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[Sex and age-dependent gaps in tetanus immunization].

To test tetanus immunity, tetanus antitoxin titres were measured in the serum of 692 subjects (354 males, 338 females), aged one day (newborns) to 92 years (mean age 29 years). Those aged 18 to 65 years were first-time blood donors, the remainder were healthy newborns, while the children and those over 65 years were patients without immune-compromising disease. An inadequate protection (titre < 0.1 IU/ml) was found in 107 (15.5%), of whom 75 (70%) were females. Women aged 20 years and above also had significantly lower average antitoxin titres than men (1.7 vs. 3.5 IU/ml); P < 0.0001). The inadequate immunization protection of many young women is reflected in the lack of protective antibodies in 10 of the 49 examined newborns. In addition, 18% of children aged between 1 and 15 years had inadequate immunity against tetanus. In the whole group the titre level decreased with age, while the proportion of unprotected persons increased. Apart from the obvious age and sex dependency of the demonstrated inadequacy of immunological protection against tetanus, attention should also be paid to the lack of protective antibodies in newborns and the marked gaps of immunity among children.

Adolescent↗

[Postoperative tetanus].

12 days after an operation for pericaecal abscess due to perforation of the appendix, a 57-year-old man developed severe tetanus requiring mechanical ventilation for 37 days. Additional complications--pneumonia with septicaemia, disseminated intravascular coagulopathy, prolonged renal failure--were controlled by intensive medical measures. The tetanus was most likely of endogenous origin: Clostridium tetani occurs as a saprophyte in the gastrointestinal tract. It is recommended that tetanus immunization status of a patient should be checked before any operation on the gastrointestinal tract. If negative, prophylactic tetanus antitoxin should be administered.

Abscess↗

Immunity against tetanus and effect of vaccination in Turkey.

The immune status against tetanus in relation to vaccination was investigated among healthy populations in 3 selected provinces in Turkey (n=2094). In-house ELISA supplemented with the particle agglutination test was performed for this purpose. An exact correlation was found between vaccination status and immunity against tetanus. The immunity was high among children and sharply decreased with age among adults. The primary vaccination for children increased the immunity, reaching a geometric mean titer (GMT) of 6.2 IU/ml at the fourth dose. There was a reduction of immunity during the next y, followed by an increase with a booster injection at primary school age. Among adolescents and adults, the GMTs after the last vaccination fell off exponentially with a slope of -0.068 log10 IU/ml per y. Extrapolation of the regression line predicted that the minimum protective level (> or =0.01 IU/ml) would be maintained for approximately 30 y on average after the last vaccination. Diyarbakir, 1 of the selected provinces, had lower immunity than the other 2 provinces with poor immunization. Adult females tended to show slightly higher GMTs than males, probably due to the neonatal tetanus elimination program. Reinforcement of immunization against tetanus for adults is recommended.

Adolescent↗

Duration of immunity induced by an adjuvanted and inactivated equine influenza, tetanus and equine herpesvirus 1 and 4 combination vaccine.

An adjuvanted vaccine containing inactivated equine influenza, herpesvirus antigens, and tetanus toxoid was administered to young seronegative foals of 8 months of age by deep intramuscular injection in the neck (Group A). The first two vaccinations were given 4 weeks apart. The third was administered 6 months later. Another group of foals (Group B) was vaccinated according to the same scheme at the same time with monovalent equine herpes virus (EHV) vaccine (EHV1.4) vaccine. Antibody responses to the equine influenza (single radial haemolysis; SRH) and tetanus (ToBi ELISA) components of the vaccines were examined from first vaccination until 1 year after the third vaccination. The influenza components of the combination vaccine induced high antibody titres at two weeks after the second vaccination whereafter titres declined until the time of the third vaccination. After the third vaccination, the titres rose rapidly again to remain high for at least 1 year. Antibody titres against tetanus peaked only after the third vaccination but remained high enough to offer protective immunity for at least 1 year. Foals vaccinated with monovalent EHV1.4 remained seronegative for influenza and tetanus throughout the study. Four and a half months after the third vaccination of groups A and B, a third group of animals was vaccinated twice with monovalent EHV1.4 vaccine 4 weeks apart (Group C). Two weeks after the administration of the second dose in the later group, all groups (A, B, C and an unvaccinated control group D) were challenged with EHV-4. Vaccinated foals (Group A, B, C) showed a clear reduction of clinical symptoms and virus excretion after EHV-4 challenge compared with the unvaccinated control foals. No difference could be demonstrated among the vaccinated groups, suggesting that the combination vaccine protects as well as the monovalent vaccine. In EHV1.4-vaccinated foals both antigenic fractions induced clear protection up to 6 months after vaccination (9). It can therefore be anticipated that the efficacy of the combination vaccine against EHV-1 challenge is similar to the efficacy against EHV-1 induced by EHV1.4 vaccination.

Adjuvants, Immunologic↗

Tetanus neonatorum--experience with intrathecal serotherapy at Muhimbili Medical Centre, Dar es Salaam, Tanzania.

In an attempt to lower the mortality rate of neonatal tetanus a study was undertaken to determine whether intrathecal serotherapy influences mortality from this disease. Sixty-six babies with tetanus neonatorum were studied. The mortality rate among babies who received intrathecal anti-tetanus serum (ATS) was 45% compared with 82% in the control group given intramuscular ATS (P congruent to 0.002). Infants who received intrathecal ATS also had fewer complications than controls (P less than 0.001) and the duration of hospital stay for the survivors was 19.3 days compared with 28.7 days for the control group (P less than 0.05). It is concluded that intrathecal ATS is superior to intramuscular ATS in the treatment of neonatal tetanus.

Female↗

Placental transfer of tetanus toxoid antibodies in Nigerian mothers.

The aim of this study was to assess the efficacy of the tetanus toxoid immunization programme in Nigeria, specifically the placental transfer of antibody to newborn Nigerian babies. Tetanus toxoid antibody levels were measured in 39 mother-baby pairs in Ibadan, Nigeria and compared with 78 British mother-baby pairs. Geometric means of the ratios of cord/mother (sequestration index SI) were 0.776 for Nigerian pairs and 1.306 for British pairs, indicating a limitation in the placental transfer of tetanus toxoid in the Nigerian population. These findings confirm that there is a block in the placental transfer of anti-tetanus toxoid antibodies in African populations which will affect current immunization programmes and requires further investigation.

Antibodies, Bacterial↗

Levels and avidity of antibodies to tetanus toxoid in children aged 1-15 years in Dar es Salaam and Bagamoyo, Tanzania.

A study was undertaken to determine the serological response in children (aged 1-15 years) immunized with diphtheria-pertussis-tetanus vaccine (DPT) alone or with a tetanus toxoid (TT) booster dose under the Expanded Programme on Immunization in Dar es Salaam and Bagamoyo, Tanzania. Using an ELISA technique, serum levels of anti-TT antibody, antibody avidity and anti-TT IgG subclasses were determined in 138 apparently healthy children. Our findings revealed that 94.7% and 98% of children aged 1-5 years in Dar es Salaam and Bagamoyo, respectively, had anti-TT antibody levels above that considered protective (> or = 0.1 IU/ml). Among 6-15-year-old children, 53.3% in Dar es Salaam and 55% in Bagamoyo had anti-TT antibody levels > or = 0.1 IU/ml. The avidity index of anti-TT antibodies was high in most of the younger children, 84.2% in Dar es Salaam and 92% in Bagamoyo. Significantly fewer older children in Dar es Salaam and Bagamoyo (53.3% and 50%, respectively) had high avidity index antibodies. The predominant anti-TT IgG subclasses were IgG1 and IgG3. It is concluded that the current DPT immunization schedule provides adequate tetanus immunity for children under 5. However, about half of the older children had no protection against tetanus.

Adolescent↗

Topical antimicrobials applied to the umbilical cord stump: a new intervention against neonatal tetanus.

BACKGROUND: Previous case-control studies of neonatal tetanus (NNT), a leading cause of infant mortality in developing countries, have suggested that antimicrobials applied after delivery to the umbilical cord stump may protect against this disease. However, assessment of their protective effect has been limited by the low prevalence of antimicrobial use in developing countries. METHODS: We conducted a population-based, matched, case-control study to assess the use of antimicrobials and other factors potentially related to NNT in rural parts of Bangladesh. We studied 359 cases (infants who were normal at birth but who died between the 3rd and 30th day of life after an illness characterized by signs of NNT), each matched to three living controls for gender, residence, and date of birth. RESULTS: In univariate analyses, the application of either antibiotics or disinfectants at delivery, and the continuous or any application of disinfectants were protective against NNT. The application of antibiotics at delivery (odds ratio [OR] = 0.21, P = 0.019), hand washing by the delivery attendant (OR = 0.64, P = 0.005), and prior maternal immunization with tetanus toxoid (OR = 0.50, P < 0.001) remained protective in conditional logistic-regression analyses. Application of animal dung to the umbilical stump (OR = 2.31, P = 0.047) was hazardous. CONCLUSIONS: Effective and inexpensive topical antimicrobials provide a new prevention opportunity that could be used by traditional birth attendants and mothers to provide additional benefits to NNT control programmes based on maternal immunization with tetanus toxoid. Promotion of hygienic delivery and cord-care practices and increasing tetanus toxoid coverage remain cornerstones for the prevention of NNT deaths.

Administration, Topical↗

Absence of a significant interaction between a Haemophilus influenzae conjugate vaccine combined with a diphtheria toxoid, tetanus toxoid and acellular pertussis vaccine in the same syringe and inactivated polio vaccine.

BACKGROUND: We compared the antibody response to Haemophilus influenzae type b capsular polysaccharide (PRP) after three doses of a diphtheria toxoid, tetanus toxoid and acellular pertussis vaccine (DTaP) combined with a PRP-tetanus conjugate (PRP-T) in infants randomized to receive oral polio vaccine (OPV) or inactivated polio vaccine (IPV). The polio vaccine was given separately at the same visit. METHODS: Three hundred fifty-six infants from pediatric practices in suburban Chicago and New Orleans were randomized into two groups. Group A received OPV at 2 and 4 months of age; Group B received IPV at 2 and 4 months of age. Both groups received DTaP/PRP-T at 2, 4 and 6 months of age and hepatitis B vaccine at 2 and 4 months of age. A serum sample was obtained before immunization (age 2 months) and 1 month after 3 doses of DTaP/PRP-T (age 7 months). Sera were assayed for antibody responses to all relevant vaccine antigens. RESULTS: No significant vaccine antigen interference was found when polio immunization was provided by IPV or OPV for anti-PRP, diphtheria, tetanus or pertussis antibodies. OPV recipients had a significantly higher mean antibody response to serotype 1 (P = 0.03) and 2 (P = 0.0001) poliovirus. CONCLUSION: Whether polio immunization was accomplished with IPV or OPV did not significantly influence the antibody responses in sera obtained at 7 months of age for anti-PRP, anti-diphtheria and anti-tetanus toxoid antibodies and antibodies to pertussis antigens, when DTaP/PRP-T was given in the primary series.

Antibodies, Bacterial↗

Greater antibody responses to an eleven valent mixed carrier diphtheria- or tetanus-conjugated pneumococcal vaccine in Filipino than in Finnish or Israeli infants.

BACKGROUND: Antibody responses to pneumococcal conjugate vaccines may vary when administered in different populations or epidemiologic settings. Understanding the causes and significance of this variation could help to determine the number of doses and timing required for protection against pneumococcal diseases in each country. METHODS: This report compares antibody responses to aluminum-adjuvanted and nonadjuvanted mixed carrier 11-valent diphtheria- or tetanus-conjugated pneumococcal vaccine (11-PncTD) formulations when given at 6, 10 and 14 weeks and 9 months of age to Filipino infants (n = 51) and at 2, 4, 6 and 12 months of age to Finnish (n = 127) and Israeli (n = 124) infants. The study populations differ in their natural exposure to pneumococcus and risk factors for pneumococcal carriage and disease. RESULTS: Filipino and Israeli infants had slightly but significantly higher prevaccination geometric mean concentration (GMC) of antibodies than did the Finnish infants. After three doses of aluminum-adjuvanted 11-PncTD vaccine, the Filipino infants had 1.8 to 6.7 and 1.5 to 5.0 times higher GMC than the Finnish and Israeli infants, respectively, against pneumococcal serotypes conjugated to tetanus protein. The GMC of serotypes conjugated to diphtheria toxoid was 1.3 to 3.0 and 0.7 to 2.0 times the GMC in Finnish and Israeli infants, respectively. The nonadjuvanted vaccine formulation induced generally lower GMCs. CONCLUSIONS: The antibody responses to the tetanus-conjugated polysaccharides were considerably higher in the Filipino than in the Finnish or Israeli infants. This may be a result of several factors including the priming effect of tetanus toxoid given to pregnant women, early pneumococcal nasopharyngeal acquisition and genetic differences among populations.

Antibodies, Bacterial↗

Comparison of enzyme-linked immunosorbent assay and passive hemagglutination method for quantification of antibodies to lipopolysaccharide and tetanus toxoid in rats.

In a comparative study, the enzyme-linked immunosorbent assay, using peroxidase labeled anti-rat immunoglobulin M and immunoglobulin G, and the passive hemagglutination test were applied to determine the primary and secondary antibody response to lipopolysaccharide and tetanus toxoid in rats. In the enzyme-linked immunosorbent assay, the antigens were bound to the wells of polystyrene microplates, tetanus toxoid directly, and lipopolysaccharide after complexing it with methylated bovine serum albumin. After incubation with dilutions of the rat sera, the amount of antibody bound to the solid phase was quantified by means of peroxidase-labeled anti-immunoglobulin. The specificity of the enzyme immunoassay was tested by absorption of the sera with their respective antigens. The enzyme-linked immunosorbent assay proved to be more sensitive than the hemagglutination reaction, except when titers were determined during the secondary response to tetanus toxoid. Besides its specificity and sensitivity, the enzyme-linked immunosorbent assay is a convenient method for measuring both immunoglobulin M and immunoglobulin G antibodies. At low serum dilutions of lipopolysaccharide antisera, inhibition of the reaction in the enzyme-linked immunosorbent assay occurred. This phenomenon could be prevented by heating the sera at 56 degrees C for 30 min. Lipopolysaccharide was immunogenic in rats over an extremely wide dose range (from 10 pg to 1 mg); the optimal immunogenic dose of lipopolysaccharide for young adult rats was 0.1 to 1,000 mug when administered intravenously, and that of tetanus toxoid was 5 to 10 lines of flocculation, as determined by the Ramon flocculation test.

Animals↗

Oral vaccination of mice against tetanus by use of a live attenuated Salmonella carrier.

A Salmonella typhimurium aroA mutant has been used as a live carrier to immunize mice against tetanus. Plasmid pTETtac4, which expresses a 50-kilodalton fragment of tetanus toxin (fragment C) under the control of the tac promoter, was introduced into SL3261 aroA. When used as a live vaccine and administered orally or intravenously, this strain was able to induce protective immunity in mice against a lethal tetanus toxin challenge. When plasmid pTETtac2, which contains the lacI gene, was used, no immunity was obtained, indicating that the expression of fragment C was repressed in vivo. We believe that this is the first example of a successful oral vaccination that uses an attenuated bacterial carrier to deliver a protective antigen derived from tetanus toxin.

Administration, Oral↗

Evaluation of a diphtheria-tetanus-acellular pertussis-inactivated poliovirus-Haemophilus influenzae type b vaccine given concurrently with meningococcal group C conjugate vaccine at 2, 3 and 4 months of age.

BACKGROUND AND OBJECTIVE: In view of the possible introduction of diphtheria-tetanus-acellular pertussis-inactivated poliovirus-Haemophilus influenzae type b (DTaP-IPV-Hib, eg Pediacel) vaccine in the UK, a study of the immunogenicity of Pediacel when given with one of two different meningococcal group C conjugate (MCC) vaccines at 2, 3 and 4 months of age was conducted. METHODS: Randomised controlled study in 241 infants. RESULTS: Post vaccination, the proportion of infants with anti-polyribosylribitol phosphate (PRP) levels > or =0.15 microg/ml was 93.2% (95% confidence interval (CI) 86.6 to 96.7) in the Pediacel group compared with 100% (95% CI 96.4 to 100) in the diphtheria-tetanus-whole-cell pertussis-Haemophilus influenzae type b (DTwP-Hib) group. The anti-PRP response was lower in infants receiving either Pediacel or DTwP-Hib when these vaccines were given concomitantly with meningococcal group C conjugate with diphtheria-derived protein CRM(197) as conjugate protein (MCC-CRM) compared with meningococcal group C conjugate with tetanus toxoid as conjugate protein (MCC-TT). For group C meningococcus, the proportion of infants with serum bactericidal antibody (SBA) titre > or =1:8 in the Pediacel group was 99.0% compared with 100% in the DTwP-Hib group. The MCC SBA geometric mean titre (GMT) was lower in those receiving Pediacel with MCC-TT than in those receiving DTwP-Hib with MCC-TT, although all titres were well above the protective threshold. The MCC SBA GMT was similar in those receiving Pediacel and DTwP-Hib and MCC-CRM. Responses to all other vaccine components were equivalent in the two groups. CONCLUSIONS: Pediacel is immunogenic when given at 2, 3 and 4 months of age. Coadministration of MCC vaccine can influence the Hib response, and the MCC response to a tetanus conjugate can be influenced by the nature of the coadministered DTP-Hib vaccine.

Diphtheria-Tetanus-Pertussis Vaccine↗

Influences on tetanus immunization in accident and emergency.

We studied the casualty records of 479 patients with open skin injury arriving over 2 single weeks, 3 months apart, to assess adequacy of adherence to protocols for active immunization against tetanus. 234 patients were treated correctly. In 114 cases immunization was insufficient or tetanus was not mentioned at all; in 29 cases immunization was excessive and 102 records were ambiguous and no conclusion could be drawn. There was no evidence in junior doctors' management indicating learning over 3 months but the mention of tetanus by a triage nurse was associated with a highly significant increase in the number of records showing correct treatment. There is a persistent high error rate in tetanus immunoprophylaxis despite a department manual, an induction course, and conspicuously displayed treatment protocols. More individual feedback seems required but the unexpected benefit from assessment by a triage nurse may have greater impact in reducing treatment errors.

Clinical Protocols↗

The effect of co-trimoxazole on antitoxin response to tetanus toxoid.

The effect of a 4-day course of co-trimoxazole (Septrin) on antitoxin response to tetanus vaccine was assessed in a double-blind study involving 22 healthy adults. The tetanus antitoxin levels were measured by in vivo and in vitro methods for up to 8 weeks after the first of two injections of tetanus vaccine, given 4 weeks apart. No sigificant difference was observed in the level of tetanus antitoxin produced in subjects who received co-trimoxazole (Septrin) in recommended therapeutic dosage during the first 4 days of the trial from that in subjects who received placebo tablets. The results indicate that a 4-day course of co-trimoxazole (Septrin) does not affect antibody production.

Animals↗

Antibody synthesis by bone marrow cells in vitro following primary and booster tetanus toxoid immunization in humans.

Normal volunteers received either initial or booster immunization with tetanus toxoid. Bone marrow and peripheral blood mononuclear cells were obtained for up to 28 d after immunization and were analyzed for synthesis of total Ig and specific antibodies to tetanus toxoid. Cells were cultured in vitro for 3 or 7 d with or without pokeweed mitogen (PWM). Synthesis of IgG and IgM antibodies to tetanus (IgG-Tet and IgM-Tet) and total IgG and IgM was determined by radioimmunoassay. Four functional B cell subpopulations were detected in the bone marrow after booster tetanus immunization: (a) B cells that spontaneously synthesized IgG-Tet appeared on day 7 after immunization but were undetectable by day 21; (b) B cells that synthesized IgG-Tet after stimulation with PWM appeared after day 21 and persisted for greater than 1 mo; (c) B cells that synthesized IgM-Tet in the presence of PWM were detectable before and after immunization; and (d) B cells that spontaneously synthesized IgM-Tet appeared on day 7 and were undetectable by day 21. In contrast to the other three types of bone marrow B cells described, this fourth subpopulation of PWM-independent IgM-Tet-synthesizing B cells was not detected in the peripheral blood. After primary immunization, no spontaneous antibody-producing cells were detected in the blood or bone marrow, although there was a small rise in IgM-Tet in two of three subjects. In the bone marrow, only IgM-Tet PWM-inducible cells were seen, although mitogen-responsive IgM and IgG-Tet cells were detected in the circulation. The IgM-Tet PWM-reactive cells were present even before primary antigen exposure and appear to represent the initial B cells involved in the antibody response. These data indicate that there are specific times after immunization when different functional classes of anti-Tet-synthesizing B cells and memory B cells appear in human bone marrow. Knowledge of these data may be important in developing a strategy for the transfer of immune memory from donors to recipients in the setting of bone marrow transplantation.

Adult↗

Extensive swelling after booster doses of acellular pertussis-tetanus-diphtheria vaccines.

BACKGROUND: Diphtheria and tetanus toxoid combined with acellular pertussis (DTaP) vaccines are less reactogenic than diphtheria and tetanus toxoid combined with whole cell pertussis (DTwP) vaccines. However, local reactions increase in rate and severity with each successive DTaP dose, and swelling of the entire injected limb has been reported after booster doses. METHODS: We reviewed reports of swelling of the entire thigh or upper arm after the fourth and fifth dose, respectively, of DTaP vaccines administered in the National Institutes of Health multicenter comparative DTaP studies. Relationships were explored among reports of severe swelling, rates of other reactions, quantity of vaccine contents, and prevaccination and postvaccination antibody levels to pertussis toxin, tetanus toxin, and diphtheria toxin. RESULTS: Entire thigh swelling was an unsolicited reaction reported in 20 (2%) of the 1015 children who received 4 consecutive doses of the same DTaP vaccine. The reaction was associated with 9 of the 12 DTaP vaccines evaluated. Although there were no reports of swelling of the entire upper arm in 121 children given a fifth dose of the same DTaP, 4 (2.7%) of 146 recipients of 5 doses of a mixed schedule of DTaP vaccines experienced such swelling. Rates of other reactions were higher in children with entire thigh swelling than in those without. Of the children with entire thigh swelling, 60% had local pain, and 60% had erythema. All swelling subsided spontaneously without sequelae. There was a significant linear association between the rates of entire thigh swelling after dose 4 and diphtheria toxoid content in the DTaP products. Lesser degrees of swelling (>50 mm but less than entire limb) correlated with pertussis toxoid content after dose 4 and aluminum content after dose 5. No relationship was established between levels of serum antibody to diphtheria, tetanus, or pertussis toxin and rates of swelling of the whole thigh. CONCLUSIONS: Booster doses of DTaP vaccines can cause entire limb swelling, which is usually associated with redness and pain. Our data suggest that this extensive swelling reaction may be more common with vaccines containing high diphtheria toxoid content.

Antibodies, Bacterial↗

[Tetanus in the climacterium].

OBJECTIVE: The purpose of this study was to evaluate Brazilian women in the climacterium who are affected by tetanus. METHODS: Data were collected from publications of DATASUS/Ministério da Saúde (Health Ministry) referring to hospital admissions (SIH) in hospitals of the Sistema Unico de Saúde (SUS) (Official Health System) and accorded hospitals. The numbers of vaccinations administered were obtained at the National Program of immunizations. Data regarding the population was obtained at the Brazilian Geography and Statistics Institute (IBGE). RESULTS: Between January 2001 and July 2004, while for the male gender, with the passing of years there was reduction in the total number of admissions due to tetanus, for the female gender there was an increase. Frequency of the disease, for both genders aged from 35 to 64 years in the different regions of Brazil, disclosed that the there is a higher incidence in the Northeast, followed by the Southeast and South. Data for the year 2002 showed that in the age bracket from 50 to 59 years, only 15.73% of the people were adequately protected against tetanus. CONCLUSIONS: In the adult phase, healthy life depends on public health policies, in the sense of supplying appropriate prevention against the disease. In the case of tetanus, vaccination is an effective prevention.

Adult↗