Tetanus

Definition

Tetanus is a rare but often fatal disease that affects the central nervous system by causing painful and often violent muscular contractions. The earliest descriptions of the disease can be found in the medical papyri of ancient Egypt. The disease begins when the tetanus bacterium (Clostridium tetani ) enters the body, usually through a wound or cut that has come in contact with the spores of the bacterium. Tetanus spores are commonly found in soil, dust, and animal manure. Tetanus is a noncommunicable disease, meaning that it cannot be passed directly from one person to another.

Description

Tetanus is uncommon in the United States, with nearly all cases occurring in adults who were not vaccinated as children, or in those who have not had a booster vaccination in 10 years.

In the United States, there are between 50 and 100 reported cases of tetanus a year. About 30% of cases are fatal. Most people who die of tetanus infections are over 50 years old.

Tetanus causes convulsive muscle spasms and rigidity that can lead to respiratory paralysis and death. It is sometimes called "lockjaw" because one of the most common symptoms is a stiff jaw that cannot be opened. Sometimes tetanus is localized, that is; it affects only the part of the body where the infection began. However, in almost all reported cases, tetanus spreads to the entire body. The incubation period from the time of the injury until the first symptoms appear ranges from five days to three weeks. Symptoms usually occur within eight to 12 days. The chance of death is increased when symptoms occur early.

Causes & symptoms

Tetanus is caused by a bacterium called Clostridium tetani, whose spores (the dormant form) are found in soil, street dust, and animal feces. The bacteria enter the body through cuts and abrasions but will multiply only in an environment that is anaerobic, or oxygen-free. Deep puncture wounds and wounds with a lot of dead tissue provide an oxygen-free environment for the bacteria to grow.

As C. tetani grows, it excretes a highly poisonous toxin called tetanospasmin into the bloodstream, spreading it throughout the nervous system. The infection is usually transmitted through deep puncture wounds or through cuts or scratches that are not cleaned well. Many people associate tetanus with rusty nails and other dirty objects, but any wound can be a source. Less common ways of getting tetanus are animal scratches and bites; surgical wounds; dental work; punctures caused by glass, thorns, needles, and splinters; and therapeutic abortion. Rare cases have been reported in people with no known wound or medical condition.

Neonatal tetanus in newborns can be caused by cutting the umbilical cord with an unsterile instrument or by improper care of the umbilical stump. Neonatal tetanus is less common in developed countries.

Tetanus toxin affects the nerve endings, causing a continuous stimulation of the muscles. Initial symptoms may include restlessness, irritability, a stiff neck, and difficulty swallowing. In about half of all cases, the first symptom is a stiff or "locked" jaw, which prevents patients from opening their mouths or swallowing. This symptom is also called trismus and results in a facial expression called risus sardonicus, which is a Latin phrase meaning "sardonic smile." Trismus is often followed by stiffness of the neck and other muscles throughout the body as well as uncontrollable spasms. Sometimes these convulsions, known as opisthotonos, are severe enough to cause broken bones. Other symptoms of tetanus include loss of appetite and drooling. People with localized tetanus experience pain and tingling only at the wound site and spasms in nearby muscles.

In the underdeveloped world, neonatal tetanus accounts for about one-half of tetanus deaths and is related to infection of the umbilical stump in a baby born of an unimmunized mother. In many cases the risk is increased by the mother's giving birth on a floor made of hardpacked soil. Worldwide, 800,000 children die of tetanus each year.

Diagnosis

Tetanus is diagnosed by the clinical symptoms and a medical history that shows no tetanus immunization. Early diagnosis and treatment is crucial for recovery.

In general, the shorter the incubation period, the more severe the disease.

Treatment

As traditional medical treatment revolves around drug therapy, traditional Chinese medicine herbal remedies are the most common alternative treatment for tetanus. Herbs that have sedative effects should be given to reduce the frequency of convulsions, along with herbs to fight the bacteria.

Tetanus and convulsions can be treated with a concoction made from the dried body of a long-nosed pit viper, called this drug Qi She in Mandarin. Chan Tui, or cicada slough (the skin the cicada sheds) is also helpful. Also helpful are the dried root of the Saposhnikovia divaricata, called divaricate saposhnikovia root, and jack-in-the-pulpit tuber, if it is treated to remove toxins.

There are several alternative treatments aimed at prevention of the disease.

Allopathic treatment

Tetanus is a life-threatening disease. Patients diagnosed with it are usually hospitalized, usually in an intensive care ward. Treatment can take several weeks and includes antibiotics to kill the bacteria and shots of antitoxin to neutralize the toxin. It also includes antianxiety drugs to control muscle spasms or barbiturates for sedation. In severe cases, patients are placed on an artificial respirator. Recovery can take six weeks or more. After recovery, since the levels of circulating toxin are quite low, the patient must still be adequately immunized against this disease.

Expected results

Full recovery is common in patients who can be kept alive during the most violent portion of the attacks. Yet up to 30% of tetanus victims in the United States die. Early diagnosis and treatment improves the prognosis. Neonatal tetanus, however, has a mortality rate of more than 90%.

Prevention

Castor oil is a natural remedy that can be used to clean out a wound and prevent tetanus. When a wound is sustained, a cotton ball dunked in castor oil should be placed on the wound, and then fixed on the wound with a bandage. Castor oil has tremendous drawing power and can pull out rust and other infectious agents. The dressing should be changed every two hours the first day of treatment and twice a day for the next three days.

Tetanus is easily preventable through vaccination. All children should have a series of five doses of DTaP, a combined vaccine that offers protection against diphtheria, tetanus, and pertussis, before the age of seven. This measure is supported by numerous organizations, including the World Health Organization, the Centers for Disease Control and Prevention, the Advisory Committee on Immunization Practices, the Committee on Infectious Diseases of the American Academy of Pediatrics, and the American Academy of Family Physicians. Children in the United States will not be admitted to school without proof of this and other immunizations.

The DTaP vaccine should be given at ages two months, four months, six months, 15-18 months, and four to six years. DTaP is the preferred vaccine for children up to the age of seven in the United States; it has fewer side effects than DTP and can be used to complete a vaccination schedule begun with DTP. DTaP was first approved by the Food and Drug Administration in September 1996. In December 1996, it was approved for use in infants. Between age 11 and 13, children should have a booster, called Td, for diphtheria and tetanus.

Adults should have a Td booster every 10 years. Statistics from the Centers for Disease Control and Prevention show that fewer than half of Americans aged 60 and older have antibodies against tetanus. The Centers for Disease Control and Prevention suggests that adults be revaccinated at mid-decade birthdays (for example, at 45). Adults who have never been vaccinated against tetanus should get a series of three injections of Td over six to 12 months and then follow the 10-year booster shot schedule.

Side effects of the tetanus vaccine are minor: soreness, redness, or swelling at the site of the injection that appear any time from a few hours to two days after the vaccination and disappear in a day or two. Rare but serious side effects that require immediate treatment by a doctor are serious allergic reactions or deep, aching pain and muscle wasting in the upper arms. These symptoms could start from two days to four weeks after the shot and could continue for months.

For those who are averse to immunizations, tetanus immunity can be boosted naturally by taking vitamin E , according to a study from Tufts University in Medford, Massachusetts. To get the most benefit, 200 mg should be taken daily.

Keeping wounds and scratches clean is important in preventing infection. Since C. tetani grows only in the absence of oxygen, the wounds must be adequately cleaned of dead tissue and foreign substances. Run cool water over the wound and wash it with a mild soap. Dry it with a clean cloth or sterile gauze. To help prevent infection, apply an antibiotic cream or ointment and cover the wound with a bandage. Try the castor oil remedy. The longer a wound takes to heal, the greater the chance of infection. Consult a doctor if the wound doesn't heal, if it is red or warm, or if it drains or swells.

If the wounded individual does not have an adequate history of immunization, a doctor may administer a specific antitoxin (human tetanus immune globulin, TIG) to produce rapid levels of circulating antibody. The antitoxin is given at the same time as a dose of vaccine but at a separate site.

Some persons will report a history of significant allergy to "tetanus shots." In most cases, the reaction occurred in the remote past and was probably caused by antitoxin derived from horse serum. More recently, however, the use of aluminum as an adjuvant, or substance added to a vaccine to increase the body's immune response, has been associated with skin eruptions and swelling in hypersensitive individuals. In some cases, these persons can be safely vaccinated for tetanus with a graduated series of shots. Adverse reactions of any kind to tetanus vaccine should be reported to the Center for Biologics Evaluation and Research (CBER) of the Food and Drug Administration (FDA).

Resources

BOOKS

Evelyn, Nancy. The Herbal Medicine Chest. Trumansburg, N.Y.: The Crossing Press, 1986.

Magill's Medical Guide, edited by Tracy Irons-Georges. Englewood Cliffs, N.J.: Salem Press, 1998.

PERIODICALS

Baylor, N. W., W. Egan, and P. Richman. "Aluminum Salts in Vaccines—US Perspective." Vaccine 20 (May 31, 2002)(Supplement 3): S18-S23.

Quddus, A., et al. "Neonatal Tetanus: Mortality Rate and Risk Factors in Loralai District, Pakistan." International Journal of Epidemiology 31 (June 2002): 648-653.

Rennels, M. B., M. A. Deloria, M. E. Pichichero, et al. "Lack of Consistent Relationship Between Quantity of Aluminum in Diphtheria-Tetanus-Acellular Pertussis Vaccines and Rates of Extensive Swelling Reactions." Vaccine 20 (May 31, 2002)(Supplement 3): S44-S47.

Shin, D. H., J. H. Park, P. J. Jung, et al. "A Case of Maternal Tetanus in Korea." Journal of Korean Medical Science 17 (April 2002): 260-262.

Williams, A. N., et al. "Tetanus Immunisation in Hypersensitive Individuals." Journal of the Royal Army Medical Corps 148 (June 2002): 148-150.

ORGANIZATIONS

Food and Drug Administration (FDA), Center for Biologics Evaluation and Research (CBER), 1401 Rockville Pike, Suite 200-N, Rockville, MD 20852. <www.fda.gov/cber>.

OTHER

Centers for Disease Control and Prevention. "Tetanus & Diphtheria (Td) Vaccine." Healthtouch Online. http://www.healthtouch.com/bin/EContent_HT/showAllLfts.asp.

"Shots for Safety." National Institute on Aging Age Page. www.nih.gov/nia/health/pubpub/shots.htm.

"TCM Herbal Database." China-Med.net. http://www.chinamed.net/herb_search.html.

Lisa Frick

Rebecca J. Frey, PhD

Tetanus

Definition

Tetanus is a rare but often fatal disease that affects the central nervous system by causing painful muscular contractions. It begins when tetanus bacteria enter the body, usually through a wound or cut exposed to contaminated soil. Tetanus is easily preventable through vaccination.

Description

Tetanus is rare in the United States, with nearly all cases occurring in adults who were not vaccinated as children. About 100 cases are reported each year; 63% of these occur in people over the age of 50. The number of tetanus cases in the United States has steadily decreased since the 1940s (500 to 600 cases per year); the number of reported cases has remained at approximately 50 to 100 cases per year since the mid-1970s. In 1999, however, the lowest number of annual cases to date was reported (33, or 0.02 per 100,000).

Tetanus causes convulsive muscle spasms and rigidity that can lead to respiratory paralysis and death. It is sometimes called "lockjaw" because one of the most common symptoms is a stiff jaw, unable to be opened. Sometimes, tetanus affects only the part of the body where the infection began, but in almost all of reported cases, it spreads to the entire body. The incubation period from the time of the injury until the first symptoms appear ranges from two to 50 days. Symptoms usually occur within five to 10 days. When symptoms occur early, the chance of death is increased. Tetanus is not contagious.

Causes and symptoms

Tetanus is caused by a bacteria called Clostridium tetani, whose spores (the dormant form) are found in soil, street dust, and animal (or even human) feces. Tetanus spores germinate in the body, producing a highly poisonous neurotoxin in the blood, spreading to the nervous system. The infection is usually transmitted through deep puncture wounds or cuts or scratches that are not cleaned well. Between 1997 and 1999, approximately 64% of tetanus cases in the United States were associated with such wounds as punctures, lacerations, or abrasions. Many people associate tetanus with rusty nails and other dirty objects, but any wound can be a source. Less common ways of getting tetanus are animal scratches and bites, surgical wounds, dental work, and therapeutic abortion. About 18% of cases reported between 1997 and 1999 were a result of intravenous drug use. Cases have also been reported in people with no known wound or medical condition.

The first symptom of tetanus is often a stiff or "locked" jaw that prevents the patient from opening his/her mouth or swallowing. This is also called trismus and results in a facial expression called a sardonic smile (or risus sardonicus). Stiffness of the neck and other muscles throughout the body and uncontrollable spasms often follow. Sometimes these convulsions are severe enough to cause broken bones. The bacterial toxin (tetanospasmin ) affects the nerve endings, causing a continuous stimulation of muscles. Other symptoms include irritability, restlessness, loss of appetite, and drooling. People with tetanus that is localized experience pain and tingling only at the wound site and spasms in nearby muscles.

In the underdeveloped world, neonatal tetanus accounts for about one-half of tetanus deaths and is related to infection of the umbilical stump in a baby born of an unimmunized mother. The Centers for Disease Control and Prevention (CDC) estimate that over 270,000 deaths occur annually worldwide as a result of neonatal tetanus. In contrast, only two cases of neonatal tetanus in the United States were reported to the CDC between 1989 and 1999. Mothers who have been adequately immunized against tetanus protect their newborns by passing the antibody through the placenta.

Diagnosis

Tetanus is diagnosed by the clinical symptoms and a medical history that shows no tetanus immunization. Early diagnosis and treatment is crucial to recovery from tetanus.

Treatment

Tetanus is a life-threatening disease that requires immediate hospitalization, usually in an intensive care unit (ICU). Treatment can take several weeks and includes antibiotics to kill the bacteria and shots of antitoxin to neutralize the toxin. It also includes muscle-relaxing drugs to control muscle spasms or barbiturates for sedation. In severe cases, patients are placed on an artificial respirator. Recovery can take six weeks or more. After recovery, since the levels of circulating toxin are too low to stimulate natural antibody production, the patient must still be immunized against this disease to prevent reinfection.

Prognosis

Up to 30% of tetanus victims in the United States die. Early diagnosis and treatment improves the prognosis. Neonatal tetanus has a mortality rate of more than 90%.

Prevention

Pre-exposure vaccination

Tetanus is easily preventable through vaccination. All children should have a series of five doses of DTaP, a combined vaccine that offers protection against diphtheria, tetanus, and pertussis, before the age of seven, according to the Centers for Disease Control and Prevention's national immunization guidelines, the Advisory Committee on Immunization Practices, the Committee on Infectious Diseases of the American Academy of Pediatrics, and the American Academy of Family Physicians. Children will not be admitted to school without proof of this and other immunizations.

The DTaP (diptheria, tetanus, accellular pertussis) vaccine should be given at ages two months, four months, six months, 15 to 18 months, and four to six years. DTaP is the preferred vaccine for children up to the age of seven in the United States; it has fewer side effects than DTP and can be used to complete a vaccination schedule begun with DTP. DTaP was first approved by the Food and Drug Administration (FDA) in September 1996. In December 1996, it was approved for use in infants. Between the ages of 11 and 13, children should have a booster for diphtheria and tetanus, called Td.

Adults should have a Td booster every 10 years. Statistics from the Centers for Disease Control and Prevention (CDC) show that fewer than half of Americans 60 years of age and older have antibodies against tetanus. The CDC suggests adults may be revaccinated at mid-decade birthdays (for example, 45, 55). Adults who have never been vaccinated against tetanus should get a series of three injections of Td over six to 12 months and then follow the 10-year booster shot schedule.

Side effects of the tetanus vaccine are minor: soreness, redness, or swelling at the site of the injection that appear anytime from a few hours to two days after the vaccination and go away in a day or two. Rare but serious side effects that require immediate treatment by a doctor are serious allergic reactions or deep, aching pain and muscle wasting in the upper arms. These symptoms could start from two days to four weeks after the shot and could continue for months.

In early 2001, a shortage of the tetanus vaccine became evident after the pharmaceutical company Wyeth-Ayerst Laboratories decided to stop production of the tetanus vaccine, leaving Aventis-Pasteur as the sole manufacturer of the vaccine. As a result, hospitals were provided with only a minimal amount of the drug on a weekly basis—enough to vaccinate patients with potentially infected wounds and other priority cases. Despite stepped-up production efforts on the part of the manufacturer, however, a spokesperson for Aventis-Pasteur predicted that the shortage would last until the end of 2001, as the vaccine takes 11 months to produce.

Post-exposure care

Keeping wounds and scratches clean is important in preventing infection. Since this organism grows only in the absence of oxygen, wounds must be adequately cleaned of dead tissue and foreign substances. Run cool water over the wound and wash it with a mild soap. Dry it with a clean cloth or sterile gauze. To help prevent infection, apply an antibiotic cream or ointment and cover the wound with a bandage. The longer a wound takes to heal, the greater the chance of infection. If the wound doesn't heal, or, it is red, warm, drains, or swells, consult a doctor.

Following a wound, to produce rapid levels of circulating antibody, a doctor may administer a specific antitoxin (human tetanus immune globulin, TIG) if the individual does not have an adequate history of immunization. The antitoxin is given at the same sitting as a dose of vaccine but at separate sites. Some individuals will report a history of significant allergy to "tetanus shots." In most cases, this occurred in the remote past and was probably due to the previous use of antitoxin derived from horse serum.

KEY TERMS

Clostridium — A genus of deadly bacteria that are responsible for tetanus and other serious diseases, including botulism and gangrene from war wounds. Clostridia thrives without oxygen.

DTaP— Diphtheria and tetanus toxoids and accellular pertussis combination vaccine.

DTP— Diphtheria, tetanus, and whole-cell pertussis vaccine.

Td— Tetanus and diphtheria vaccine.

Toxin— A poisonous substance that flows through the body.

Wound— Any injury that breaks the skin, including cuts, scratches, and puncture wounds.

Resources

PERIODICALS

Landers, Susan J. "Tetanus vaccine shortage leads to rationing." American Medical News. March 19, 2001. 〈http://www.ama-assn.org/sci-pubs/amnews/pick_01/hlsb0319.htm〉.

OTHER

"Tetanus." Centers for Disease Control and Prevention. 〈http://www.cdc.gov/nip/publications/pink/tetanus.pdf〉.

Tetanus (Lockjaw)

What Is Tetanus?

How Common Is It?

Is Tetanus Contagious?

What Are the Signs and Symptoms of Infection?

How Do Doctors Make the Diagnosis?

What Is the Treatment for Tetanus?

How Long Does Tetanus Last?

What Are the Complications?

Can Tetanus Be Prevented?

Resources

Tetanus (TET-nus) is a serious bacterial infection that affects the body’s central nervous system*. Tetanus, also known as lockjaw, can lead to muscle rigidity, convulsions*, and death.

*central nervous system

(SEN-trul NER-vus SIS-tem) is the part of the nervous system that includes the brain and spinal cord.

*convulsions

(kon-VUL-shuns), also called seizures, are involuntary muscle contractions caused by electrical discharges within the brain and are usually accompanied by changes in consciousness.

KEYWORDS

for searching the Internet and other reference sources

Clostridium tetanl

Lockjaw

Tetanospasmin

Trismus

What Is Tetanus?

Tetanus is a disease caused by infection with Clostridium tetani (klos-TRIH-dee-um teh-TAH-nye) bacteria, which are found all over the world in soil, dust, and some animal feces (FEE-seez, or bowel movements) and even on human skin. The bacteria can enter the body through any type of wound, such as a scratch or deep cut. Infection begins after bacterial spores* have moved deep within the body and become active. Clostridium tetani bacteria are anaerobic (ah-nuh-RO-bik), meaning that they grow best in places with very little oxygen—so the deeper they travel into the body, the better their chances to survive.

*spores

are a temporarily inactive form of a germ enclosed in a protective shell.

Once tetanus spores become active, the bacteria begin producing a toxin (a poisonous substance) called tetanospasmin (teh-tuh-no-SPAZ-min), which attaches to the nerves around the area of the wound. The tetanus toxin also can spread and attach to the ends of nerves of the spinal cord and at neuromuscular junctions (where nerves meet muscles). The toxin blocks the release of a neurotransmitter (nur-o-trans-MIH-ter), a chemical that carries a signal from nerves to other nerves or muscles. This affects the messages that the muscles receive, resulting in severe muscle spasms* that can be powerful enough to tear muscles apart.

*spasms

(SPAH-zumz) are involuntary muscular tightenings or contractions.

There are three types of tetanus infection. Local tetanus is limited to the area of the wound; cephalic (seh-FAH-lik) tetanus is an uncommon form that affects the nerves of the face after a head injury or, rarely, a long-lasting ear infection; and generalized tetanus affects much of the body and accounts for the majority of tetanus cases. Neonatal tetanus is a generalized form of the infection that occurs in newborns. It is caused by bacteria contaminating the stump of the umbilical cord*, particularly if the cord has been cut with an instrument that has not been sterilized*.

*umbilical

(um-BIH-lih-kul) cord is the flexible cord that connects a baby to the placenta, the organ that unites the unborn child to the mother’s uterus, the organ in which the baby develops.

*sterilize

(STAIR-uh-lyze) is to eliminate all live bacteria or microorgranisms from something, usually through the use of heat, pressure, chemicals, or other antimicrobial agents.

How Common Is It?

Tetanus occurs around the world but is found frequently in densely populated areas that have hot, damp climates. The disease is rare in the United States, primarily because of vaccination. Nearly all reported cases of tetanus occur in people who have never been vaccinated or who have not had a booster shot in the previous 10 years. Neonatal tetanus infection is rare in developed countries because of improved surgical techniques, but there are hundreds of thousands of deaths from tetanus annually worldwide, mostly in developing countries. Intravenous* drug abusers, such as people who inject heroin, are at a higher risk of contracting the disease.

*intravenous

(in-tra-VEE-nus), or IV, means within or through a vein. For example, medications, fluid, or other substances can be given through a needle or soft tube inserted through the skin’s surface directly into a vein.

Is Tetanus Contagious?

Tetanus is not spread from person to person. Bacterial spores must enter a wound for the infection to spread.

What Are the Signs and Symptoms of Infection?

Symptoms of tetanus appear from 3 to 21 days or longer after infection, but usually they develop within 7 days. In about 50 percent of generalized cases of tetanus, the first sign is trismus, or stiffness in the jaw muscles (also known as lockjaw), followed by a stiff neck, shoulder, or back; trouble swallowing; and fever. Spasms can soon spread to the abdominal* muscles, upper arms, and thighs. Other symptoms include sweating, high blood pressure, and periods of rapid heartbeat. The closer the infection is to the central nervous system, the sooner the symptoms appear. The earlier the symptoms begin to appear, the greater the risk of death.

*abdominal

(ab-DAH-mih-nul) refers to the area of the body below the ribs and above the hips that contains the stomach, intestines, and other organs.

How Do Doctors Make the Diagnosis?

The diagnosis is made based on the presence of symptoms and the patient’s history (for example, getting a wound by stepping on a soil-contaminated nail). Laboratory tests are not useful in determining whether a patient has tetanus. A culture* of the wound can be done, but these cultures generally do not show the bacteria.

*culture

(KUL-chur) is a test in which a sample of fluid or tissue from the body is placed in a dish containing material that supports the growth of certain organisms. Typically, within days the organisms will grow and can be identified.

What Is the Treatment for Tetanus?

Typically, tetanus infection is treated in a hospital. Treatment begins with giving the patient tetanus immune globulin* to control or reverse the effects of toxin that has not yet attached itself to nerve endings. Penicillin or other antibiotics also may be given to kill the bacteria. Cleaning the wound and removing dead tissue, in some cases by surgery, is important in ridding the body of invading bacteria. Muscle spasms can be treated with muscle relaxants. Respiratory system* support, provided by a respirator*, may be necessary to help maintain breathing if the respiratory muscles have been affected.

*immune globulin

(ih-MYOON GLAH-byoo-lin), also called gamma globulin, is the protein material that contains antibodies.

*respiratory system ,

or respiratory tract, includes the nose, mouth, throat, and lungs. It is the pathway through which air and gases are transported down into the lungs and back out of the body.

*respirator

is a machine that helps people breathe when they are unable to breathe adequately on their own.

How Long Does Tetanus Last?

Symptoms may last 3 to 4 weeks, although complete recovery can take several months. Tetanus can be mild, but in most cases the illness is severe and death may occur even after treatment has begun. Tetanus usually requires a long stay in the intensive care unit of the hospital.

What Are the Complications?

Complications of the illness include spasms of the vocal cords and the muscles that control breathing, which can lead to difficulty breathing; fractures in the long bones or the spine from severe muscle spasms and convulsions; high blood pressure; abnormal heart rhythm; secondary infections, such as sepsis* and pneumonia (inflammation of the lung); a blood clot* in the lungs; and death. In the United States, 11 percent of reported tetanus cases are fatal. Unvaccinated children and the elderly are at greater risk of dying if they become infected with tetanus bacteria.

*sepsis

is a potentially serious spreading of infection, usually bacterial, through the bloodstream and body.

*blood clot

is a thickening of the blood into a jelly-like substance that helps stop bleeding. Clotting of the blood within a blood vessel can lead to blockage of blood flow.

Can Tetanus Be Prevented?

Immunization is the best means of preventing tetanus. The vaccination usually is given in combination with other vaccines: the DTaP (diphtheria*/tetanus/acellular pertussis*) form for children and the Td (tetanus/diphtheria) form for adults. A series of shots is required to develop immunity to tetanus toxin, followed by booster shots every 10 years. In some cases of unclean wounds, a booster will be given after the injury to help prevent tetanus.

*diphtheria

(dif-THEER-e-uh) is an infection of the lining of the upper respiratory tract (the nose and throat). It is a serious disease that can cause breathing difficulty and other complications, including death.

*pertussis

(per-TUH-sis) is a bacterial infection of the respiratory tract that causes severe coughing.

See also

Skin and Soft Tissue Infections

Vaccination (Immunization)

Resources

Organization

U.S. Centers for Disease Control and Prevention (CDC), 1600 Clifton Road, Atlanta, GA 30333. The CDC provides fact sheets and other information on tetanus at its website.

Telephone 800-311-3435 http://www.cdc.gov

Website

KidsHealth.org. KidsHealth is a website created by the medical experts of the Nemours Foundation and is devoted to issues of children’s health. It contains articles on a variety of health topics, including tetanus.

http://www.KidsHealth.org

Tetanus

Introduction

Disease History, Characteristics, and Transmission

Scope and Distribution

Treatment and Prevention

Impacts and Issues

BIBLIOGRAPHY

Introduction

Tetanus is a serious but easily prevented acute neurological disease that affects the muscles and nerves of the human body. The bacterium Clostridium tetani causes the disease, typically through any injury to the skin, such as a burn, crushing injury, cut, gangrene, or wound, that becomes contaminated. Tetanus can also come about from the use of non-sterile needles in drug use, body piercing, and tattooing. Tetanus can be classified as local tetanus (muscle contraction in one local area) and cephalic tetanus (found in the middle ear). Newborn babies can also get neonatal tetanus, a special type of tetanus, when they are born in unsanitary conditions.

However, most tetanus is generalized tetanus, which descends from the head down through the body. Once in the human body, the bacteria produce a neurotoxin (a poisonous protein that acts on the nervous system) called tetanospasmin. The neurotoxin causes contraction and rigidity of the skeletal muscles. According to the U.S. Centers for Disease Control and Prevention (CDC), tetanus cannot be spread from human to human. Thus, it is not contagious.

Disease History, Characteristics, and Transmission

Tetanus has been medically reported as far back as the fifth century BC. According to the CDC, the first passively transferred antitoxin (an antibody that is able to neutralize a toxin) was developed in 1897. In 1924, the first tetanus toxoid was developed. A toxoid is a toxin that has been treated to destroy toxicity, but the toxoid is still capable of inducing the formation of antibodies when injected into the human body.

C. tetani is widely found in soil and in the intestines and feces of such animals as cattle, chickens, cats and dogs, guinea pigs, horses, rats, and sheep. Manuretreated soils also may contain large amounts of the bacteria. Cases of tetanus in the United States are usually from a cut or deep wound that has been contaminated with feces, saliva, or soil.

The puncture of the skin with a rusty nail, for instance, is typically seen as the source of possible tetanus. However, rust does not cause tetanus, but the nail itself causes the puncture into the skin and the rust may only harbor C. tetani on its surface.

The first sign of tetanus is usually in the nerves that control the muscles near the wound, which first allowed the bacterium to enter the body. Later, as the bacteria have had time to travel through the bloodstream and lymph system, other nerves become adversely affected. The widely spreading bacteria soon produce general muscle spasms. Without treatment, tetanus can cause death to humans.

The incubation period for tetanus is 2–21 days. Symptoms often begin around the seventh or eighth day. Initial symptoms include muscle spasms in the jaw (what is called trismus and what gives tetanus its commonly used name—lockjaw). Later, swallowing may become difficult and stiffness or pain may occur in the muscles of the shoulders, neck, and back. Still later, additional spasms may spread throughout the muscles of the upper arms, thighs, and abdomen. Other symptoms include fever, sweating, high blood pressure, and rapid heart rate. Symptoms generally begin to subside after about 17 days. Spasms may continue for three to four weeks. A complete recovery may take months.

Scope and Distribution

Tetanus is relatively rare in the United States and other countries with comprehensive tetanus vaccination programs to prevent and immunize their citizens when compared to countries without such programs. Most cases of tetanus occur in densely populated areas with hot, humid climates and rich organic soils. Around five cases are reported in the United States in an average year. Over two million cases are reported worldwide each year. According to the CDC, about 11% of all reported cases of tetanus around the world are fatal, totaling over 225,000 people. People most susceptible to death from tetanus are unvaccinated persons and those people over the age of 60 years.

Treatment and Prevention

Tetanus is diagnosed only by clinical signs and symptoms. There is no laboratory confirmation for the bacteria. It is treated with a tetanus booster (for children still receiving their series of tetanus shots) or an injection of tetanus antitoxin, such as tetanus immune globulin (TIG), to neutralize any toxin released by the bacteria. Intravenous immune globulin (IVIG) can be given if TIG is unavailable. Metronidazole can be given to control bacteria. The wound should be cleaned and all dead or infected skin should be removed. Severe cases of tetanus should be treated in the intensive care unit of a hospital. Medicines to control breathing and prevent muscle spasms are usually given.

Tetanus is prevented with a routine tetanus immunization. Children in the United States and other such countries usually receive an injection that combines diphtheria and tetanus toxoids with pertussis vaccine. This immunization protects children from diphtheria (throat and respiratory infection), tetanus, and pertussis (whooping cough). According to the Mayo Clinic, the latest version is called the diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccine. The DTaP vaccine generally consists of a series of five shots in the arm or thigh given to children at two months, four months, eight months, 15–18 months, and 4–6 years of age. The Mayo Clinic recommends that adolescents get a booster shot between the ages of 11 and 18 years. Thereafter, a vaccination should be given every 10 years. A medical professional should be consulted for each particular situation.

Impacts and Issues

Although tetanus is rare, it is still a serious illness. Tetanus is considered an international health problem because so many people around the world are still unvaccinated or inadequately vaccinated. It is especially serious in children. As a result, children are often treated in intensive care units of hospitals after contracting tetanus. The child being treated in such situations will usually be given antibiotics to kill bacteria and TIG to neutralize the toxins. Medicines may be given to control muscle spasms. Other medicines may need to be given to support life functions for cases involving pneumonia and other respiratory problems.

Adults may also have complications including spasms of the vocal cords, spasms of the muscles of respiration, and fractures of the spine and longer bones of the body. Various treatment methods have been tried in such serious cases. However, no medical consensus has yet been reached as to the best method to use.

WORDS TO KNOW

ANTITOXIN: An antidote to a toxin that neutralizes its poisonous effects.

INCUBATION PERIOD: Incubation period refers to the time between exposure to disease causing virus or bacteria and the appearance of symptoms of the infection. Depending on the microorganism, the incubation time can range from a few hours (an example is food poisoning due to Salmonella) to a decade or more (an example is acquired immunodeficiency syndrome, or AIDS).

TOXIN: A poison that is produced by a living organism.

TOXOID: A toxoid is a bacterial toxin that has been altered chemically to make it incapable of causing damage, but still capable of stimulating an immune response. Toxoids are used to stimulate antibody production, which is protective in the event of exposure to the active toxin.

TRISMUS: Trismus the medical term for lockjaw, a condition often associated with tetanus, infection by the Clostridium tetani bacillus. In trismus or lockjaw, the major muscles of the jaw contract involuntarily.

Even though tetanus can be prevented and treated, many countries still do not immunize their citizens against tetanus. For example, in India about 90% of the population is inadequately protected against tetanus. Many underdeveloped and developing countries continue to ignore the problem. Newborn babies are especially at risk in such countries, since their umbilical cords are likely to become infected due to unhygienic conditions during and following birth.

See AlsoBacterial Disease; CDC (Centers for Disease Control and Prevention); Diphtheria.

BIBLIOGRAPHY

Books

Atkinson, William, et al., eds. Epidemiology and Prevention of Vaccine-preventable Diseases. Atlanta: U.S. Centers for Disease Control and Prevention, 2002.

Bellenir, Karen, ed. Infectious Diseases Sourcebook. Detroit, MI: Omnigraphics, 2004.

Periodicals

Centers for Disease Control and Prevention. Advisory Committee on Immunization Practices. “Preventing Tetanus, Diphtheria, and Pertussis Among Adolescents: Use of Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular Pertussis Vaccines.” Morbidity and Mortality Weekly Report 55 (February 23, 2006): 1–34. Also available online at: <http://www.cdc.gov/mmwr/preview/mmwrhtml/rr55e223a1.htm> (accessed May 11, 2007).

Centers for Disease Control and Prevention. Advisory Committee on Immunization Practices. “Preventing Tetanus, Diphtheria, and Pertussis Among Adults: Use of Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular Pertussis Vaccines.” Morbidity and Mortality Weekly Report 55 (December 15, 2006): 1–33. Also available online at: <http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5517a1.htm> (accessed May 11, 2007).

Web Sites

Centers for Disease Control and Prevention. “Tetanus.” <http://www.cdc.gov/niP/publications/pink/tetanus.pdf> (accessed March 27, 2007).

MayoClinic.com. “Tetanus.” December 29, 2006. <http://www.mayoclinic.com/health/tetanus/DS00227/DSECTION=7> (accessed March 27, 2007).

Tetanus

Definition

Tetanus, also called lockjaw, is a serious disease of the nervous system that can cause uncontrolled muscle spasms and death. It is caused by toxins (poisons) produced by the bacterium Clostridium tetani.

Description

Tetanus occurs when the body is infected with spores of the bacterium C. tetani. This bacterium is found worldwide in soil and animal manure. The spores can remain alive in the soil for years and are resistant to heating and chemical destruction. They are more common in hot, damp environments than in cold or dry ones.

Once spores enter the body through a break in the skin, they begin producing bacteria. These bacteria multiply in areas where there is little oxygen present and produce a toxin that affects the nervous system. The toxin spreads along the nerves of the body, causing the nerves to fire (react). This results in muscle spasms and convulsions.

Transmission

The bacteria that cause tetanus enter the body through a scrape, cut, or wound, in about 70 percent of cases. The most susceptible wounds are those that are caused by blunt trauma such as crushing or by bites . The bacteria can also enter at the site of a burn, bedsore, or frostbite , or be introduced into the body during surgery. In developing countries, newborns often contract tetanus from contaminated instruments used to tie off the umbilical cord after birth. Often the site where the bacteria enter is insignificant, does not become swollen or red, and does not require medical attention. Any time between two and 50 days later (most commonly between days seven and 21 days), the individual begins to show the signs of tetanus.

The severity of the disease is related to several factors:

• The sooner symptoms appear, the more severe the disease.
• If the point of entry was in the head or face, symptoms are more severe.
• The very young and the very old suffer more severe symptoms and higher death rates.

Demographics

With almost universal vaccination starting in the 1940s, tetanus has become rare in the United States. Fewer than 50 cases have been reported annually since 1995. Worldwide, the disease is common, especially in newborns in developing parts of Asia, Africa, and South America where immunization is not universally available. The disease can affect individuals of any race, age, or gender.

Causes and symptoms

Since the incubation period can range from several days to many weeks, individuals often do not associate their initial symptoms with wound infection. The first sign of tetanus is a tightening of the jaw muscles that gives the disease its common name, lockjaw. This symptom is followed by waves of back spasms. The spasms then extend to the arms producing clenched fists and to the legs. Any stimulus, such as noise or light, can set off a round of convulsions. Other symptoms include drooling, increase in blood pressure (hypertension ), irregular heart beat, inability to open the mouth, high fever , kidney failure, and respiratory failure.

When to call the doctor

Tetanus is a medical emergency, and individuals should be taken to the emergency room as soon as symptoms are noticed. About 75 percent of individuals with tetanus are first seen by a dentist or oral surgeon for pain and stiffness in the jaw and mouth region.

Diagnosis

Diagnosis of tetanus is based on presenting symptoms rather than laboratory tests. Less than one-third of the time can the bacteria that causes the disease be cultured from a wound.

Treatment

Treatment begins immediately in the emergency room or intensive care unit of a hospital. There are five aspects of treatment. Initially the patient is placed in a dark, quiet room and given a sedative, usually a drug in the benzodiazepine family, through direct injection into a vein (IV) in an effort to reduce muscle spasms. A tube may be inserted in to the trachea (tracheotomy) in order to keep the airways open.

The second aspect of treatment is to clean and disinfect any wounds and remove any dead flesh.

The third aspect of treatment involves killing the bacteria producing the toxin using antimicrobial drugs given as an injection. The drug of choice is metronidazole (Flagyl), with penicillin the second choice.

Fourth, the toxin already circulating in the blood must be neutralized so that it causes no further damage to the nervous system. This is done with injections of human tetanus immunoglobulin (TIG).

Finally, complications of the disease are managed. This may involve IV fluid replacement, use of a respirator, or kidney dialysis. Contracting tetanus does not provide immunity against future infections, so tetanus immunizations are also given.

Prognosis

Individuals who develop symptoms within a few days of infection have close to a 100 percent mortality rate. The mortality rate for infections originating in the head and in newborns is also very high. The sooner an individual is treated, the more likely he or she is to survive. Overall, the death rate in the United States is 10 percent. Worldwide it is 45 percent. According the United States Centers for Disease Control, the average hospital stay is 16 days. Recovery for those who survive is normally complete after about four weeks.

Prevention

Tetanus is completely preventable by immunization. The recommendation in the United States, as of 2004, is to immunize children against tetanus on the following schedule:

• initial vaccination at two months of age
• repeat at four months of age
• repeat at six months of age
• repeat at 12 to 15 months of age
• repeat at four to six years of age
• booster dose given every 10 years there after, normally at ages 15, 25, 35, etc.

Receiving the complete schedule of multiple vaccinations is necessary to ensure full protection. For children, vaccination against tetanus is normally included in a vaccine called DTaP that protects against diphtheria , tetanus, and whooping cough (acellular pertussis). Many school districts require proof of vaccination before a child may enroll.

Other prevention measures involve prompt cleaning and protection of wounds and hygiene measure such as washing well after exposure to soil containing animal manure. Sterile conditions during surgery also help prevent infection.

Nutritional concerns

Food is not given by mouth to individuals who are having muscle spasms for fear they will breathe the food into their lungs. During this time, they are fed intravenously.

Parental concerns

Some parents hesitate to vaccinate their children for religious reasons or because they fear side effects of the vaccination. The bacteria that cause tetanus are so common and the disease is so serious that protection against acquiring tetanus outweighs any risks associated with vaccination.

KEY TERMS

Intravenous —Into a vein; a needle is inserted into a vein in the back of the hand, inside the elbow, or some other location on the body. Fluids, nutrients, and drugs can be injected. Commonly called IV.

Toxin —A poisonous substance usually produced by a microorganism or plant.

Trachea —The windpipe. A tube composed of cartilage and membrane that extends from below the voice box into the chest where it splits into two branches, the bronchi, that lead to each lung.

Tracheotomy —An surgical procedure in which the surgeon cuts directly through the patient's neck into the windpipe below a blockage in order to keep the airway open.

Umbilical cord —The blood vessels that allow the developing baby to receive nutrition and oxygen from its mother; the blood vessels also eliminate the baby's waste products. One end of the umbilical cord is attached to the placenta and the other end is attached to the baby's belly button (umbilicus).

See also Vaccination.

Resources

BOOKS

Marx, John, et al. Rosen's Emergency Medicine: Concepts and Clinical Practice, 5th ed. St. Louis: Mosby, 2003.

Parker, James N., et al. Tetanus: A Medical Dictionary, Bibliography, and Annotated Research Guide to Internet References. Boulder, CO: netLibrary, 2004.

PERIODICALS

Roper, Martha H. "Tetanus Prophylaxis in the Emergency Department." Annals of Emergency Medicine 43, no. 3 (March 2004): 315–17.

WEB SITES

Sonali, Ray, and Robert W. Tolan. "Tetanus." eMedicine Medical Library February 24, 2004. Available online at <www.emedicine.com/ped/topic3038.htm> (accessed October 14, 2004).

Tish Davidson, A.M.