national immunization programme (i.e. over 40) may or may not have received all five recommended doses of toxoid, and is quite likely not to know. Of the 145 cases of tetanus (notifications, deaths and laboratory reports) between 1984 and 1995, 75% were in people over 45. If the patient has served in the Armed Forces, one can be more confident that full immunization has been given. Also to be considered are the large number of people who have immigrated to the UK from countries that lacked immunization programmes—Asia and Africa in particular. Even today, the take-up of formal immunization programmes is low in some parts of the world.
In an elderly population, Reid and co-workers3 found that 50% had tetanus antibody titres too low for protection. Low titres were very prevalent in the over-80s, especially women. In our opinion, all people who do not know their tetanus immune status should be encouraged to consult their general practitioners about the need for immunization. This includes many of the over-40s and people from the migrant population. Although the official guideline is clearly sound, there will be numerous occasions in the A&E department when toxoid must be given simply because of an uncertain immunization history. Over the years, these will diminish. For patients with tetanus-prone wounds, toileting and debridement will still need to be coupled with use of toxoid and also tetanus immune globulin.