Correspondence

Protection against Tetanus

N Engl J Med 1995; 333:599-600August 31, 1995

Article

To the Editor:

The serologic survey by Gergen et al. (March 23 issue)1 corroborates earlier studies showing that more than half of Americans over the age of 50 lack what are considered protective levels (>0.15 IU per milliliter) of tetanus antitoxin. Although serologic surveys often predict the epidemiologic features of a disease, the incidence of tetanus is far better predicted by a history of inadequate primary immunization with tetanus toxoid. Almost all cases occur in persons who never completed a primary immunization series, did not receive appropriate treatment of a wound, or both.2

There is strong epidemiologic evidence that primary immunization confers a long-term benefit even though levels of antitoxin wane with time. Among the few patients who contract tetanus but report having completed a primary immunization series, the disease is milder than in less well immunized persons. Booster doses of tetanus toxoid induce anamnestic increases in antitoxin levels even after intervals of 25 to 30 years. Experimental studies in animals and humans indicate that low antitoxin titers still provide substantial protection.

High rates of seronegativity for antitoxin indicate poor compliance with the current recommendation of the Advisory Committee on Immunization Practices that booster doses of tetanus toxoid be given every 10 years.2 Despite this serologic evidence of widespread susceptibility among adults, tetanus is rare among those who have received a complete primary series. The epidemiologic evidence indicates that routine decennial boosters are of marginal value and are not cost effective.3 In addition, brachial-plexus neuropathy, which the Institute of Medicine has accepted as causally related to tetanus toxoid (with 0.5 to 1 case per 100,000 recipients of tetanus toxoid),4 has occurred almost exclusively in adults who have received multiple injections of tetanus toxoid.

As an alternative strategy to the policy of giving decennial booster immunizations, the Task Force on Adult Immunization of the American College of Physicians recommends that “special emphasis be given to the completion of a primary immunization series with tetanus and diphtheria toxoids, followed by a single booster at the age of 50 for persons who have completed the full pediatric series, including the teenage and young-adult booster.”5 The task force believes that recommending the booster dose at this specific age will result in better compliance and raise the levels of immunity to tetanus and diphtheria in adults. Both the Task Force on Adult Immunization and the Advisory Committee on Immunization Practices strongly recommend the age of 50 as an ideal time to review immunization status and other preventive health measures (e.g., cancer screening, diet, and estrogen replacement). In addition to an evaluation of immunity to tetanus and diphtheria, an assessment should be made of risk factors that would indicate a need for pneumococcal vaccine, annual influenza immunization, or both.

Pierce Gardner, M.D.
State University of New York at Stony Brook School of Medicine, Stony Brook, NY 11794

F. Marc LaForce, M.D.
Genesee Hospital, Rochester, NY 14607

5 References

1. 1

   Gergen PJ, McQuillan GM, Kiely M, Ezzati-Rice TM, Sutter RW, Virella G. A population-based serologic survey of immunity to tetanus in the United States. N Engl J Med 1995;332:761-766
   Full Text | Web of Science | Medline

2. 2

   Tetanus surveillance -- United States, 1989-1990. Mor Mortal Wkly Rep CDC Surveill Summ 1992;41:1-9
   Medline

3. 3

   Balestra DJ, Littenberg B. Should adult tetanus immunization be given as a single vaccination at age 65? A cost-effectiveness analysis. J Gen Intern Med 1993;8:405-412
   CrossRef | Web of Science | Medline

4. 4

   Adverse events associated with childhood vaccines: evidence bearing on causality. Stratton KR, Howe CJ, Johnston RB Jr, eds. Washington, D.C.: National Academy Press, 1994.
   

5. 5

   American College of Physicians, Task Force on Adult Immunization, Infectious Diseases Society of America. Guide for adult immunization. 3rd ed. Philadelphia: American College of Physicians, 1994.
   

Author/Editor Response

The authors reply:

To the Editor: Gardner and LaForce advocate replacing the current recommendation for decennial booster doses of diphtheria and tetanus toxoids with a single booster dose at the age of 50 years. Both the Advisory Committee on Immunization Practices and the Task Force on Adult Immunization of the American College of Physicians currently recommend that the need for primary or booster immunization against tetanus be assessed at that age. However, the advisory committee endorses and seeks to enhance compliance with the recommendation for a decennial booster and considers that the assessment at the age of 50 is complementary to the current recommendation.

A strategy that requires booster doses less often than every 10 years may be cost effective for tetanus prevention in the United States.1 However, this conclusion may not apply to the prevention of diphtheria. Epidemic diphtheria has emerged since 1990 in virtually all 15 newly independent states of the former Soviet Union, with more than 47,000 cases of diphtheria and 1700 deaths reported in 1994 alone.2 More than two thirds of these cases have been reported among adults, who have not routinely received booster doses with diphtheria and tetanus toxoids in these countries.

The reasons for the resurgence of diphtheria in the countries of the former Soviet Union include the high susceptibility of the adult population. This epidemic should be considered a warning signal for the United States, where approximately 50 percent of the adult population lacks protective levels of diphtheria antibodies. Although no cases of diphtheria were imported from those countries into the United States in 1990 through 1994, two cases were recently reported in U.S. citizens whose symptoms began in Russia and Ukraine.3

An additional consideration is the difference between diphtheria toxoid and tetanus toxoid in the protection provided. A primary series with diphtheria toxoid induces lower levels of antitoxin than a primary series with tetanus toxoid. Consequently, titers of diphtheria antitoxin fall below protective levels more rapidly than those of tetanus antitoxin, and more frequent booster doses may be required to ensure lasting protection.4

Until the resurgence of epidemic diphtheria in the former Soviet Union is controlled, adults need enhanced protection against diphtheria. Visits for immunization to a health care provider at the age of 50 should be promoted as an opportunity to receive either the primary series of tetanus and diphtheria toxoids or decennial booster doses, as needed. Compliance with the recommendations for decennial booster doses must be enhanced to ensure that epidemic diphtheria in the United States remains a disease that current and future generations know only from history.

Roland W. Sutter, M.D., M.P.H.&T.M.
Stephen C. Hadler, M.D.
Centers for Disease Control and Prevention, Atlanta, GA 30333

Geraldine McQuillan, Ph.D.
National Center for Health Statistics, Rockville, MD 20782

Peter J. Gergen, M.D.
National Institutes of Health, Bethesda, MD 20892

4 References

1. 1

   Balestra DJ, Littenberg B. Should adult tetanus immunization be given as a single vaccination at age 65? A cost-effectiveness analysis. J Gen Intern Med 1993;8:405-412
   CrossRef | Web of Science | Medline

2. 2

   Diphtheria epidemic -- new independent states of the former Soviet Union, 1990-1994. MMWR Morb Mortal Wkly Rep 1995;44:177-181
   Medline

3. 3

   Diphtheria acquired by U. S. citizens in the Russian Federation and Ukraine -- 1994. MMWR Morb Mortal Wkly Rep 1995;44:237, 243-4
   

4. 4

   Simonsen O. Vaccination against tetanus and diphtheria: evaluations of immunity in the Danish population, guidelines for revaccination, and methods for control of vaccination programs. Dan Med Bull 1989;36:24-47
   Web of Science | Medline

Citing Articles (2)

Citing Articles

1. 1

   Marcela Pasetti, Patricia Eriksson, Marcela Manghi, F. Ferrero. (1997) Serum antibodies to diphtheria-tetanus-pertussis vaccine components in Argentine children. Infection 25:6, 339-345
   CrossRef

2. 2

   MARCELA F. PASETTI, JOSÉ DOKMETJIAN, PATRICIA V. ERIKSSON, MARCELA A. MANGHI, MARÍA LUISA BRERO, FERNANDO FERRERO. (1997) Structure and Protective Capacity of Tetanus and Diphtheria Antibodies Produced During Human Pregnancy and Transferred to New-Born. American Journal of Reproductive Immunology 37:3, 250-256
   CrossRef