What vaccine and immunoglobulin should a 7-year-old child with no prior tetanus vaccination receive after sustaining a contaminated deep cut?

Tetanus Prophylaxis for an Unvaccinated Child with Contaminated Wounds

For a 7-year-old child with no prior tetanus vaccination who has sustained contaminated deep cuts from a barbed-wire fence, tetanus immunoglobulin (TIG) and diphtheria tetanus acellular pertussis (DTaP) series should be administered (option C).

Rationale for TIG + DTaP Series

The decision is based on two critical factors:

1. Wound characteristics: Deep cuts contaminated by soil/dirt from a barbed-wire fence are classified as tetanus-prone wounds
2. Vaccination status: The child has never received tetanus vaccination

According to the CDC Advisory Committee on Immunization Practices (ACIP) guidelines, persons with unknown or uncertain previous tetanus vaccination histories should be considered to have had no previous tetanus toxoid-containing vaccine 1. For contaminated wounds in unvaccinated individuals, both passive immunization (TIG) and active immunization (tetanus toxoid-containing vaccine) are required.

Tetanus Immune Globulin (TIG) Administration

• TIG provides immediate passive protection against tetanus
• For children, the routine prophylactic dose is 250 units given by deep intramuscular injection 2
• TIG should be administered at a different site from the tetanus toxoid-containing vaccine 1
• TIG is essential for unvaccinated individuals with contaminated wounds to provide immediate protection while active immunity develops 1, 2

Active Immunization Selection

For a 7-year-old child:

• DTaP is recommended for children aged <7 years 1
• Since the child is exactly 7 years old, the appropriate vaccine is DTaP to begin the primary vaccination series 1, 3

Vaccination Schedule

The child should receive:

1. Immediate administration:

   • TIG (250 units) intramuscularly
   • First dose of DTaP

2. Follow-up doses:

   • Second DTaP dose 4 weeks after the first dose
   • Third DTaP dose 6-12 months after the second dose 1

Why Other Options Are Incorrect

• Option A (Booster tetanus toxoid vaccine only): Inadequate for an unvaccinated child with contaminated wounds. A booster is only appropriate for those who have completed a primary series 1.

• Option B (Booster tetanus toxoid and TIG): Incorrect terminology - this is not a "booster" situation since the child has never been vaccinated. Additionally, a complete series is needed, not just a single dose 1.

• Option D (TIG only): Inadequate protection as it provides only temporary passive immunity without initiating active immunity. The ACIP guidelines clearly indicate that both TIG and a tetanus toxoid-containing vaccine are necessary for unvaccinated individuals with contaminated wounds 1, 2.

Important Clinical Considerations

• Proper wound cleaning is essential in addition to immunoprophylaxis 3
• The physician must emphasize to the parents the importance of completing the full vaccination series 2
• Monitor for potential adverse reactions after administration of both TIG and DTaP 3
• Document this as the beginning of the child's tetanus vaccination series

This approach provides immediate protection through passive immunity (TIG) while simultaneously initiating the process of developing long-term active immunity (DTaP series), which is essential for preventing tetanus-related morbidity and mortality in this unvaccinated child with contaminated wounds.