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In terms of specific vaccines, and we’ll talk about these when indicated, there are hyperimmune globulins with higher titer of antibody.These preparations are for hepatitis B, V-fig, tetanus immune globulin, rabies immune globulin and I hope we’ll have time to talk about RSV as well and the specific indications for that. Now we are going to talk about the specific vaccines, and also sometimes we will talk about the specific diseases if they haven’t been covered elsewhere in the course. This is a slide from the CDC showing tonsillar diphtheria and diphtheria is produced, a toxin-mediated disease, by Carinii bacterium diphtheria. This normally causes a respiratory disease. You can get cutaneous diphtheria also, and at other sites. The complication comes from the toxin which is a toxin that may cause myocarditis and other complications. Diphtheria vaccine is a toxoid vaccine, so it is taking the toxin and inactivating it. Therefore vaccination will not prevent colonization but it will prevent disease. There are two vaccine formulations. There is a big D, and you will see that with the DTaP, DTPM and DT vaccines, and then the little d, the TD vaccine and that’s to be used seven years of age and older. A smaller dose of the diphtheria toxoid and that’s all that’s needed for booster doses. When we talk about HIB vaccines you’ll notice some of them use, as a carrier, diphtheria toxoid. Diphtheria toxoid as a carrier in the HIB vaccine is not a primary immunogen and you can’t count that as vaccinating against diphtheria. You have to have the big D or the little d to count it as a diphtheria immunization.
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Next we’ll talk about tetanus. This is a slide also from the CDC which shows a subject with opisthotonos, which is muscle spasm from tetanus. This is a neurotoxin and in pediatrics, one of the main problems with tetanus is neonatal tetanus. And this child has neonatal tetanus. This slide is from the WHO and this shows this child with this sardonic smile of neonatal tetanus. This is lockjaw in a baby and this occurs in areas of the world where the mothers are not immune to tetanus. So their children are born without the passively acquired tetanus antibodies. Commonly the umbilical stump, which is devitalized tissue, may get infected with Clostridium tetani which is an anaerobe, and then it produces the toxin and causes – it’s a neurotoxin – and causes lockjaw, muscle spasm. So to prevent term tetanus we have two tools available to us; active immunization and passive immunization. Tetanus toxoid, again toxin-mediated disease, purified component will prevent disease. Will not prevent colonization. Vaccine formulations include DTaP, DTP, DT and TD and tetanus immune globulin may also be used. That’s a hyperimmune globulin against tetanus, with high titers of tetanus antibodies. Then the issue comes up, when do you use the toxoid, when do you use tetanus immune globulin? The thing to remember about tetanus is that it is ubiquitous in the environment. It’s in dirt and it’s all around and because of that when a wound occurs, if the wound is contaminated and there is any sort of anaerobic tissue, devitalized tissue or foreign body, this may result in the organism colonizing the wound, producing the neurotoxin and then somebody coming down with tetanus. So if somebody has a wound that is significant and they’ve had less than three tetanus immunizations, then they need to be immunized and given tetanus immune globulin for a dirty wound only; three or more past tetanus immunizations, for dirty wounds immunized just more than five years since the last dose; and for clean wounds, immunized if more than ten years for the last dose. But in any case, if they’ve had three or more past tetanus immunizations you don’t need to give tetanus immune globulin because when you give tetanus toxoid there is a rapid memory response, an anamnestic response, that does result in adequate antibody to make sure that even if the organism is there that there will be enough antibody to fight off the toxin and prevent the disease.
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The question arises; what’s a dirty wound, what’s a clean wound? All I can do is really give you an example. A patient is riding their motorcycle through a cow pasture, they crash into a rusty barbed wire fence, they have a mangled leg, devitalized tissue and they have some cow dung in the wound. That’s a dirty wound. A clean wound is, you are at home, you are slicing tomatoes and you make a nice clean slice in your finger and that’s a clean wound. You can wash it out, there is no foreign bodies in there, there is no real devitalized tissue, you can approximate the edges nicely. That will heal over nicely, and that’s a clean wound. So it’s a question of contamination and risk of disease from the wound.