Tetanus

Clostridium tetani spores are present in the intestine of most mammals (including horses, sheep, cattle, dogs, cats, rats, guinea pigs and chickens). They are passed into soil via faeces.

The disease is spread when material containing tetanus spores contaminates a wound. In anaerobic conditions the spores germinate and a toxin is produced. The toxin travels throughout the body via the blood, causing symptoms.

Risk of tetanus is higher in:

• People who are >60 years
• Neonates
• Those who lack immunisation
• Drug addicts

Wounds considered to be a high risk for tetanus are those that show one or more of the following:

• Deep puncture wounds where there has been contact with soil, faeces or manure
• Wounds contaminated by foreign material
• Bone fractures where the skin is broken
• Burn wounds with sepsis
• Cuts, scrapes tears or splits in the skin
• Human or animal bites,
• Body piercings and tattoos
• Eye injuries
• Injecting contaminated drugs or using non-sterile injecting equipment¹

Although C.tetani is found worldwide, tetanus infections are rare in developed countries. In developing countries tetanus is predominant in neonates and children, due to inadequate immunisation and poor local medical practice.

An estimated 12476 cases of tetanus occurred globally in 2017. Between 2011–2016, 72 600 deaths globally were attributed to tetanus.²

The incubation period for tetanus is on average 7-21. If left untreated, the symptoms can get worse over the following hours and days. The shorter the incubation period, the worse the severity of the disease. The incubation period of neonatal tetanus is 3-10 days.

Symptoms of tetanus include:

• Stiffness of the jaw muscles (lockjaw)
• Neck stiffness
• Swallowing difficulties
• Muscle spasms and rigidity – may cause breathing difficulty as respiratory muscles are affected
• Fever³

Complications of tetanus infection may include:

• Respiratory failure
• Aspiration pneumonia
• Laryngospasm, which may lead to asphyxia
• Fractures from sustained contractions and convulsions
• Arrhythmias or cardiac arrest
• Seizures
• Blockage of blood vessels in the lungs (particularly in drug abusers and the elderly)³

If tetanus is suspected seek medical attention as soon as possible.

Tetanus requires hospital admission and possible treatment may include:

• Tetanus immunoglobulin
• Antibiotics
• Medication to relieve muscle stiffness and spasms³

 Management of tetanus prone wounds:

• Initially done by thorough cleaning of the wound
• If the risk of tetanus is especially high, human tetanus immunoglobulin should be given for immediate additional protection. This should be done regardless of the patient’s immunisation history.
• If a full 5-dose course of tetanus vaccine at the recommended intervals has been received, no further doses of vaccine are recommended
• If the immunisation schedule is not up-to-date or its status is unknown, a reinforcing dose of Td/IPV should be given at the time of treatment of an injury and further doses given as required to complete the recommended five-dose schedule
• Patients who are immunosuppressed may not be adequately protected against tetanus, despite having been fully immunised. They should be managed as if they were incompletely immunised.⁴

Effective vaccination is available and all travellers should be immunised regardless of age.  Travellers should be up to date on their tetanus immunisation (regardless of their age). They should be aware of the risk of accidents while travelling.

It is important to seek urgent medical attention in the case of a tetanus prone wound as thorough cleaning of the injury is essential and further vaccine/immunoglobulin may be recommended.

Tetanus infection does not confer immunity; immediate vaccination (inactivated tetanus toxoid) is too slow to address a current infection. Antibiotics for prophylaxis against tetanus in wound management are not recommended. They are only given for an active infection.¹

Travellers should consider getting vaccinated against tetanus if:

• There is no easy access to medical care
• Their last dose of tetanus containing vaccine was over 10 years ago (only a booster is required)¹

A total of 5 doses of vaccine at the appropriate intervals are considered to give satisfactory long-term protection. The UK schedule for primary immunisation is as follows:

• Children <10 years: at 2, 3 and 4 months of age
• Children >10 years and adults: the primary course is 3 doses

Those who miss a dose need to resume the schedule but do not need to have repeat doses. There should be a minimum for one month in between doses of the vaccine.

The UK schedule for reinforcing immunisation is as follows:

• Children <10 years: should receive the first booster (combined with diphtheria, pertussis and polio vaccines as the pre-school booster) 3 years after completion of the primary course
• Children >10 years and adults: should receive the first booster (combined with diphtheria and polio vaccines) at least 5 years after their primary course
• The second booster (Td/IPV) should be given to all people 10 years after their first booster vaccine

For travellers to areas where medical attention may not be accessible and whose last dose of a tetanus-containing vaccine was more than 10 years previously, a booster dose should be given prior to travelling, even if the individual has received five doses of vaccine previously. This is in case immunoglobulin is not available should a tetanus-prone injury occur.

Travellers who have never had a tetanus vaccination before are advised to have as many of the 3 initial doses as possible before travelling, ensuring sufficient time between each dose. The completion of the full course is advised upon return.⁵

This information is taken from trusted third party websites, NaTHNaC (Travel Health Pro) and EMIS (Patient info) and use of all information has been licenced under the Open Government. Licence http://www.nationalarchives.gov.uk/doc/open-government-licence/version/3/

Although the materials are being used/replicated under the provisions of the Open Government Licence this in no way represents endorsement of Traveljab.co.uk by NaTHNaC, Emis, Public Health England, the NHS or the Department of Health and Social Care.

1. Travel Health Pro: Tetanus factsheet
2. World Health Organization (WHO): Tetanus – Immunization, Vaccines and Biologicals
3. NHS: Tetanus
4. Public Health England: Tetanus
5. The Green Book: Chapter 30 – Tetanus