Tetanus Prophylaxis and Serum Sensitivity Tests
Authors: N. H. Moynihan
Journal: BMJ (1956)

In a review of the incidence of tetanus among civilians in England and Wales from 1931 to 1948, Conybeare and Logan (1951) showed that the number of fatal cases dropped from an average of 100 a year up. to 1944 to an average of 74 in the period 1944-8. Since then the average has dropped still further to 71 in the years 1949-53. As Cole (1951) has pointed out, exact data about the incidence of the disease are hard to obtain, since tetanus is not a notifiable disease. It is estimated, however, that there are on an average about 200 cases annually in England and Wales (Parish, 1954b), the average mortality rate varying between 40 and 70% in different case series. Comparison of the total of 23 deaths from diphtheria-in 1953 with 61 from tetanus in the same year would, however, seem to indicate that the problem of adequate tetanus prophylaxis is still not fully solved, although provisional figures for 1954 show that both these fatality figures are again reduced. There is, indeed, a wide variation in practice among general practitioners and in different hospitals concern ing when and in what circumstances antitetanus serum should be administered. Some hospitals follow the practice that all cases with a break in the skin, however slight, should receive a prophylactic dose; others leave it to the discretion of the casualty officer or houseman whether this course should be adopted. In this latter category, the regulations are almost invariably either extremely vague on the subject or non-existent. In these present times when, unfortunately, so much emphasis has to be laid on the medico-legal consequences which may follow medical practice, especially in hospitals, there is little doubt that circumstances could quite easily arise under such a system where failure to administer tetanus prophylaxis might place an inexperienced house officer in serious jeopardy. Indeed, the medico-legal societies have had to settle a number of claims in the past few years involving instances where there was failure to give antitetanus protection (French, 1955 Robinson, 1955). Consultation of the literature shows no evidence of unanimity or of clear guidance in this matter. Generally speaking, the American authorities are in favour of giving prophylaxis in any case where there is a break in the skin. Newell and McVea (1940), discussing the problem of reactions to antitetanus serum injection, state that these complications should not in any way influence the administration of serum to any patient with a break in the skin unless it was felt, as was rarely the case, that contamination by the tetanus bacillus was practically impossible. Abstracts of the reported discussion which followed the reading of their paper show that most of their colleagues agreed with them. The same conclusion was reached by Rackemann (1942) and many other authorities. In this comAntry very few writers commit themselves on what ruzres should be laid down to ensure passive immunization. Parish (1954a) comments that there are considerable differences in procedure and that some doctors are reluctant to use any serum in prophylaxis so. as to avoid possible sensitization. Cole (1954), however. in reply to a direct question on the subject states that  prophylactic antitoxin for passive immunization should only be given after wounds in which there is a reason able possibility of tetanus infection. A needle prick in the finger is very unlikely to cause tetanus if it is kept ,clean, but if it becomes infected and leads, for example, to a whitlow, it may do so. A clean cut sustained in the home is unlikely to cause it, provided that it is kept clean, but every case must finally be judged on its merits. Analysing 50 consecutive civilian cases seen between 1928 and 1945, Cole (1951) found that passive immuni zation should have been given to and would have pre vented about half the number, and particularly those with severe infected wounds, most of the whitlows (which were 10 in number, 20% of the total-a surprisingly high figure), and some of the penetrating wounds. He added his opinion that, even if practitioners were more alert to the possibility of tetanus and gave prophylactic antitoxin more frequently, it is doubtful if, in practice, the present incidence of the disease could be reduced by more than another 20%.