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Update: Vaccine Side Effects, Adverse Reactions, Contraindications,  Practices (ACIP) part-3
 

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Preparations Containing Diphtheria Toxoid and Tetanus Toxoid

The only contraindication to tetanus and diphtheria toxoids is a history of a neurologic or severe hypersensitivity reaction following a previous dose. Vaccination with tetanus and diphtheria toxoids is not known to be associated with an increased risk of convulsions. Local side effects alone do not preclude continued use. If an anaphylactic reaction to a previous dose of tetanus toxoid is suspected, intradermal skin testing with appropriately diluted tetanus toxoid may be useful before a decision is made to discontinue tetanus toxoid vaccination (86). In one study, 94 of 95 persons with histories of anaphylactic symptoms following a previous dose of tetanus toxoid were nonreactive following intradermal testing and tolerated further tetanus toxoid challenge without incident (86). One person had erythema and induration immediately following skin testing, but tolerated a full IM dose without adverse effects. Mild, nonspecific skin-test reactivity to tetanus toxoid, particularly if used undiluted, appears to be fairly common. Most vaccinees develop inconsequential cutaneous delayed hypersensitivity to the toxoid. Although very rare, severe hypersensitivity reactions may occur after receipt of tetanus-toxoid-containing vaccines; these reactions can be life-threatening (5).

Persons who experienced Arthus-type hypersensitivity reactions or a temperature of greater than 103 F ( greater than 39.4 C) following a prior dose of tetanus toxoid usually have high serum tetanus antitoxin levels and should not be given even emergency doses of Td more frequently than every 10 years, even if they have a wound that is neither clean nor minor.

If a contraindication to using tetanus-toxoid-containing preparations exists for a person who has not completed a primary series of tetanus toxoid immunization and that person has a wound that is neither clean nor minor, only passive immunization should be given using tetanus IG (TIG).

On the basis of a) a report of a 42-year-old man who had GBS on three separate occasions after receipt of tetanus toxoid and b) evidence that a vaccine-induced immunologic response can cause GBS, IOM concluded that tetanus-toxoid-containing vaccines can trigger the onset of GBS in adults. GBS can be a life-threatening disease. Persons who have a history of GBS associated with a particular vaccine may be at increased risk for recurrent GBS after subsequent doses of that vaccine (5).

Risk for GBS has been observed with the use of DTP in children. In a study of 0.7 million children of preschool-ages who were vaccinated with DTP during a 7-year period, three cases of GBS were expected during the 6 weeks after vaccination, and only two cases were reported (17).

Because tetanus vaccination has been associated rarely with recurrence of GBS, the decision to administer additional doses of tetanus-toxoid-containing vaccine to persons who have had GBS within 6 weeks after receiving tetanus toxoid should be based on the benefits of subsequent vaccination and the risk for recurrence of GBS. For example, vaccination is usually justified for children whose primary immunization schedules are incomplete (i.e., fewer than three doses have been received); but routine booster vaccination probably is not indicated for adults who have received three or more doses.

Vaccination with tetanus-toxoid-containing vaccines has been associated with brachial neuritis in adult vaccinees, with a relative risk of 5-10 in comparison with the population-based background incidence and a 1-month attributable incidence of approximately one-half to one case per 100,000 recipients of tetanus toxoid (5).