Original Contribution
Tetanus Quick Stick as an applicable and cost-effective test in assessment of immunity status

https://doi.org/10.1016/j.ajem.2010.01.046Get rights and content

Abstract

Introduction

Tetanus vaccine and immunoglobulin administration are challenging decisions mostly because of the fact that the current protocol for immunization against tetanus is based on 2 variables: the vaccination status of the patient and the nature of wound and its exposure. To solve this problem, Tetanus Quick Stick (TQS; Nephrotek Laboratory, Rungis, France), an immunochromatographic dipstick test, was developed to determine the tetanus immunity of the patients. The aim of this present study was to investigate the sensitivity, specificity, and the positive and negative predictive values and cost-effectiveness of TQS in the emergency department (ED) setting.

Methods

Blood samples were collected from 200 patients presenting to our ED. Information including demographic information, tetanus immunization status, wound description, and the preventive measures taken by the emergency physician were gathered by a preeducated nurse. Tetanus Quick Stick test and enzyme-linked immunosorbent assay were performed as the standard diagnostic test by an emergency physician and a laboratory technician, respectively; and results of the 2 techniques were compared.

Result

Overall, tetanus vaccine was administered to 141(70.5%) patients and immunoglobulin to 105 (52.5%) patients. The analysis revealed 88.1% sensitivity and 97.6% specificity for the TQS test. The positive and negative predictive values of TQS test were 99.3% and 66.1%, respectively. Our analysis is also showed a significant decrease in cost when TQS was applied for patients with dirty, tetanus prone wounds or injuries and unknown or incomplete vaccination history (€ 9.48 versus € 12.1).

Conclusion

This study revealed TQS test to be appropriate and cost-effective for ED use especially in evaluating patients who do not remember or cannot give their tetanus immunization history.

Introduction

Although preventive medicine has progressed in recent decades, tetanus infection remains a life-threatening condition and is still an important health issue worldwide. Tetanus is caused by Clostridium tetani, an anaerobic, motile, gram-positive rod found worldwide in the soil, as well as in animal and, occasionally, human feces. Although tetanus is ubiquitous, infections in certain developing regions of the world are associated with high mortality and morbidity largely because of a lack of rigorous immunization programs and available treatment options. Consequently, tetanus has become one of the target diseases of the World Health Organization (WHO) Expanded Program on Immunization.

In the clinic, patients often present with an array of injuries and wounds in which tetanus prophylaxis should be considered. Current protocols for immunization against tetanus are dependent on 2 factors: (1) the nature of the injury and (2) the vaccination status of the patient (Table 1). With respect to the former, wounds are classified as clean minor or dirty. With respect to the latter, patient recollection of past immunizations and the physician carrying out proper protocols are important considerations. For example, if the physician cannot remember the proper course of action, he or she may simply administer both vaccine and immunoglobulin to err on the side of caution. Indeed, although many patients do not remember their vaccination history, the attending physicians' memory may not be relied upon either [1]. Although this course of action could be lifesaving for some patients, it is a considerable waste of resources from the level of community medicine. Moreover, booster vaccines have adverse effects, such as moderate and severe local reactions, Arthus reactions (type III hypersensitivity reactions), or Guillain-Barré syndrome, particularly if it is administered in less-than-5-year intervals [2], [3], [4], [5].

Based on what WHO has declared, concentrations of tetanus antibody greater than 0.1 IU/mL in the serum are deemed to be protective [6]. The criterion standard method for evaluating tetanus antibody concentrations in serum is enzyme-linked immunosorbent assay (ELISA). However, this assay is time consuming, expensive, and technician and instrument dependent and is therefore not aptly suited for many clinical settings. To this end, Tetanus Quick Stick (TQS; Nephrotek Laboratory, Rungis, France), an immunochromatographic dipstick test, was developed to determine the immunity status of the patients against tetanus [7], [8], [9] faster and that is more applicable than ELISA.

Given that prior immunizations may negate the need for expensive immunoglobulin treatments, the aim of the present study was to assess the cost-effectiveness of TQS in our emergency department (ED). In addition, we sought to assess the sensitivity, the specificity, and the positive and negative predictive values of the test.

Section snippets

Material and methods

Between January 2009 and April 2009, 200 patients were randomly selected and enrolled in the study from those patients who presented to the ED of the Imam Hussein Teaching Hospital (Tehran, Iran) with any kind of wounds or injuries. This study was approved by the medical ethics committee of Shahid Beheshti University of Medical Sciences, and an informed consent was obtained from all subjects. Exclusion criteria were age less than 18 years, pregnancy, and inability to provide data on

Results

The mean age of patients was 33.2 years (SD = 15.9, minimum = 18, maximum = 87), and 85% were male. DT vaccine was administered to 141 (70.5%) patients and TIG to 105 (52.5%). Subjects' history of vaccination is presented in Table 2. Based on the vaccination history, 33% (66) of patients were presumed to be protected. Overall, the TQS test was positive for 137 (67.5%) patients and negative for 63 (31.5%) (Table 3). Serum TIG levels, assessed by ELISA, indicated that 79% of patients had levels

Discussion

Despite the emphasis on immunization and preventive measures for wounds and injuries in medical education, tetanus infection is still common in developing countries. To help physicians take appropriate measures, an immunochromatographic dipstick test (TQS) was developed to assess the tetanus immune status of patients in an easy and timely manner. Our results are consistent with previous studies demonstrating the validity of TQS assessments of immunity against tetanus [7], [8], [9], [10], [11],

Conclusion

This present study demonstrates that TQS is a valid assessment of tetanus immunity status and demonstrates that this is a cost-effective approach to determining requirements for type of tetanus prophylaxis measure in patients with incomplete vaccination histories whose wounds warrant such an approach.

Acknowledgment

The authors would like to gratefully thank the Imam Hussein Hospital laboratory personnel and ED nurses, in particular, Mr Josef Zare, without whose help this work could not be done. We would also like to thank emergency medicine faculties and residents of Shahid Beheshti University of Medical Sciences at the aforementioned hospital for their participation and useful hints that made this research a fruitful experience. We also owe a great debt of gratitude to Dr Stephan Bourque and Dr Jude

References (12)

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