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Medical Science Publication No. 4, Volume II



The recent experience in the Far East including that in Korea had addedlittle, if any, new information concerning immunization to tetanus. Itis perhaps of some interest and significance, however, that the entirelysatisfactory effect of this procedure has been confirmed during this latestconflict. The World War II experience with active immunization to tetanususing tetanus toxoid has been reported elsewhere and need not be recountedhere (1). It is adequate to recall that as shown in table 1 onlysome 12 cases of tetanus occurred

Table 1. Incidence of Tetanus Among Wound andInjury Casualties


Admissions for wounds and injuries

Cases of tetanus

Cases per 100,000 wounds and injuries

World War I




1920-41 (inclusive)




World War II (1942-45)




among nearly 3,000,000 wound and injury casualties during that period.This represents a reduction in frequency of tetanus to about one-thirtiethof that reported during World War I. There is no question of the potentialhazards from the infection during the World War II period since numerouscases were reported among the unimmunized German Forces in Europe and amongJapanese troops and civilians in the Pacific areas.

Table 2 indicates the status of immunization of the 12 cases reported.It is seen that only 4 of the 12 were in individuals whose records indicatedthat immunization was in complete accordance with established procedures.

As indicated above, this success was repeated during the Korean conflict,when only one case of tetanus was reported. This resulted from a nonbattletype of injury occurring as a result of a bulldozer accident. It was nonfataland occurred in an individual who, though

*Presented 29 April 1954, to the Course on Recent Advances in Medicine and Surgery, Army Medical Service Graduate School, Walter Reed Army Medical Center, Washington, D. C.


Table 2. Immunization Status of Cases


Fatal cases

Total cases

No active immunization



Basic immunization (three injections) accomplished but no emergency stimulating injection given



Basic immunization plus emergency stimulating injection given






he had received adequate basic immunization, was not given an emergencystimulating dose of toxoid at the time of injury. This, of course, servesto emphasize again that protection from tetanus by active immunizationis based on the immunologic preparation of the individual by the basicimmunization and the stimulation of protective antitoxin levels by thedose of toxoid administered at the time of injury. (In this connection,it is worthy of note that in at least one surgical hospital during theearly days of the Korean episode, the laboratory officer organized a tetanustoxoid-penicillin team whose duty it was to administer the emergency stimulatingdose of tetanus toxoid to all wounded patients on admission and at thesame time to give the expectant treatment dose of penicillin (2).

Although the records are incomplete as to the number of cases of tetanusoccurring among non-American United Nations personnel in Korea, it is knownthat a number were experienced and that among these, there were some fatalities.Details of these cases are not known. That they occurred in non-immunizedpersonnel, however, is unquestioned. It is possible that some of them atleast may not even have received passive protection in the form of tetanusantitoxin. It is well, then, to keep in mind that when American forcesare in conflict side by side with allied troops not protected with tetanustoxoid, the prevention of tetanus in such individuals may well rest withthe administration of prophylactic antitoxin.

Not arising directly from the Korean experience but resulting from acontinuation of studies, has come new knowledge concerning the intervalbetween stimulating doses of toxoid. At the end of World War II, it waspossible to demonstrate that the conditioning afforded by the basic immunizationpersisted for at least 4 to 5 years. Evidence resulting from the more recentstudies indicates that this period may extend up to 10 years (3-5).Based on this new information, it is quite likely that the next revisionof the Army immunization policy statement will direct that toxoid stimulatingdoses be admin-


istered at intervals of about 6 years for the maintenance of the basicimmunologic conditioning required for protection from tetanus.

There is one other change contemplated for the tetanus immunizationprocedure. This has less to do with tetanus than with diphtheria so willbe mentioned only briefly. For reasons which need not be reviewed here,it has become desirable to effect active immunization of American troopsto diphtheria and to accomplish this as simply and as efficiently as possible.Accordingly, it has been decided to add a very small amount of diphtheriatoxoid (about 2 Lf. per ml.) to the tetanus toxoid (6). This procedurehas now been well studied and its two most important features have beendetermined: first, that even such a small dose of diphtheria toxoid willproduce an immune status in the great majority of young American adults;and second, that this combination of antigens can be administered withessentially no more local or systemic reaction than that resulting fromthe administration of tetanus toxoid alone.


Current knowledge and experience indicate that active immunization totetanus utilizing tetanus toxoid is a highly effective and extremely practicalprocedure. One other antigen such as diphtheria toxoid may be added tothe tetanus toxoid in small quantities and give adequate immunogenic responseswithout significant increases in reactions.


1. a. Long, A. P.: Tetanus Toxoid: Its Use in theUnited States Army. Am. J. Pub. Health 33 : 53-57, January 1943.

b. Long, A. P.: Immunization in the United StatesArmy. Am. J. Pub. Health 34 : 27-33, January 1944.

c. Long, A. P., and Sartwell, P. E.: Tetanus inthe United States Army in World War II. Bull. of the U. S. Army Med. Dept.7 : 371-385, April 1947.

d. Long, A. P.: Current Status of ImmunizationProcedures, Tetanus and Exotic Diseases of Military Importance. Am. J.Pub. Health 38 : 485-488, April 1948.

e. Edsall, G.: Active Immunization. New EnglandJ. Med. 235 : 256-265, 298-305, 328-336, 22-29 Aug., 5 Sept. 1946.

2. Lincoln, A. F.: Personal Communication.

3. Bigler, A.: Tetanus Immunization. Am. J. Dis. Child.81 : 226-232, February 1951.

4. Williams, W. C., and Peterson, J. C.: Tetanus ToxoidStudy. To be published.

5. Looney, J. M., Edsall, G., and Chasen, W. H.: Effectof a Booster Dose of Tetanus Toxoid after Five or More Years. Fed. Proceedings12 : 452, March 1953.

6. Edsall, G., Altman, J. S., and Gaspar, A. J.: CombinedDiphtheria-Tetanus Immunization of Adults: Use of Small Doses of DiphtheriaToxoid. Presented in part at the American Public Health Association, 24Oct. 1952.