Room 605A

Skipton House

80 London Road

London SE1 6LH

Tel: 020 7972 1526

Fax: 020 7972 5758

jane.leese@doh.gsi.gov.uk

16 May 2002

To: All Immunisation Co-ordinators

All Pharmacists

All GPs via Practice Managers

Dear Colleague,

REPLACEMENT OF SINGLE ANTIGEN TETANUS VACCINE BY COMBINED TETANUS/LOW DOSE DIPHTHERIA VACCINE FOR ADULTS AND ADOLESCENTS

Single antigen Tetanus vaccine (T) is being replaced by the combined Tetanus/low dose diphtheria vaccine for adults and adolescents (Td) for all routine uses.

Td vaccine replaced single antigen Tetanus vaccine for the routine booster immunisation given to school-leavers in 1994. CMO’s Update 5, issued in March 1995, clarified that Td should now always be given rather than tetanus (T) alone.

The change was on the advice of the Joint Committee on Vaccination and Immunisation (JCVI), generated by concern at the low levels of immunity to diphtheria in older people in the UK. It brings us into line with recommendations from the World Health Organization.

Td should now be used:

For primary immunisation of adults and adolescents previously unimmunised against tetanus

Where booster doses of tetanus are indicated, following a tetanus prone wound or for the purposes of travel

Please note that for both tetanus and diphtheria a total of 5 doses of vaccine are considered to give lifelong immunity. These may have been given either as the primary 3 dose course in childhood followed by school entry and school leaving doses, OR as a primary course at any time followed by a booster 10 years later and a further booster 10 years after that.

Booster doses are therefore indicated only:

Following a tetanus prone wound, where the individual has not received a full 5 dose course and is due a further dose, OR, the immunisation status is unknown (if the wound is contaminated, a dose of human tetanus immunoglobulin should be given);

For travellers to areas where medical attention may not be accessible should a tetanus prone injury occur, and the last dose was more than 10 years previously.

Single antigen low dose diphtheria vaccine for adults and adolescents (d) can still be used where diphtheria vaccine is indicated in an individual who is fully immunised against tetanus. However, from time to time this vaccine is not available; when this occurs, the combined vaccine can be used.

Adverse reactions

Adverse reactions to the tetanus and diphtheria components are similar, but are more likely to be due to the ‘T’ component.

Local reactions such as pain, redness and swelling round the injection site may occur and may persist for several days. General reactions are uncommon, but include headache, lethargy, malaise, myalgia and pyrexia. Acute anaphylactic reactions and urticaria may occasionally occur and, rarely, peripheral neuropathy or other neurological reactions. Persistant nodules at the injection site may arise if the injection is not given deeply enough.

Contraindications

The vaccine should not be given to an individual suffering an acute febrile illness except in the presence of a tetanus prone wound.

Immunisation should not proceed in individuals who have had an anaphylactic reaction to a previous dose. Otherwise, tetanus containing vaccines can be given to people who have had previous severe adverse reactions, but in a setting where full facilities are available to deal with any acute allergic reaction.

Supplies

The hospital contract for the supplies of combined tetanus and low dose diphtheria vaccine for adults and adolescents is in place with the manufacturer Aventis Pasteur MSD. Details of this contract are available from the NHS Purchasing and Supply Agency (contact Alan White, tel: 0118 980 8785). Hospitals should continue to use existing stocks of adsorbed tetanus before changing to the combined vaccine.

Stocks of the combined vaccine can be ordered by Practices from Aventis Pasteur MSD who are currently the sole manufacturer in the UK.

Many practices will have standing orders or individual agreements with Aventis Pasteur MSD, Evans Vaccines or Glaxo SmithKline for the supply of adsorbed tetanus vaccine. These companies will continue to supply tetanus vaccine until current stocks are exhausted. Practices should continue to use existing stocks of adsorbed tetanus before changing to the combined vaccine.

Yours sincerely,

Jane Leese FRCP

Senior Medical Officer

Communicable Disease Immunisation Branch