Tetanus (Immunization) for Pregnant Women

Evidence Statement Benefit Plan Language Other Information and Resources Author(s)

References


Updated 11/30/11

Evidence Statement

Clinical Preventive Service Recommendations

U.S. Preventive Services Task Force Recommendation
Not Applicable — The U.S. Preventive Services Task Force defers to the Advisory Committee on Immunization Practices and the CDC on recommendations surrounding immunization.
CDC Recommendation
The 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.2

A 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

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The Value of Prevention

Economic Burden of Condition/Disease
There 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.5
Workplace Burden of Condition/Disease
Not Provided
Economic Benefit of Preventive Intervention
The averted mortality and morbidity costs due to prevented tetanus cases constitute the major economic benefit of immunization.
Estimated Cost of Preventive Intervention
As 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 $20.8
Estimated Cost of Treatment
Not Provided
Cost-Effectiveness and/or Cost-Benefit Analysis of Preventive Intervention
In 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.8

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Condition / Disease Specific Information

Epidemiology of Condition/Disease
Tetanus 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.3
Condition/Disease Risk Factors
All pregnant women who are not fully immunized are at risk of infection.

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Preventive Intervention Information

Preventive Intervention: Purpose of Immunization
Tetanus 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.3

Benefits and Risks of Intervention
The 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.1

Initiation, Cessation, and Interval of Immunization
Women 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 Process
Risk Assessment
Clinicians 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 Information
Health benefits should include provisions for treatment services.

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Strength of Evidence

The level of evidence supporting the recommendations contained in this section is described below.
Recommended Guidance:
Advisory Council on Immunization Practices (ACIP)
Strength of Evidence: Expert Consensus

The ACIP recommends that all adults with an uncertain history of a complete tetanus vaccination series receive a three-dose primary tetanus series, and that all adults receive periodic tetanus boosters every 10 years.1

This recommendation is supported by the:
  • American Academy of Family Physicians (AAFP)
  • U.S. Preventive Services Task Force (USPSTF)

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Summary Plan Description

Covered Immunizations
All brands and types of tetanus immunization are covered as medically indicated.

Initiation, Cessation, and Interval
Coverage 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.

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CPT Codes

Tetanus (Immunization)
90471 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); one vaccine (single or combination vaccine/toxoid)
90703 Tetanus toxoid adsorbed, for intramuscular use
90714 Tetanus and diphtheria toxoids (Td) adsorbed, preservation free, for use in individuals seven years or older, intramuscular use
90718 Tetanus and diphtheria toxoids (Td) adsorbed for use in individuals seven years or older, for intramuscular use

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Other Information and Resources

Business Group Resource(s)

CDC Resource

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Author(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.

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References

  1. Centers for Disease Control and Prevention. Prevention of Pertussis, Tetanus, and Diphtheria Among Pregnant and Postpartum Women and Their Infants: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2008; 57(04):1-47,51.
  2. Centers for Disease Control and Prevention. Updated Recommendations for Use of Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular Pertussis Vaccine (Tdap) in Pregnant Women and Persons Who Have or Anticipate Having Close Contact with an Infant Aged ‹12 Months --- Advisory Committee on Immunization Practices (ACIP). MMWR 2011; 60(41);1424-1426. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6041a4.htm?s_cid=mm6041a4_w. Accessed November 11, 2011.
  3. Centers for Disease Control and Prevention. Tetanus surveillance - United States, 1998-2000. MMWR 2003; 52(SS-3):1-8.
  4. Vandelaer J, Birmingham M, Gasse F, Kurian M, Shaw C, Garnier S. Tetanus in developing countries: an update on the Maternal and Neonatal Tetanus Elimination Initiative. Vaccine 2003; 21:3442-3445.
  5. Zhou F, Santoli J, Messonnier ML, Yusuf HR, Shefer A, Chu SY, et al. Economic evaluation of the 7-vaccine routine childhood immunization schedule in the United States, 2001. Arch Pediatr Adolesc Med 2005;159:1136-1144.
  6. Centers for Disease Control and Prevention. Vaccine Price List. November 2, 2011. http://www.cdc.gov/vaccines/programs/vfc/cdc-vac-price-list.htm#adult. Accessed November 11, 2011.
  7. Thomson Medstat. Marketscan. 2004.
  8. Lee, G et al. Cost Effectiveness of a Pertussis Vaccination in Adults. American Journal of Preventive Medicine. 2007; 32(3): 186-193.
  9. Demicheli, V., Barale, A. and Rivetti, A. Cochrane review: Vaccines for women to prevent neonatal tetanus. Evidence-Based Child Health: A Cochrane Review Journal. 2007; 2(3): 965-986.
  10. Centers for Disease Control and Prevention. Tetanus. In Atkinson W, Hamborsky J, McIntyre L, Wolfe S, eds. Epidemiology and Prevention of Vaccine-Preventable Diseases, 9th ed. Washington D.C.: Public Health Foundation; 2006:69-78.