Tetanus immunity and physician compliance with tetanus prophylaxis practices among emergency department patients presenting with wounds☆

Received 26 June 2003; received in revised form 19 September 2003; accepted 24 September 2003.

Refers to article:

Tetanus prophylaxis in the emergency department
Martha H Roper
Annals of Emergency Medicine
March 2004 (Vol. 43, Issue 3, Pages 315-317)
Full Text | Full-Text PDF (64 KB)

Abstract

Study objective

We determine tetanus seroprotection rates and physician compliance with tetanus prophylaxis recommendations among patients presenting with wounds.

Methods

A prospective observational study of patients aged 18 years or older who presented to 5 university-affiliated emergency departments (EDs) because of wounds was conducted between March 1999 and August 2000. Serum antitoxin levels were measured by enzyme immunoassay with seroprotection defined as more than 0.15 IU/mL. Seroprotection rates, risk factors for lack of seroprotection, and rates of physician compliance with tetanus prophylaxis recommendations by the Advisory Committee on Immunization Practices were determined.

Results

The seroprotection rate among 1,988 patients was 90.2% (95% confidence interval 88.8% to 91.5%). Groups with significantly lower seroprotection rates were persons aged 70 years or older, 59.5% (risk ratio [RR] 5.2); immigrants from outside North America or Western Europe, 75.3% (RR 3.7); persons with a history of inadequate immunization, 86.3% (RR 2.9); and persons without education beyond grade school, 76.5% (RR 2.5). Despite a history of adequate immunization, 18% of immigrants lacked seroprotection. Overall, 60.9% of patients required tetanus immunization, of whom 57.6% did not receive indicated immunization. Among patients with tetanus-prone wounds, appropriate prophylaxis (ie, tetanus immunoglobulin and toxoid) was provided to none of 504 patients who gave a history of inadequate primary immunization (of whom 15.1% had nonprotective antibody titers) and to 218 (79%) of 276 patients who required only a toxoid booster.

Conclusion

Although seroprotection rates are generally high in the United States, the risk of tetanus persists in the elderly, immigrants, and persons without education beyond grade school. There is substantial underimmunization in the ED (particularly with regard to use of tetanus immunoglobulin), leaving many patients, especially those from high-risk groups, unprotected. Better awareness of tetanus prophylaxis recommendations is necessary, and future tetanus prophylaxis recommendations may be more effective if they are also based on demographic risk factors.

a Department of Medicine, Divisions of Emergency Medicine and Infectious Diseases, Olive View–University of California–Los Angeles Medical Center, Sylmar, CA, USA

b Emergency Medicine Center, University of California–Los Angeles Medical Center, Los Angeles, CA, USA

c Department of Emergency Medicine, Long Island Jewish Medical Center, New Hyde Park Island, NY, USA

d Department of Emergency Medicine, Maricopa Medical Center, Phoenix, AZ, USA

e Department of Emergency Medicine, Truman Medical Center, University of Missouri–Kansas City, Kansas City, MO, USA

f Department of Emergency Medicine, Charity Medical Center, Louisiana State University, New Orleans, LA, USA

g National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA

Address for correspondence: David A. Talan, MD, Olive View–University of California–Los Angeles Medical Center, 14445 Olive View Drive, North Annex, Sylmar, CA 91342; 818-364-3107; fax 818-364-3268

☆ Author contributions: DAT, GJM, KA, BRT, CVP, MTS, LMD, RSW, and SMO conceived and designed the study. FMA, KA, BRT, CVP, MTS, and LMD acquired the data. WRM, DAT, and FMA analyzed and interpreted the data. DAT and FMA drafted the manuscript. WRM and FMA conducted the statistical analysis. MDB conducted the serologic testing. DAT obtained funding. DAT, KA, BRT, CVP, MTS, LMD, RSW, and SMO provided administrative, technical, and material support. DAT, FMA, KA, BRT, CVP, MTS and LMD supervised the study. All authors take responsibility for the paper as a whole.

Supported by a research grant from Bayer Biological Products, Research Triangle Park, NC.

Dr. Talan, Dr. Abrahamian, Dr. Moran, and Dr. Alagappan have received speaking honoraria and research grants from Bayer. Dr. Dunbar has received research grants from Bayer.

Reprints not available from the authors.

1 Dr. Pollack is currently affiliated with the Pennsylvania Hospital, University of Pennsylvania Health System, Philadelphia, PA.

PII: S0196-0644(03)01051-5

doi:10.1016/j.annemergmed.2003.09.017

8 of 54