Tetanus in a Child with Improper Medical Exemption from
Immunization -- Florida
In June 1984, a 12-year-old male was brought to a Florida
emergency room for an inflamed splinter wound on the foot. The
injury
had occurred 14 days previously and had been treated with herbal
remedies. The child was given tetanus toxoid and intramuscular
penicillin and was sent home. Later that day, he developed neck
stiffness, interscapular pain, and spasms. He returned to the
emergency room, where generalized stiffness and difficulty opening
the
jaw were noted. A small splinter was removed from his foot, and
some
pus was expressed. He was admitted to an intensive-care unit,
placed
on high-dose penicillin, and given 7,000 units of tetanus immune
globulin (TIG) over a 5-day period. Diazepam was begun to control
increasingly frequent muscle spasms lasting 1-2 minutes. Episodic
periods of tachycardia, hypertension, and diaphoresis occurred.
Respiratory function remained stable, and on the ninth day of
hospitalization, the child was transferred to the pediatric ward.
He
recovered and was discharged on day 12 of hospitalization.
Investigation revealed that the child had received a dose of
oral
polio vaccine at about 18 months of age but had received no other
immunizations. In the school record was a form granting him
permanent
medical exemption to all vaccines. The form, signed by a
health-care
provider, gave the reason for exemption as "due to recent medical
literature." The provider later stated that the literature
referred
to "cytotoxic allergies secondary to immunization," but cited no
specific references. Review of immunization records in the child's
school revealed two other children with similar exemptions granted
by
this same provider.
Reported by JJ Witte, HT Janowski, JJ Sacks, MD, Acting State
Epidemiologist, Florida Dept of Health and Rehabilitative Svcs; Div
of
Field Svcs, Epidemiology Program Office, Surveillance,
Investigations,
and Research Br, Div of Immunization, Center for Prevention Svcs,
CDC.
Editorial Note
Editorial Note: This case illustrates several important points:
(1)
a thorough attempt should be made to determine the tetanus
immunization status of persons with wounds treated in emergency
rooms;
(2) appropriate antitetanus wound prophylaxis should reflect the
patient's immunization status and type of wound (1); (3) even with
a
school immunization law in place, proper immunization of a
school-aged
child cannot be assumed; and (4) granting of medical exemptions
should
not be given indiscriminately.
A recent study of antitetanus prophylaxis in emergency rooms
found
that 23% of patients with wounds were treated incorrectly (6%
undertreated, 17% overtreated). Moreover, only 27% of patients at
highest risk of acquiring tetanus, i.e., those with contaminated
puncture wounds or other serious wounds and/or fewer than three
previous doses of tetanus toxoid, received appropriate prophylaxis
against tetanus (2). In this particular instance, little could
have
been done to prevent tetanus at the time the patient presented to
the
emergency room because so much time had elapsed since the wound
occurred. A summary guide to tetanus prophylaxis in routine wound
management is presented in Table 1.
Tetanus toxoid is generally well tolerated, even in individuals
with histories of presumed adverse reactions to tetanus toxoid. In
one study, 94 of 95 persons giving histories of anaphylactic
symptoms
following a previous tetanus toxoid dose were nonreactive following
intradermal testing and tolerated a further tetanus toxoid
challenge
without a reaction (3). Booster doses are routinely recommended
every
10 years. More frequent boosters are not indicated and may result
in
an increased occurrence and severity of adverse reactions,
particularly the Arthus-type hypersensitivity reaction (4).
Adults are less likely than children to be adequately immunized
or
adequately protected against tetanus and diphtheria (5-7). The
routine use of tetanus and diphtheria toxoids (Td) in all medical
settings is, therefore, recommended; emergency room visits by
adults
may be the best opportunity to boost immunity to both tetanus and
diphtheria.
At least four doses of a tetanus toxoid-containing preparation
are
required for entering kindergarten in Florida. Exemptions from
immunization in Florida are allowed for religious or medical
reasons
but only a very small proportion (0.1%) of Florida schoolchildren
have
such exemptions. To maintain the current high levels of
immunization
in the school system and to avoid incidents such as the one
described
here, medical exemptions should be carefully evaluated. For
example,
a contraindication (e.g., immune deficiency) to live virus vaccines
does not mean inactivated vaccines are necessarily contraindicated
as
well. Blanket medical exemptions for all vaccines are rarely
indicated.
References
ACIP. Diphtheria, tetanus, pertussis: guidelines for vaccine
prophylaxis and other preventive measures. MMWR
1985;34:405-14,
419-26.
Brand DA, Acampora D, Gottlieb LD, Glancy KE, Frazier WH.
Adequacy of antitetanus prophylaxis in six hospital emergency
rooms. N Engl J Med 1983;309:636-40.
Edsall G, Elliot MW, Peebles TC, et al. Excessive use of
tetanus
toxoid boosters. JAMA 1967;202:111-3.
Mullooly JP. Tetanus immunization of adult members of an HMO.
Am
J Public Health 1984;74:841-2.
Ruben FL, Nagel J, Firemen P. Antitoxin responses in the
elderly
to tetanus-diphtheria (TD) immunization. Am J Epidemiol
1978;108:145-9.
Crossley K, Irvine P, Warren JB, Lee BK, Mead K. Tetanus and
diphtheria immunity in urban Minnesota adults. JAMA
1979;242:2298-3000.
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