Tetanus (Immunization) for Pregnant Women
Evidence Statement
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Updated 11/30/11
Evidence StatementClinical Preventive Service RecommendationsU.S. Preventive Services Task Force RecommendationNot Applicable — The U.S. Preventive Services Task Force defers to the Advisory Committee on Immunization Practices and the CDC on recommendations surrounding immunization.CDC RecommendationThe Advisory Committee on Immunization Practices (ACIP) recommends that all previously vaccinated pregnant women who have not been vaccinated against tetanus in the past 10 years receive a booster vaccination against tetanus.1 Pregnant women who have not completed a three-dose primary vaccination series against tetanus should complete the series.1 Pending guidance from ACIP, pregnant women should receive the Td vaccine in preference to the Tdap vaccine.2A summary of guidelines for the immunization of pregnant women can be found online (www.cdc.gov/nip/publications/preg_guide.htm). Evidence Rating: Expert Consensus The Value of PreventionEconomic Burden of Condition/DiseaseThere are few economic data on the burden of tetanus disease and no data about the costs of neonatal tetanus in the United States. A recent economic evaluation of the 7-vaccine routine childhood immunization schedule in the United States estimated that, if there had not been a tetanus vaccination program in the United States, 153 cases of tetanus and 23 deaths from tetanus would have occurred at a total cost of $29 million (direct and indirect costs in year 2001 dollars) based on a hypothetical 2001 birth cohort of 3.8 million infants that was followed from birth to death.5Workplace Burden of Condition/DiseaseNot ProvidedEconomic Benefit of Preventive InterventionThe averted mortality and morbidity costs due to prevented tetanus cases constitute the major economic benefit of immunization.Estimated Cost of Preventive InterventionAs of November 2, 2011, the listed private-sector cost of an adult tetanus booster vaccine (includes tetanus, diphtheria and pertussis) was $37.55, which included a $2.25 dose Federal Excise Tax.6 CITE In 2004, the private-sector cost of an adult tetanus vaccine (usually given as Td) averaged $15; approximately 95% of all paid claims fell within the range of $0 to $28.7 The additional cost of vaccine administration averaged $10 and 95% of paid claims fell within the range of $0 to $20.8Estimated Cost of TreatmentNot ProvidedCost-Effectiveness and/or Cost-Benefit Analysis of Preventive InterventionIn one analysis, it was estimated that administering tetanus booster immunizations every 10 years ('decennial' boosters) is associated with preventing between $160 to $31,000 per pertussis case, depending on the incidence assumptions. Although decennial boosters are more expensive than once-in-a-lifetime booster immunizations, they also prevent more than twice the number of tetanus cases that would be prevented by a single lifetime booster.8Condition / Disease Specific InformationEpidemiology of Condition/DiseaseTetanus is generally characterized by painful muscle rigidity and uncontrollable spasms. Between 1998 and 2000, 18% of persons in the United States who contracted tetanus died as a result of the disease.3 Neonatal tetanus is a severe and often fatal disease; it accounted for an estimated 200,000 deaths worldwide in 2000 but is extremely rare in the United States.4 Because nearly all neonatal tetanus occurs in infants born to mothers who are not adequately immunized against tetanus, it is important that all pregnant women be vaccinated against tetanus.3Condition/Disease Risk FactorsAll pregnant women who are not fully immunized are at risk of infection.Preventive Intervention InformationPreventive Intervention: Purpose of ImmunizationTetanus immunization offers long-term protection against tetanus for the vaccinated woman, and maternal vaccination confers significant protection to the fetus. One analysis reported 98% effectiveness of the vaccine in preventing neonatal tetanus among the children of women receiving at least two doses of tetanus vaccine.9 Notably, in all three cases of neonatal tetanus that have occurred in the United States since 1989, the infant's mother was not fully immunized against tetanus.3Benefits and Risks of InterventionThe benefits of tetanus immunization are substantial. Adverse reactions to tetanus vaccination can include local swelling or pain; extensive swelling and systemic reactions are rare, however.10 Although no evidence exists that tetanus immunization during pregnancy causes harm to the fetus, delaying needed tetanus immunizations to the second or third trimester is a reasonable precaution to minimize any concerns about the theoretical possibility of such adverse effects.1Initiation, Cessation, and Interval of ImmunizationWomen should be assessed for risk of tetanus at their first prenatal care visit. Pregnant women without adequate documentation of a completed primary tetanus series and a tetanus vaccination within the past ten years should be immunized against tetanus in the second or third trimester.Intervention ProcessRisk AssessmentClinicians should assess all pregnant women for susceptibility to tetanus. Pregnant women are considered susceptible to tetanus if they have an uncertain immunization history (i.e., they cannot provide written proof of immunization) or if they have not had a tetanus booster in the previous 10 years. Immunization Susceptible women who have not completed a primary series of immunizations against tetanus should complete a three-dose series; women who have completed the primary series but have not been vaccinated against tetanus in the past ten years should receive a booster dose.1 In October 2011, ACIP recommended that all women who have not previously received Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular Pertussis Vaccine (Tdap)should receive it during pregnancy, preferably during the third or late second trimester (after 20 weeks' gestation).2 Tdap vaccination during pregnancy prevents more infant cases, hospitalizations, and deaths compared with the postpartum dose, however, if it is not administered during pregnancy, Tdap should be administered immediately postpartum.2 If a tetanus and diphtheria booster vaccination is indicated during pregnancy for a woman who has previously not received Tdap (i.e., more than 10 years since previous Td), then Tdap should be administered during pregnancy, preferably during the third or late second trimester (after 20 weeks' gestation).2 Treatment InformationHealth benefits should include provisions for treatment services.Strength of EvidenceThe level of evidence supporting the recommendations contained in this section is described below.Recommended Guidance: Summary Plan DescriptionCovered ImmunizationsAll brands and types of tetanus immunization are covered as medically indicated.Initiation, Cessation, and IntervalCoverage for tetanus vaccines is provided for all pregnant women without adequate documentation of a completed primary tetanus series and those without a tetanus vaccination within the past ten years.CPT Codes
Other Information and ResourcesBusiness Group Resource(s)CDC ResourceAuthor(s)Lindley MC, Bhatt A, Campbell KP, Chattopadhyay S. Tetanus immunization evidence-statement. In: Campbell KP, Lanza A, Dixon R, Chattopadhyay S, Molinari N, Finch RA, editors. A Purchaser's Guide to Clinical Preventive Services: Moving Science into Coverage. Washington, DC: National Business Group on Health; 2006. Updated 2011.References
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