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Chapter 6, Part 6
IMMUNIZATION TO TETANUS*
COLONEL ARTHUR P. LONG, MC
The recent experience in the Far East including that in Korea had added little, if any, new information concerning immunization to tetanus. It is perhaps of some interest and significance, however, that the entirely satisfactory effect of this procedure has been confirmed during this latest conflict. The World War II experience with active immunization to tetanus using tetanus toxoid has been reported elsewhere and need not be recounted here (1). It is adequate to recall that as shown in table 1 only some 12 cases of tetanus occurred
Table 1. Incidence of Tetanus Among Wound and Injury Casualties
among nearly 3,000,000 wound and injury casualties during that period. This represents a reduction in frequency of tetanus to about one-thirtieth of that reported during World War I. There is no question of the potential hazards from the infection during the World War II period since numerous cases were reported among the unimmunized German Forces in Europe and among Japanese troops and civilians in the Pacific areas.
Table 2 indicates the status of immunization of the 12 cases reported. It is seen that only 4 of the 12 were in individuals whose records indicated that immunization was in complete accordance with established procedures.
As indicated above, this success was repeated during the Korean conflict, when only one case of tetanus was reported. This resulted from a nonbattle type of injury occurring as a result of a bulldozer accident. It was nonfatal and occurred in an individual who, though
*Presented 29 April 1954, to the Course on Recent Advances in Medicine and Surgery, Army Medical Service Graduate School, Walter Reed Army Medical Center, Washington, D. C.
Table 2. Immunization Status of Cases
he had received adequate basic immunization, was not given an emergency stimulating dose of toxoid at the time of injury. This, of course, serves to emphasize again that protection from tetanus by active immunization is based on the immunologic preparation of the individual by the basic immunization and the stimulation of protective antitoxin levels by the dose of toxoid administered at the time of injury. (In this connection, it is worthy of note that in at least one surgical hospital during the early days of the Korean episode, the laboratory officer organized a tetanus toxoid-penicillin team whose duty it was to administer the emergency stimulating dose of tetanus toxoid to all wounded patients on admission and at the same time to give the expectant treatment dose of penicillin (2).
Although the records are incomplete as to the number of cases of tetanus occurring among non-American United Nations personnel in Korea, it is known that a number were experienced and that among these, there were some fatalities. Details of these cases are not known. That they occurred in non-immunized personnel, however, is unquestioned. It is possible that some of them at least may not even have received passive protection in the form of tetanus antitoxin. It is well, then, to keep in mind that when American forces are in conflict side by side with allied troops not protected with tetanus toxoid, the prevention of tetanus in such individuals may well rest with the administration of prophylactic antitoxin.
Not arising directly from the Korean experience but resulting from a continuation of studies, has come new knowledge concerning the interval between stimulating doses of toxoid. At the end of World War II, it was possible to demonstrate that the conditioning afforded by the basic immunization persisted for at least 4 to 5 years. Evidence resulting from the more recent studies indicates that this period may extend up to 10 years (3-5). Based on this new information, it is quite likely that the next revision of the Army immunization policy statement will direct that toxoid stimulating doses be admin-
istered at intervals of about 6 years for the maintenance of the basic immunologic conditioning required for protection from tetanus.
There is one other change contemplated for the tetanus immunization procedure. This has less to do with tetanus than with diphtheria so will be mentioned only briefly. For reasons which need not be reviewed here, it has become desirable to effect active immunization of American troops to diphtheria and to accomplish this as simply and as efficiently as possible. Accordingly, it has been decided to add a very small amount of diphtheria toxoid (about 2 Lf. per ml.) to the tetanus toxoid (6). This procedure has now been well studied and its two most important features have been determined: first, that even such a small dose of diphtheria toxoid will produce an immune status in the great majority of young American adults; and second, that this combination of antigens can be administered with essentially no more local or systemic reaction than that resulting from the administration of tetanus toxoid alone.
Current knowledge and experience indicate that active immunization to tetanus utilizing tetanus toxoid is a highly effective and extremely practical procedure. One other antigen such as diphtheria toxoid may be added to the tetanus toxoid in small quantities and give adequate immunogenic responses without significant increases in reactions.
1. a. Long, A. P.: Tetanus Toxoid: Its Use in the United States Army. Am. J. Pub. Health 33 : 53-57, January 1943.
b. Long, A. P.: Immunization in the United States Army. Am. J. Pub. Health 34 : 27-33, January 1944.
c. Long, A. P., and Sartwell, P. E.: Tetanus in the United States Army in World War II. Bull. of the U. S. Army Med. Dept. 7 : 371-385, April 1947.
d. Long, A. P.: Current Status of Immunization Procedures, Tetanus and Exotic Diseases of Military Importance. Am. J. Pub. Health 38 : 485-488, April 1948.
e. Edsall, G.: Active Immunization. New England J. Med. 235 : 256-265, 298-305, 328-336, 22-29 Aug., 5 Sept. 1946.
2. Lincoln, A. F.: Personal Communication.
3. Bigler, A.: Tetanus Immunization. Am. J. Dis. Child. 81 : 226-232, February 1951.
4. Williams, W. C., and Peterson, J. C.: Tetanus Toxoid Study. To be published.
5. Looney, J. M., Edsall, G., and Chasen, W. H.: Effect of a Booster Dose of Tetanus Toxoid after Five or More Years. Fed. Proceedings 12 : 452, March 1953.
6. Edsall, G., Altman, J. S., and Gaspar, A. J.: Combined Diphtheria-Tetanus Immunization of Adults: Use of Small Doses of Diphtheria Toxoid. Presented in part at the American Public Health Association, 24 Oct. 1952.