Health Information
Tetanus
- Introduction
- Epidemiology
- Risk for Travellers
- Transmission
- Signs and symptoms
- Treatment
- Prevention
- Vaccine Information
- References
- Reading List
- Links
Tetanus is an acute, often fatal, but vaccine-preventable disease caused by an exotoxin (tetanospasmin) produced by Clostridium tetani. C. tetani is a slender Gram positive anaerobic rod, which is heat sensitive and cannot survive in the presence of oxygen. It develops a terminal spore which is resistant to heat, antiseptics, phenol and other chemical agents. Tetanus occurs worldwide and tetanus spores are present in soil and the dung of a number of animals [1].
(Data from the Travel Health Surveillance Section of the Health Protection Agency Communicable Disease Surveillance Centre)
Global Epidemiology
The organism that causes tetanus, Clostridium tetani, is ubiquitous throughout the world. As the disease is acquired through environmental exposure, tetanus is one of the few vaccine-preventable diseases that is infectious but not contagious from human-to-human. Therefore, the incidence of tetanus in a region or country is dependent upon vaccine coverage from both childhood and adult vaccination programs. In resource-rich countries, such as the UK , vaccine coverage is high [2] and the number of tetanus cases reported is very low [3]. In resource-poor countries, however, vaccine coverage is variable and incidences are higher.
Neonatal tetanus is a problem in resource poor countries where routine vaccination coverage is inadequate and where unclean procedures are practiced when the umbilical cord is cut after childbirth. The 1989 World Health Assembly set a goal to eliminate neonatal tetanus globally (definition of elimination: <1 cases per 1000 live births in each health district in every country) by 2000 [4]. By December 1999, 104 of 161 developing countries had achieved elimination, but due to problems in the remaining countries, UNICEF, the WHO and the United Nations Population Fund (UNFPA) agreed a new five-year strategic plan, setting the year 2005 as the target date for worldwide elimination.
In 2003, there were 8,997 cases of neonatal tetanus reported to the WHO; 78% of the reports were from ten countries in sub-Saharan Africa (465 Democratic Republic of the Congo, 353 Chad, 316 Uganda, 238 Guinea), SE Asia (2,245 China, 238 Cambodia, 239 Philippines), and the Indian sub-continent (1,691 India, 812 Pakistan, 390 Bangladesh) [5]. Since the elimination goal was set, the global number of reported neonatal cases and total tetanus cases has decreased, although the numbers must be interpreted with caution as there is great variability in reporting. For example, some countries such as China and Chad only report neonatal cases, and other countries are unable to submit any data during some years.
In 2001, the WHO estimated that worldwide around 281,000 deaths occur annually, of which 210,000 are in children under five (including neonatal tetanus). However this may be revised when better surveillance data becomes available [6].
Tetanus in Travellers from England and Wales
Tetanus is occasionally reported in England and Wales but in low numbers. Since 1991, there has been an average of six cases reported each year; there have been no cases of neonatal tetanus in England and Wales for more than 30 years [7]. The majority of cases reported between 1984 and 2003 occurred in unvaccinated individuals over 65 years of age, who were born before routine vaccination for tetanus was implemented [3, 7]. Tetanus reported in England and Wales associated with foreign travel is rare.
Tetanus is an uncommon disease in many resource-rich countries of the western hemisphere; the WHO Western Pacific and European regions have largely controlled clinical tetanus through universal vaccination. However, no country is free of C. tetani, so maintaining immunity in individuals is important [8,9,10].
Tetanus spores are present in the intestine and dung of horses, sheep, cattle, dogs, cats, rats, guinea pigs and chickens, and are passed into soil via faeces, making them ubiquitous in the environment. The disease is acquired when material containing tetanus spores contaminates a wound that could be major or minor in severity. Wounds with a high risk for tetanus are those that show one or more of the following: devitalised tissue, deep puncture, contact with soil or manure, and clinical evidence of sepsis [8]. In resource-rich regions of the world many cases are associated with injecting drug users, where the drugs, injecting equipment or puncture wound may be contaminated [11,12] In anaerobic conditions spores germinate and tetanospasmin is produced which disseminates throughout the body via the blood, leading to the clinical symptoms of tetanus [8,13].
The incubation period of the disease is usually a week, but ranges from 3 to 21 days. Generally, the further the injury site is from the central nervous system the longer the incubation period. The risk of fatality is highest in those with the shortest incubation period.
Signs and symptoms can be categorised according to the type of symptoms:
Local tetanus
This is a rare and mild form of the disease. Local tetanus is characterised by persistent contraction of muscles in the same anatomic area as the injury, and may persist for several weeks before gradually subsiding. In some cases local symptoms may precede the development of generalised tetanus.
Cephalic tetanus
Cephalic tetanus is a particular form of generalized tetanus, occurring when the tetanus spores enter through the middle ear, following a middle ear infection or a head injury. Generalised disease may or may not develop and prognosis is often poor.
Generalised tetanus
Generalised tetanus accounts for about 80% of cases worldwide. After a period of general malaise, trismus (also known as lockjaw) develops; this is characterised by spasm of the facial muscles and produces a characteristic grinning expression (risus sardonicus). Stiffness of the neck, difficulty in swallowing, and rigidity of muscles in the back, thorax and extremities follow. Autonomic dysfunction is seen with the temperature rising between 2°C and & 4°C above normal, sweating, elevated blood pressure, and episodic rapid heart rate. Spasms lasting for several minutes also may occur and continue for 3 to 4 weeks.
Complications include respiratory failure, aspiration pneumonia and fractures of the spine or long bones resulting from sustained contractions/convulsions. With intensive medical support, death from tetanus occurs in 10-20% of cases.
Neonatal tetanus
Neonatal tetanus is the main form of tetanus in resource-poor areas of the world. Without specific treatment death occurs in more than 95% of cases, even with therapy mortality is still 25-90 % [13]. Death usually occurs secondary to infection of the umbilical stump if the end is cut with unsterilised instruments. The custom in some cultures is to smear animal dung on the open end of the stump. Failure to thrive, poor sucking, grimacing and irritability are quickly followed by intense rigidity and spasms.
- All wounds must be cleaned and debrided (if necessary) to remove the source of tetanospasmin
- Human tetanus immunoglobulin and tetanus toxoid should be given
- Intravenous antibiotics should be given to kill C.tetani
- Benzodiazepines can be used for sedation and to control the spasms. A neuromuscular blocker may be necessary.
- Intubation and respiratory support if needed
- Intensive medical and nursing care in quiet, darkened conditions
Effective vaccination is available and all persons should be immunised regardless of age.
Travellers should be up to date on their tetanus immunisation, be aware of the risk of accidents while travelling, and the importance of seeking urgent medical attention in the case of a penetrating wound [9,10].
1. Centers for Disease Control Chapter 6; Tetanus in National Immunisation Program Pink Book 8th ed. Atlanta : CDC; 30 January 2004 www.cdc.gov/nip/publications/pink/tetanus.pdf
2. Health Protection Agency. Notifications, Deaths and Vaccine Uptake Rates, 1985 - 2002 [online] [cited 29 September 2004 ] London : HPA; 2004. Available at http://www.hpa.org.uk/infections/topics_az/tetanus/teta_t02.
3.Rushdy AA, White JM, Ramsay ME, Crowcroft NS . Tetanus in England and Wales 1984 - 2000. Epidemiol Infect 2003; 130: 71-77.
4. Maternal and Neonatal Tetanus Elimination by 2005. Strategies for achieving and maintaining elimination. UNFPA/UNICEF/WHO (unpublished document WHO/V&B/02.09); available http://www.who.int/vaccines-documents/DocsPDF02/www692.pdf
5.WHO. Neonatal tetanus reported cases. Vaccines, Immunization and Biologicals. Geneva : WHO; 2004. http://www-nt.who.int/vaccines/globalsummary/timeseries/
6.World Health Organization. WHO vaccine-preventable disease monitoring system, 2003 global summary. Geneva : WHO; 2003. Available online at http://www.who.int/vaccines-documents/GlobalSummary/GlobalSummary.pdf .
7.Department of Health. Tetanus cases 1984 to 2004. NHS Immunisation Information [online] [cited 29 September 2004 ]. London : Department of Health; 2004. Available at http://www.immunisation.nhs.uk/Vaccines/Td_IPV/The_
diseases/Tetanus/Tetanus_Cases_1984-2004
8. Salisbury DM, Begg NT , editors. Immunisation against Infectious Disease. London: HMSO; 1996 www.dh.gov.uk/PublicationsAndStatistics/Publications
/PublicationsPolicyAndGuidance/PublicationsPolicyAnd
/fs/en?CONTENT_ID=4072977&chk=87uz6M
(The link shows the 2004 updated chapters).
9. Lea G, Leese J, editors. Health Information for Overseas Travel. 2nd ed. London: The Stationery Office; 2001 www.archive.official-documents.co.uk/document/doh/hinfo/travel02.htm
10. World Health Organization. International Travel & Health. Geneva: WHO; 2003 www.who.int/ith/index.html
11. Kumar P, Clark M. Clinical Medicine 5th ed. Edinburgh: WB Saunders; 2002 www.kumarandclark.com
12. Health Protection Agency. Cluster of cases of tetanus in
injecting drug users in England: update. CDR Weekly 2003 27 13; 48 http://www.hpa.org.uk/cdr/archives/2003/cdr4803.pdf
13. World Health Organization (WHO) Vaccines, Immunizations & Biologicals;
Tetanus. 2003
www.who.int/vaccines/en/neotetanus.shtml
14. Health Protection Agency. Tetanus cases in injecting drug users:
Questions and answers [online] [cited 30 September 2004]
HPA: London: 2004. Available at
www.hpa.org.uk/infections/topics_az/tetanus/
Cook G, Zumla A editors. Manson's Tropical Diseases. 21st ed. London: WB Saunders Co Ltd; 2003
World Health Organization (WHO) http://www.who.int/vaccines/en/neotetanus.shtml
Committee to Advise on Tropical Medicine and Travel (CATMAT) http://www.phac-aspc.gc.ca/im/vpd-mev/tetanus_e.html
The Merck Manual of Medical Information online 2004 http://www.merck.com/mmhe/sec17/ch190/ch190t.html
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