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Td/IPV (diphtheria, tetanus and polio)

The vaccine: Revaxis® made by Sanofi Pasteur


The claim:  The teenage booster, also known as the 3-in-1 or the Td/IPV vaccine, is given to boost protection against 3 separate diseases, tetanus, diphtheria, and polio. [1]


Why is this vaccine recommended to students? The 3-in-1 teenage booster is intended to "top-up" immunity from previous tetanus, diphtheria and polio vaccines. [1]


The facts:


Tetanus, commonly called lockjaw, is caused by a bacterium that is mostly present in soil, manure, and in the digestive tracts of animals and humans. Tetanus is not contagious and cannot be transmitted from person to person [2]. It is most common in densely populated regions in hot, damp climates, such as sub-Saharan Africa [3]. Tetanus is extremely rare in first-world countries like the UK, with just seven cases of tetanus reported in England and Wales in 2013 [4]. None of these cases were in people under 30 [4].


Dphtheria is a rare bacterial infection which occurs most often in sub-Saharan Africa, India, and Indonesia [5] [6]. Symptoms of respiratory diphtheria include a sore throat, croupy cough, low-grade fever, runny nose, and breathing problems. Complications can include heart inflammation, and death occurs in 5-10% of cases. Cutaneous diphtheria is more rare than respiratory diphtheria and presents as infected skin lesions that lack a uniform appearance [8]. Diphtheria is exceptionally rare in the UK [7], and in the US, the last confirmed case was in 2003 [8].


Poliomyelitis, commonly called polio, is an infection caused by a virus that multiplies in the gastrointestinal tract. In about 95% of cases, polio infection is subclinical and does not cause symptoms. In 4-5% of cases there may be minor symptoms which resolve within a few weeks.  In less than 1% of cases, the polio virus infects the central nervous system and paralyzes the muscles, which can lead to permanent paralysis or death [9], though usually doesn't [10]. Polio has effectively been eradicated in the UK, and there hasn't been a single case since the mid-90s [10].


What are the risks of the vaccine?


The manufacturer warns possible adverse reactions to the vaccine may include:


Lymphadenopathy; systemic allergic / anaphylactic reactions; convulsions; Guillain Barre syndrome; brachial neuritis; myalgia; arthralgia; allergic-type reactions such as urticaria, various types of rash, and face oedema. [11]


Using the US MedAlerts search engine, as of September 30, 2015, there had been 22,686 serious adverse events reported to the Vaccine Adverse Events Reporting System (VAERS) in connection with tetanus and tetanus-containing vaccines combined with diphtheria vaccine since 1990 [2].


Vaccine ingredients:


Purified diphtheria toxoid; not less than 2 IU* (5 Lf) 

Purified tetanus toxoid; not less than 20 IU* (10 Lf)

Inactivated poliomyelitis virus type 1**; 40 D antigen units*** 

Inactivated poliomyelitis virus type 2**; 8 D antigen units*** 

Inactivated poliomyelitis virus type 3**; 32 D antigen units***

Aluminium hydroxide as adsorbant; 0.35 mg (as aluminium)

Phenoxyethanol

Formaldehyde
Medium 199****
Water for injections


* As lower confidence limit (p = 0.95) of activity measured according to the assay described in the European Pharmacopoeia.

** Produced in Vero (monkey kidney) cells.
*** Or equivalent antigenic quantity determined by a suitable immunochemical method

****Medium 199 is a complex medium of amino acids, mineral salts, vitamins, polysorbate 80 and other substances diluted in water for injections.

[11]


Are there alternatives?


Yes. According to the Mayo Clinic, if you have a minor wound, these steps will help prevent tetanus:


  • Keep the wound clean. After the bleeding stops, rinse the wound thoroughly with clean running water. Clean the area around the wound with soap and a washcloth. If something is embedded in a wound, see your doctor.
  • Use an antibiotic. After you clean the wound, apply a thin layer of an antibiotic cream or ointment, such as the multi-ingredient antibiotics Neosporin and Polysporin. These antibiotics won't make the wound heal faster, but they can discourage bacterial growth and infection [12].


    Remember that tetanus can only survive in an anaerobic environment [13], such as a puncture wound. If your wound bleeds, you are unlikely to contract tetanus. A very deep wound or a cut on rusty metal doesn’t automatically mean you have been exposed. Tetanus is primarily found in soil or manure and rarely around the home [14].


    If a deep non-bleeding wound in a farm-like environment with a lot of exposure to manure is sustained, you should seek the TiG (tetanus immunoglobulin) shot. Tetanus immunoglobulin is an anti-toxin, as opposed to a vaccine. Giving a vaccination after the exposure is of no value, as the vaccine does not instantly kill the bacteria; the vaccine takes about two weeks for seroconversion to take place. Seroconversion is the production of measurable antibodies the body develops to a pathogen. Giving a tetanus shot after an injury provides no benefit [14].


    Preventing diphtheria mainly involves avoiding contact with infected people. UK residents can achieve this by not travelling to countries where diphtheria primarily occurs, such as sub-Saharan Africa. Diphtheria is vanishingly rare in the UK, and so UK students have almost no chance of coming into contact with an infected person [7].


    This is also true for polio, where there have been no recorded cases in the UK for at least twenty years [10]. Also, it is important to note that the polio vaccine can cause polio, and in 2017, there were more cases of polio caused by the polio vaccine than by the wild virus [15]. 


STRIVE opinion - is it worth getting this vaccine? 


If you do not intend on travelling to sub-Saharan Africa, or any other area where tetanus, diphtheria or polio are common, then we would not recommend this vaccine. The diseases it aims to prevent are exceptionally rare in first-world countries like the UK, so if you are resident in the UK, your chances of contracting diphtheria or polio are very close to nil. If you live in the UK and do not spend time in farm-like environments, your chances of contracting tetanus are also extremely small. Conversely, it is not known how likely you may be to have a bad reaction to the vaccine, as the manufactuers acknowledge on the package insert [11] that the prevalence of many possible side-effects is "unknown". Taking an unknown risk to potentially prevent very rare diseases may not necessarily be a wise decision. As for all vaccines, we recommend doing as much research as possible, reading the package insert (linked below), and talking to a healthcare professional before reaching a decision. 


CLICK HERE FOR FULL 8-PAGE REVAXIS PACKAGE INSERT (What's a package insert?)


References:


1. https://www.nhs.uk/conditions/vaccinations/3-in-1-teenage-booster/?

2. http://www.nvic.org/Vaccines-and-Diseases/Tetanus.aspx

3. https://www.cdc.gov/vaccines/pubs/pinkbook/tetanus.html

4. https://www.gov.uk/government/publications/tetanus-in-england-and-wales-2013/tetanus-in-england-and-wales-2013

5. http://www.who.int/wer/2006/wer8103.pdf

6. https://books.google.co.uk/books?id=73pYBAAAQBAJ&pg=PA2372&redir_esc=y#v=onepage&q&f=false

7. https://www.gov.uk/government/publications/diphtheria-in-england-and-wales-annual-reports

8. http://www.nvic.org/vaccines-and-diseases/Diphtheria.aspx

9. http://www.nvic.org/Vaccines-and-Diseases/Polio-SV40.aspx

10. https://www.nhs.uk/conditions/polio/

11. https://mri.cts-mrp.eu/download/DE_H_0193_001_FinalSPC.pdf

12. https://www.mayoclinic.org/diseases-conditions/tetanus/diagnosis-treatment/drc-20351631

13. https://www.sciencedirect.com/topics/medicine-and-dentistry/clostridium-tetani

14. https://worldwidechoice.org/tetanus-shot/

15. https://www.npr.org/sections/goatsandsoda/2017/06/28/534403083/mutant-strains-of-polio-vaccine-now-cause-more-paralysis-than-wild-polio


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