Who needs a tetanus shot?

The Pediatric Insider

© 2014 Roy Benaroch, MD

Rich asked, “After a cut, how do I know if my child needs a tetanus shot?”

When in doubt, get one. Tetanus is way-bad news, and prevention is much better than trying to treat it. Keep your child up-to-date and fully vaccinated so you don’t have to worry about this; but if you’re not sure, or you’ve let immunizations lapse, just get the booster.

Tetanus is a deadly illness caused by contamination of a wound with the bacteria Clostridium tetani. The bacteria itself lives in soil all over the world, and can also happily colonize your intestine without making anyone sick. So it’s impossible to eradicate the bacteria itself, and no amount of good hygiene or clean living can eliminate the risk of tetanus. Still, good wound care does decrease the risk. In the developed world, tetanus often develops from contamination of the umbilical cord after delivery, when the cord is cut with dirty instruments. Without intensive care, most of these babies will die.

Photo from CDC

Photo from CDC

When a wound is contaminated, the tetanus bacteria produces a potent neurotoxin that causes severe muscle spasms, including spasms of the face and jaw muscles, causing “lockjaw”. The spasms are aggravated by any external stimulus—light or sound or movement—and can be so severe that swallowing and breathing become impossible. The spasms are so rigid and unremitting they look more like a seizure, though unlike a seizure they’re very painful and can last for weeks. Treatment with immune globulin and antibiotics can help, but it’s not very effective. People with tetanus may need complete sedation and mechanical ventilation for several weeks to survive.

Photo from CDC

Photo from CDC

Tetanus vaccinations have been available since the 1930s, and since then the burden of tetanus has all but disappeared. In the United States, only about 40 cases occur each year, almost all of these in people who have not been properly vaccinated. One recent report reviewed two cases of tetanus in Oklahoma, both in homeschooled, unvaccinated children. One of them was in the ICU on mechanical ventilation for over two weeks. Both families reported that they didn’t realize tetanus was so serious.

The usual vaccine series for tetanus starts with DTaP, which includes components to protects against diphtheria, tetanus, and pertussis. Five doses of this are given by age five (usually at ages 2 months, 4 months, 6 months, 18 months, and 4 or 5 years.) After that, a dose of Tdap is given at age 11 or 12, followed by a Td tetanus booster every five to ten years. If a child is up-to-date on vaccinations, no extra booster of tetanus is typically needed after a cut or wound, unless it’s very large and very contaminated. However, if you’re not sure your child is up-to-date, check with your child’s doctor. It is much more effective—and safer—to stay up on tetanus vaccines rather than get one after a wound.

It’s also important to clean cuts, burns, and other wounds thoroughly, with plenty of running water. The most high-risk wounds for tetanus and other infections are ones that are deep and difficult to clean, or ones with a lot of crushed or damaged tissue nearby. Even with a complete tetanus series, other kinds of wound infections can occur. If a wound is deep or hard to clean, or if the area starts to ooze, turns red, or has increasing pain, see your doctor.

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