1. Hagiga, Ahmed MBBCh
  2. Arif, Tooba MBChB, MSc, MRCS(Ed)
  3. Gultiaeva, Mariia MBBCh
  4. El-Askary, Mohamed MBBCh(Hon), MSc, FRCEM

Article Content

Dear Editor,


The incidence of tetanus infection in the United Kingdom has diminished in recent decades, primarily due to vaccination (National Notifiable Diseases Surveillance System, 1990-2017). However, mortality has been reported in those who are unvaccinated.


When asked about their tetanus immunization status, patients presenting with traumatic wounds are often unable to recall when they were vaccinated. Consequently, there is a tendency for the health care professional to administer a booster dose, or on some occasions an immunoglobulin injection to provide prophylaxis. Guidelines from Public Health England (PHE, 2019) are available pertaining to this.


ProTetanus (Prospec Diagnostics, Ltd., Dronfield, United Kingdom) is a point-of-care immunochromatographic test for anti-tetanus antibodies that provides results in 10 min at a cost of [pounds]4.30 ($5.83) per test. The aim of this test is to decrease unnecessary administration of vaccine or immunoglobulin. A review paper found that the test's sensitivity ranges from 55% to 100% and specificity from 66.6% to 100% (Martin-Casquero et al., 2019).


We studied pharmacy records and the patient database for those who presented to our unit with tetanus-prone wounds, as defined by PHE, from September 2017 to April 2018. Nineteen patients who met these criteria were selected at random. Fourteen of 19 cases were documented as tetanus vaccination status unknown (73.6%). In half of those, the PHE guidance had not been followed. Four cases were not given tetanus toxoid when necessary; yet, seven cases were overtreated (36.8%). Fortunately, no side effects were experienced from vaccination, nor did any of the cohort participants develop tetanus infection. Such findings in guideline adherence mirror those reported in the literature (Savage et al., 2007).


Had the seven overtreated patients been tested with Pro Tetanus, the cost would have been [pounds]30.10 ($40.82). Without testing, the cost of treating these patients universally with booster vaccination would be [pounds]7.26 ($9.84) per unit-a total of [pounds]50.82 ($68.91), in addition to the clinical implications. Therefore, it is likely that testing bears the potential to save money. In 2018, our hospital dispensed a total of 1,644 units, resulting in a total cost of [pounds]11,935.44 ($16,184.28). By extrapolation from our study, if we assume that 36.84% of these patients were overtreated, this results in an unnecessary expenditure of [pounds]4,397 ($5,962.27); yet, if ProTetanus were used in these patients to confirm antibody status, [pounds]2,601.5 ($3,527.59) could potentially be saved.


Incorporating ProTetanus into clinical protocol when presented with a tetanus-prone wound may therefore save unnecessary treatment, improve patient safety, and reduce costs to the hospital (McVicar, 2013). We plan to introduce the test kit into practice within our unit and further evaluate both the efficacy and cost-effectiveness, while bearing the PHE guidelines in mind.




Ahmed Hagiga, MBBCh


Plastic Surgery Fellow


Tooba Arif, MBChB, MSc, MRCS(Ed)


Plastic Surgery Fellow


Queen Victoria Hospital NHS Foundation Trust


East Grinstead, United Kingdom


Mariia Gultiaeva, MBBCh


Medical Doctor


University Hospitals Sussex NHS Foundation Trust


East Sussex, United Kingdom


Mohamed El-Askary, MBBCh(Hon), MSc, FRCEM


Emergency Medicine Consultant


Chelsea & Westminster Hospitals Foundation Trust


London, United Kingdom




Martin-Casquero T., Ruescas-Escolano E., Tuells J. (2019). Use of the tetanus quick stick (TQS) test in the emergency services. Medicina Clinica, 153(10), 394-401. doi: 10.1016/j.medcli.2019.06.004 [Context Link]


McVicar J. (2013). Should we test for tetanus immunity in all emergency department patients with wounds? Emergency Medicine Journal, 30(3), 177-179.[Context Link]


National Notifiable Diseases Surveillance System. (1990-2017). Division of Health Informatics and Surveillance, Center for Surveillance, Epidemiology, and Laboratory Services, Office of Public Health Scientific Services, Centers for Disease Control and Prevention, US Department of Health and Human Services. [Context Link]


Public Health England. (2019). Guidance on the management of suspected tetanus cases and on the assessment and management of tetanus-prone wounds. Retrieved September 2019 from[Context Link]


Savage E. J., Nash S., McGuinness A., Crowcroft N. S. (2007). Audit of tetanus prevention knowledge and practices in accident and emergency departments in England. Emergency Medicine Journal, 24(6), 417-421. [Context Link]