Update on Adult Immunization Recommendations of the
Immunization Practices Advisory Committee (ACIP) 

MMWR 40(RR12);1-52 

Publication date: 11/15/1991

[excerpts]

SUMMARY

This statement on adult immunization is a supplement to the "General
Recommendations on Immunization" of the Immunization Practices Advisory
Committee (ACIP) (1) and updates the previous supplement published in
September 1984. This statement presents an overview on immunization for
adults and makes specific immunization recommendations. The statement
provides information on vaccine-preventable diseases; indications for
use of vaccines, toxoids, and immune globulins recommended for adults;
and specific side effects, adverse reactions, precautions, and
contraindications associated with use of these immunobiologics. It also
gives immunization recommendations for adults in specific age groups and
for those who have special immunization requirements because of
occupation, life-style, travel, environmental situations, and health
status.

This statement is a compendium of ACIP recommendations and will not be
updated regularly. The ACIP periodically reviews individual immunization
statements that are published in the MMWR. The reader must use the
detailed, up-to-date individual statements in conjunction with this
compendium to keep abreast of current information. A list of the current
ACIP recommendations for specific diseases and vaccines can be found in
Appendix 1. 

[N.B. -- there are no updates on tetanus since this one  --KC]

Tetanus

The occurrence of tetanus has decreased dramatically, largely because of
the widespread use of tetanus toxoid. Nevertheless, the number of cases
remained relatively constant from 1986 through 1989, during which 48-64
cases were reported annually. Tetanus occurs almost exclusively among
unvaccinated or inadequately vaccinated persons. Immune pregnant women
transfer temporary protection against tetanus to their infants through
transplacental maternal antibody.

In the period 1982-1989, persons greater than or equal to 20 years of
age accounted for 95% of the 513 reported tetanus cases for which
patient ages were known; persons greater than or equal to 60 years of
age accounted for 59%. The age distribution of persons who died from
tetanus was similar. Serosurveys done since 1977 indicate that 6%-11% of
adults 18-39 years of age and 49%-66% of those greater than or equal to
60 years of age lack protective levels of circulating antitoxin against
tetanus (10-13). Although surveys of emergency rooms suggest that only
1%-6% of all persons who receive medical care for injuries that can lead
to tetanus receive inadequate prophylaxis (14), in 1987-1988, 81% of the
people who developed tetanus after an acute injury and sought medical
care did not receive adequate prophylaxis as recommended by the ACIP
(14).

Tetanus toxoid. Complete and appropriately timed vaccination is nearly
100% effective in preventing tetanus. Td is the preferred preparation
for active tetanus immunization of adults because a large proportion of
them also lack protective levels of circulating antitoxin against
diphtheria (10-13).

Toxoid indications. All adults lacking a complete primary series of
diphtheria and tetanus toxoids should complete the series with Td. A
primary series for adults is three doses of preparations containing
tetanus and diphtheria toxoids, with the first two doses given at least
4 weeks apart and the third dose given 6-12 months after the second.
Persons who have served in the military can be considered to have
received a primary series of diphtheria and tetanus toxoids. The
practitioner should be aware that policies of the different branches of
the military have varied among themselves and over time. All adults for
whom greater than or equal to 10 years have elapsed since completion of
their primary series or since their last booster dose should receive a
booster dose of Td. Thereafter, a booster dose of Td should be
administered every 10 years. Doses need not be repeated if the primary
schedule for the series or booster doses is delayed.

The recommended pediatric schedule for DTP includes a booster dose at
age 4-6 years. The first Td booster is recommended at age 14-16 years
(10 years after the dose at age 4-6 years). One means of ensuring that
persons continue to receive boosters every 10 years is to vaccinate
persons routinely at mid-decade ages (e.g., 25 years of age, 35 years of
age).

For wound management, the need for active immunization, with or without
passive immunization, depends on the condition of the wound and the
patient's vaccination history. A summary of the indications for active
and passive immunization is provided in Table 8. Only rarely have cases
of tetanus occurred among persons with a documented primary series of
toxoid injections.

Evidence indicates that complete primary vaccination with tetanus toxoid
provides long-lasting protection (greater than or equal to 10 years
among most recipients). Consequently, after complete primary tetanus
vaccination, boosters are recommended at 10-year intervals. For clean
and minor wounds occurring during the 10-year interval, no additional
booster is recommended. For other wounds, a booster is appropriate if
the patient has not received tetanus toxoid within the preceding 5
years. Antitoxin antibodies develop rapidly in persons who have
previously received at least two doses of tetanus toxoid.

Persons who have not completed a full primary series of injections or
whose vaccination status is unknown or uncertain may require tetanus
toxoid and passive immunization at the time of wound cleaning and
debridement. Ascertaining the interval since the most recent toxoid dose
is not sufficient. A careful attempt should be made to determine whether
a patient has previously completed primary vaccination and, if not, how
many doses have been given. Persons with unknown or uncertain previous
vaccination histories should be considered to have had no previous
tetanus toxoid doses.

In managing the wounds of adults, Td is the preferred preparation for
active tetanus immunization. This toxoid preparation is also used to
enhance protection against diphtheria, because a large proportion of
adults are susceptible. Thus, if advantage is taken of visits for care
of acute health problems, such as for wound management, some patients
who otherwise would remain susceptible can be protected against both
diseases. Primary vaccination should ultimately be completed for persons
documented to have received fewer than the recommended number of doses,
including doses given as part of wound management.

If passive immunization is needed, human tetanus immune globulin (TIG)
is the product of choice. The currently recommended prophylactic dose of
TIG for wounds of average severity is 250 units IM. When T or Td and TIG
are given concurrently, separate syringes and separate sites should be
used. Most experts consider the use of adsorbed toxoid mandatory in this
situation.




TABLE 8. Summary guide to tetanus prophylaxis * in routine wound management,
United States
========================================================================
                         Clean, minor wounds          All other wounds +
                         -------------------          ------------------
                         Td &          TIG @          Td &          TIG
------------------------------------------------------------------------
Uncertain or <3          Yes            No            Yes           Yes

>3 **                    No ++          No            No &&          No
------------------------------------------------------------------------

* Refer also to text on specific vaccines or toxoids for
contraindications, precautions, dosages, side effects, adverse
reactions, and special considerations. Important details are in the text
and in the ACIP recommendations on diphtheria, tetanus, and pertussis
(DTP) (MMWR 1991: 40{RR-10)).

+ Such as, but not limited to: wounds contaminated with dirt, feces, and
saliva; puncture wounds; avulsions; and wounds resulting from missiles,
crushing, burns, and frostbite.

& Td = Tetanus and diphtheria toxoids, adsorbed (for adult use). For
children <7 years old, DTP (DT, if pertussis vaccine is contraindicated)
is preferred to tetanus toxoid alone. For persons >=7 years old, Td is
preferred to tetanus toxoid alone.

@ TIG = Tetanus immune globulin.

** If only three doses of fluid toxoid have been received, a fourth dose
of toxoid, preferably an adsorbed toxoid, should be given.

++ Yes, >10 years since last dose.

&& Yes, >5 years since last dose. (More frequent boosters are not needed
and can accentuate side effects.)
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