Verification of tetanus vaccination status of children admitted for animal bites in a pediatric emergency department

ABSTRACT

Animal bites are high-risk wounds for tetanus. Our objective was to verify that children admitted to the pediatric emergency department (PED) for bites had reliable management of the risk of tetanus. This retrospective descriptive study was conducted at Lille University Hospital between 2015 and 2020. Patients under the age of 16 years admitted to the PED for bite wounds were included. The rate of appropriate management was calculated using a strict or pragmatic definition, based on the presentation or not of the health booklet. Among 336 patients included (median age 5 years, 47% boys, 69% wounds on the face; 90% of bites by dogs), 86% had their vaccination status mentioned in the medical observation, more often during daytime hours (p = .02) and by the medical team (as compared to the surgical team; p < 10⁻³). 90% of these were declared up-to-date for their tetanus vaccination. Management was deemed appropriate in 16% according to the strict definition and in 80% using the pragmatic definition. 28 patients were not up to date (10%). Eight of these 28 (29%) had an appropriate management. The management of a bite wound must be systematized with verification of tetanus vaccination status to avoid preventable disasters.

Introduction

Tetanus is a severe and potentially fatal disease caused by Clostridium tetani, which lives as a commensal anaerobe in the soil and in the digestive tract of many animals. Contamination occurs when tetanus spores enter a wound in a nonvaccinated or poorly vaccinated person. As tetanus infection is still common in low- or middle-income countries, post-exposure tetanus vaccine is given to almost all children admitted for an animal bite.¹ Thanks to a high level of vaccine coverage, tetanus is now rare in high-income countries.² But the disease is not extinct.^3,4 In France, for example, 1 to 10 annual cases were reported between 2012 and 2021, including three in children between 3 and 8 years of age.⁵

Lack of immunization is the greatest risk factor for contracting tetanus. In 2012, a 4-year-old patient boy presented at our institution’s pediatric emergency department (PED) for a severe tetanus infection after he had wounded his leg playing in the garden. He was subsequently admitted to the pediatric intensive care unit, where he received ventilation support and curare treatment for 2 months. Although the initial doses of tetanus vaccine were noted in the boy’s child health booklet, he had not received the first booster dose. The boy was tested negative for anti-tetanus antibodies in a serology test.

Although any skin wound is at risk, animal bites are major risks for tetanus,⁶ and children are particularly at risk of being bitten by animals. Such tetanus risk must always be considered.⁶ This should include a check on the patient’s tetanus vaccination status and, if the latter is nonoptimal, a booster dose.⁷ Hence, vaccination status must always be noted in a patient’s medical records. The objective of this study was to check whether the patients’ tetanus vaccination status was reliably documented for children admitted to the PED for animal bites.

Materials and methods

We conducted a descriptive, retrospective, single-center study at Lille University Hospital from 2015 to 2020. All patients under the age of 16 admitted to the PED for an animal bite were included. These patients were identified by searching the PED’s medical information system with the following codes from the 10^th revision of the International Statistical Classification of Diseases: K131, L03, S00, S01, S21, S31, S41, S51, S61, S71, S81, S91, and T79.3. Duplicate files that involved children readmitted after the first admission for a checkup or a complication were merged, and those with coding errors or a too high proportion of missing data were excluded. The children’s parents or legal guardian were sent a letter about the study a posteriori. In line with the French legislation on non-interventional, retrospective studies of routine clinical practice, consent from the patient and/or parent was not required. However, children were not included in the analysis if their parent or legal guardian objected to research use of the personal data. In strict compliance with the MR-004 data handling procedure established by French National Data Protection Commission, the study database was registered with Lille University Hospital’s data protection authority (Approval #DEC19–524, Lille University Hospital IRB).

The primary endpoint was documentation of tetanus vaccination status in the patient’s medical records. The secondary endpoints were appropriate documentation of tetanus vaccination status in the child health booklet, and appropriate management of the patient as a function of his/her tetanus vaccination status, based on the national guidelines.⁸ Strictly, appropriate management should include all five of the following steps: (i) a check on whether tetanus vaccination was documented in the patient’s medical records, (ii) a check in the child health booklet whether the patient’s tetanus vaccination schedule was up to date, (iii) prescription of a rapid tetanus test, if available, if the health booklet was not available or if the vaccine schedule was not up to date, (iv) administration of a booster dose of tetanus vaccine if the vaccine schedule was not up to date or if the rapid test was negative and (v) injection of specific immunoglobulins if the rapid test was negative or could not be performed. However, the parents of children attending the PED rarely have the health booklet to hand and often know the details of their child’s vaccination status. Hence, we adopted a more pragmatic definition of “appropriate management”: (i) a check on whether tetanus vaccination was documented in the patient’s medical records, (ii) a check on whether the parents thought that the child’s tetanus vaccination schedule was up to date, (iii) prescription of a rapid tetanus test if available, if the child’s tetanus vaccination status was uncertain, (iv) administration of a booster dose of tetanus vaccine if the vaccine schedule was thought not to be up to date or if the rapid test was negative, and (v) injection of specific immunoglobulins if the rapid test was negative or could not be performed or if the vaccine schedule was thought not to be up to date. We collected anonymous demographic and clinical data and then calculated the proportions of children for whom the tetanus vaccination was documented and who had received appropriate management (according to both the strict and pragmatic definitions). The statistical analyses were performed with Excel software (Microsoft, Redmond, WA, USA). Groups were compared in a chi-squared test for qualitative variables or a Mann Whitney U test for quantitative variables. The threshold for statistical significance was set to p < .05.

Results

Of the 366 children having attended the PED for a bite-related wound during the study period, 336 were included (boys: 47%, median age: 5 years [interquartile range: 2–9]). The non-inclusions were variously due to refusal by a parent [n = 1], missing data [n = 2], readmission [n = 24], and coding errors [n = 3]). The wound was mostly commonly located on the face (69%), followed by the upper limb (18%). In 303 of the 336 cases (90%), the child had been bitten by a dog. The other bites were variously due to horses or donkeys (n = 15), rabbits (n = 6), cats (n = 6), rodents (n = 2), a goat (n = 1), a bird (n = 1), a reptile (n = 1), and a monkey (n = 1). Tetanus vaccination status was documented in the medical record for 288 of the 336 children (86%). The absence of documentation was associated with admissions at night or at the weekend (p = .02) and when the child was managed by a surgeon (p < .001). Of these 288 children, 260 (90%) had an up-to-date vaccination schedule. An up-to-date vaccination schedule was not significantly associated with the child’s age (p = .73) or sex (p = .22). The vaccination status was checked in the health booklet for 41 (14%) of the 288 children. The proportion of the children having been appropriately managed was 16% according to the strict definition or 80% according to the pragmatic definition (Figure 1). According to the pragmatic definition, 8 (29%) of the 28 patients who were not up to date were appropriately managed at the PED and 11 were not appropriately managed (Table 1). A rapid tetanus test was prescribed in 21 children (28% of those with an indication for this test) and was negative in 13 of these. However, no case of tetanus by bite in children was reported during the study period.

Figure 1.

Diagram flow of children with an animal bite appropriately managed for the prevention of the tetanus risk, according to (A) strict or (B) pragmatic criteria.

Table 1.

Details of the 20 inappropriately managed patients with an animal bite and a tetanus risk.

n	Age (years)	Sex	Bite site	Health booklet	Rapid tetanus test	Test result	ATS	ATV	Medical follow-up	ATBs
1	0	M	Hand	ND	No	/	No	No	No	Yes
2	0	F	Hand	Missing	No	/	No	No	Yes	Yes
3	1	F	Hand	ND	No	/	No	Yes	No	Yes
4	1	M	Face	ND	Yes	Neg	Yes	No	No	Yes
5	1	F	Face	Missing	No	/	No	No	No	Yes
6	2	M	Face	ND	Yes	Neg	Yes	No	Yes	Yes
7	3	F	Face	ND	No	/	No	No	Yes	Yes
8	5	F	Face	Missing	No	/	No	Yes	No	Yes
9	6	M	Face	ND	No	/	No	No	No	Yes
10	6	M	Face	ND	No	/	No	Yes	No	Yes
11	6	M	Hand	ND	Yes	Neg	No	No	Yes	No
12	7	M	Face	ND	No	/	No	Yes	No	Yes
13	8	F	Lips	ND	No	/	No	Yes	No	Yes
14	8	M	Lips	ND	No	/	No	Yes	No	Yes
15	9	M	Leg	Missing	Yes	Neg	No	Yes	No	Yes
16	11	M	Leg	ND	No	/	No	Yes	No	Yes
17	12	M	Arm	Missing	No	/	No	No	Yes	Yes
18	12	F	Face	ND	No	/	No	Yes	No	Yes
19	13	F	Face	ND	No	/	No	Yes	No	Yes
20	14	M	Lips	Missing	No	/	No	No	No	Yes
Stats	6*	0.6**	/	/	20%	/	10%	50%	25%	95%

ATS, anti-tetanus serum; ATV, anti-tetanus vaccine; ATBs, antibiotics; ND, not documented; Neg, negative.

Stat, statistics; *Median age; **Male/Female ratio.

Discussion

Tetanus vaccination status was documented in the medical record for only 288 (86%) of the 336 included patients. When considering the 28 children who were not up to date, 20 were not appropriately managed and thus were exposed to an elevated risk of a subsequent tetanus infection.

However, the nonoptimal documentation rate might have been underestimated because the medical staff might have questioned the patients about vaccination status but might not necessarily have documented the answer in the medical records. The vaccination status documentation rate observed was nevertheless higher than in the literature. For example, a study conducted in a PED in Australia found that most immunization histories (60.5%) were recorded simply as up-to-date and only 3.5% had a documented up-to-date vaccination schedule.⁹ In contrast to our study, the results of this study identified that almost one third (34/114) of charts had no immunization history documented by ED staff; this proportion did not depend significantly on the reason for the emergency consultation.⁹ When parents forget to bring their child’s health booklet to the PED, vaccination status can only be checked on the basis of the parents’ or patients’ statements. In a study of patients hospitalized in a New York hospital in 2001, only 49% of children presented their vaccination certificate on admission.⁹ However, 98% of the parents correctly certified their child’s vaccination status after checking with the attending physician.¹⁰

Children’s characteristics were similar to the literature data regarding animal bites.¹¹ Since our study was retrospective, some data were missing; in particular, the availability of the child’s health booklet was not recorded in 57% of cases. Given that not checking in the health booklet was frequent, the number of children with a documented up-to-date vaccination status was underestimated. According to our strict definition, a rapid tetanus test was probably prescribed too frequently to children thought not to be up to date and whose health record was not available. This is why we adopted a pragmatic definition of “appropriate management,” based on the parents’ statements.¹⁰

Reporting any case of tetanus to the health authorities was mandatory in France, at least during the study period. And no case of tetanus was reported in our cohort, even in children with inappropriate management. This may be due to a quasi-systematic use of antibiotics in these children. The only patient who did not receive prophylactic antibiotic treatment had medical follow-up, with no bite-related complication reported. An animal bite must always be treated, with a systematic check on the patient’s tetanus vaccination status. According to the results of a study that included adult patients with tetanus-prone wounds, only 1.5% of the physicians adhered to tetanus prevention guidelines.¹² Repeated training and a clear management protocol might facilitate the standardized documentation of a child’s vaccination status. As the patient’s health booklet is not always available in emergency situations, this information must be obtained from parents and/or family physicians. Information on a child’s vaccination status should be made available to PEDs, via (for example) access to electronic medical or vaccination records.

Biography

François Dubos is Professor in Pediatrics, Head of the Pediatric Emergency Department and of the Pediatric Infectious Diseases unit in the Lille University Medical Center, France. His research is mainly focused on the epidemiology of preventable infectious diseases in children, evaluation of medical practice, and derivation and validation of clinical decision rules.

Funding Statement

The author(s) reported there is no funding associated with the work featured in this article.

Disclosure statement

No potential conflict of interest in relation with this work was reported by the author(s).

Data availability statement

The dataset can be made available on reasonable request.