Tetanus Immunity cquired immunity

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Tetanus Immunity cquired immunity Powered By Docstoc
					                                                                                                       Revised 5/11/07




                                                        Tetanus
                                                        Immunity

                                                        Developed by

                                                        Parker A. Small, Jr, MD
                                                        J. Edwin Blalock, PhD
                                                        Department of Immunology and
                                                        Medical Microbiology
                                                        College of Medicine
                                                        University of Florida
                                                        Gainesville, Florida

                                                        Susan M. Johnson, PhD
                                                        College of Pharmacy
                                                        University of Florida
                                                        Gainesville, Florida




Note to Ins tructo rs


This workbook is divided into five sections:

1. Introduction to the POPS System, introduction to and objectives of the clinical simulation, and a
     pretest
2. Color-coded booklets with pretest answers and the clinical problem
3. Group question and answer sheets
4. Posttest
5. Posttest answers

Each student should receive a copy of the first section to study and answer questions before the
group problem- solving session. If you wish, the second section also may be distributed for the
students to review prior to the group session.




                                                         Tetanus- page 1
Tetanus Immunity
Pretes t

Instruc tions : Pl eas e ma rk you r ans wers to th e f ollowing qu es tions on this exa m to facili tate
later dis cussion and review. If you r ins truc tor h as p rovi d ed a sepa rate answ er for m, pleas e
be sur e to fill in th e id en tifica tion s ection ; th en answ er th e qu es tions bo th on the for m and
on this exam .
Choose the on e cor r ec t o r mos t ap p rop riate ans wer. If you do not kno w an answ er , leav e it
blank. Do no t gu es s. Heal th p rofes sionals who think they know som ething, bu t don' t, can
do r eal har m . Thos e who know they don 't kno w something can g et h elp .
Don' t b e ups et if you don' t know all the ans wer s. T he pur pos e of th e p r etes t and
objecti ves is to al er t you to i mpo r tant con c ep ts . Th e pos ttes t will b e simila r to th e
pr etest.

1.   Judging from the following graph, how many days does it take to detect antibody in the serum after a
     primary and a secondary immunization, respectively? The arrows above "Ag" indicate the times when
     antigen injections were given to the patient. The term "mg% Antibody" refers to the number of
     milligrams of antibody detected in 100 mL of the patient's serum.




        (A)   15 and 10
        (B)   10 and 15
        (C)   10 and 4
        (D)   4 and 10
        (E)   3 and 3




                                                                                                              2




                                                       Tetanus-2
Tetanus Immunity
Pretes t ( c td .)

2.   A car accident victim, who is 12 years old, suffered severe lacerations when she was thrown clear of
     the vehicle and has just been brought into the hospital. Her parents stated that she has not had
     previous immunization against tetanus. To provide protection against the possibility of tetanus now
     and in the future, which of the following is the preferred method of treatment?

     (A) A mixture of tetanus toxoid and tetanus antitoxin as one injection, thereby causing less pain and
         producing an adjuvant effect
     (B) A tetanus antitoxin injection this visit
     (C) A tetanus toxoid injection this visit, with an injection of tetanus antitoxin approximately three
         weeks later
     (D) Separate injections of tetanus toxoid and tetanus antitoxin in different sites on this visit to
         ensure active and passive immunization
     (E) None of the above

3.   In which of the following pairs will the first substance function as an antigen to elicit a potentially beneficial
     immune response and the second substance function as an antigen to produce a potentially dangerous
     immune response? (Homologous means "made in the same species" [e.g., humans], whereas heterologous
     means "made in a different species" [e.g., horses].)

     (A)   Toxin and toxoid
     (B)   Toxoid and toxin
     (C)   Heterologous antiserum and toxin
     (D)   Homologous antiserum and heterologous antiserum
     (E)   Toxoid and heterologous antiserum

4.   Tetanus toxoid
     (A) is an active toxin.
     (B) cannot react with antibody to tetanus toxin.
     (C) retains antigenicity for immunization purposes.
     (D) is chemically identical to tetanus toxin.
     (E) stimulates antibody formation to the organism Clostridium tetani.

5.   You have decided your patient needs passive immunization for snake bite, but the only available
     antisera are from horses. The following important aspect must be taken into account before
     administering the serum:
     (A) The patient's blood type
     (B) The patient's history of passive immunizations
     (C) The patient's history of active immunizations
     (D) The snake's blood type
     (E) The half-life of the passive antibody, which is such that passive immunization should be repeated
          every six to eight months if protection is to be maintained

6.   A typical secondary (anamnestic) response is characterized by a change in antibody level. The type of
     change differs from a primary response, since it is usually
     (A) neither higher nor faster, but is more prolonged.
     (B) higher, but no sooner.
     (C) sooner, but no higher.
     (D) sooner, higher, and more prolonged.
     (E) sooner and higher, but less prolonged.




                                                                                                                          3




                                                        Tetanus-3
Tetanus Immunity
Pretes t ( c td .)

7.   The   passive immunity to tetanus provided by antisera is
     (A)   nonspecific and innate.
     (B)   acquired and antibody-mediated.
     (C)   innate and specific.
     (D)   acquired and cell-mediated.
     (E)   none of the above.

8.   The immunity to many bacteria such as streptococci and staphylococci provided by intact skin(i.e.,
     bacteria on your skin will not usually produce disease) is
     (A) specific and innate.
     (B) acquired and antibody-mediated.
     (C) innate and nonspecific.
     (D) acquired and cell-mediated.
     (E) innate and antibody-mediated.

9.   Serum sickness can be a serious problem with which of the following procedures?
     (A) Active immunization with tetanus toxin
     (B) Active immunization with tetanus toxoid
     (C) Passive immunization against tetanus using heterologous antiserum
     (D) Passive immunization against tetanus using homologous antiserum
     (E) None of the above

10. A 25-year-old man who recently sustained a severe, dirty laceration of his right foot is brought to
    you. He has never received any immunizations. At age 7 he had tetanus. He was treated with penicillin
    and tetanus immune globulin (human). Fortunately, he recovered. Which of the following would you
    do to prevent tetanus now?
    (A) Immunize with tetanus toxoid, which will stimulate a secondary antibody response.
    (B) Administer tetanus immune globulin (human) to passively immunize the patient.
    (C) Administer tetanus immune globulin (human) in addition to tetanus toxoid, because you cannot
         depend on a secondary immune response after 18 years.
    (D) Administer tetanus immune globulin (human) plus tetanus toxoid, because the patient has
         absolutely no immunity to tetanus.
    (E) Give no injection, because the residual immunity from the clinical tetanus will protect the patient.




When you hav e co mpl eted the pr etest, consul t your s tud y ma terials . T r y to i d en tify th e
cor rec t ans w ers an d un d er stan d th e con cep ts that mak e th em cor r ec t. Th e list of
objecti ves may b e u sed as a guid elin e fo r your stu dies. Wh en you r g rou p m eets , you will
have th e r es ponsibility of explaining som e of th e cor r ec t p r etes t answ ers to th e oth ers .
Please bring your textbook and pretest to the group meeting.




                                                                                                               4




                                                      Tetanus-4
                                                         Tetanus
                                                         Immunity

                                                         Developed by

                                                         Parker A. Small, Jr, MD
                                                         J. Edwin Blalock, PhD
                                                         Department of Immunology and
                                                         Medical Microbiology
                                                         College of Medicine
                                                         University of Florida
                                                         Gainesville, Florida

                                                         Susan M. Johnson, PhD
                                                         College of Pharmacy
                                                         University of Florida
                                                         Gainesville, Florida




                                                 BOOK A


Note to S tuden ts The fundamental purpose of all activities in the health-care professions
is to help other people. Like all behavior, helping behavior becomes more effective and
natural with practice. This workbook enables you to practice by helping your fellow students
to learn basic science. Your skill at helping your fellow students should relate to your ability
to help your patients in the future. This is a Patient-Oriented Problem-Solving ("POPS")
workbook designed for four students. Before beginning this session, you should have (a)
studied the objectives designed to prepare you for it, (b) taken the pretest, and (c)
reviewed the topics listed at the end of the pretest. Now, each of you should take one of
the four color-coded booklets and follow the directions in it. If your group has only three
students, one of you should take two booklets. Leave the remainder of the workbook intact
until you are given further instructions.

                                                                                                   5




                                                              Tetanus-5
Tetanus Immunity
Introduction to the Pat ient-Oriented Pro blem-So lving
(POPS) Sy stem

This is a Patient-Oriented Problem-Solving activity. The purposes are

1. To help you learn how to apply your basic science knowledge to the solution of clinical problems

2. To help you learn how to better use sources (i.e., textbooks and peers) that will be available to you
   throughout your career

This activity consists of four phases. First, you will review the attached set of objectives, do background
reading on the topics to be covered, and complete the pretest on your own. In the second phase, you will
join three other students and review the pretest answers in an "open-book" discussion. In the third phase,
the group will solve patient-oriented problems. Information exchange and group interaction are keys to the
success of this phase. This process will allow you to teach your fellow students and, at the same time,
learn from them. Finally, you will take a posttest, individually, which will enable you to assess your
progress.




                                                                                                              6




                                                      Tetanus-6
Tetanus Immunity
Introdu ction

This clinical Simulation deals with tetanus, a life-threatening infection. Tetanus is caused by an exotoxin
synthesized by the bacterium Clostridium tetani. The toxin is released after a wound is infected by this
bacterium. This toxin causes muscle spasm, which may lead to death if not treated correctly. Spasms of
the masseter muscles have led to the name lockjaw. Every time a patient with a wound is examined, the
physician must determine the appropriate immunization for the prevention of tetanus. This simulation will
help you understand the different approaches to the prevention of tetanus as well as the indications for
each approach. The immunologic concepts addressed in this problem are fundamental to the
understanding of many other diseases.

When you have completed this activity you should be able to

1) define and give several examples of i m munity.

2) compare and contrast the terms antig en and an tibod y.

3) differentiate between ac tiv e and passi ve immunization and be able to give examples of each.

4) compare and contrast the p rima ry and seconda ry (anamnestic) immune responses in terms of their
   time course and magnitude.

5) state differences between ac quir ed and innate immunity, as well as between s p ecific and
   nonsp ecific immunity.

6) state which cell types are involved with c ell- media ted and an tibod y- m edia ted immunity.

7) compare tetanus toxin and tetanus toxoid relative to toxicity and i m munogeni ci ty .

8) select the appropriate immunization for a patient with a wound, given his past medical history.




When you hav e b ecom e fa miliar wi th th e obj ec tiv es, com pl ete th e p r etes t on th e n ex t pag e.




                                                                                                               7




                                                      Tetanus-7
Tetanus Immunity
Pretes t Cor r ec t Ans wers

You have the ans wers to th e ten p retes t qu es ti ons. Fi rs t, s tud y th e answ ers in your
booklet an d th en EXPL AIN th em to your grou p. Please don' t jus t r ea d th em to your
classma tes , an d don' t l et you r class ma tes r ead thei r answ er s to you . In explaining
something to ano ther p erson, mos t peo ple gain a better und ers tanding of i t an d often
trans mi t a b etter un d ers tan ding. Th e pretes t di scussion and pati en t-ori en ted
probl em -solving pa rts of thi s a c tivity are "o pen book" Be su re to r efer to tex tbooks ,
notes, and o ther wri tten r esour c es wh enever qu es tions a ris e.

1.   After the first injection, it took about ten days for antibody to be detectable, but after the secondary
     (booster) injection of antigen, antibody was detectable in three to four days. Therefore, the correct answer is
     C. These times vary with the doses and type of antigen, but almost all primary immune responses require one
     to two weeks before antibody can be detected in the serum. Most secondary responses are detectable in three
     or four days. These times are important because if a disease can be prevented by antibody and takes longer
     than two weeks to kill a person, it is possible to prevent the disease by primary immunization. Rabies is an
     example of such a disease. On the other hand, if a disease can kill someone in two or three days, even booster
     immunization is worthless. Snakebite is an example of such a process.

4. Toxoids are toxins that have been detoxified by moderate heat or treatment with a chemical (e.g.,
   formaldehyde) but have intact antigenic and immunogenic properties. C is therefore correct. B is incorrect since
   toxoid and toxin share antigenic sites, i.e.; antibody to one will react with the other. E is incorrect because the
   antibody is made against the exotoxin, not the bacteria. Incidentally, the terms antigenic and immunogenic are
   often used interchangeably, but in principle antigenic means able to react with an antibody, while immunogenic
   means able to induce the immune response. Obviously, all immunogenic compounds are also antigenic.

10. The purpose of this question is to emphasize the fact that the lethal dose of tetanus toxin is less than the
    immunogenic dose of toxin. Put another way, recovery from tetanus does not provide any immunity to future
    infections. (E is wrong.) Hence, you cannot stimulate a secondary response with a toxoid injection. (A is
    wrong.) Passive antibody will not give prolonged protection but will prevent tetanus with this wound. (B is
    wrong because it is only half of what should be done.) C is wrong because there never was a primary
    immunization. If there had been, a booster would suffice even after 25 years. The correct answer is D.




When your g rou p has finish ed discu ssing th e p r etes t, you shoul d r ead the "Ins truc tions for
the Clinical Probl em" on the next page of your booklet.




                                                                                                                         8




                                                      Tetanus-8
Tetanus Immunity
Instruc tions for th e Clini cal P roblem

The purpose of this exercise is to allow you to apply your knowledge of active vs. passive immunization
and primary vs. secondary (or anamnestic) immune response to a common medical problem.

Each of the four group members has a different case history First, deal with your own patient. After
reading your patient's case history, decide the therapy you would use, the reasons for the choice, and the
consequences of alternative therapy. Next, fill out your answer sheet concerning your patient. After
everybody has finished his/her problem, the group member with the first patient should present that case
history to the other three group members and allow them time to individually decide therapy, the reasons
for their choice, and the consequences of alternative therapy. They should then fill out their answer sheets
for that patient (i.e., commit themselves to therapy before the group discussion). The group member who
has the first patient should then present his/her choice of therapy to the group and defend it. Members
who disagree with this choice, the reasons for it, or consequences of it should present their ideas and
defend them. After discussion of the first patient is completed, compare your answers with those on the
correct answer sheet for each patient.

This process will then be repeated for the other three cases. Patients should be presented in numerical
order. At first glance, the patients' cases seem repetitious, but there are subtle and important differences!

Remember, this is an "open-book" activity, and you should consult your textbooks about any point you
don't understand.




                                                                                                                9




                                                      Tetanus-9
Tetanus Immunity
First Pa tien t: Joe Al sop

A 31-year-old veteran of war in Iraq arrives at your office with a one-inch laceration of his right forearm
caused by a dog bite through his wool shirt. The dog, which belongs to a neighbor, has had rabies shots
and is chained so that he can be watched to be certain he doesn't have rabies. But your real concern is
possible infection, especially tetanus, since that is the primary life-threatening consequence of the event.
What are you going to do about it? Indicate your therapy on the "Joe Alsop" part of the Tetanus Immunity
Clinical Problem Answer Sheet (next page).




                                                                                                               1 0




                                                     Tetanus-10
Tetanus Immunity
Cli nic al Pr o ble m A ns we r Sheet

Check the box(es) that indicate(s) the preferred therapy for each patient. Then briefly write the reasons
for your choice in the space provided. Finally, describe the consequences of each of the other therapies in
the space provided under each therapy. Commit yourself in writing before the discussion begins. The
answer sheet will not be collected.

Joe Also p (Firs t Pa ti ent)

❏ 1. Give tetanus toxin.
❏ 2. Give tetanus toxoid.
❏ 3. Give tetanus antitoxin (equine).
❏ 4. Give tetanus immune globulin (human).
Les ter Willia ms (S econ d Pati en t)

❏ 1. Give tetanus toxin.
❏ 2. Give tetanus toxoid.
❏ 3. Give tetanus antitoxin (equine).
❏ 4. Give tetanus immune globulin (human).

Tomm y C riton (Thir d Pati en t)

❏ 1. Give tetanus toxin.
❏ 2. Give tetanus toxoid.
❏ 3. Give tetanus antitoxin (equine).
❏ 4. Give tetanus immune globulin (human).
Alic e Wip pl e (Fou rth Pa tien t)

❏ 1. Give tetanus toxin.
❏ 2. Give tetanus toxoid.
❏ 3. Give tetanus antitoxin (equine).
❏ 4. Give tetanus immune globulin (human).




                                                                                                              1 1




                                                     Tetanus-11
Tetanus Immunity
Co rr ect A ns we r for J o e Al so p (Patie nt #1)

Tetanus Toxin

The patient died as a result of tetanus toxin treatment! He developed spasms of his muscles (especially
the masseters). As a result, he could not open his mouth (hence the name lockjaw) and died due to lack of
ventilation.

Tetanus toxin is the "poison" produced by the organism Clostridium tetani, The toxin produces all the
signs and symptoms of the disease, tetanus. Don't confuse toxoid with toxin. Toxoid is formalin treated
toxin. The treatment destroys the toxin's toxicity but not its immunogenicity (or antigenicity). Ask your
group mates the difference between antigenicity and immunogenicity. (Answer: An immunogen is a
substance that will both induce antibody formation when injected into an animal and combine with
antibody. In other words, A substance that is immunogenic will also combine with antibody, i.e., it is also
an antigen. Antigenicity refers to only the first property (binding to a pre-formed antibody). These are
semantic differences.

Hopefully, this was obvious to everybody, but it was included as a way to fix in your memory the
difference between toxin and toxoid. '

Tetanus Toxoi d

You saved the patient's life. As you recognized, all veterans of all branches of the US military receive
tetanus immunization with tetanus toxoid during their service time. This assures that the patient has
memory lymphocytes even though he may not have adequate circulating antibody The booster shot can
therefore give an anamnestic immune response, which will produce antibody before significant amounts of
toxin are produced (i.e., antibody production wins the race). In addition, the active immunization probably
protects the patient for five to ten years from tetanus due to infection of minor wounds. Toxoid is also
cheaper and safer than antitoxin.

Tetanus An titoxin (Equin e)

Although you may have saved your patient's life with the passive immunization, you have subjected him to
great additional and unnecessary risk. The foreign protein could have produced a fatal anaphylactic
response minutes after its injection or may have led to serum sickness in a week or two. You should have
actively Immunized him with a booster shot of tetanus toxoid, thereby stimulating an anamnestic or
booster antibody response that would not only protect him for this event but also for at least five to ten
years in the future.

In reality, tetanus antitoxin (equine) is no longer available in the United States, since tetanus immune
globulin (human) is readily available. Tetanus antitoxin (equine) has been included in this list because in
other situations (e.g., snake bite) an antiserum from a nonhuman species must be used, and you should be
aware of the potential problems associated with its use.




                                                                                                              1 2




                                                     Tetanus-12
Tetanus Immunity
Tetanus Im mun e Globulin (Human)

Although you have helped this patient and have subjected him to minimal danger, you did waste some
precious antibody; a booster injection of tetanus toxoid would have helped more and cost less. A dose of
tetanus immune globulin (human) costs $35 to $110.

The immune globulin is produced by fractionating the human antitetanus antiserum, thereby removing
much of the nonimmunoglobulin protein. It is not, however, pure antibody. Even in a hyperimmunized
person, the amount of antibody is rarely more than 10% of the immunoglobulin and usually closer to 1 %.
The remainder of the immunoglobulin is presumably antibody to other antigens. By now you should be able
to state why active immunization would have been better. Ask your group mates to contrast the duration
of active and passive immunity. (Answer: Active immunity lasts years; passive immunity lasts weeks to
months.)




                                                                                                           1 3




                                                   Tetanus-13
Tetanus Immunity
Summa ry of Majo r Conc epts of Tetanus I mmuni ty an d Boos ter s

Primary Immunization should be given to everybody to prevent tetanus. The precise ages at which
diphtheria, pertussis, and tetanus (DPT) shots are given are listed in any p ediatric s textbook and are
best learned when you are studying pediatrics. In general, however, children receive three doses in the first
six months of life and boosters at ages 1 and 5. These injections stimulate lymphocytes to produce
antibody. These IgG antibody molecules have a half-life of three weeks, just like passively administered
human IgG, but the "antibody factories" continue to turn out more antibody so it persists in high enough
concentrations to provide protection for five to ten years (see Table 1). The injections also produce
memory lymphocytes that, unlike the antibody, persist throughout life and are ready to rapidly produce
antibody the next time the antigen, tetanus toxoid, is administered.

Booster immunization with tetanus toxoid can lead to the production of adequate amounts of protective
antibody within three to five days (even when there is little or no circulating antibody) if there are memory
lymphocytes primed by a previous tetanus toxoid injection. Remember: Previous disease will not stimulate
the immune system in patients with tetanus, but it does in patients with most other infectious diseases.

Passive immunization with tetanus immune globulin (human) will provide instantaneous immunity, but
antibodies disappear with a half-life of three weeks and memory lymphocytes are not produced to help the
next time. It should never be the sole therapy in normal patients. Consult Table 1 for the appropriate
treatment. Tetanus antitoxin (equine) should be used only when human antiserum is not available and
passive immunization is imperative. When tetanus immune globulin (human) or tetanus antitoxin (equine)
and tetanus toxoid are given at the same time, each should always be injected at different sites.

TABLE 1. Guid e to tetanus p ro phylaxis in wound manag em en t

Td = tetanus toxoid      TIG = tetanus immune globulin (human)




                                                                                                                1 4




                                                     Tetanus-14
                                               Tetanus
                                               Immunity

                                               Developed by

                                               Parker A. Small, Jr, MD
                                               J. Edwin Blalock, PhD
                                               Department of Immunology and
                                               Medical Microbiology
                                               College of Medicine
                                               University of Florida
                                               Gainesville, Florida

                                               Susan M. Johnson, PhD
                                               College of Pharmacy
                                               University of Florida
                                               Gainesville, Florida




                                                BOOK B



Note to S tuden ts The fundamental purpose of all activities in the health-care professions is to help
other people. Like all behavior, helping behavior becomes more effective and natural with practice.
This workbook enables you to practice by helping your fellow students to Ilearn basic science. Your
skill at helping your fellow students should relate to your ability to help your patients in the future.
This is a Patient-Oriented Problem-Solving ("POPS") workbook designed for four students. Before
beginning this session, you should have (a) studied the objectives designed to prepare you for it, (b)
taken the pretest, and (c) reviewed the topics listed at the end of the pretest. Now, each of you
should take one of the four color-coded booklets and follow the directions in it. If your group has only
three students, one of you should take two booklets. Leave the remainder of the workbook intact
until you are given further instructions.

                                                                                                           1 5




                                                            Tetanus-15
Tetanus Immunity
Introduction to the Pat ient-Oriented Pro blem-So lving
(POPS) Sy stem

This is a Patient-Oriented Problem-Solving activity. The purposes are

1. To help you learn how to apply your basic science knowledge to the solution of clinical problems

2. To help you learn how to better use sources (i.e., textbooks and peers) that will be available to you
   throughout your career

This activity consists of four phases. First, you will review the attached set of objectives, do background
reading on the topics to be covered, and complete the pretest on your own. In the second phase, you will
join three other students and review the pretest answers in an "open-book" discussion. In the third phase,
the group will solve patient-oriented problems. Information exchange and group interaction are keys to the
success of this phase. This process will allow you to teach your fellow students and, at the same time,
learn from them. Finally, you will take a posttest, individually, which will enable you to assess your
progress.




                                                                                                              1 6




                                                     Tetanus-16
Tetanus Immunity
Introdu ction

This clinical Simulation deals with tetanus, a life-threatening infection. Tetanus is caused by an exotoxin
synthesized by the bacterium Clostridium tetani. The toxin is released after a wound is infected by this
bacterium. This toxin causes muscle spasm, which may lead to death if not treated correctly. Spasms of
the masseter muscles have led to the name lockjaw. Every time a patient with a wound is examined, the
physician must determine the appropriate immunization for the prevention of tetanus. This simulation will
help you understand the different approaches to the prevention of tetanus as well as the indications for
each approach. The immunologic concepts addressed in this problem are fundamental to the
understanding of many other diseases.

When you have completed this activity you should be able to

1) define and give several examples of i m munity.

2) compare and contrast the terms antig en and an tibod y.

3) differentiate between ac tiv e and passi ve immunization and be able to give examples of each.

4) compare and contrast the p rima ry and seconda ry (anamnestic) immune responses in terms of their
   time course and magnitude.

5) state differences between ac quir ed and innate immunity, as well as between s p ecific and
   nonsp ecific immunity.

6) state which cell types are involved with c ell- media ted and an tibod y- m edia ted immunity.

7) compare tetanus toxin and tetanus toxoid relative to toxicity and i m munogeni ci ty .

8) select the appropriate immunization for a patient with a wound, given his past medical history.




When you hav e b ecom e fa miliar wi th th e obj ec tiv es, com pl ete th e p r etes t on th e n ex t pag e.




                                                                                                               1 7




                                                     Tetanus-17
Tetanus Immunity
Pretes t Cor r ec t Ans wers

You have the ans wers to th e ten p retes t qu es ti ons. Fi rs t, s tud y th e answ ers in your
booklet an d th en EXPL AIN th em to your grou p. Please don' t jus t r ea d th em to your
classma tes , an d don' t l et you r class ma tes r ead thei r answ er s to you . In explaining
something to ano ther p erson, mos t peo ple gain a better und ers tanding of i t an d often
trans mi t a b etter un d ers tan ding. The pretest discussion and patient-oriented problem-solving parts
of this activity are "open book" B e sur e to ref er to textbook s, notes , and oth er wri tten
resour ces when ev er qu es tions a ris e.

2.   This patient will need passive immunization to provide immediate but short-lived protection and active
     immunization to provide antibody for a longer period. Active immunization also provides sensitized
     lymphocytes (memory cells) that can be quickly "turned on" at any future time by booster
     immunization. D is the correct answer. The Public Health Service recommends that tetanus toxoid and
     tetanus immune globulin (human) be given concurrently at separate sites (e.g., - arm and buttocks or
     left arm and right arm). Ask your group mates why it is important to give the antigen and the antibody
     in different sites. (Answer: This allows the toxoid [antigen] to get to the lymph nodes before the
     passive antibody can combine with it. This procedure leads to both active and passive immunity). The
     patient should return later for two booster immunizations with tetanus toxoid.

     Passive immunization with a heterologous antitoxin (e.g., tetanus antitoxin [equine] should be avoided
     if possible because of the risk of serious anaphylactic or serum sickness reactions. One of 20 patients
     given heterologous serum requires hospitalization for the treatment of serum sickness.

     B is incorrect since the patient will again be susceptible to tetanus when the passive antibody is
     eliminated. She needs active immunization with tetanus toxoid as well as passive immunization with
     tetanus immune globulin (human).

     Answer A is incorrect since Ab:Ag complexes would be formed in vitro before injection of the mixture,
     possibly leading to tolerance and certainly decreasing the effectiveness of the passive antibody.

     C is incorrect because the primary active immune response is not fast enough to give protection
     before the toxin level becomes lethal.

5. Previous passive immunization with heterologous (horse) antiserum (e.g., tetanus antitoxin [equine]) can
   stimulate the production of antibody to horse serum proteins. This can cause anaphylaxis immediately following
   another injection of horse serum. B is therefore correct. A is incorrect since blood cells are not being
   transferred, only serum. Also, this serum does not have a significant amount of antibody directed to human red
   blood cells. C is incorrect since active immunization with antigens such as tetanus toxoid does not produce
   sensitivity to horse serum proteins. E is incorrect since injections would have to be repeated every three to four
   weeks to maintain protection, which would be impossible with heterologous serum. Even more obvious is the
   idea that snakebite is so rare that prophylactic treatment is inappropriate.




When your g rou p has finish ed discu ssing th e p r etes t, you shoul d r ead the "Ins truc tions for th e
Clinical P robl em" on the next page of your booklet.




                                                                                                                    1 8




                                                     Tetanus-18
Tetanus Immunity
Instruc tions for th e Clini cal P roblem

The purpose of this exercise is to allow you to apply your knowledge of active vs. passive immunization
and primary vs. secondary (or anamnestic) immune response to a common medical problem.

Each of the four group members has a different case history. First, deal with your own patient. After
reading your patient's case history, decide the therapy you would use, the reasons for the choice, and the
consequences of alternative therapy. Next, fill out your answer sheet concerning your patient. After
everybody has finished his/her problem, the group member with the first patient should present that case
history to the other three group members and allow them time to individually decide therapy, the reasons
for their choice, and the consequences of alternative therapy. They should then fill out their answer sheets
for that patient (i.e., commit themselves to therapy before the group discussion). The group member who
has the first patient should then present his/her choice of therapy to the group and defend it. Members
who disagree with this choice, the reasons for it, or consequences of it should present their ideas and
defend them. After discussion of the first patient is completed, compare your answers with those on the
correct answer sheet for each patient.

This process will then be repeated for the other three cases. Patients should be presented in numerical
order. At first glance, the patients' cases seem repetitious, but there are subtle and important differences!

Remember, this is an "open-book" activity, and you should consult your textbooks about any point you
don't understand.




                                                                                                                1 9




                                                     Tetanus-19
Tetanus Immunity
Secon d Pa ti ent: Les ter Williams

A 23-year-old mountaineer, who arrived in town only last week, has just come to your office with a
fractured right upper central incisor and a severe laceration in the roof of his mouth. The wound does not
penetrate his hard palate. He fell on a stick in the woods. The wound has some dirt in it. He has had no
previous immunizations. After treating the wound, what do you do to prevent tetanus? Indicate your
therapy on the "Lester Williams" part of the Tetanus Immunity Clinical Problem Answer Sheet (next page).




                                                                                                             2 0




                                                    Tetanus-20
Tetanus Immunity
Cli nic al Pr o ble m A ns we r Sheet

Check the box(es) that indicate(s) the preferred therapy for each patient. Then briefly write the reasons
for your choice in the space provided. Finally, describe the consequences of each of the other therapies in
the space provided under each therapy. Commit yourself in writing before the discussion begins. The
answer sheet will not be collected.

Joe Also p (Firs t Pa ti ent)

❏ 1. Give tetanus toxin.
❏ 2. Give tetanus toxoid.
❏ 3. Give tetanus antitoxin (equine).
❏ 4. Give tetanus immune globulin (human).
Les ter Willia ms (S econ d Pati en t)

❏ 1. Give tetanus toxin.
❏ 2. Give tetanus toxoid.
❏ 3. Give tetanus antitoxin (equine).
❏ 4. Give tetanus immune globulin (human).
Tomm y C riton (Thir d Pati en t)

❏ 1. Give tetanus toxin.
❏ 2. Give tetanus toxoid.
❏ 3. Give tetanus antitoxin (equine).
❏ 4. Give tetanus immune globulin (human).
Alic e Wip pl e (Fou rth Pa tien t)

❏ 1. Give tetanus toxin.
❏ 2. Give tetanus toxoid.
❏ 3. Give tetanus antitoxin (equine).
❏ 4. Give tetanus immune globulin (human).




                                                                                                              2 1




                                                     Tetanus-21
Tetanus Immunity
Cor rec t Answ ers for L es ter Williams (Pati en t # 2 )

Tetanus Toxin

The patient dies!

Tetanus Toxoi d

If the wound was infected by Clostridium tetani, the patient would die from tetanus within one to two
weeks after the injury if this was the only treatment. The patient had never had an immunization, and the
primary immune response is not rapid enough to provide antibody before lethal amounts of toxin are
produced. Active immunization with tetanus toxoid is not appropriate in this case as the only treatment,
but it should be given at the same time as tetanus immune globulin (human) in a separate location.

Tetanus An titoxin (Equin e)

Passive immunization may have saved this patient's life since antibodies were provided "instantaneously"
to neutralize the toxin produced by Clostridium tetani. However, you should also be aware of the potential
problems you have caused Lester by using heterologous antiserum. The most immediate problem is the
potential of an anaphylactic response to the horse antiserum at the time it is given. This reaction could be
fatal. The second problem is that the antibodies administered are foreign proteins that may induce serum
sickness in the patient in one to two weeks. Ask your group mates to briefly describe the pathophysiology
of serum sickness. (Answer: See answer to pretest question 9.) A longer range problem is that, due to the
immune elimination of the foreign antibody the patient will have no protection from tetanus two or three
weeks from now and probably will be hypersensitive to horse serum, so you could not use tetanus
antitoxin (equine) again. In order to give your patient prolonged protection, you will actively immunize him
by giving him a series of toxoid injections. Ask your colleagues when the toxoid series should be started.
(Answer: Before he leaves your office, since you may not see him again.)

Tetanus Im mun e Globulin (Human)

This is half of the optimal treatment for this patient. Passive immunization is the fastest and only foolproof
way of producing toxin-neutralizing antibody in time to prevent tetanus. By choosing human antibody, you
virtually eliminated the potential adverse effects such as anaphylaxis and serum sickness. However, the
passively administered antibody will be eliminated with a half-life of about three weeks. Therefore, you
should administer tetanus toxoid at the same time in a separate location followed by a series of active
immunizations with tetanus toxoid. Ask your colleagues, "What fraction of the passive antibody will be
present in nine weeks?" (Answer: one eighth.)




                                                                                                                 2 2




                                                     Tetanus-22
Tetanus Immunity
Summa ry of Majo r Conc epts of Tetanus I mmuni ty an d Boos ter s

Primary Immunization should be given to everybody to prevent tetanus. The precise ages at which
diphtheria, pertussis, and tetanus (DPT) shots are given are listed in any p ediatric s textbook and are
best learned when you are studying pediatrics. In general, however, children receive three doses in the first
six months of life and boosters at ages 1 and 5. These injections stimulate lymphocytes to produce
antibody. These IgG antibody molecules have a half-life of three weeks, just like passively administered
human IgG, but the "antibody factories" continue to turn out more antibody so it persists in high enough
concentrations to provide protection for five to ten years (see Table 1). The injections also produce
memory lymphocytes that, unlike the antibody, persist throughout life and are ready to rapidly produce
antibody the next time the antigen, tetanus toxoid, is administered.

Booster immunization with tetanus toxoid can lead to the production of adequate amounts of protective
antibody within three to five days (even when there is little or no circulating antibody) if there are memory
lymphocytes primed by a previous tetanus toxoid injection. Remember: Previous disease will not stimulate
the immune system in patients with tetanus, but it does in patients with most other infectious diseases.

Passive, immunization with tetanus immune globulin (human) will provide instantaneous immunity, but
antibodies disappear with a half-life of three weeks and memory lymphocytes are not produced to help the
next time. It should never be the sole therapy in normal patients. Consult Table 1 for the appropriate
treatment. Tetanus antitoxin (equine) should be used only when human antiserum is not available and
passive immunization is imperative. When tetanus immune globulin (human) or tetanus antitoxin (equine)
and tetanus toxoid are given at the same time, each should always be injected at different sites.

TABLE 1. Guid e to tetanus p ro phylaxis in wound manag em en t

Td = tetanus toxoid      TIG = tetanus immune globulin (human)




                                                                                                                2 3




                                                     Tetanus-23
                                               Tetanus
                                               Immunity

                                               Developed by

                                               Parker A. Small, Jr, MD
                                               J. Edwin Blalock, PhD
                                               Department of Immunology and
                                               Medical Microbiology
                                               College of Medicine
                                               University of Florida
                                               Gainesville, Florida

                                               Susan M. Johnson, PhD
                                               College of Pharmacy
                                               University of Florida
                                               Gainesville, Florida




                                                BOOK C



Note to S tuden ts The fundamental purpose of all activities in the health-care professions is to help
other people. Like all behavior, helping behavior becomes more effective and natural with practice.
This workbook enables you to practice by helping your fellow students to Ilearn basic science. Your
skill at helping your fellow students should relate to your ability to help your patients in the future.
This is a Patient-Oriented Problem-Solving ("POPS") workbook designed for four students. Before
beginning this session, you should have (a) studied the objectives designed to prepare you for it, (b)
taken the pretest, and (c) reviewed the topics listed at the end of the pretest. Now, each of you
should take one of the four color-coded booklets and follow the directions in it. If your group has only
three students, one of you should take two booklets. Leave the remainder of the workbook intact
until you are given further instructions.

                                                                                                           2 4




                                                            Tetanus-24
Tetanus Immunity
Introduction to the Pat ient-Oriented Pro blem-So lving
(POPS) Sy stem

This is a Patient-Oriented Problem-Solving activity. The purposes are

1. To help you learn how to apply your basic science knowledge to the solution of clinical problems

2. To help you learn how to better use sources (i.e., textbooks and peers) that will be available to you
   throughout your career

This activity consists of four phases. First, you will review the attached set of objectives, do background
reading on the topics to be covered, and complete the pretest on your own. In the second phase, you will
join three other students and review the pretest answers in an "open-book" discussion. In the third phase,
the group will solve patient-oriented problems. Information exchange and group interaction are keys to the
success of this phase. This process will allow you to teach your fellow students and, at the same time,
learn from them. Finally, you will take a posttest, individually, which will enable you to assess your
progress.




                                                                                                              2 5




                                                     Tetanus-25
Tetanus Immunity
Introdu ction

This clinical Simulation deals with tetanus, a life-threatening infection. Tetanus is caused by an exotoxin
synthesized by the bacterium Clostridium tetani. The toxin is released after a wound is infected by this
bacterium. This toxin causes muscle spasm, which may lead to death if not treated correctly. Spasms of
the masseter muscles have led to the name lockjaw. Every time a patient with a wound is examined, the
physician must determine the appropriate immunization for the prevention of tetanus. This simulation will
help you understand the different approaches to the prevention of tetanus as well as the indications for
each approach. The immunologic concepts addressed in this problem are fundamental to the
understanding of many other diseases.

When you have completed this activity you should be able to

1) define and give several examples of i m munity.

2) compare and contrast the terms antig en and an tibod y.

3) differentiate between ac tiv e and passi ve immunization and be able to give examples of each.

4) compare and contrast the p rima ry and seconda ry (anamnestic) immune responses in terms of their
   time course and magnitude.

5) state differences between ac quir ed and innate immunity, as well as between s p ecific and
   nonsp ecific immunity.

6) state which cell types are involved with c ell- media ted and an tibod y- m edia ted immunity.

7) compare tetanus toxin and tetanus toxoid relative to toxicity and i m munogeni ci ty .

8) select the appropriate immunization for a patient with a wound, given his past medical history.




When you hav e b ecom e fa miliar wi th th e obj ec tiv es, com pl ete th e p r etes t on th e n ex t pag e.




                                                                                                               2 6




                                                     Tetanus-26
Tetanus Immunity
Pretes t Cor r ec t Ans wers

You have the ans wers to th e ten p retes t qu es ti ons. Fi rs t, s tud y th e answ ers in your
booklet an d th en EXPL AIN th em to your grou p. Please don' t jus t r ea d th em to your
classma tes , an d don' t l et you r class ma tes r ead thei r answ er s to you . In explaining
something to ano ther p erson, mos t peo ple gain a better und ers tanding of i t an d often
trans mi t a b etter un d ers tan ding. The pretest discussion and patient-oriented problem-solving parts
of this activity are "open book" B e sur e to ref er to textbook s, notes , and oth er wri tten
resour ces when ev er qu es tions a ris e.


6. The correct answer is D. The differences between primary and secondary (anamnestic) immune responses are
   displayed graphically in question 1. For further information, consult your textbook relative to primary and
   secondary immune responses.

8.   The answer is C. The skin protects against many different infections and hence provides nonspecific immunity.
     This type of immunity is present before birth and does not require prior exposure to a pathogen to provide
     protection; therefore, it provides innate immunity. Cell-mediated and antibody-mediated are terms that apply
     only to specific, acquired immunity, and both are incorrect. The fact that the skin is made up of cells is
     irrelevant; "cell-mediated" is synonymous with "T-lymphocyte mediated." "Antibody-mediated" immunity, on
     the other hand, is a function of B-lymphocyte activity.




When your g rou p has finish ed discu ssing th e p r etes t, you shoul d r ead the "Ins truc tions for
the Clinical Probl em" on the next page of your booklet.




                                                                                                                     2 7




                                                     Tetanus-27
Tetanus Immunity
Instruc tions for th e Clini cal P roblem

The purpose of this exercise is to allow you to apply your knowledge of active vs. passive immunization
and primary vs. secondary (or anamnestic) immune response to a common medical problem.

Each of the four group members has a different case history First, deal with your own patient. After
reading your patient's case history, decide the therapy you would use, the reasons for the choice, and the
consequences of alternative therapy. Next, fill out your answer sheet concerning your patient. After
everybody has finished his/her problem, the group member with the first patient should present that case
history to the other three group members and allow them time to individually decide therapy, the reasons
for their choice, and the consequences of alternative therapy. They should then fill out their answer sheets
for that patient (i.e., commit themselves to therapy before the group discussion). The group member who
has the first patient should then present his/her choice of therapy to the group and defend it. Members
who disagree with this choice, the reasons for it, or consequences of it should present their ideas and
defend them. After discussion of the first patient is completed, compare your answers with those on the
correct answer sheet for each patient.

This process will then be repeated for the other three cases. Patients should be presented in numerical
order. At first glance, the patients' cases seem repetitious, but there are subtle and important differences!

Remember, this is an "open-book" activity, and you should consult your textbooks about any point you
don't understand.




                                                                                                                2 8




                                                     Tetanus-28
Tetanus Immunity
Third Pa tien t: To mm y C ri ton

A 5-day-old baby has just been brought to your office by his mother, a Peace Corps nurse. Mother and
baby have just flown in from Africa, where the baby was born. The mother is concerned because the baby
was cared for by a native friend. She discovered that the umbilicus of the baby was coated with cow
manure, a primitive local custom, and she is concerned about neonatal tetanus. What do you plan to do?
Indicate your therapy on the Tetanus Immunity Clinical Problem Answer Sheet (instructions on the next
page and treatment options for Tommy Criton on the following page).




                                                                                                         2 9




                                                  Tetanus-29
Tetanus Immunity
Cli nic al Pr o ble m A ns we r Sheet

Check the box(es) that indicate(s) the preferred therapy for each patient. Then briefly write the reasons
for your choice in the space provided. Finally, describe the consequences of each of the other therapies in
the space provided under each therapy. Commit yourself in writing before the discussion begins. The
answer sheet will not be collected.

Joe Also p (Firs t Pa ti ent)

❏ 1. Give tetanus toxin.
❏ 2. Give tetanus toxoid.
❏ 3. Give tetanus antitoxin (equine).
❏ 4. Give tetanus immune globulin (human).
Les ter Willia ms (S econ d Pati en t)

❏ 1. Give tetanus toxin.
❏ 2. Give tetanus toxoid.
❏ 3. Give tetanus antitoxin (equine).
❏ 4. Give tetanus immune globulin (human).
Tomm y C riton (Thir d Pati en t)

❏ 1. Give tetanus toxin.
❏ 2. Give tetanus toxoid.
❏ 3. Give tetanus antitoxin (equine).
❏ 4. Give tetanus immune globulin (human).
Alic e Wip pl e (Fou rth Pa tien t)

❏ 1. Give tetanus toxin.
❏ 2. Give tetanus toxoid.
❏ 3. Give tetanus antitoxin (equine).
❏ 4. Give tetanus immune globulin (human).




                                                                                                              3 0




                                                     Tetanus-30
Tetanus Immunity
Co rr ect A ns we rs fo r T o m my Cr ito n (Pati ent #3)

Tetanus Toxin

The patient dies!

Tetanus Toxoi d

Toxoid would not be adequate therapy since a primary response would take seven to ten days to yield
significant antibody levels. In addition, an infant's immune system often lacks the ability to make adult-
type immune responses, and the passive antibody that the baby received transplacentally from his mother
may further inhibit antibody formation. This situation differs from Lester Williams' in that the antibody will
already be dispersed throughout the extracellular fluid space before the antigen is given. It will therefore
combine with the antigen before it gets to the lymph nodes. Thus, at this age there is no benefit to giving
a tetanus toxoid "baby shot" along with the correct treatment of tetanus immune globulin. (human).
Remember that the baby did receive passive antibody from his mother transplacentally. Ask your
colleagues what class of antibody the baby received transplacentally (Answer: IgG) and what class via
colostrum if he nursed (Answer.- IgA).

Tetanus An titoxin (Equin e)

This patient already has passive antibody from his previously immunized mother (all Peace Corps
volunteers get tetanus immunization), but he may not have enough and therefore should be given more
passive antibody. If tetanus antitoxin (equine) was all you had available, this was good treatment, but in
this country it is unnecessarily dangerous.

Tetanus Im mun e Globulin (Human)

As with Mr. Williams, this is the optimal treatment. Tommy is really a "peculiar mixture" of Mr. Williams and
Mr. Alsop. Like Mr. Williams, Tommy has no active immunity, but he is at least partially immune as was Mr.
Alsop. Unlike the latter, however, Tommy's immunity is passive; hence, he cannot give an anamnestic
response. To be safe, he needs more passive antibody now and active immunization as part of his regular
"baby shots" starting at about three months of age.




                                                                                                                 3 1




                                                      Tetanus-31
Tetanus Immunity
Summa ry of Majo r Conc epts of Tetanus I mmuni ty an d Boos ter s

Primary Immunization should be given to everybody to prevent tetanus. The precise ages at which
diphtheria, pertussis, and tetanus (DPT) shots are given are listed in any p ediatric s textbook and are
best learned when you are studying pediatrics. In general, however, children receive three doses in the first
six months of life and boosters at ages 1 and 5. These injections stimulate lymphocytes to produce
antibody. These IgG antibody molecules have a half-life of three weeks, just like passively administered
human IgG, but the "antibody factories" continue to turn out more antibody so it persists in high enough
concentrations to provide protection for five to ten years (see Table 1). The injections also produce
memory lymphocytes that, unlike the antibody, persist throughout life and are ready to rapidly produce
antibody the next time the antigen, tetanus toxoid, is administered.

Booster immunization with tetanus toxoid can lead to the production of adequate amounts of protective
antibody within three to five days (even when there is little or no circulating antibody) if there are memory
lymphocytes primed by a previous tetanus toxoid injection. Remember: Previous disease will not stimulate
the immune system in patients with tetanus, but it does in patients with most other infectious diseases.

Passive, immunization with tetanus immune globulin (human) will provide instantaneous immunity, but
antibodies disappear with a half-life of three weeks and memory lymphocytes are not produced to help the
next time. It should never be the sole therapy in normal patients. Consult Table 1 for the appropriate
treatment. Tetanus antitoxin (equine) should be used only when human antiserum is not available and
passive immunization is imperative. When tetanus immune globulin (human) or tetanus antitoxin (equine)
and tetanus toxoid are given at the same time, each should always be injected at different sites.

TABLE 1. Guid e to tetanus p ro phylaxis in wound manag em en t

Td = tetanus toxoid      TIG = tetanus immune globulin (human)




                                                                                                                3 2




                                                     Tetanus-32
                                              Tetanus
                                              Immunity

                                              Developed by

                                              Parker A. Small, Jr, MD
                                              J. Edwin Blalock, PhD
                                              Department of Immunology and
                                              Medical Microbiology
                                              College of Medicine
                                              University of Florida
                                              Gainesville, Florida

                                              Susan M. Johnson, PhD
                                              College of Pharmacy
                                              University of Florida
                                              Gainesville, Florida




                                               BOOK D



Note to S tuden ts The fundamental purpose of all activities in the health-care professions is to help other people. Like
all behavior, helping behavior becomes more effective and natural with practice. This workbook enables you to practice
by helping your fellow students to Ilearn basic science. Your skill at helping your fellow students should relate to your
ability to help your patients in the future. This is a Patient-Oriented Problem-Solving ("POPS") workbook designed for
four students. Before beginning this session, you should have (a) studied the objectives designed to prepare you for it,
(b) taken the pretest, and (c) reviewed the topics listed at the end of the pretest. Now, each of you should take one of
the four color-coded booklets and follow the directions in it. If your group has only three students, one of you should
take two booklets. Leave the remainder of the workbook intact until you are given further instructions.

                                                                                                                            3 3




                                                           Tetanus-33
Tetanus Immunity
Introduction to the Pat ient-Oriented Pro blem-So lving
(POPS) Sy stem

This is a Patient-Oriented Problem-Solving activity. The purposes are

1. To help you learn how to apply your basic science knowledge to the solution of clinical problems

2. To help you learn how to better use sources (i.e., textbooks and peers) that will be available to you
   throughout your career

This activity consists of four phases. First, you will review the attached set of objectives, do background
reading on the topics to be covered, and complete the pretest on your own. In the second phase, you will
join three other students and review the pretest answers in an "open-book" discussion. In the third phase,
the group will solve patient-oriented problems. Information exchange and group interaction are keys to the
success of this phase. This process will allow you to teach your fellow students and, at the same time,
learn from them. Finally, you will take a posttest, individually, which will enable you to assess your
progress.




                                                                                                              3 4




                                                     Tetanus-34
Tetanus Immunity
Introdu ction

This clinical Simulation deals with tetanus, a life-threatening infection. Tetanus is caused by an exotoxin
synthesized by the bacterium Clostridium tetani. The toxin is released after a wound is infected by this
bacterium. This toxin causes muscle spasm, which may lead to death if not treated correctly. Spasms of
the masseter muscles have led to the name lockjaw. Every time a patient with a wound is examined, the
physician must determine the appropriate immunization for the prevention of tetanus. This simulation will
help you understand the different approaches to the prevention of tetanus as well as the indications for
each approach. The immunologic concepts addressed in this problem are fundamental to the
understanding of many other diseases.

When you have completed this activity you should be able to

1) define and give several examples of i m munity.

2) compare and contrast the terms antig en and an tibod y.

3) differentiate between ac tiv e and passi ve immunization and be able to give examples of each.

4) compare and contrast the p rima ry and seconda ry (anamnestic) immune responses in terms of their
   time course and magnitude.

5) state differences between ac quir ed and innate immunity, as well as between s p ecific and
   nonsp ecific immunity.

6) state which cell types are involved with c ell- media ted and an tibod y- m edia ted immunity.

7) compare tetanus toxin and tetanus toxoid relative to toxicity and i m munogeni ci ty .

8) select the appropriate immunization for a patient with a wound, given his past medical history.




When you hav e b ecom e fa miliar wi th th e obj ec tiv es, com pl ete th e p r etes t on th e n ex t pag e.




                                                                                                               3 5




                                                     Tetanus-35
Tetanus Immunity
Pretes t Cor r ec t Ans wers

You have the ans wers to th e ten p retes t qu es ti ons. Fi rs t, s tud y th e answ ers in your
booklet an d th en EXPL AIN th em to your grou p. Please don' t jus t r ea d th em to your
classma tes , an d don' t l et you r class ma tes r ead thei r answ er s to you . In explaining
something to ano ther p erson, mos t peo ple gain a better und ers tanding of i t an d often
trans mi t a b etter un d ers tan ding. The pretest discussion and patient-oriented problem-solving parts
of this activity are "open book" B e sur e to ref er to textbook s, notes , and oth er wri tten
resour ces when ev er qu es tions a ris e.
3. The correct answer is E. Toxoid will stimulate the production of antitoxin, which will be protective.
   Heterologous antiserum will stimulate the production of antibody to the foreign protein; this response
   can lead to serum sickness. Toxin is lethal at doses below those required to stimulate antibody
   formation, so it will not produce an immune response but obviously will produce a very harmful
   nonimmune response (i.e., toxin will kill the first time a person is exposed to it).
     There is a very important implication to the fact that it takes more toxin to stimulate the antibody
     production than to kill a person; unlike most diseases, someone recovering from tetanus (a very rare
     event if untreated) will not have developed immunity.
     Homologous antiserum may, on some occasions, elicit antibody responses in certain situations
     (different allotypes or idiotypes). but these are neither beneficial nor dangerous.
7. The correct answer is B. Immunity means lack of susceptibility to a disease. Immunity can be innate or acquired,
   as shown in the diagram below. Innate immunity is present from birth and is independent of the life experiences
   of the person, whereas acquired immunity arises only after an infection or immunization and hence is acquired
   during life. Acquired immunity is specific for the infecting organism or immunizing antigen. Thus, a chickenpox
   infection protects specifically against reinfection by chickenpox virus but does not protect against measles
   virus infection. Innate immunity is usually nonspecific. For example, stomach acid destroys many different
   bacteria and viruses in food and thereby protects us from infection nonspecifically. Lysozyme in tears digest
   the cell wall of many bacteria and in so doing nonspecifically prevent conjunctivitis.

                                           IMMUNITY


                      INNATE                                   ACQUIRED
               (USUALLY NON-SPECIFIC)                     (USUALLY SPECIFIC)


                                                   ANTIBODY-                     CELL-
                                                   MEDIATED                     MEDIATED


                                            ACTIVE         PASSIVE       ACTIVE        ADOPTIVE

Specific acquired immunity is further subdivided into "antibody-mediated" or "cell-mediated," depending on
whether antibody alone provides the protection or whether T-lymphocytes alone provide the protection. Do not be
confused by the fact that antibody is synthesized in cells (B-lymphocytes); the origin of the molecules is not
relevant to how protection is provided.




9.   One injection of a heterologous serum, such as horse serum, may stimulate production of antibody to the
     foreign proteins. The foreign proteins may persist in the body long enough (seven to 14 days) to react with
     the newly formed antibody. Antibody-antigen complexes form in the blood and are deposited in various tissues,
     producing pathologic changes in those tissues. More specifically, deposition of immune complexes in the renal
                                                                                                                  3 6




                                                      Tetanus-36
    glomeruli leads to glomerulonephritis, and deposition in synovial membranes leads to arthritis. This process
    produces the disease called serum sickness. C is therefore correct.
When your g rou p has finish ed discu ssing th e p r etes t, you shoul d r ead the "Ins truc tions for th e
Clinical P robl em" on the next page of your booklet.




                                                                                                                   3 7




                                                     Tetanus-37
Tetanus Immunity
Instruc tions for th e Clini cal P roblem

The purpose of this exercise is to allow you to apply your knowledge of active Vs passive immunization
and primary Vs secondary (or anamnestic) immune response to a common medical problem.

Each of the four group members has a different case history First, deal with your own patient. After
reading your patient's case history, decide the therapy you would use, the reasons for the choice, and the
consequences of alternative therapy. Next, fill out your answer sheet concerning your patient. After
everybody has finished his/her problem, the group member with the first patient should present that case
history to the other three group members and allow them time to individually decide therapy, the reasons
for their choice, and the consequences of alternative therapy. They should then fill out their answer sheets
for that patient (i.e., commit themselves to therapy before the group discussion). The group member who
has the first patient should then present his/her choice of therapy to the group and defend it. Members
who disagree with this choice, the reasons for it, or consequences of it should present their ideas and
defend them. After discussion of the first patient is completed, compare your answers with those on the
correct answer sheet for each patient.

This process will then be repeated for the other three cases. Patients should be presented in numerical
order. At first glance, the patients' cases seem repetitious, but there are subtle and important differences!

Remember, this is an "open-book" activity, and you should consult your textbooks about any point you
don't understand.




                                                                                                                3 8




                                                     Tetanus-38
Tetanus Immunity
Fo urth Pati ent : Alic e Wi p ple

A 35-year-old migrant worker arrives at your office with a three-inch jagged wound on her head. She was
hit with a brick. Ten years ago she fell off a tractor while tilling a field and received a six-inch laceration of
her left thigh. At that time, she was given tetanus antitoxin (equine) because she had never been
immunized against tetanus. She and her fellow migrant workers left town before her physician could
immunize her with tetanus toxoid. What do you do to prevent tetanus? Indicate your therapy on the
Tetanus Immunity Clinical Problem Answer Sheet (instructions on the next page and treatment options for
Alice on the bottom of the following page).




                                                                                                                     3 9




                                                        Tetanus-39
Tetanus Immunity
Cli nic al Pr o ble m A ns we r Sheet

Check the box(es) that indicate(s) the preferred therapy for each patient. Then briefly write the reasons
for your choice in the space provided. Finally, describe the consequences of each of the other therapies in
the space provided under each therapy. Commit yourself in writing before the discussion begins. The
answer sheet will not be collected.

Joe Also p (Firs t Pa ti ent)

❏ 1. Give tetanus toxin.
❏ 2. Give tetanus toxoid.
❏ 3. Give tetanus antitoxin (equine).
❏ 4. Give tetanus immune globulin (human).
Les ter Willia ms (S econ d Pati en t)

❏ 1. Give tetanus toxin.
❏ 2. Give tetanus toxoid.
❏ 3. Give tetanus antitoxin (equine).
❏ 4. Give tetanus immune globulin (human).
Tomm y C riton (Thir d Pati en t)

❏ 1. Give tetanus toxin.
❏ 2. Give tetanus toxoid.
❏ 3. Give tetanus antitoxin (equine).
❏ 4. Give tetanus immune globulin (human).
Alic e Wip pl e (Fou rth Pa tien t)

❏ 1. Give tetanus toxin.
❏ 2. Give tetanus toxoid.
❏ 3. Give tetanus antitoxin (equine).
❏ 4. Give tetanus immune globulin (human).




                                                                                                              4 0




                                                     Tetanus-40
Tetanus Immunity
Co rr ect A ns we rs fo r Ali ce W ip pl e ( Pat ie nt #4)

Tetanus Toxin

The patient dies!

Tetanus Toxoi d

If the wound was infected by Clostridium tetani, the patient would die of tetanus one to two weeks after
her injury Alice had never been immunized against tetanus, and the primary immune response produced by
tetanus toxoid is not rapid enough to provide adequate antibody before lethal amounts of toxin are
produced. However, active immunization with tetanus toxoid should be used in conjunction with passive
immunization so the patient will have immunity in the future.

Tetanus An titoxin (Equin e)

The patient died from an anaphylactic response. Alice was sensitized to the foreign protein (horse gamma
globulin or other horse serum proteins) ten years earlier, i.e., the prior immunization led to prolonged
production of anti-horse protein antibody. Upon injection of the horse protein this time, that antibody
rapidly combined with the horse antigen and produced anaphylaxis.

Tetanus Im mun e Globulin (Human)

This is part of the optimal treatment for Alice. Passive immunization is the fastest and only foolproof way
of getting toxin-neutralizing antibody to her in time to prevent tetanus. By the use of human antibody,
you virtually eliminated the potential adverse effects that would probably occur with tetanus antitoxin
(equine). Passive immunization does not confer prolonged protection, so she also needs to be actively
immunized with tetanus toxoid at the same time in a separate injection site.




                                                                                                              4 1




                                                     Tetanus-41
Tetanus Immunity
Summa ry of Majo r Conc epts of Tetanus I mmuni ty an d Boos ter s

Primary Immunization should be given to everybody to prevent tetanus. The precise ages at which
diphtheria, pertussis, and tetanus (DPT) shots are given are listed in any p ediatric s textbook and are
best learned when you are studying pediatrics. In general, however, children receive three doses in the first
six months of life and boosters at ages 1 and 5. These injections stimulate lymphocytes to produce
antibody. These IgG antibody molecules have a half-life of three weeks, just like passively administered
human IgG, but the "antibody factories" continue to turn out more antibody so it persists in high enough
concentrations to provide protection for five to ten years (see Table 1). The injections also produce
memory lymphocytes that, unlike the antibody, persist throughout life and are ready to rapidly produce
antibody the next time the antigen, tetanus toxoid, is administered.

Booster immunization with tetanus toxoid can lead to the production of adequate amounts of protective
antibody within three to five days (even when there is little or no circulating antibody) if there are memory
lymphocytes primed by a previous tetanus toxoid injection. Remember: Previous disease will not stimulate
the immune system in patients with tetanus, but it does in patients with most other infectious diseases.

Passive, immunization with tetanus immune globulin (human) will provide instantaneous immunity, but
antibodies disappear with a half-life of three weeks and memory lymphocytes are not produced to help the
next time. It should never be the sole therapy in normal patients. Consult Table 1 for the appropriate
treatment. Tetanus antitoxin (equine) should be used only when human antiserum is not available and
passive immunization is imperative. When tetanus immune globulin (human) or tetanus antitoxin (equine)
and tetanus toxoid are given at the same time, each should always be injected at different sites.

TABLE 1. Guid e to tetanus p ro phylaxis in wound manag em en t

Td = tetanus toxoid      TIG = tetanus immune globulin (human)




                                                                                                                4 2




                                                     Tetanus-42
Tetanus Immunity
Posttest

Selec t th e b es t answ er for each qu es tion. Pl eas e mar k your ans wers on this exam to
facilitate di scus sion an d la ter r evi ew . If your ins tru c tor has p rovi ded a s epara te ans w er
form, b e sur e you hav e i dentifi ed yours elf on th e fo rm , th en b egin you r an sw ers with
question 1. Mar k your answ ers both on th e fo rm and on this exam . Only on e ans w er is
cor rec t.

1. A 23-year-old medical student who had four injections of diphtheria, pertussis, and tetanus (DPT) in
   her first year of life and a booster at age 12 years but no subsequent tetanus immunization, is bitten
   by a mouse while doing an experiment. She should be given:
   (A) tetanus toxoid, which will passively immunize her.
   (B) tetanus antitoxin (equine), which will passively immunize her.
   (C) tetanus immune globulin (human), which will passively immunize her.
   (D) tetanus toxoid, which will actively immunize her.
   (E) tetanus immune globulin (human), which will stimulate an anamnestic response.

2. A 10-year-old girl who received a deep laceration when she was water skiing was just brought into
   your office. Her parents state that she has had no previous immunization against tetanus. As
   protection against the possibility of tetanus now and in the future, the preferred method of treatment
   would be
   (A) A mixture of tetanus toxoid and tetanus immune globulin (human) as one injection.
   (B) A tetanus toxoid injection this visit, with an injection of tetanus immune globulin (human) approximately
       three weeks later.
   (C) Separate injections of tetanus toxoid and tetanus immune globulin (human) on different sites on this one
       visit.
   (D) A tetanus immune globulin (human) injection this visit, with an injection of tetanus toxoid about three
       weeks later.
   (E) A tetanus immune globulin (human) injection this visit, with an injection of tetanus toxoid
       about five weeks later.

3. You know that your 3-year-old patient received the standard DPT immunization series starting at 3
   months of age. You discovered recently that he has no detectable antibody to diphtheria, pertussis, or
   tetanus and hence is deficient in his humoral immunity. You are faced with treating him for a deep
   puncture wound in his foot, which he obtained while playing near his grandfather's barn. The best
   treatment to prevent tetanus would be
   (A) active immunization with tetanus toxoid.
   (B) active immunization with tetanus toxin.
   (C) passive immunization with tetanus antitoxin (equine).
   (D) passive immunization with tetanus immune globulin (human).
   (E) none of the above. Under the circumstances, it is best to avoid any type of injection.

4. Administration of tetanus immune globulin (human) has been decided upon for the immediate
   protection of a patient with a two-inch deep cut in his thigh. The patient is a normal 6-year-o!d.
   You must consider
   (A) that the antibody half-life is such that passive immunization should be repeated every two to three
       weeks.
   (B) that the antibody half-life is such that active immunization with tetanus toxoid should also be
       done, since prolonged protection is desired.
   (C) the possibility that serum sickness will occur.
   (D) the possibility that hypersensitivity (anaphylaxis) will occur.
   (E) that the blood types must be properly matched.
5.    Serum sickness can be a serious problem after which of the following?
     (A) Injection of tetanus toxoid
     (B) Injection of tetanus antitoxin (equine)
                                                                                                                   4 3




                                                      Tetanus-43
     (C) Injection of tetanus immune globulin (human)
     (D) Injection of tetanus toxin
     (E) None of the above

6.    Active immunization after exposure to an infectious disease should be done to prevent that
      disease if
     (A) the incubation period of the disease exceeds the time required to produce immunity.
     (B) the patient has been previously immunized and hence will have an anamnestic immune response.
     (C) the immunity is antibody-mediated.
     (D) the patient is very sick.
     (E) the immunity is cell-mediated.

7. Reckless Richard, your accident-prone, 10-year-old patient, has just come in with a deep puncture
   wound on his foot. Your records show that he had a standard DPT series as a baby and a booster at
   age 5 and again six months ago after another bad wound. 'The proper treatment is
   (A) tetanus toxoid.
   (B) tetanus antitoxin (equine).
   (C) tetanus immune globulin (human).
   (D) tetanus toxoid and tetanus immune globulin (human) at two different sites.
   (E) no tetanus immunization.

8.    Diphtheria toxoid, like tetanus toxoid, is an effective inducer of active immunity because it   IS
     (A) immunogenic but not antigenic.
     (B) antigenic but not immunogenic.
     (C) both immunogenic and antigenic.
     (D) chemically identical to diphtheria toxin.
     (E) an active toxin.

9.    Immunity induced by tetanus toxoid injection is
     (A) specific and cell-mediated.
     (B) innate and nonspecific.
     (C) cell-mediated and innate.
     (D) antibody-mediated and active.
     (E) nonspecific and passive.

10. Protection of a patient by administration of passive antibody has one primary advantage over
    active immunization, which is that it
   (A) is cheaper.
   (B) hurts less.
   (C) gives higher antibody titers.
   (D) provides antibody more rapidly.
   (E) provides antibody for a longer time.

When your group has finished reviewing the posttest, you have completed the activity. Have you achieved
the objectives set forth in the Introduction? Some of you may wish to discuss your reactions to this
Patient-Oriented Problem-Solving session with your instructor.




                                                                                                           4 4




                                                        Tetanus-44
Tetanus Immunity
Posttest

Selec t th e b es t answ er for each qu es tion. Pl eas e mar k your ans wers on this exam to
facilitate di scus sion an d la ter r evi ew . If your ins tru c tor has p rovi ded a s epara te ans w er
form, b e sur e you hav e i dentifi ed yours elf on th e fo rm , th en b egin you r an sw ers with
question 1. Mar k your answ ers both on th e fo rm and on this exam . Only on e ans w er is
cor rec t.

1. A 23-year-old medical student who had four injections of diphtheria, pertussis, and tetanus (DPT) in
   her first year of life and a booster at age 12 years but no subsequent tetanus immunization, is bitten
   by a mouse while doing an experiment. She should be given:
   (A) tetanus toxoid, which will passively immunize her.
   (B) tetanus antitoxin (equine), which will passively immunize her.
   (C) tetanus immune globulin (human), which will passively immunize her.
   (D) tetanus toxoid, which will actively immunize her.
   (E) tetanus immune globulin (human), which will stimulate an anamnestic response.

2. A 10-year-old girl who received a deep laceration when she was water skiing was just brought into
   your office. Her parents state that she has had no previous immunization against tetanus. As
   protection against the possibility of tetanus now and in the future, the preferred method of treatment
   would be
   (A) A mixture of tetanus toxoid and tetanus immune globulin (human) as one injection.
   (B) A tetanus toxoid injection this visit, with an injection of tetanus immune globulin (human) approximately
       three weeks later.
   (C) Separate injections of tetanus toxoid and tetanus immune globulin (human) on different sites on this one
       visit.
   (D) A tetanus immune globulin (human) injection this visit, with an injection of tetanus toxoid about three
       weeks later.
   (E) A tetanus immune globulin (human) injection this visit, with an injection of tetanus toxoid
       about five weeks later.

3. You know that your 3-year-old patient received the standard DPT immunization series starting at 3
   months of age. You discovered recently that he has no detectable antibody to diphtheria, pertussis, or
   tetanus and hence is deficient in his humoral immunity. You are faced with treating him for a deep
   puncture wound in his foot, which he obtained while playing near his grandfather's barn. The best
   treatment to prevent tetanus would be
   (A) active immunization with tetanus toxoid.
   (B) active immunization with tetanus toxin.
   (C) passive immunization with tetanus antitoxin (equine).
   (D) passive immunization with tetanus immune globulin (human).
   (E) none of the above. Under the circumstances, it is best to avoid any type of injection.

4. Administration of tetanus immune globulin (human) has been decided upon for the immediate
   protection of a patient with a two-inch deep cut in his thigh. The patient is a normal 6-year-o!d.
   You must consider
   (A) that the antibody half-life is such that passive immunization should be repeated every two to three
       weeks.
   (B) that the antibody half-life is such that active immunization with tetanus toxoid should also be
       done, since prolonged protection is desired.
   (C) the possibility that serum sickness will occur.
   (D) the possibility that hypersensitivity (anaphylaxis) will occur.
   (E) that the blood types must be properly matched.
5.    Serum sickness can be a serious problem after which of the following?
     (A) Injection of tetanus toxoid
     (B) Injection of tetanus antitoxin (equine)
                                                                                                                   4 5




                                                      Tetanus-45
     (C) Injection of tetanus immune globulin (human)
     (D) Injection of tetanus toxin
     (E) None of the above

6.    Active immunization after exposure to an infectious disease should be done to prevent that
      disease if
     (A) the incubation period of the disease exceeds the time required to produce immunity.
     (B) the patient has been previously immunized and hence will have an anamnestic immune response.
     (C) the immunity is antibody-mediated.
     (D) the patient is very sick.
     (E) the immunity is cell-mediated.

7. Reckless Richard, your accident-prone, 10-year-old patient, has just come in with a deep puncture
   wound on his foot. Your records show that he had a standard DPT series as a baby and a booster at
   age 5 and again six months ago after another bad wound. 'The proper treatment is
   (A) tetanus toxoid.
   (B) tetanus antitoxin (equine).
   (C) tetanus immune globulin (human).
   (D) tetanus toxoid and tetanus immune globulin (human) at two different sites.
   (E) no tetanus immunization.

8.    Diphtheria toxoid, like tetanus toxoid, is an effective inducer of active immunity because it   IS
     (A) immunogenic but not antigenic.
     (B) antigenic but not immunogenic.
     (C) both immunogenic and antigenic.
     (D) chemically identical to diphtheria toxin.
     (E) an active toxin.

9.    Immunity induced by tetanus toxoid injection is
     (A) specific and cell-mediated.
     (B) innate and nonspecific.
     (C) cell-mediated and innate.
     (D) antibody-mediated and active.
     (E) nonspecific and passive.

10. Protection of a patient by administration of passive antibody has one primary advantage over
    active immunization, which is that it
   (A) is cheaper.
   (B) hurts less.
   (C) gives higher antibody titers.
   (D) provides antibody more rapidly.
   (E) provides antibody for a longer time.

When your group has finished reviewing the posttest, you have completed the activity. Have you achieved
the objectives set forth in the Introduction? Some of you may wish to discuss your reactions to this
Patient-Oriented Problem-Solving session with your instructor.




                                                                                                           4 6




                                                        Tetanus-46
Tetanus Immunity
Posttest

Selec t th e b es t answ er for each qu es tion. Pl eas e mar k your ans wers on this exam to
facilitate di scus sion an d la ter r evi ew . If your ins tru c tor has p rovi ded a s epara te ans w er
form, b e sur e you hav e i dentifi ed yours elf on th e fo rm , th en b egin you r an sw ers with
question 1. Mar k your answ ers both on th e fo rm and on this exam . Only on e ans w er is
cor rec t.

1. A 23-year-old medical student who had four injections of diphtheria, pertussis, and tetanus (DPT) in
   her first year of life and a booster at age 12 years but no subsequent tetanus immunization, is bitten
   by a mouse while doing an experiment. She should be given:
   (A) tetanus toxoid, which will passively immunize her.
   (B) tetanus antitoxin (equine), which will passively immunize her.
   (C) tetanus immune globulin (human), which will passively immunize her.
   (D) tetanus toxoid, which will actively immunize her.
   (E) tetanus immune globulin (human), which will stimulate an anamnestic response.

2. A 10-year-old girl who received a deep laceration when she was water skiing was just brought into
   your office. Her parents state that she has had no previous immunization against tetanus. As
   protection against the possibility of tetanus now and in the future, the preferred method of treatment
   would be
   (A) A mixture of tetanus toxoid and tetanus immune globulin (human) as one injection.
   (B) A tetanus toxoid injection this visit, with an injection of tetanus immune globulin (human) approximately
       three weeks later.
   (C) Separate injections of tetanus toxoid and tetanus immune globulin (human) on different sites on this one
       visit.
   (D) A tetanus immune globulin (human) injection this visit, with an injection of tetanus toxoid about three
       weeks later.
   (E) A tetanus immune globulin (human) injection this visit, with an injection of tetanus toxoid
       about five weeks later.

3. You know that your 3-year-old patient received the standard DPT immunization series starting at 3
   months of age. You discovered recently that he has no detectable antibody to diphtheria, pertussis, or
   tetanus and hence is deficient in his humoral immunity. You are faced with treating him for a deep
   puncture wound in his foot, which he obtained while playing near his grandfather's barn. The best
   treatment to prevent tetanus would be
   (A) active immunization with tetanus toxoid.
   (B) active immunization with tetanus toxin.
   (C) passive immunization with tetanus antitoxin (equine).
   (D) passive immunization with tetanus immune globulin (human).
   (E) none of the above. Under the circumstances, it is best to avoid any type of injection.

4. Administration of tetanus immune globulin (human) has been decided upon for the immediate
   protection of a patient with a two-inch deep cut in his thigh. The patient is a normal 6-year-o!d.
   You must consider
   (A) that the antibody half-life is such that passive immunization should be repeated every two to three
       weeks.
   (B) that the antibody half-life is such that active immunization with tetanus toxoid should also be
       done, since prolonged protection is desired.
   (C) the possibility that serum sickness will occur.
   (D) the possibility that hypersensitivity (anaphylaxis) will occur.
   (E) that the blood types must be properly matched.
5.    Serum sickness can be a serious problem after which of the following?
     (A) Injection of tetanus toxoid
     (B) Injection of tetanus antitoxin (equine)
                                                                                                                   4 7




                                                      Tetanus-47
     (C) Injection of tetanus immune globulin (human)
     (D) Injection of tetanus toxin
     (E) None of the above

6.    Active immunization after exposure to an infectious disease should be done to prevent that
      disease if
     (A) the incubation period of the disease exceeds the time required to produce immunity.
     (B) the patient has been previously immunized and hence will have an anamnestic immune response.
     (C) the immunity is antibody-mediated.
     (D) the patient is very sick.
     (E) the immunity is cell-mediated.

7. Reckless Richard, your accident-prone, 10-year-old patient, has just come in with a deep puncture
   wound on his foot. Your records show that he had a standard DPT series as a baby and a booster at
   age 5 and again six months ago after another bad wound. 'The proper treatment is
   (A) tetanus toxoid.
   (B) tetanus antitoxin (equine).
   (C) tetanus immune globulin (human).
   (D) tetanus toxoid and tetanus immune globulin (human) at two different sites.
   (E) no tetanus immunization.

8.    Diphtheria toxoid, like tetanus toxoid, is an effective inducer of active immunity because it   IS
     (A) immunogenic but not antigenic.
     (B) antigenic but not immunogenic.
     (C) both immunogenic and antigenic.
     (D) chemically identical to diphtheria toxin.
     (E) an active toxin.

9.    Immunity induced by tetanus toxoid injection is
     (A) specific and cell-mediated.
     (B) innate and nonspecific.
     (C) cell-mediated and innate.
     (D) antibody-mediated and active.
     (E) nonspecific and passive.

10. Protection of a patient by administration of passive antibody has one primary advantage over
    active immunization, which is that it
   (A) is cheaper.
   (B) hurts less.
   (C) gives higher antibody titers.
   (D) provides antibody more rapidly.
   (E) provides antibody for a longer time.

When your group has finished reviewing the posttest, you have completed the activity. Have you achieved
the objectives set forth in the Introduction? Some of you may wish to discuss your reactions to this
Patient-Oriented Problem-Solving session with your instructor.




                                                                                                           4 8




                                                        Tetanus-48
Tetanus Immunity
Posttest

Selec t th e b es t answ er for each qu es tion. Pl eas e mar k your ans wers on this exam to
facilitate di scus sion an d la ter r evi ew . If your ins tru c tor has p rovi ded a s epara te ans w er
form, b e sur e you hav e i dentifi ed yours elf on th e fo rm , th en b egin you r an sw ers with
question 1. Mar k your answ ers both on th e fo rm and on this exam . Only on e ans w er is
cor rec t.

1. A 23-year-old medical student who had four injections of diphtheria, pertussis, and tetanus (DPT) in
   her first year of life and a booster at age 12 years but no subsequent tetanus immunization, is bitten
   by a mouse while doing an experiment. She should be given:
   (A) tetanus toxoid, which will passively immunize her.
   (B) tetanus antitoxin (equine), which will passively immunize her.
   (C) tetanus immune globulin (human), which will passively immunize her.
   (D) tetanus toxoid, which will actively immunize her.
   (E) tetanus immune globulin (human), which will stimulate an anamnestic response.

2. A 10-year-old girl who received a deep laceration when she was water skiing was just brought into
   your office. Her parents state that she has had no previous immunization against tetanus. As
   protection against the possibility of tetanus now and in the future, the preferred method of treatment
   would be
   (A) A mixture of tetanus toxoid and tetanus immune globulin (human) as one injection.
   (B) A tetanus toxoid injection this visit, with an injection of tetanus immune globulin (human) approximately
       three weeks later.
   (C) Separate injections of tetanus toxoid and tetanus immune globulin (human) on different sites on this one
       visit.
   (D) A tetanus immune globulin (human) injection this visit, with an injection of tetanus toxoid about three
       weeks later.
   (E) A tetanus immune globulin (human) injection this visit, with an injection of tetanus toxoid
       about five weeks later.

3. You know that your 3-year-old patient received the standard DPT immunization series starting at 3
   months of age. You discovered recently that he has no detectable antibody to diphtheria, pertussis, or
   tetanus and hence is deficient in his humoral immunity. You are faced with treating him for a deep
   puncture wound in his foot, which he obtained while playing near his grandfather's barn. The best
   treatment to prevent tetanus would be
   (A) active immunization with tetanus toxoid.
   (B) active immunization with tetanus toxin.
   (C) passive immunization with tetanus antitoxin (equine).
   (D) passive immunization with tetanus immune globulin (human).
   (E) none of the above. Under the circumstances, it is best to avoid any type of injection.

4. Administration of tetanus immune globulin (human) has been decided upon for the immediate
   protection of a patient with a two-inch deep cut in his thigh. The patient is a normal 6-year-o!d.
   You must consider
   (A) that the antibody half-life is such that passive immunization should be repeated every two to three
       weeks.
   (B) that the antibody half-life is such that active immunization with tetanus toxoid should also be
       done, since prolonged protection is desired.
   (C) the possibility that serum sickness will occur.
   (D) the possibility that hypersensitivity (anaphylaxis) will occur.
   (E) that the blood types must be properly matched.
5.    Serum sickness can be a serious problem after which of the following?
     (A) Injection of tetanus toxoid
     (B) Injection of tetanus antitoxin (equine)
                                                                                                                   4 9




                                                      Tetanus-49
     (C) Injection of tetanus immune globulin (human)
     (D) Injection of tetanus toxin
     (E) None of the above

6.    Active immunization after exposure to an infectious disease should be done to prevent that
      disease if
     (A) the incubation period of the disease exceeds the time required to produce immunity.
     (B) the patient has been previously immunized and hence will have an anamnestic immune response.
     (C) the immunity is antibody-mediated.
     (D) the patient is very sick.
     (E) the immunity is cell-mediated.

7. Reckless Richard, your accident-prone, 10-year-old patient, has just come in with a deep puncture
   wound on his foot. Your records show that he had a standard DPT series as a baby and a booster at
   age 5 and again six months ago after another bad wound. 'The proper treatment is
   (A) tetanus toxoid.
   (B) tetanus antitoxin (equine).
   (C) tetanus immune globulin (human).
   (D) tetanus toxoid and tetanus immune globulin (human) at two different sites.
   (E) no tetanus immunization.

8.    Diphtheria toxoid, like tetanus toxoid, is an effective inducer of active immunity because it   IS
     (A) immunogenic but not antigenic.
     (B) antigenic but not immunogenic.
     (C) both immunogenic and antigenic.
     (D) chemically identical to diphtheria toxin.
     (E) an active toxin.

9.    Immunity induced by tetanus toxoid injection is
     (A) specific and cell-mediated.
     (B) innate and nonspecific.
     (C) cell-mediated and innate.
     (D) antibody-mediated and active.
     (E) nonspecific and passive.

10. Protection of a patient by administration of passive antibody has one primary advantage over
    active immunization, which is that it
   (A) is cheaper.
   (B) hurts less.
   (C) gives higher antibody titers.
   (D) provides antibody more rapidly.
   (E) provides antibody for a longer time.

When your group has finished reviewing the posttest, you have completed the activity. Have you achieved
the objectives set forth in the Introduction? Some of you may wish to discuss your reactions to this
Patient-Oriented Problem-Solving session with your instructor.




                                                                                                           5 0




                                                        Tetanus-50
Tetanus Immunity
Posttest Co r rec t Answ ers

Discus s ans wers wi th ea ch o th er to b e sur e non e of you hav e an y mis conc eptions !

1.   D is co rr ec t. The anamnestic response will provide antibody before the Clostridium tetani can produce
     enough toxin to harm the patient. Stated another way: although the patient does not have enough antibody
     present in her serum to protect her from tetanus, she does have memory lymphocytes that are "ready and
     waiting to be turned on." C is wrong because tetanus immune globulin (human) is both expensive and
     unnecessary in previously immunized patients. Passive immunization will not provide protection for more than
     several months. Tetanus toxoid will protect her for five to ten years.

2.   C is the tr ea tm en t ap pro ved by the Public H ealth Servi ce. The patient may not return and would
     remain susceptible to tetanus in the future if she were given only passive antibody. You should also ask her to
     return for two tetanus toxoid booster injections.

3.   D is co rr ec t. The child cannot produce antibody; therefore, there are no memory cells to count on! This is a
     rare patient. The problem-solving session on Immunodeficiency Disease covers this.

4.   B is cor r ec t.

5.   B is cor r ec t.

6.   A is alway s cor r ec t. B is correct for some diseases but not all. It is always necessary for the onset of
     immune response to "beat" the disease. This does not occur in infectious diseases with short incubation
     periods (e.g., influenza or botulism) nor in other situations such as snakebite, even with booster immunization.

7.   E i s cor r ec t. The patient has adequate immunity due to prior immunization. The Public Health Service
     suggests a booster when the last booster was given more than five years previously.

8.   C is cor rec t.

9.   D is co rr ec t. The immunity is specific for tetanus. It is antibody-mediated as proven by the fact that passive
     administration of antibody will protect. Passive transfer (adoptive immunity) of sensitized T-cells will not
     protect the recipient. Since an antigen has stimulated the body to produce antibody, it is active immunity.

10. D is co rr ec t.




                                                                                                                         5 1




                                                      Tetanus-51
Tetanus Immunity
Posttest Co r rec t Answ ers

Discus s ans wers wi th ea ch o th er to b e sur e non e of you hav e an y mis conc eptions !

1.   D is co rr ec t. The anamnestic response will provide antibody before the Clostridium tetani can produce
     enough toxin to harm the patient. Stated another way: although the patient does not have enough antibody
     present in her serum to protect her from tetanus, she does have memory lymphocytes that are "ready and
     waiting to be turned on." C is wrong because tetanus immune globulin (human) is both expensive and
     unnecessary in previously immunized patients. Passive immunization will not provide protection for more than
     several months. Tetanus toxoid will protect her for five to ten years.

2.   C is the tr ea tm en t ap pro ved by the Public H ealth Servi ce. The patient may not return and would
     remain susceptible to tetanus in the future if she were given only passive antibody. You should also ask her to
     return for two tetanus toxoid booster injections.

3.   D is co rr ec t. The child cannot produce antibody; therefore, there are no memory cells to count on! This is a
     rare patient. The problem-solving session on Immunodeficiency Disease covers this.

4.   B is cor r ec t.

5.   B is cor r ec t.

6.   A is alway s cor r ec t. B is correct for some diseases but not all. It is always necessary for the onset of
     immune response to "beat" the disease. This does not occur in infectious diseases with short incubation
     periods (e.g., influenza or botulism) nor in other situations such as snakebite, even with booster immunization.

7.   E i s cor r ec t. The patient has adequate immunity due to prior immunization. The Public Health Service
     suggests a booster when the last booster was given more than five years previously.

8.   C is cor rec t.

9.   D is co rr ec t. The immunity is specific for tetanus. It is antibody-mediated as proven by the fact that passive
     administration of antibody will protect. Passive transfer (adoptive immunity) of sensitized T-cells will not
     protect the recipient. Since an antigen has stimulated the body to produce antibody, it is active immunity.

10. D is co rr ec t.




                                                                                                                         5 2




                                                      Tetanus-52
Tetanus Immunity
Posttest Co r rec t Answ ers

Discus s ans wers wi th ea ch o th er to b e sur e non e of you hav e an y mis conc eptions !

1.   D is co rr ec t. The anamnestic response will provide antibody before the Clostridium tetani can produce
     enough toxin to harm the patient. Stated another way: although the patient does not have enough antibody
     present in her serum to protect her from tetanus, she does have memory lymphocytes that are "ready and
     waiting to be turned on." C is wrong because tetanus immune globulin (human) is both expensive and
     unnecessary in previously immunized patients. Passive immunization will not provide protection for more than
     several months. Tetanus toxoid will protect her for five to ten years.

2.   C is the tr ea tm en t ap pro ved by the Public H ealth Servi ce. The patient may not return and would
     remain susceptible to tetanus in the future if she were given only passive antibody. You should also ask her to
     return for two tetanus toxoid booster injections.

3.   D is co rr ec t. The child cannot produce antibody; therefore, there are no memory cells to count on! This is a
     rare patient. The problem-solving session on Immunodeficiency Disease covers this.

4.   B is cor r ec t.

5.   B is cor r ec t.

6.   A is alway s cor r ec t. B is correct for some diseases but not all. It is always necessary for the onset of
     immune response to "beat" the disease. This does not occur in infectious diseases with short incubation
     periods (e.g., influenza or botulism) nor in other situations such as snakebite, even with booster immunization.

7.   E i s cor r ec t. The patient has adequate immunity due to prior immunization. The Public Health Service
     suggests a booster when the last booster was given more than five years previously.

8.   C is cor rec t.

9.   D is co rr ec t. The immunity is specific for tetanus. It is antibody-mediated as proven by the fact that passive
     administration of antibody will protect. Passive transfer (adoptive immunity) of sensitized T-cells will not
     protect the recipient. Since an antigen has stimulated the body to produce antibody, it is active immunity.

10. D is co rr ec t.




                                                                                                                         5 3




                                                      Tetanus-53
Tetanus Immunity
Posttest Co r rec t Answ ers

Discus s ans wers wi th ea ch o th er to b e sur e non e of you hav e an y mis conc eptions !

1.   D is co rr ec t. The anamnestic response will provide antibody before the Clostridium tetani can produce
     enough toxin to harm the patient. Stated another way: although the patient does not have enough antibody
     present in her serum to protect her from tetanus, she does have memory lymphocytes that are "ready and
     waiting to be turned on." C is wrong because tetanus immune globulin (human) is both expensive and
     unnecessary in previously immunized patients. Passive immunization will not provide protection for more than
     several months. Tetanus toxoid will protect her for five to ten years.

2.   C is the tr ea tm en t ap pro ved by the Public H ealth Servi ce. The patient may not return and would
     remain susceptible to tetanus in the future if she were given only passive antibody. You should also ask her to
     return for two tetanus toxoid booster injections.

3.   D is co rr ec t. The child cannot produce antibody; therefore, there are no memory cells to count on! This is a
     rare patient. The problem-solving session on Immunodeficiency Disease covers this.

4.   B is cor r ec t.

5.   B is cor r ec t.

6.   A is alway s cor r ec t. B is correct for some diseases but not all. It is always necessary for the onset of
     immune response to "beat" the disease. This does not occur in infectious diseases with short incubation
     periods (e.g., influenza or botulism) nor in other situations such as snakebite, even with booster immunization.

7.   E i s cor r ec t. The patient has adequate immunity due to prior immunization. The Public Health Service
     suggests a booster when the last booster was given more than five years previously.

8.   C is cor rec t.

9.   D is co rr ec t. The immunity is specific for tetanus. It is antibody-mediated as proven by the fact that passive
     administration of antibody will protect. Passive transfer (adoptive immunity) of sensitized T-cells will not
     protect the recipient. Since an antigen has stimulated the body to produce antibody, it is active immunity.

10. D is co rr ec t.




                                                                                                                         5 4




                                                      Tetanus-54

				
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Description: Tetanus Immunity cquired immunity