cases of tetanus infection occur in patients where the wound 
was of such minor consequence that passive immunization with 
Tetanus Antitoxin was not considered necessary or so minor 
that medical advice was not even sought. 5 However, if a patient 
has been adequately actively immunized with tetanus toxoid, 
this almost never happens. This is borne out by experience in 
the Armed Forces during World War II. Only fifteen cases of 
tetanus occurred in over 2,500,000 wounded American Troops 
and of these, only six had received the full immunizing course. 6 
Active immunization against tetanus is indicated in all 
children and in those adults who are frequently exposed to 
abrasions or other traumas. 7 Tetanus immunization is especially 
indicated in those individuals sensitive to horse serum whether 
it be either natural sensitivity or acquired as a result of previous 
injections of horse serum 7 - 8 and in those persons such as farm 
workers and other occupations associated with horses. 8 
Administration and Dosage 
Two doses of 0.5 cc. each injected intramuscu’arly with an 
interval of four to eight weeks between injections. Although 
it is usually advisable to immunize children with Triple Antigen, 
Diphtheria and Tetanus Toxoids and Pertussis Vaccine Com¬ 
bined Aluminum Phosphate Adsorbed, the individual antigen 
tetanus toxoid may be used if preferred in the same dosage as 
above. There is ample evidence that infants immunized with 
tetanus toxoid show an excellent response, even when injec¬ 
tions are started at the third and second month of life. 4 > 9 . 10 
A booster of 0.5 cc. is indicated one year after completion of 
the primary immunization and at four to five year intervals 
thereafter. Should injury occur, a 0.5 cc. booster is indicated 
unless the last routine booster was given within the preceding 
three months. In the event of injury where any possible con¬ 
tamination with tetanus organisms or spores is likely, at a time 
(1) during the course of immunization or in a period within two 
months after the last primary immunizing dose or (2) after five 
years or more have elapsed since completion of the primary 
immunization or the last booster following such a course, a 
prophylactic dose of at least 1500 units of Tetanus Antitoxin, 
Wyeth, should be given. In grossly contaminated wounds, 
compound fractures or severe burns or if treatment is delayed, 
combined active-passive immunization may be indicated. Inject 
0.5 cc. of Tetanus Toxoid Aluminum Phosphate Adsorbed 
and at least 5000 units of Tetanus Antitoxin in another 
extremity. However, the Army experiences in World War II 
and the Korean incident, where complete reliance was placed on 
tetanus toxoid only, regardless of the extent or severity of 
wounds, refute the need for combined active-passive immuniza¬ 
tion in those having had a basic immunization series and 
properly spaced boosters. 6 - 8 
Precautions 
The intramuscular injections should be given either into the 
upper outer quadrant of the gluteus, the vastus lateralis, or 
the deltoid. Peripheral neuropathy may result from mechanical 
injury to nerve fibers or sheaths during injection; hence great 
care should be used to avoid major peripheral nerve segments. 11 
A separate syringe and needle adequately sterilized by boiling 
for at least 20 minutes or preferably by dry heat (160° to 175° C. 
for one hour) should be used for each patient to prevent trans¬ 
mission of homologous serum hepatitis and other infectious 
agents from one person to another. 
"The occurrence of an outbreak of poliomyelitis in one’s 
community is a signal for deferring elective immunization pro¬ 
cedures in individuals over the age of six months. Primary 
immunization and/or recall injections obviously cease to be 
elective procedures” when possible exposure to tetanus 
co-exists with an outbreak of poliomyelitis. 7 
Before the injection of any biological, the physician should 
take all precautions known for prevention of allergic or any 
other side reactions. This should include: a review of the 
patient’s history regarding possible sensitivity; and a knowledge 
of the recent literature pertaining to use of the biological 
concerned. 
Technic for Withdrawal and Injection 
Shake the vial vigorously before withdrawing each dose. 
Raise metal hood from stopper of vial. Apply antiseptic to 
rubber diaphragm of stopper. Draw up piston of properly 
sterilized syringe so that the barrel will contain an amount of 
air equal to the amount of antigen to be withdrawn from vial. 
Insert properly sterilized needle through sterilized rubber 
diaphragm until the point of the needle clears the rubber 
(and no further). Force down piston of the syringe, thereby 
causing sufficient air pressure within the vial to permit with¬ 
drawal of the dose. Then hold the syringe in a vertical position 
with needle and vial elevated and slowly withdraw the piston, 
thereby transferring the desired amount of antigen from vial 
to syringe. The skin should be prepared with a suitable germ¬ 
icide. After insertion of the needle, aspirate to make sure the 
point of the needle has not entered a vein. Expel the antigen 
slowly and terminate the dose with a small bubble of air 
(0.1 to 0.2 cc.). 4 ' 7 Injections must be administered promptly 
to prevent settling of the toxoid in the syringe. Do not inject 
Tetanus Toxoid Aluminum Phosphate Adsorbed intra- 
cutaneously or into superficial subcutaneous structures. Follow¬ 
ing administration of the antigen, there should be no pressure 
or vigorous manipulation at the injected site, nor undue 
muscular activity of the limb. However, very gentle massage of 
area immediately after injection is considered desirable. 
Flush the syringe after injection to prevent the remaining 
toxoid from drying within the syringe. 
