Tetanus

Tetanus from the Centers for Disease Control and Prevention

The Disease
Most of the diseases discussed in this booklet are spread from one person to another, but tetanus is not. Tetanus enters the body through a wound. It can get in through even a tiny pinprick or scratch, but prefers deep puncture wounds or cuts, like those made by nails or knives.

Tetanus germs are found everywhere, usually in soil, dust, and manure. Once they enter a wound, they can produce a poison which spreads throughout the body.

The first signs of tetanus infection are usually a headache and spasms of the jaw muscles. The victim may become irritable. As the poison spreads, it causes muscle spasms in the neck, arms, legs, and stomach. The victim may get painful convulsions, which can be severe enough to cause broken bones. People with tetanus may have to spend several weeks in the hospital under intensive care. In the United States, three of every 10 persons who get tetanus die from it.

Immunization
Tetanus vaccine is usually given together with diphtheria and pertussis vaccines in a shot called DTP. You can read about DTP vaccine on page.

State Immunization Requirements
Laws requiring school children to be immunized against tetanus now exist in 47 of the 50 States. All 50 states require children entering day care to be immunized against tetanus.

DTP Immunization
You can protect your children from Diphtheria, Tetanus and Pertussis by getting them immunized with DTP vaccine. DTP is actually three vaccines-- Diphtheria, Tetanus, and Pertussis--combined into one shot. A child needs five DTP shots for complete protection. The first shot should be given at 2 months of age, and the second and third shots given within the child's first year. The fourth shot is given at about 15 or 18 months, and a fifth shot, or booster, is given when the child is about to enter school.

When DTP vaccine is given in the recommended number of shots it protects over 95% of children against tetanus, over 85% against diphtheria, and 70%- 90% against pertussis. It also make the diseases milder for those who do catch them.

Possible Side Effects and Adverse Reactions to DTP Immunization
Most children will get a slight fever and be cranky for a day or two after getting a DTP shot. Half of them will have a sore spot and some swelling where the shot was given. Occasionally, a child will have a more serious side effect. For every 330 DTP shots given, one child will get a fever of 105°F or more. About one child in 100 may cry for a long time (3 hours or more) after getting the shot. About once in 1,750 shots a child will have convulsions. Also, about one child in 1,750 shots may become limp or pale afterwards. These side effects are not long-lasting and have not been known to cause any permanent harm. Convulsions that occur after a DTP shot are usually caused by fever, and not the vaccine itself. Some experts say that giving a child drugs to lower the fever (Tylenol®* or other acetaminophen products) should also make these convulsions less likely. These drugs can be given at the time of vaccination and every 4-6 hours over the next 24 hours. Most experts believe that convulsions with fever do not cause any permanent damage to the child.

Serious reactions to DTP are very rare. Permanent brain damage has been reported on rare occasions after a child has been vaccinated with DTP. However, most experts believe that a connection between DTP and brain damage has not been proven. If DTP ever does cause brain damage, this would be very rare. As with any drug or vaccine, there is a very slight possibility that other serious problems, or even death, could occur. Some people have suggested that DTP shots might cause Sudden Infant Death Syndrome (SIDS), but studies have not shown this to be true.

A child who has had convulsions or other nervous system problems in the past has a slightly higher risk than other children of having a serious reaction after DTP, although this risk is still very small. Children whose brothers or sisters or parents have had convulsions are also slightly more likely to have a convulsion after a DTP shot.

If you can answer "yes" to any of the following questions, check with a doctor before having your child vaccinated with DTP vaccine.

1. Is the child sick with anything more serious than a common cold?
2. Has the child ever had a convulsion?
3. Has the child had any kind of nervous system problem, or does it seem not to be developing normally?
4. Has the child ever had a serious reaction to DTP, DTaP, DT, or Td shots before, such as:
   • A serious allergic reaction (swelling in the mouth, throat, or face, or difficulty breathing) within 1 day after getting the shot?
   • A temperature of 105°F or higher within 2 days after getting the shot?
   • limpness and paleness within 2 days after getting the shot?
   • Crying that lasts for more than 3 hours and cannot be stopped, within the 2 days after getting the shot?
   • A convulsion within 3 days after getting the shot?
   • Encephalopathy within 7 days after getting the shot?

Alternate Vaccines
DTaP is a vaccine that contains diphtheria and tetanus vaccines, and a type of pertussis vaccine that is different from that used in standard DTP. DTaP may be used instead of DTP vaccine for the 4th and 5th shots of the series. Fewer children will be cranky or drowsy after DTaP vaccine than after DTP. They are also less likely to be sore or swollen where the shot was given, and less likely to have a fever. Since convulsions that occur after DTP vaccine are usually caused by fever, there will probably also be fewer convulsions with DTaP. DTaP is being tested to see if it can be used for the first, second and third doses of the DTP series.

Td is a vaccine for children 7 years old and over. Td does not contain the pertussis part of the vaccine, because pertussis is not very serious in older children. It also has less of the diphtheria part, because reactions to diphtheria vaccine occur more often among older children. Booster shots of Td vaccine should be gotten every 10 years.

DT is a vaccine which contains the diphtheria and tetanus parts, but no pertussis. DT is given to children under 7 who should not get pertussis vaccine. Usually these are children who have had certain reactions, such as very high fever or convulsions, after a previous DTP shot. Report any reactions to your health care provider. He or she can then decide whether your child should get DTP or DT.

Side effects from DT or Td vaccine are not common and usually consist only of soreness and slight fever.

If your child has any serious or unusual problem after getting any of these vaccines, call a doctor or get the child to a doctor promptly.

MORE DETAILED INFORMATION
TETANUS - DISEASE INFO
Tetanus, sometimes known as lockjaw, is a disease manifested by uncontrolled muscle spasms. The disease is frequently fatal, especially to the very old or very young, and is preventable by immunization. It occurs predominantly in developing countries among new-born infants, children, and young adults, but it is still encountered in the United States, especially in unimmunized or inadequately immunized adults over 50 years of age.

The tetanus bacterium depends upon the introduction of its spores into damaged tissue along with foreign bodies and/or other bacteria to provide the necessary conditions favorable for its growth.

Tetanus is not directly transmitted from person to person. Instead tetanus spores may be introduced into the body, through a puncture wound contaminated with soil, street dust, animal feces, injected contaminated street drugs, lacerations, burns and even trivial or unnoticed wounds.

Tetanus disease is due to a potent poison produced by the bacteria. The poison has a stimulating effect on certain muscle groups. Most of the time the muscles of the jaw, face, and neck are affected first and then progressively more distant muscles such as the arms and legs. In this type of generalized tetanus, which is the most frequent form of the disease, the release of larger quantities of poison from a wound into the blood stream will tend to produce both a quicker onset and a more rapid progression of symptoms, as well as more severe disease.

The tetanus bacteria spores are found everywhere. Any wound can serve as an entry point for the disease. The number of cases of tetanus in any given population decreases as more of the population receives effective immunization. Thus, tetanus is a major problem in developing countries where compulsory immunization of children in not required or enforced. It is often among the 10 most frequent causes of death in such countries, and the number of cases per year worldwide has been estimated at 1 million.

In the United States, tetanus cases average between 50 and 100 per year, mostly in under-immunized older adults, and the source is usually a wound. About 30% of the people who get tetanus die from it.

The time between an injury and the occurrence of first symptoms is typically less than 2 weeks but may range from 2 days to months. Usually the shorter the period the more severe the disease.

Initial symptoms of tetanus may include such complaints as localized or generalized weakness, stiffness or cramping, or difficulty chewing and swallowing food. An early sign is often the complaint of "lockjaw". Increasing muscle rigidity follows in the generalized disease and progressively involves more muscle groups.

For patients who survive tetanus recovery can be long (1-2 months) and arduous. Muscle spasms may begin to decrease after 10-14 days and disappear after another week or two. Residual weakness, stiffness, and other complaints may persist for a prolonged period, but complete recovery can occur from uncomplicated tetanus.

Patients with tetanus are hospitalized in an intensive care unit until it is clear that progression of disease has stabilized at a level that does not interfere with vital functions and therapy can be managed outside the unit.

Human tetanus immune globulin (TIG) is administered intramuscularly as soon as possible to neutralize the toxin that has not gained entry to the nervous system.

Illness with tetanus usually does not result in immunity, therefore immunization for all recovered patients is recommended.

TETANUS - PREGNANCY
A pregnant woman should not be concerned if she inadvertently received a dose of tetanus toxoid. In fact a previously unimmunized pregnant woman who may deliver her child under unhygienic circumstances should receive two doses of the adult formulated tetanus and diphtheria toxoid vaccination. The doses should be spaced as usual, 4 to 8 weeks apart, during the last two trimesters. Incompletely immunized pregnant women should complete the 3 dose series. Those immunized more than 10 years previously should have a booster dose.

The children of a pregnant women can receive tetanus toxoid. This will pose no risk to the pregnant woman.

TETANUS - WOUNDS
Appropriate treatment of patients with wounds is very important for preventing tetanus. Tetanus-prone wounds include those contaminated with dirt, feces, or saliva; puncture wounds; tears; and wounds from bullets, crushing, burns and frostbite. Cleansing of the wound and use of antibiotics for contaminated or infected wounds may also reduce the likelihood of tetanus.

Persons who have wounds may need either the primary series, a booster dose, or no additional doses, depending on whether they previously have had tetanus toxoid.

Tetanus toxoid can not act fast enough to give immunity to someone who has been wounded, particularly for those who are not completely vaccinated against tetanus. There is a substance called tetanus immune globulin (TIG) which can provide immediate immunity, and which may be given for tetanus- prone wounds. Questionable injuries are best examined by local physicians or health-care providers who are trained to evaluate wounds and recommend treatment procedures.

TETANUS - VACCINE INFORMATION
Tetanus toxoid has proved to be safe and effective since its introduction during the 1920's. Tetanus toxoid consists of inactivated tetanus toxin. For practical purposes tetanus should be considered a disease against which there is no naturally acquired immunity and one that is entirely preventable with appropriate immunization and wound care.

Tetanus toxoid is very effective in preventing illness. There are two types of tetanus toxoid available, and both produce immunity to the tetanus toxin or poison. Tetanus toxoid is available by itself, or frequently is administered as one of two or three components in a vaccine. It can be combined as follows:

1. with diphtheria toxoid and pertussis vaccine (DTP) for primary immunization of children younger than 7 years old,
2. with full-dose diphtheria toxoid (DT) for children who are younger than 7 years old and have a medical reason not to receive pertussis vaccination, and
3. with reduced-dose diphtheria toxoid (Td) for immunization of older children and adults.

Completion of the primary series will produce immunity to tetanus for at least 10 years in 95 percent or more of the vaccinees. Booster doses are recommended every 10 years to ensure the maintenance of protective antitoxin levels.

However, anyone who sustains a wound other than a minor cut - and especially a wound that is deep or becomes contaminated with dirt - should receive a tetanus booster if more than 5 years have elapsed since the last dose. If you aren't sure whether your wound is serious enough to require a dose of tetanus toxoid, check with your doctor.

WHO SHOULD RECEIVE THE VACCINE & DOSING SCHEDULE
Primary tetanus immunization, usually the combined diphtheria, tetanus, pertussis (DTP) shot, is recommended for all persons at least 6 weeks old, but less that 7 years of age who do not have a medical reason to be exempted from immunization. The recommended five dose routine schedule calls for DTP vaccinations at 2 months, 4 months, 6 months, 15 months, and 4 to 6 years. After the initial dose of the primary series, the second and third doses are spaced 4-8 weeks apart. The fourth dose of the primary series should be given approximately one year after the third dose. Normally, a fifth dose should be given after the fourth birthday but before the seventh birthday. The fifth dose is not required for children who receive their fourth dose after their fourth birthday.

For persons over 7 years old, a different, adult formulated vaccine, containing tetanus and diphtheria, but no pertussis, is recommended. For primary immunization a series of three doses of adult formulated tetanus and diphtheria toxoid is recommended. The second dose is given 4 to 8 weeks after the first, and the third dose is given 6 to 12 months after the second.

If a dose is given as part of wound management, the next booster dose is not needed for an additional 10 years. More frequent boosters are not needed and have been reported to increase the number and severity of adverse reactions.

BOOSTER DOSES
A booster dose of the adult formulated combined tetanus and diphtheria toxoids is recommended for all persons over 7 years of age. Normally the first booster dose is given 10 years after the last dose in the primary series (usually between 14 and 16 years of age), and then every 10 years thereafter.

If a dose is given as part of wound management, the next booster dose is not needed for an additional 10 years. More frequent boosters are not needed and have been reported to increase the number and severity of adverse reactions.

NORMAL SIDE EFFECTS AND ADVERSE REACTIONS
Reactions to tetanus vaccine are generally minor and local, such as redness, swelling or tenderness at the site of injection, but the administration of more frequent booster vaccinations increases the risk of these and, also generalized reactions such as fever.

Local reactions are similar to DTP, but are generally milder. They are usually self-limited and require no therapy.

Severe local reactions, for example painful swelling from shoulder to elbow, generally beginning 2-8 hours after injections, have been reported in some adults, particularly those who have received frequent, which means annual, doses of tetanus toxoid. Persons experiencing these severe reactions should not get routine or emergency booster doses of adult formula tetanus - diphtheria toxoid more frequently than every 10 years. Less severe local, allergic reactions may occur in persons who have had multiple prior boosters. Rarely, severe reactions such as generalized rashes, difficulty in breathing, or nervous system problems have been reported after receipt of tetanus toxoid.

WHO SHOULD NOT RECEIVE THE VACCINE
Children with moderate or severe fever can be vaccinated as soon as they have recovered. Children with minor illness, such as a mild upper-respiratory infection with or without low-grade fever, can be vaccinated.

Persons on immunosuppressive therapies given for cancer or other treatments may not develop the same immune response as a normal person. Therefore, if immuno-suppressive therapy is to be discontinued shortly, it is reasonable to defer immunization until the patient has been off the therapy for one month, otherwise, give it now.

Any person who experienced difficulty in breathing following a previous dose of tetanus toxoid should not receive further doses of tetanus toxoid. If there is reason to suspect a sensitive reaction to tetanus toxoid, skin testing may be useful before deciding whether to discontinue tetanus toxoid immunization altogether.

Persons who develop encephalitis, which is a swelling of the covering of the brain, within 7 days of DTP immunization should not receive additional immunizations containing the pertussis vaccine. It may be desirable to postpone further doses of diphtheria-tetanus toxoid until the child's neurologic status becomes clear.

Immunizing children with known or suspected problems with the brain must be decided on an individual basis. A family history of convulsions or other central nervous system disorders does not justify withholding DTP immunization.

TETANUS - STATISTICS
There was a marked decrease in tetanus associated deaths from the early 1900's to the late 1940's. In the late 1940's, tetanus toxoid was introduced into routine childhood immunization and the public health departments began to keep track of the number of tetanus cases.

Since the 1940's, the reported number of tetanus cases has fallen steadily. However, over the past decade, the rate of decline has decreased only slightly. An all-time low of 48 cases was reported in 1987. About three out of every 10 cases results in death.

Cases of tetanus occur nationwide. However, the largest proportion occurs in the Southeast, with highest number in the summer months. Adults over 50 and non-white individuals are most often affected. Essentially all reported cases are in individuals who have either never been vaccinated, or who completed a primary series but have not had a booster in the preceding 10 years. Another high-risk group is heroin addicts, particularly persons who inject themselves with quinine. Quinine, used to dilute heroin, may actually help tetanus bacteria to grow.

New-born infants delivered from unimmunized mothers in poor hygienic conditions are yet another high-risk group. From 1972 to 1985, 29 cases of tetanus in newborn infants were reported, however, since 1985 there has been only one new case reported.

Case fatality rates during 1985-86 in the United States were only 5 percent for children and adults less than 50 years old but rose to 42 percent for patients 50 years of age or older. The availability of modern intensive care units has been associated with significant reductions in deaths due to tetanus.

*Use of trade names is for identification only and does not imply endorsement by the Public Health Service or the U.S. Department of Health and Human Services. Aspirin products are not generally recommended for children.