Should adult tetanus immunization be given as a single vaccination at age 65?
A cost-effectiveness analysis
10.1007/BF02599616 Cite this article as: Balestra, D.J. & Uttenberg, B. J Gen Intern Med (1993) 8: 405. doi:10.1007/BF02599616 Abstract Objective: To compare three vaccination strategies for the prevention of adult tetanus. Each strategy includes childhood primary immunization and wound prophylaxis, and one of the following: 1) the currently recommended booster every ten years; 2) a single booster at 65 years of age; or 3) no intervention after age 6 except for wound prophylaxis. Methods: Cost-effectiveness analysis was used to compare the three different strategies. A Markov model, cycled annually from age 5 through age 85, was applied to each strategy to predict the incidence and costs of tetanus for the U.S. adult population. Results: The three strategies have very similar effects on life expectancy but different costs. Expressed incremental to no intervention after childhood primary immunization, the decennial booster strategy is least cost-effective, with a discounted incremental cost-effectiveness ratio of $143,138 per year of life saved compared with $4,527 for the single-booster strategy. Sensitivity analysis demonstrates that the decennial strategy is more effective but more costly over a wide range of model assumptions. Conclusions: The current policy of recommending tetanus booster vaccinations every ten years is effective but much more costly than a more easily implemented policy that also provides considerable protection against tetanus. The authors recommend forsaking decennial boosters in favor of a policy of including a single booster at age 65 along with other recommended health maintenance maneuvers reserved for that age. Key words tetanus preventive medicine cost-benefit analysis immunization policy vaccines
Presented in part at the annual meeting of the Society of General Internal Medicine, Seattle, Washington, May 2, 1991. Dr. Littenberg is an American College of Physicians George Morris Piersol Teaching and Research Scholar.
Williams WW, Hickson MA, Hane MA, et al. Immunization policies and vaccine coverage among adults. Ann Intern Med. 1988;108:616–25.
Frame PS. Critical review of adult health maintenance, Part 2. Prevention of infectious diseases. J Fam Pract. 1986;22:417–22.
Immunization Practices Advisory Committee. General recommendations on immunization. Ann Intern Med. 1989;111:133–42.
LaForce FM. Immunizations, immuno-prophylaxis, and chemo-prophylaxis to prevent selected infections. JAMA. 1987;257:2464–70.
U.S. Preventive Service Task Force. Guide to Clinical Preventive Service. Baltimore: Williams and Wilkins, 1989.
Immunization Practices Advisory Committee. Diphtheria, tetanus and pertussis: guidelines for vaccine prophylaxis and other preventive measures. MMWR. 1985;34:405–25.
Hutchison BG, Stoddart GL. Cost-effectiveness of primary tetanus vaccination among elderly Canadians. Can Med Assoc J. 1988;139:1143–51.
Rappuoli R, Perugini M, Falsen E. Molecular epidemiology of the 1984–1986 outbreak of diphtheria in Sweden. N Engl J Med. 1988;318:12–4.
Karzon DT, Edwards KM. Diphtheria outbreaks in immunized populations. N Engl J Med. 1988;318:41–3.
Bader M. Diphtheria in immunized populations. N Engl J Med. 1988;319:446–7.
Taranger J, Rabo E. Diphtheria in immunized populations. N Engl J Med 1988;319:447.
Harnisch JP, Tronca E, Nolan CM, Turck M, Holmes KK. Diphtheria among alcoholic urban adults. A decade of experience in Seattle. Ann Intern Med. 1989;111:71–82.
Hoblin BA, Townsend TR. Immunity to diphtheria and tetanus in inner-city women of childbearing age. Am J Public Health. 1989;79:1297–8.
U.S. Bureau of the Census. Statistical Abstracts of the United States; 1990 (110th edition). Washington, DC, 1990.
Edsall G. Specific prophylaxis of tetanus. JAMA. 1959;171:417–27.
Berger SA, Cherubin LE, Nelson S, et al. Tetanus despite pre-existing antitetanus antibody. JAMA. 1978;240:769–70.
Passen EL, Anderson BR. Clinical tetanus despite a “protective” level of toxin-neutralizing antibody. JAMA. 1986;255:1171–3.
Maselle SY, Matre R, Moise R, Hofstad T. Neonatal tetanus despite protective serum antitoxin concentration. FEMS Microbiol Immunol. 1991;3(3):171–5.
Crossley K, Irvine P, Warren JB, et al. Tetanus and diphtheria immunity in urban Minnesota adults. JAMA. 1979;242:2298–300.
Ruben FL, Nagel J, Fireman P. Antitoxin responses in the elderly to tetanus-diphtheria (Td) immunization. Am J Epidemiol. 1978;108:145–9.
Weiss BP, Strassburg MA, Feeley JC. Tetanus and diphtheria immunity in an elderly population in Los Angeles County. Am J Public Health. 1983;73:802–4.
Simonsen O, Block AV, Klaerke A, et al. Immunity against tetanus and response to revaccination in surgical patients more than 50 years of age. Surg Gynecol Obstet. 1987;164:329–34.
Trinca JC. Antibody response to successive booster doses of tetanus toxoid in adults. Infect Immun. 1974;10:1–5.
Simonsen O, Kjeldsen K, Heron I. Immunity against tetanus and effect of revaccination 25–30 years after primary vaccination. Lancet. 1984;2:1240–2.
Peebles TC, Levine L, Eldred MC, Edsall G. Tetanus toxoid emergency boosters. A reappraisal. N Engl J Med. 1969;280:575–81.
White WG, Barnes GM, Griffith AH, Gall D, Barker E, Smith JW. Duration of immunity after active immunization against tetanus. Lancet. 1969;2:95–6.
Matveev KI, Sergeeva TI, Zarubina EK, Minaeva ZL. Single-dose immunization of human subjects against tetanus. J Hyg Epidemiol Microbial Immunol. 1976;20:1121–30.
Ullberg-Olsson K, Eriksson E. Active immunization against tetanus in man. I. Duration of anamnestic reaction after one dose of vaccine. Eur Surg Res. 1975;7:249–58.
Immunization Practices Advisory Committee. Tetanus—United States, 1982–1984. MMWR. 1985;34:602–11.
Singh GP, Sikka PK, Gupta MM. Tetanus—a method of scoring to determine prognosis. Indian J Med Sci. 1986;40:124–8.
Edmondson RS, Flowers MW. Intensive care in tetanus: management, complications, and mortality in 100 cases. BMJ. 1979;l:1401–4.
Frank JW, Schabas R, Arshinoff R, Brant R. Diphtheria-tetanus over-immunization in children with no records: can it be prevented? Can Med Assoc J. 1989;141:1241–6.
Immunization Practices Advisory Committee. Tetanus—United States, 1985–1986. MMWR. 1987;36:477–81.
Mullooly JP. Tetanus immunization of adult members of an HMO. Am J Public Health. 1984;74:841–2.
Sutter RW, Cochi SL, Brink EW, Sirotkin BI. Assessment of vital statistics and surveillance data for monitoring tetanus mortality, United States, 1979–1984. Am J Epidemiol. 1990;131:132–42.
White WG. Reactions after plain and adsorbed tetanus vaccines. Lancet. 1980;1:42.
Levine L, Edsall G. Tetanus toxoid: what determines reaction proneness. Infect Dis. 1981;144:376.
Mansfield LE, Ting S, Rawls DO, Frederick R. Systemic reactions during cutaneous testing for tetanus toxoid hypersensitivity. Ann allergy. 1986;57:135–7.
Zimmerman B, Gold R, Lavi S. Adverse effects of immunization. Postgrad Med. 1987;82:225–32.
Edsall G, Elliott MW, Peebles TC, et al. Excessive use of tetanus toxoid boosters. JAMA. 1967;202:111–3.
Jacobs RL, Lowe RS, Lanier BL. Adverse reactions to tetanus toxoid. JAMA. 1982;247:40–2.
Beck JR, Pauker SG. The Markov process in medical prognosis. Med Decis Making. 1983;3:419–58.
Hilton E, Singer C, Kozarsky P, Smith MA, Lardis MP, Borenstein MT. Status of immunity to tetanus, measles, mumps, rubella, and polio among U.S. travelers. Ann Intern Med. 1991;115:32–3.
LaForce FM. Adult immunizations: are they worth the trouble? J Gen Intern Med. 1990;5 (S/O suppl):S57-S61.
Belcher DW. Implementing preventive services: success and failure in an outpatient trial. Arch Intern Med. 1990;150:2533–41.
Littenberg B, Garber AM, Sox HC. Screening for hypertension. Ann Intern Med. 1990;112:192–202.
Saha K, Sharma VK, Sehgal VN, Agarwol SK. Natural resistance against tetanus in patients with lepromatous leprosy. Trans R Soc Trop Med Hyg. 1981;75:832–4.
Dostur FD, Awatramani VP, Dixit SK, et al. Response to single dose of tetanus vaccine in subjects with naturally acquired tetanus antitoxin. Lancet. 1981;2:219–22.
Singh M, Kumar B, Ayagiri A, Kaur S. Natural tetanus immunity in lepromatous leprosy patients. Indian J Lepr. 1986;58:91–5.
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