Description

A disease of the nervous system caused by bacteria.

Tetanus (lockjaw) is a serious disease that causes painful tightening of the muscles, usually all over the body. It can lead to "locking" of the jaw so the victim cannot open his mouth or swallow. Several vaccines are used to prevent tetanus among children, adolescents, and adults including DTaP, Tdap, DT, and Td. Tetanus differs from other vaccine-preventable diseases in that it is not contagious. It does not spread from person to person. Clostridium tetani bacteria are usually found in soil, dust, and manure, and they enter the body through breaks in the skin. Children usually become infected through deep puncture wounds or cuts, like those made by nails or knives. But the bacteria can enter through even a tiny pinprick or scratch. Children can also get tetanus following severe burns, ear infections, tooth infections, or animal bites. Tetanus (Deadly Diseases and Epidemics) Symptoms When tetanus gets into the body it can take up to 3 weeks for the first symptoms to appear. These are usually a headache, crankiness, spasms of the jaw muscles, stiffness in the neck and abdomen, and difficulty swallowing. The bacteria produce a toxin (poison), which spreads throughout the body, causing painful muscle spasms in the neck, arms, legs, and stomach. These can be strong enough to break a child's bones. Children with tetanus might have to spend several weeks in the hospital under intensive care.

Later symptoms: severe muscle spasms, generalized tonic seizure-like activity, severe autonomic nervous system disorders

Complications

1 out of every 10 people who get tetanus dies from it (Death is about 10-20% of cases, higher among older people)

Cases per year (average) before vaccines: 1,314
Cases in 2003: 20
Decrease in cases per year: 98.5%

Transmission

• Enters the body through a break in the skin
• Tetanus is a global health problem because C. tetani spores are ubiquitous in the environment.
• Lesions that are considered “tetanus prone” are wounds contaminated with dirt, feces, or saliva, deep wounds, burns, crush injuries, or those with necrotic tissue.
• Tetanus has also been associated with apparently clean superficial wounds, surgical procedures, insect bites, dental infections, chronic sores and infections, and intravenous drug use.
• A reservoir of tetanus bacteria exists in the intestines of horses and other animals, including humans, in which the organism is a harmless normal inhabitant. Soil or fomites contaminated with animal and human feces propagate transmission.
• Tetanus has no direct person-to-person transmission.

Occurrence

• In 2006, an estimated 290,000 people worldwide died of tetanus, most of them in Asia, Africa, and South America.
• The disease occurs almost exclusively in persons who are inadequately immunized.
• Worldwide, the disease is more common in agricultural regions and in areas where contact with animal excreta is more likely and immunization is inadequate.
• In developing countries, tetanus in neonates born to unvaccinated mothers (neonatal tetanus) is the most common form of the disease.
• In 10% of reported cases in the United States, no antecedent wound was identified.

Diagnosis

• The diagnosis is almost always made clinically.
• The disease is characterized by painful muscular contractions, primarily of the masseter and neck muscles, secondarily of trunk muscles.
• A common first sign suggestive of tetanus in older children and adults is abdominal rigidity, though rigidity is sometimes confined to the region of injury.
• Generalized spasms occur, frequently induced by sensory stimuli; typical features of the tetanic spasm are the position of opisthotonos and the facial expression known as “risus sardonicus.”
• History of an injury or apparent portal of entry may be lacking.
• The organism is rarely recovered from the site of infection, and usually there is no detectable antibody response.

Treatment

• Tetanus is a medical emergency requiring hospitalization, immediate treatment with human tetanus immune globulin (TIG) (or equine antitoxin if human immune globulin is not available), a tetanus toxoid booster, agents to control muscle spasm, and, if indicated, aggressive wound care and antibiotics.

  Specific treatment: TIG administered intramuscularly in doses of 3000–6000 IU. If immunoglobulin is not available, tetanus antitoxin (equine origin) in a single large dose should be given intravenously, following testing for hypersensitivity.

• Metronidazole is the most appropriate antibiotic. It is associated with the shortest recovery time and lowest case-fatality rate. It should be given for 7–14 days in large doses; this also allows for a reduction in the amount of muscle relaxants and sedatives required.
• The wound should be debrided widely and excised if possible. Wide debridement of the umbilical stump in neonates is not indicated.
• Depending on the severity of disease, mechanical ventilation and agents to control autonomic nervous system instability may be required.
• An adequate airway should be maintained, and sedation should be used as indicated; muscle relaxant drugs, together with tracheostomy or nasotracheal intubation and mechanically assisted respiration, may be lifesaving.
• Active immunization should be initiated concurrently with treatment.

Vaccine

Tetanus toxoid (contained in Tdap, DTP, DT, DTaP, and Td vaccines) can prevent this disease.

Everyone needs protection from tetanus. If you have not had a booster shot in 10 years or more, you should receive a tetanus shot. If you never had the initial childhood tetanus vaccines, you should receive a series of three tetanus shots.

DTaP Vaccine

There are four combination vaccines used to prevent diphtheria, tetanus and pertussis: DTaP, Tdap, DT, and Td. Two of these (DTaP and DT) are given to children younger than 7 years of age, and two (Tdap and Td) are given to older children and adults. Several other combination vaccines contain DTaP along with other childhood vaccines.

Children should get 5 doses of DTaP, one dose at each of the following ages: 2, 4, 6, and 15-18 months and 4-6 years. DT does not contain pertussis, and is used as a substitute for DTaP for children who cannot tolerate pertussis vaccine.

Td is a tetanus-diphtheria vaccine given to adolescents and adults as a booster shot every 10 years, or after an exposure to tetanus under some circumstances. Tdap is similar to Td but also containing protection against pertussis. A single dose of Tdap is recommended for adolescents 11 or 12 years of age, or in place of one Td booster in older adolescents and adults age 19 through 64.

[Upper-case letters in these abbreviations denote full-strength doses of diphtheria (D) and tetanus (T) toxoids and pertussis (P) vaccine. Lower-case “d” and “p” denote reduced doses of diphtheria and pertussis used in the adolescent/adult-formulations. The “a” in DTaP and Tdap stands for “acellular,” meaning that the pertussis component contains only a part of the pertussis organism rather than the whole cell.) The diphtheria and tetanus components of the vaccine are not technically vaccines, but "toxoids." In other words, they help the immune system develop protection against the toxins produced by the diseases rather than against the disease bacteria themselves. All three components of DTaP are "inactivated" (killed). Tetanus, diphtheria and pertussis (DTP) vaccines have been in common use since the 1940s. DTaP vaccine (with the acellular pertussis component) was first licensed in 1991.

DTaP Vaccine Side Effects

Up to one third of children who get DTaP have local reactions (tenderness, pain, redness, swelling). These are most common after the 4th or 5th doses. When they occur it is usually within 2 days after the shot. Some children also experience swelling of the entire arm or leg after the 4th or 5th DTaP dose. This happens within 3 days of the shot and usually lasts around 4 days, with no after-effects. Up to about 1 child in 20 will get a fever of over 101°F - also more often after the 4th or 5th dose. And up to about 1 child in 5 may become fussy or lose their appetite for a day or two; nearly half may become drowsy after the shot.

More serious side effects include a fever of 104°F or higher (1 in 3,000), continuous crying for 3 hours or more (separate studies have found this in 1 in 900 to 1 in 8,000), and convulsions (1 in 14,000). Convulsions that occur after DTaP are usually not caused directly by the vaccine, but by a fever, which in turn was triggered by the vaccine. These are called "febrile seizures" and, while they might be alarming, children recover from them quickly and they do not cause permanent harm. Some experts recommend giving a non-aspirin pain reliever, such as acetaminophen, to reduce the chances of a fever.

Over the years several cases of permanent brain damage were reported following DTP vaccine (an earlier version of DTaP). Whether these were true vaccine reactions or merely coincidence is impossible to say, because they occurred so infrequently. Some people used to believe that DTP vaccine could cause Sudden Infant Death Syndrome (SIDS), but studies have discredited this theory.

DTaP Vaccine Precautions

In addition to the normal precautions for all vaccines, shown on page 30, a child who developed encephalopathy (brain illness) within 7 days after a dose of DTaP should not get another dose of pertussis-containing vaccine (see DT vaccine, below).

There are several other conditions that might cause a doctor to recommend not getting DTaP. These are: a temperature of 105°F, a collapse or "shock-like" state, or continuous crying for 3 or more hours, occurring within 48 hours of a previous dose; or convulsions occurring within 3 days after a previous dose. If your child had any of these conditions after a previous dose of DTaP, be sure to talk with your doctor before getting another dose of the vaccine. He or she might recommend getting a non-pertussis containing vaccine.

Other Related Vaccines

• DT is a tetanus/diphtheria vaccine, which does not contain pertussis. It is used for children younger than 7 years old who should not get pertussis vaccine (for example, because they have had a reaction to pertussis vaccine in the past).
• Td is a version of DT for children 7 years old and older and for adults. It has a lower concentration of diphtheria toxoid than DT. It is used for routine 10-year boosters.
• Tdap was licensed in 2005. It contains a full concentration of tetanus and lower concentrations of both diphtheria and pertussis. It is the first pertussis-containing vaccine licensed in the United States for children 7 years of age and older, adolescents, and adults. It is currently recommended as a once-only booster for adolescents.

General Preventive Measures

• Universal active immunization with adsorbed tetanus toxoid, gives durable protection for at least 10 years; after the initial basic series has been completed, single booster doses elicit high levels of immunity.
• In children under 7 years of age, the toxoid is generally administered together with diphtheria toxoid and pertussis vaccine as a triple (DTP or DTaP) antigen, or as a double (DT) antigen when contraindications to pertussis vaccine exist.
• Td is used for children over 7 years of age.
• For adolescents 11–12 years of age, a single dose of Tdap is recommended for routine booster, and for adolescents and adults 13–64 years of age, a single dose of Tdap is recommended to replace the next decennial Td booster or when indicated as part of wound prophylaxis.
• In countries with incomplete immunization programs for children, all pregnant women should receive two doses of tetanus toxoid in the first pregnancy, with an interval of at least 1 month, and with the second dose at least 2 weeks prior to childbirth.
• Vaccine-induced maternal immunity is important in preventing maternal and neonatal tetanus. Active protection should be maintained by administering booster doses of Td every 10 years, preferably before or between pregnancies.
• For children and adults who are severely immunocompromised or infected with HIV, tetanus toxoid is indicated in the same schedule and dose as for immunocompetent persons even though the immune response may be suboptimal.
• Minor local reactions following tetanus toxoid injections are relatively frequent; severe local and systemic reactions are infrequent but do occur, particularly after excessive numbers of prior doses have been given.