Can a patient with Amyotrophic Lateral Sclerosis (ALS) receive a tetanus shot prior to Percutaneous Endoscopic Gastrostomy (PEG) tube placement surgery?

Tetanus Vaccination in ALS Patients Prior to PEG Placement

Yes, patients with ALS can and should receive tetanus vaccination prior to PEG placement surgery if their immunization is not up to date, following standard tetanus prophylaxis guidelines for the general population.

Key Recommendation

ALS patients should receive tetanus prophylaxis according to the same schedule as the general population, with no specific contraindications related to their neurological condition. 1 The presence of ALS does not preclude tetanus vaccination, and the procedure should follow standard wound prophylaxis protocols.

Tetanus Prophylaxis Guidelines for Surgical Procedures

• For clean surgical wounds (including PEG placement): Administer tetanus toxoid-containing vaccine if the last dose was ≥10 years ago 1
• For contaminated or high-risk wounds: Administer tetanus vaccine if the last dose was ≥5 years ago 1, 2
• Preferred vaccine for adults 19-64 years: Tdap (tetanus, diphtheria, acellular pertussis) if not previously received, otherwise Td 1

Critical Considerations Specific to ALS

Progressive Neurologic Disorder as a Precaution

The 2006 CDC guidelines list "progressive neurologic disorder" as a precaution for vaccines containing pertussis components, NOT for tetanus toxoid itself. 1 This is an important distinction:

• If there is concern about the pertussis component in Tdap, Td (tetanus-diphtheria) vaccine can be safely administered instead 1
• The precaution applies to uncontrolled or progressive neurologic conditions until stabilized, but this refers primarily to the pertussis component 1
• Tetanus toxoid vaccination itself is not contraindicated in ALS patients 1

Timing Relative to PEG Placement

Ideally, administer the tetanus vaccine at least 2 weeks before the PEG procedure to optimize immune response, similar to recommendations for other inactivated vaccines before procedures 3. However, if the patient requires urgent PEG placement:

• The vaccine can be given immediately before or even after the procedure if needed 1
• There is no requirement to delay PEG placement for tetanus vaccination 1

PEG Placement Considerations in ALS

Optimal Timing for the Procedure

PEG should be performed before severe weight loss occurs and before respiratory function is severely impaired (ideally FVC >50%). 1 This timing consideration is separate from tetanus prophylaxis but important for overall procedural safety:

• Early gastrostomy placement (before >10% weight loss) reduces 30-day mortality risk 1
• Patients with FVC <50% can still undergo PEG safely with noninvasive ventilation support 4

Pre-Procedure Requirements

Standard PEG preparation includes 1:

• Fasting for at least 8 hours (longer if gastric motility is impaired) 1
• Coagulation parameters: INR <1.5, platelets >50,000/mm³ 1
• Antibiotic prophylaxis (2g cephalosporin IV) is recommended by some guidelines 1
• Tetanus immunization status should be verified and updated if needed 1

Contraindications to Tetanus Vaccination (None Apply to ALS)

The only absolute contraindications to tetanus toxoid are 1:

• History of anaphylaxis to vaccine components 1
• Encephalopathy within 7 days of previous pertussis-containing vaccine (applies only to Tdap, not Td) 1

ALS itself is NOT a contraindication to tetanus vaccination. 1

Common Pitfalls to Avoid

• Do not withhold tetanus vaccination based solely on the ALS diagnosis – the progressive neurologic disorder precaution applies primarily to pertussis components, not tetanus toxoid 1
• Do not delay necessary PEG placement to administer tetanus vaccine – the vaccine can be given concurrently with the procedure if needed 1
• Do not over-vaccinate – verify prior immunization history; patients vaccinated within 10 years for clean wounds or 5 years for contaminated wounds do not need revaccination 1, 2, 5
• Consider using Td instead of Tdap if there is specific concern about the pertussis component in a patient with rapidly progressive ALS 1

Practical Algorithm

1. Verify tetanus immunization history 1, 5
2. If last tetanus vaccine was ≥10 years ago: Administer Td or Tdap (Td preferred if concern about pertussis component in progressive ALS) 1
3. If last tetanus vaccine was <10 years ago: No vaccination needed for clean surgical procedure 1
4. Proceed with PEG placement according to standard protocols, optimally when FVC >50% and before significant weight loss 1