Is a tetanus injection painful

Are vaccine reactions predictable?

Are local reactions after vaccinations predictable? How are they influenced? What are the risk factors? With which vaccines do you have to fear more local reactions, with which fewer?

Vaccinations: questions and answers
Hardly any other field of medicine raises as many questions as the subject of "vaccinations and vaccines". The STIKO recommendations sometimes leave room for interpretation. In addition, the individual constellations are so diverse that uncertainties are almost inevitable - be it about questionable vaccinations, vaccination intervals, vaccination reactions, dosages or indications, and, and, and. This new series deals with specific questions on the subject of vaccinations that our expert, Dr. med. Andreas Leischker, answered professionally.

Local reactions in the form of reddening, swelling or painfulness at the injection site occur frequently and are a sign that the organism is "dealing" with the vaccine and forming antibodies. These symptoms usually last one to three days, rarely longer. It is a "common vaccination reaction" and not a "vaccination complication". According to the recommendations of the STIKO, local reactions that do not exceed the usual level must expressly not be reported to the Paul Ehrlich Institute as a vaccination complication via the health department.

It is not easy to predict who will develop a pronounced local reaction in individual cases. There are some clues, however. In general: patients with a good immune system develop more frequent and stronger local reactions than people with a poor or weakened immune system. Elderly people develop pronounced local reactions much less often because the immune response is less pronounced in old age. The same goes for patients on immunosuppressive therapy. If you explain to a vaccinee who is concerned about a local reaction or the parents of a vaccinated child that the local reaction is a sign that antibodies are being formed and that this is a sign of a functioning immune system, the reactions are usually well tolerated.

More frequent local reactions after boosting

Patients who receive a booster vaccination develop local reactions more frequently than with the first dose: after the primary vaccination, memory cells are already present, so the formation of antibodies - also locally - is much more pronounced. Particularly pronounced local reactions can occur if the recommended booster intervals are clearly undercut (Arthus phenomenon). In practice, this is often the case if, in the event of an injury, it is unclear when the last tetanus booster vaccination was given. However, this should in no way result in the vaccination being omitted in the event of an injury if the vaccination status is unclear or vaccination documentation is missing. The STIKO specifies this in its recommendations for the tetanus and diphtheria booster vaccinations: "Even minor injuries can be entry points for tetanus pathogens or spores and should give the attending physician a reason to check the current tetanus vaccination protection. The tetanus immune prophylaxis must be carried out immediately ... If the vaccination status is unknown, i.e. if there is no or incomplete documentation of vaccinations, in the interests of the person to be protected, it must be assumed that there are no vaccinations. "

"There is no particular risk from additional vaccinations if you already have vaccination protection." In exceptional cases, repeated administration of dead vaccines can lead to side effects such as a pronounced local intolerance reaction with painful swelling and reddening of the affected extremity (so-called Arthus phenomenon). This self-limiting reaction is most likely to occur with high pre-existing serum antibody concentrations after very frequent vaccinations with tetanus and / or diphtheria toxoid. After the occurrence of an Arthus phenomenon, an antibody determination should be carried out before further vaccinations with Td. There is no such risk for pertussis antigens.

Higher risk with adjuvanted vaccines

Vaccines that contain adjuvants (e.g. adjuvanted influenza vaccines or hepatitis B vaccines for dialysis patients) have better immunogenicity and therefore lead to stronger local reactions. Adjuvanted vaccines must be given "strictly" intramuscularly. The adjuvanted vaccine must not be injected into the subcutaneous tissue, otherwise very severe local reactions up to the formation of granulomas and cysts can occur. It is therefore important to use a sufficiently long injection needle when administering adjuvanted vaccines. In its current recommendation, the STIKO takes a specific position on the length of the injection needles to be used: "The needle length should be 15 mm for babies under two months old, 25 mm for older babies and small children and 25 - 50 mm for young people and adults." Especially in adults with extensive subcutaneous fat tissue, a needle (at least) 50 mm long should be used, at least when administering adjuvanted vaccines.

But there are also differences in local tolerability with the non-adjuvanted vaccines: injections of the pneumococcal and MMR vaccines can be particularly painful. You should therefore be injected last at one appointment if you have several vaccinations. The dead vaccine against herpes zoster - not yet available on the market - often led to local reactions in the approval studies, especially with the second injection.

How can you prevent or minimize local reactions?

The STIKO names the two most important measures in its current recommendations: "The injection cannula should be dry, in particular the vaccine should not wet the outside of the cannula. This makes the injection painful and can lead to inflammation in the area of ​​the puncture canal Syringe and the removal of any air, a new cannula should be attached for the injection. Before the injection, the vaccination site must be disinfected. The skin should be dry again after the injection. "

However, the STIKO's recommendation to disinfect the injection site is not evidence-based and - at least if the disinfectant has not yet completely evaporated at the time of the injection - probably leads to more local complications than is useful. Actually, at least if the skin is not visibly soiled, no skin disinfection is necessary in non-immunocompromised vaccinees. Since almost all laypeople expect skin disinfection before an injection and the STIKO also takes this view, in practice, for pragmatic reasons, disinfection will usually be carried out. However, you have to make sure that the disinfectant is completely dried off before the injection. Otherwise disinfectant can get into the branch duct. This leads to local reactions and, in the case of live vaccines, can also impair the effectiveness of the vaccination.

No aspiration should be performed prior to injection, regardless of the age of the vaccinee. This is not only superfluous because there are no large blood vessels at the parts of the body that are used for the injection (M. vastus lateralis or M. deltoideus). Rather, the aspiration can be painful and encourage the occurrence of local reactions.

It is explicitly not recommended to warm up the vaccine, which was often practiced in the past, e.g. B. in the hand of the doctor or the vaccinee, and a "manual stimulation" of the vaccination site before or after vaccination z. B. by rubbing or pinching.

In my personal clinical experience, local reactions occur more frequently when the muscle used for the injection is used heavily in the first few days after the injection. I therefore recommend sparing the arm in which the injection was made for the first three days, if possible. For example, I advise tennis players to take a three-day break from training. However, neither clinical studies nor a STIKO recommendation exist for this personal recommendation.

What to do if a vaccinated person presents because of a local reaction?

The most important measure is to explain to the vaccinated person or the parents that this is a normal reaction of the immune system and that almost all local reactions subside completely within a few days.

If there is pronounced redness and overheating, the painful area can be cooled locally. I personally recommend envelopes with the preparation Retterspitz®. If that is not enough, an oral analgesic, e.g. B. ibuprofen (which also has an anti-inflammatory effect), are given.

1) Taddio A, McMurtry CM, Shah V. et al .: Reducing pain during vaccine injections: clinical practice guideline. CMAJ 2015; 187: 975-982
2) Recommendations of the Standing Vaccination Commission (STIKO) at the Robert Koch Institute - 2016/2017. Epidemiological Bulletin No. 34, August 29, 2016 DOI 10.17886 / EpiBull-2016-051.4

Dr. Andreas H. Leischker, M.A.
Specialist in internal medicine - travel medicine (DTG), aviation medical expert

Conflicts of Interest: Dr. Leischker has received honoraria / travel support from Pfizer, Novartis, and Sanofi-Pasteur-MSD. He is a lecturer and member of the Academy of the Center for Travel Medicine (CRM) Düsseldorf