Zostavax for Herpes Zoster (Shingles)

Zostavax is a new vaccine to reduce the risk for herpes zoster (HZ), commonly known as “shingles,” in elder adults. It is given as a single subcutaneous injection.Having encountered shingles in emergency department patients regularly over the years, and in a few unfortunate victims during adventure travel, I can state affirmatively that shingles can be quite debilitating. We are keeping our fingers crossed that this new vaccine will be as effective in the general population as it was demonstrated to be in a study population.

HZ is caused when varicella-zoster virus (VZV), which causes chickenpox, is reactivated from a latent or dormant (inactive) state. After an infection with VZV, a person can retain the virus, quite commonly in nerve tissue. While most cases of reactivation can not be linked definitively to a specific cause, some cases of viral reactivation are felt to be related to physiological stresses, such as extreme fatigue, suppression of the immune system, concurrent cancer, or intense exposure to environmental extremes (sunlight or heat), or significant emotional stress. Shingles is a situation wherein the virus becomes active in the distribution of one or more nerve roots, which are branches off the spinal cord.

In a typical episode of shingles, the victim (most commonly a person older than 60 years of age – but this is an affliction certainly seen in younger individuals as well) notes symptoms prior to eruption of the rash. These include a sensation of tingling or burning in the skin that will soon become reddened and blistered. Sometimes the tingling and burning can become sharply and intensely painful prior to appearance of the rash. When the skin is examined at this stage, it may appear normal.

Within a few days of the abnormal sensations, the skin reddens and blisters, with clusters of fluid-filled skin bubbles corresponding to the distribution of the particular involved nerve(s). During this stage, pain may be very severe. If the face, mouth, eyes, or genitals are involved, a person may have difficulty with eating, vision, or urinating.

After a case of HZ, the victim may suffer the complication of postherpetic neuralgia (PHN), which may cause debilitating pain for months. PHN is often defined as severe pain associated with HZ that persists for 90 days after the initial onset of pain.

Treatment for acute HZ includes prompt administration of an antiviral drug, such as famciclovir or acyclovir. However, this treatment is not curative, but rather, shortens the duration of the rash and pain. Furthermore, the antiviral agents do not seem to prevent the occurrence of PHN.

Zostavax is a vaccine from the pharmaceutical company Merck composed of live attenuated VZV. In one large study, vaccine administration in an elder population decreased the incidence of shingles by 51% and also diminished the duration and severity of pain and discomfort in recipients of the vaccine who developed shingles, as compared to non-immunized individuals. Immunized individuals also showed a lower incidence of postherpetic neuralgia, although this effect may largely be attributed to the decreased incidence of HZ. The beneficial effects declined as the age of the recipients rose, with the youngest age being 60 years, and the oldest begin greater than 80 years. This observation may have to do with declining immune response (to the vaccine) with increasing age.

As physicians and patients accumulate more experience with the vaccine, it may become an important immunization for elders as they prepare to embark on wilderness adventures, where an episode of HZ might at best be inconvenient, and at worse, become a medical cause for discontinuation of the trip.

Tags: Zostavax, herpes zoster, shingles, wilderness medicine, outdoor medicine, healthline


photo by Paul Auerbach

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Thank You to Grand Rounds at Dr Hebert's Medical Gumbo

Thank you to Dr. Hebert's Medical Gumbo for including my post about methicillin-resistant Staphylococcus aureus (MRSA) infection in this week’s Grand Rounds. Grand Rounds is a weekly hosted event where a medical blogger recommends notable posts of the prior week from other medical bloggers. This week's collection is hosted by Michael C. Hebert, M.D., who writes about pediatrics, internal medicine, and philosophy.

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MRSA

The Staphyloccus aureus bacteria has long been a cause of skin and soft tissue infections in humans. Recently, however, the bacteria has become more of a problem because it has become resistant to the antibiotic methicillin. Thus, we now have methicillin-resistant S. aureus, commonly known by its abbreviation, “MRSA.” Initially, MRSA was found in hospitals, where patients exposed to S. aureus (“staph”) germs developed infections with bacteria that had become resistant to antibiotics, presumably due to the co-existence of bacteria and antibiotics found in health care facilities.

The situation has taken a turn for the worse, because doctors are now seeing MRSA infections that are acquired outside of the hospital. These are known as “community acquired” infections. I have been made aware of a few infections that seem to have been acquired in the outdoors. In one case, it was almost certainly acquired from a wet suit worn by a surfer.

These infections do not respond to the antibiotics we used to use for “routine” (non-MRSA) infections. Instead, they must be treated with antibiotics such as trimethoprim-sulfamethoxazole, tetracycline, or vancomycin. In the future, they may become resistant to these antibiotics and we will have to hope that other drugs prove effective.

The appearance of a MRSA infection may resemble that of a spider bite, in that there may be evidence of tissue destruction. The best prevention is good hygiene, including washing skin on a regular basis, using clean clothing and linens, and washing all cuts and scrapes thoroughly with soap and disinfected water. Using an antiseptic ointment, such as bacitracin, on open wounds may not prevent a MRSA infection, but will certainly help prevent other Staphylococcus infections and Streptococcus (“strep”) skin infections.

Tags: MRSA, methicillin resistant Staphylococcus aureus, skin infection, medical, physician, health, wilderness medicine, outdoor medicine, healthline

photo by Paul Auerbach

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Detergent in the Wilderness

About the post "Doing the Dishes," a reader comments, "Using detergent or bleach is not appropriate in wilderness areas."

I am grateful for this reader's willingness to speak up, because the issue of human intrusion into our wilderness environments is one of great concern, not only to environmentalists, but to all of us. Under what circumstances and to what degree should men and women be allowed to enter the wilderness? What conveyances should they be allowed to use? What equipment should they be permitted to carry? Should they be rescued by mechanical means if they become ill or injured? Should a man-made fire be allowed? What may be harvested for food? Do all human waste products need to be carried out? These are important questions about which there are much discussion and debate. Underlying these queries are the definition of wilderness, the responsibilities of people, and our approach to preservation of the natural environment.

The definition of wilderness to which I subscribe is, "Wilderness exists where large areas are characterized by the dominance of natural processes, there is a full complement of plant and animal communities characteristic of the region, and there are no human constraints on nature. Man is a visitor who does not remain." Inherent in this definition is that humans are allowed to visit the wilderness, but do not remain as permanent inhabitants. Furthermore, I believe that to the greatest extent possible, they should leave it in as good condition as it was prior to their visitations.

Does this mean that they can in no way alter the wilderness? I think it means that they should not knowingly detrimentally alter it. Prescribed fires are used by expert foresters and fire-fighters to prevent devastating fires that would do more damage than those accidentally set by man. Waters are diverted to allow preservation of plants and animals that would otherwise perish by drought. Trails are cut through wilderness areas to keep men and women on paths so that they do not crush vegetation and delicate earth structures underfoot. In the long run, are these manipulations proper or wise, or should we just let nature take its course? I do not know for sure, but I know that humans are so inextricably entwined with the planet that it seems counterproductive to sit by passively and just let things happen. Man is part of nature. When there are choices to be made, each should be done taking into account history, current scientific knowledge, and what we know about behavior in the absence of an action or intervention.

So, what about detergent and bleach in the wilderness? The comment was made that they have no place. I agree that it is not appropriate or necessary to degrade the environment to provide adequate water disinfection for the purposes of human health and safety. No artificial or natural chemical should be used in a situation where its use or disposal will harm the environment. That means that one should try to get by with methods that do not involve increasing pollution as a byproduct. This might be done with biodegradable products or non-additive based methods. If people can prevent the initiation or spread of disease by methods that are entirely "natural," that is well and good.

However, from my perspective, it is not reasonable to state that under no circumstances should one bring detergent or bleach into a wilderness setting. If the purpose is to prevent infectious diseases that would be debilitating to humans, and the method chosen does not damage the wilderness, then the means may justify the ends. Damaged and dead humans are difficult to justify. This puts a great deal of responsibility on the user, who must keep concentrations of products to a minimum, dispose of them properly and in a non-injurious fashion, and consider them as a means of last resort or ultimate practicality.

One can prioritize the act of keeping the wilderness pristine above any consideration of comfort or safety for humans. But that is based on a certain point of view. I believe that there is a reasonable middle ground. If someone disposes of dishwashing water where it will alter the landscape or have an irrevocable ecologic effect, that is wrong. However, to say that detergent and chlorine have no place in the wilderness under any circumstance seems as extreme as saying that one can never walk in the woods because of the death of insects and microorganisms under foot. I don't throw my dishwater in the lake, but I wouldn't hesitate to escalate from boiled water and biodegradable soap to use detergent and bleach (and to dispose of them properly) if everyone in camp was getting sick. The people and maintaining their health are important, too. Having recently returned from a trek where infectious diarrhea laid low a number of participants and nearly forced evacuations, it is easy for me to have this conviction.

I will continue to report the science and observations of others, and let my readers decide how best to value the information and advice. It's a good thing to contemplate how every action has effects that may not be apparent, but are directly related to how we approach the wilderness environment. Your comments are welcome.

Tags: detergent, wilderness, medical, physician, health, wilderness medicine, outdoor medicine, healthline

photo by Paul Auerbach

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Thank You to Grand Rounds at Health Care Law Blog

I would like to thank Health Care Law Blog for including my post about the stingray "attack" that occurred in Florida in this week’s Grand Rounds. Grand Rounds is a weekly event where a medical blogger “hosts” notable posts of the week from other medical bloggers. This week's collection is the first hosted by a health care attorney, Bob Coffield, who regularly provides very interesting commentary.

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Experimental Vaccine for Hay Fever

An article in the October 5, 2006 issue of the New England Journal of Medicine discusses a controlled trial of a vaccine that may be useful for persons allergic to ragweed, which is a major precipitant of allergic rhinitis ("hay fever"). The vaccine was given to 25 patients in a single (for each patient) series of six injections over a 6-week period, and appeared to lessen the symptoms of hay fever through 2 consecutive allergy (ragweed) seasons. The shots were given once a week for six weeks.

This study indicates that in this particular trial, the vaccine was effective, and that the effect may be long-lasting. This is in contrast to current standard allergy immunotherapy injections, which are given as a series of 14 to 27 injections prior to the beginning of the ragweed season. In prior studies, recipients of the standard allergy shots did not show persistent (e.g., beyond one season) benefit after discontinuation of shots until after they had been the recipients of shots for at least 3 to 4 years. So, if the data presented in this current study of the new vaccine hold up, the new vaccine would represent the first immunotherapy method for ragweed allergy that creates a persistent effect after a single course of therapy.

Other encouraging observations are the fact that there were no adverse events attributable to the new vaccine, and there were no local reactions (to the injections). While the number of patients studied was small, this may indicate that the vaccine is not only quite useful, but safer than current products used for standard allergy immunotherapy.

Dynavax Technologies is the company behind the vaccine. The next step in development of this vaccine will be a large phase-3 study to prove if these results can be generalized to a larger patient population. Given the tens of millions of Americans who suffer each year from hay fever, this will be an important investigation.

Tags: hay fever, allergic rhinitis, vaccine, medical, ragweed, health, wilderness medicine, outdoor medicine, healthline

photo by Paul Auerbach

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Another Stingray Attack

Against the odds, another stingray has speared a victim in the chest. As reported in the news, an 81-year old man from Florida was in a boat when a stingray exited the water, jumped into the boat, and had its barb strike him as the man attempted to remove the ray from the boat. From a picture posted on the Internet, the ray appears to be a spotted eagle ray, species Aetobatus narinari. Also according to news reports, the victim was promptly treated by surgeons, who removed at least part of the barb. The reports that I read indicated a closed chest injury (puncture wound), collapsed lung (pneumothorax), and initial diagnosis of a possible injury to the heart. A later report stated that the victim underwent heart surgery, because a portion of the spine was lodged in his heart. The fragment was "pulled through" in order to completely extract it. At the time of this writing, the victim was in critical condition.

The ray was estimated to have a 5 foot "wingspan" and to weigh approximately 30 pounds. It reportedly died on the boat.

As I mentioned in my first post regarding stingrays that followed the tragic death of Steve Irwin, rays are not known to attack humans, except in self defense. They occasionally have been seen to leap from the water. This is presumed to occur, among other reasons, because they have been startled by a passing boat. If a stingray lands in a boat, either because it has leaped from the water or because it has been captured in a net or by hook-and-line, it is frightened and agitated, and will act in self defense. The only method of self defense possessed by a stingray (unless someone places a body part close to or into the animal's mouth, in which case it may bite) is to forcefully strike with its tail, which often carries a venom-laden barb. The ray can aim its tail in the general direction of the victim, but is probably not accurate enough to chose a specific target site. Being struck in the chest is bad luck indeed for the victim, and probably has more to do with the victim's positioning than with the aiming ability of the stingray.

Underwater and approached in an open and non-threatening manner, stingrays will flee from humans. I have often dived near spotted eagle rays, single and grouped, and have never found them to be curious or aggressive. However, if stingrays are approached too closely, and especially if they are cornered or trapped, they may lash out in defense. So, while it may be tempting to get close to obtain a photograph or to even attempt to touch a ray, these animals should be given a wide berth. If a ray is captured and is out of the water, it may strike with its tail, so must be approached and handled very carefully. Otherwise, a human injury may occur.

As was the case with the Steve Irwin tragedy, our thoughts and prayers are with the victim and his family.

Tags: stingray, eagle ray,hazardous marine life, heart, medical, health, wilderness medicine, outdoor medicine, healthline

photo by Paul Auerbach

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Thank You to Grand Rounds at Emergiblog

I would like to thank Emergiblog for including my post on the upcoming Wilderness Medical Society Winter Specialty Meeting on Mountain Medicine in this week’s Grand Rounds. Grand Rounds is a weekly event where a medical blogger “hosts” notable posts of the week from other medical bloggers. It's a terrific collection of interesting and informative posts.

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Muscarine and Mushrooms

Upon reading the post about poisonous mushrooms, a reader offered, "Viking fighters called Berserkers ate mushrooms containing muscarine to prepare for battle. They went so wild that we get the word "berzerk" from them."

Many authors refer to the fact that the Vikings would consume Amanita muscaria mushrooms prior to going into battle. These mushrooms cause hallucinations, which undoubtedly accounted for the strength and odd behaviors of the bearskin-clad warriers. Although muscarine was first isolated from A. muscaria over 150 years ago, the hallucinations caused by these mushrooms are not attributed to muscarine, but to other chemical components.

For the sake of contrast, a classic muscarinic reaction includes excessive salivation (drooling), lacrimation (eyes tearing), urination, sweating, abdominal pain, nausea, vomiting, and diarrhea. It may also include skin flushing (redness) and shortness of breath caused by excessive secretions from the lining of the bronchial tubes. Rapid or slow heartbeat may be noticed, as might headache, difficulty with balance when walking, and blurred vision. Many Inocybe and Clitocybe mushrooms contain larger concentrations of muscarine than does A. muscaria.

Amanita muscaria has a cap 5 to 30 cm in diameter that is scarlet red with white "warts." One doesn't need to be a Viking to obtain these mushrooms, as they grow in eastern North America and throughout much of the western United States, often under hardwoods and conifers from spring to autumn.

Ibotenic acid is found in the bright red cap of A. muscaria and undergoes a chemical reaction during drying to form muscimol, an even more toxic compound. The potency of the cap remains high despite drying. Eating as little as 10 milligrams of A. muscaria produces intoxication, dizziness, and difficulty walking. Ingestion of 15 milligrams can cause severe balance and vision problems. Symptoms begin within 30 minutes of ingestion and generally last for approximately 2 hours, although it is possible to be affected for up to 2 days, particularly with regard to a lingering headache. Death is possible, but rarely reported. The victim of this mushroom poisoning may become delirious and hyperactive, suffer hallucinations or even seizures, and demonstrate muscle twitching.

As I mentioned in my prior post about wild mushrooms, they can pack a potent punch. No person should knowingly eat A. muscaria. Persons who eat them to obtain a "natural high" often regret the experience.

Tags: poisonous mushrooms, mushrooms, outdoor medicine, wilderness medicine, healthline

photo of Amanita muscaria from the textbook Wilderness Medicine

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Wilderness Medical Society Winter Specialty Meeting on Mountain Medicine

I'm very excited to have been invited to speak at the upcoming Winter Specialty Meeting on Mountain Medicine sponsored by the Wilderness Medical Society (WMS). This continuing medical education (CME) meeting will be held March 16-21, 2007 at Park City, Utah. The focus is upon medical topics related to the mountain medicine aspects of wilderness medicine. These include a preconference workshop on avalanche awareness, rescue, and medical treatment, in part taught by the Exum Utah guides and with input from the Utah Avalanche Forecast Center and the Canyons Ski Patrol.

Topics that will be covered in the educational sessions that comprise the main meeting include high altitude illness, eye care at high altitude and in the wilderness, medical kits and antibiotics, patient assessment, hypothermia, cold weather hiking and trekking, ski and snowboard injuries, litters and evacuation, lightning, frostbite, and many others. Participants will also have the opportunity to obtain Advanced Wilderness Life Support (AWLS) field certification.

Special evening programs will be the film "Everest ER: Everest Base Camp Medicine" with comments by an expert panel led by Luanne Freer, M.D., who organizes and runs the medical clinic at Everest base camp each climbing season, and "Impossible Dreams" presented by Geoff Tabin, M.D., who was the fourth person to climb the "7 summits," the highest points on all seven continents.

The conference will be held at The Yarrow Resort Hotel & Conference Center. It should be a terrific event for physicians, nurses, paramedics & EMTs, wilderness medicine educators, and other persons interested in learning more about practical aspects of medicine practiced in the mountains.

Tags: Wilderness Medical Society, mountain medicine, WMS, medical, physician, health, wilderness medicine, outdoor medicine, healthline

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Autumn Advice

Autumn is a wonderful time to be outdoors, particularly camping and visiting our National Parks, because there are fewer people present than during summertime. Here are a few safety tips:

1. Even if the day starts with sunshine and no clouds, always anticipate a rain shower, thunderstorm (sometimes with hail), and/or cold weather. On the cusp of winter, you may get caught in an early snowstorm. I've mentioned before the need to anticipate having to spend an unexpected night outdoors. You may not need to go to that extreme on a day hike, but you definitely should carry adequate clothing to allow you to dress in layers, as well as raingear.
2. Be able to recognize poison ivy and oak as the leaves change color. Until the leaves begin to dry and shrivel and the internal moisture returns to the stems, the resin (urushiol) is present and potent, so you can get a significant exposure. Be particularly careful when clearing out forested and shrub-laden areas, and even more so when burning wood and leaves. Poison oak can grow up around wood--I've treated more than one person with nasty reactions who had been exposed to the resin via the smoke from burning leaves.
3. Take care to properly contain campfires. After a long, dry summer, the fire risk remains high until there has been enough precipitation to lower the risk. Be especially careful with matches and other firestarters.
4. Water safety, particularly if you are camping near a lake, stream, or river, is essential.
5. Instruct children to not put strange plants (such as poisonous mushrooms) in their mouths.
6. Because it is not as warm outside, you many underestimate your needs for hydration. Drink lots of water.

Tags: poison ivy, poison oak, camping, medical, physician, health, wilderness medicine, outdoor medicine, healthline

photo of autumn colors (NOT poison oak or ivy) by Paul Auerbach

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Thank You to Grand Rounds at Unbounded Medicine

I would like to thank Unbounded Medicine for including my post Head Injuries in this week’s Grand Rounds. Grand Rounds is a weekly event where a medical blogger “hosts” the notable posts of the week from other medical bloggers. As always, it's nice to see such good-natured collaboration.

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More on Washing Dishes

A reader asks (about rinsing dishes): "If using bleach in bowl 2, can the water be lukewarm or should it be cold?

The answer is that while it can be cold, it is fine if it is warm or even hot. Although the rinsewater used to wash dishes is not intended for drinking, we know from the process for disinfecting drinking water that disinfection is influenced by both the concentration of chemical(s) in the water as well as the contact time of the chemical with any infectious organisms (e.g., bacteria or viruses) in the water. In general, for the purposes of water disinfection, one doubles the contact time if half the concentration of a chemical such as iodine or chlorine is used. If the water is cold, one multiplies the contact time by a factor of 4 to assure disinfection, regardless of the concentration of disinfectant used. Furthermore, if the water is cloudy, one may need to double the concentration of disinfectant. So for cold and cloudy water, one doubles the concentration of disinfectant and quadruples the contact time.

In the study I mentioned in my previous post, the authors noted that the washing-up bowls contained "room temperature" water, but did not specify the precise temperature. If we assume that the temperature of the water was in the vicinity of 70 degrees Fahrenheit, then it is reasonable to suppose that heating the water would certainly not be harmful, and might be helpful, in increasing the disinfecting capability of the rinse water. Having the water be cold might diminish the disinfection effects. Without having any data to support this recommendation, one might allow longer contact time in colder rinse water, based on the principles we follow for disinfection of drinking water.

I note a comment from a reader stating that neither bleach nor detergent are appropriate in the wilderness. I'm glad that someone brought this up, because it represents an important perspective. So, I will address that comment in a future post.

Tags: hygiene, dishwashing, diarrhea, wilderness medicine, outdoor medicine, healthline

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This Weeks' Best of Health Matters

The Health Matters HealthBlog Network consists of a dozen independent and unfiltered medical professionals blogging about the topics that matter to you. Each week, Healthline's Editors select the three top posts from the network to share with all of our readers in one convenient post. We hope you'll enjoy them!

Infertility Stress Reduction Tips
If you, or someone you know, has struggled with infertility you know what a stressful time that can be. Visit The ART of Conception where expert Carl “Rusty” Herbert MD offers some tips for getting through these rough patches … read more

What Should Cancer Patients and Family Do About the Flu Vaccine?
Vaccinations can be a lifesaver. Most vaccines contain inactive viruses, but others contain a small amount of a live virus. Tune into Cyndy King’s Cancer Treatment and Survivorship blog to learn what people undergoing cancer treatment that can compromise their immunity should do…read more.

Throw a Stronger Punch (or Push a Car or Stroller)
People don’t always realize how many times a day they are hurting their backs. Read on to learn more about what Dr. Jolie Bookspan of the Fitness Fixer blog says is one of the most common misconceptions in fitness….read more.

Additionally, we're pleased to announce the launch of two new blogs this week! Freedom from Smoking with expert Lowell Kleinman, MD and Straight Talk from the ER with expert Robert L. Norris, MD.

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Head Injuries

In outdoor activities, particularly sports, it is not uncommon to sustain a head injury. Most of these occur from a blow to the head incurred by a falling object (e.g., rock or tree limb), a collision of some sort (e.g., skiing into a tree), or a fall (during activities such as rock climbing, mountaineering, tumble in the surf, etc.). One area of constant discussion in the medical profession is the determination of which patients with "minor" or "minimal" head injury should undergo computed tomographic (CT) scanning of the brain in order to determine if there is a significant injury to the skull or brain.

What are the definitions of "minimal" and "minor head" injuries? A minimal head injury is generally defined as a situation in which there has not been any loss of consciousness or other neurological problem. A minor head injury may include a concussion, in which there has been brief loss of consciousness, amnesia, or disorientation in a person who is currently awake and talking. Doctors determine neurological status by applying a series of questions and a physical examination to patients to calculate a numeric score for the "Glasgow Coma Scale (GCS)." The highest number that can be achieved, which indicates that no abnormality can be found, is 15.

In a recent evaluation of 4,551 study patients with head injury and GCS score of 15, published in the September 2006 issue of the Annals of Emergency Medicine, Catherine Clement, RN, Ian Stiell MD, and their colleagues found that only 26 of these patients required an acute neurosurgical intervention. Of these 26, 11 required an urgent operation within 7 days of their injury. These patients demonstrated one or more of the following warning signs: vomiting, restlessness, observed decrease in GCS score, severe headache, confusion, and a focal blow to the side of the head. So, if a person appears normal, but has suffered any one of these, he or she is perhaps at a greater risk for having a serious brain injury. They should therefore be watched very closely. If you are far from medical attention, you should make plans for a prompt evacuation.

Tags: head injuries, concussion, Glasgow Coma Scale, medical, physician, health, wilderness medicine, outdoor medicine, healthline

photo by Frank Tramontano at HawaiianSwell.com

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The Best of the Medical Blogosphere

I want to say thanks to RDoctor Medical for including two of my posts – More Spinach and Outdoor Adventurer’s Pledge - in this week’s Grand Rounds. For those of you who are new to the “Medical Blogosphere,” Grand Rounds is a weekly event where a medical blogger “hosts” the best posts of the week from other medical bloggers. To check out this week’s Grand Rounds click here. To find out more about Grand Rounds click here.

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Tetanus Shot After a Bee Sting

Regarding a bee sting, a reader asks, "Do I need to get a tetanus shot after a sting? What if I had a shot 5 years ago? Do I need another?"

Everyone should be properly immunized against tetanus, which is caused by the bacterium Clostridium tetani. In the U.S., diphteria-tetanus-pertussis (DTaP) vaccine is given as an intramuscular injection at ages 2, 4, 6, and 8 months, followed by a booster at age 4 to 6 years, usually before entry into school. These shots provide immunity from tetanus, as well as from diphtheria and pertussis [whooping cough]) for about 10 years. The first booster shot is usually given at age 11 or 12 years in the form of Tdap vaccine. Thereafter, Td (tetanus and diphtheria) vaccine is usually recommended at 10 year intervals. However, given a resurgence of whooping cough seen in adults, the recommendation may change to continue immunizing against pertussis with the Tdap vaccine in perpetuity. Following immunization against tetanus, immunity in any individual is unknown, and can be determined by measuring antibodies in blood. This is particularly important in elders, in whom the immune response to vaccination may be suppressed by a general lower level of the immune system associated with age.

The current practice is to take a booster shot (Td) if one sustains a "dirty" wound, deep puncture, serious burn, significant crush injury, etc. and has not had a tetanus shot in the preceding 5 years. If a wound is felt to be at particularly high risk for infection with C. tetani (e.g., if it is a very deep puncture or contaminated by soil or animal feces), it may also be recommended to have an injection of tetanus immune globulin as well as a tetanus booster immunization. Whether or not to administer tetanus immune globulin is generally a judgment call by the treating health care professional. The immune globulin contains actual antibodies against the bacteria, so that the recipient carries protective antibodies against the bacteria until his or her body has a chance to manufacture its own antibodies in response to the Td booster shot.

A bee sting in general does not pose a large risk for tetanus infection. Although deep punctures of other varieties deposit bacteria into the wound(s), where C. tetani can thrive in the absence of oxygen, a bee sting puncture isn't that deep. The stinger might transfer bacteria from the skin surface, wherein lies the greatest risk. So, my recommendation is that if a person has been immunized within the past 5 years, it is unnecessary to get a Td booster immunization. If it has been more than 5 years but less than 10 years since the last tetanus shot, a Td booster is indicated. If it has been more than 10 years since the last tetanus shot, both a Td booster and tetanus immune globulin are indicated, if you go by the book.

Remember to write down the dates of all immunizations in a place where you can readily find the record. Many of us have had extra tetanus shots because we were unable to record the date of our prior immunization. Also, remember that it is essential to clean all wounds if possible promptly with soap and water, followed by a fresh water rinse, in order to remove as much dirt and bacteria as possible. This may be difficult with a tiny puncture wound like a bee sting, but do the best you can, particularly with open cuts and scrapes that have been contaminated with dirt or other grime.

Tags: tetanus shot, bee sting, immunization, medical, physician, health, wilderness medicine, outdoor medicine, healthline

photo courtesy of ruppweb.dyndns.org/ttfc/ttfc.htm

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