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Tetanus derived from greek word to "stretch" an acute diseases caused by anaerobic gram positive, non capsulated spore forming bacteria. It can be categorized into four different forms:
a. Generalized Tetanus
b. Localized Tetanus
c. Cerebral Tetanus
d. Neonatal Tetanus.

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- is an infection caused by bacteria called clostridium tetani.
- It is also refer as "Lockjaw".
- Tetanus is different from other vaccine preventable diseases and also  known for non communicable diseases.

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C.tetani produce two exotoxins,tetanolysin and tetanospasmin, which are encoded by plasmid borne genes.

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-When the bacteria invade the body, they produce toxin that causes painful muscle contraction.
- Stepping on nails or other sharp objects is one way to expose on tetanus.
- Bacteria usually found in the soil, dust, and manure, enter in the body through breaks in the skin usually cuts or puncture.

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- Clean suferial wound
- Surgical Procedure
-Insect bites
- Dental infection
-Chronic sores and infection
- Intravenous (IV) diseases
- Intramuscular injection (shots given to muscles).
- When mothers and newborns contact tetanus through wounds during birth.

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Arthur Nicolaier discovered the toxins that caused tetanus in the late 1800s. The first vaccine for passive immunology was discovered by a group of German scientist under the leadership of Emil von Behring in 1890.

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Tetanus neurotoxin binds to the presynaptic membrane of the neuromuscular junction is internalized and transported retoxanally in the spinal cord. The spastic paralysis induced by the toxins is due to the blockade of neurotransmitter release from spinal inhibitory interneurons.

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How specially the virulence factor contribute to pathogenicity?

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How specially the virulence factor contribute to pathogenicity?

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Tetanospasmin blocks the inhibitory nerve impulses by interfering with the release of neurotransmitter and this in turns leads to spare paralysis CF.Clostridium botulism.

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Doctor diagnoses tetanus based on physical exam, medical exam, immunization history, and the signs and symptoms of muscle spasm, stiffness and pain.
Treatment:
There is no cure for Tetanus.
-Treatment consist of care in the hospital.
- Aggressive wound care
- Drugs to control muscle spasm
- Medication such as Antitoxins, Antibiotics, Tetanus Vaccine, Sedatives and other drugs.

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The first sign is most commonly spasm of the muscles of jaw or "lockjaw".
The other symptoms are:
- Jaw cramping
- sudden, involuntary muscle tightening (often in the stomach)
- Painful muscle stiffness all over the body
- trouble swallowing
- Headache, Fever, and sweating
-Change in blood pressure and heart rate.

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-It is uncommon in the United States with an average of 30 reported cases each year. Those who did not take tetanus vaccine are the one to report the cases.
- Most report cases occurs in adults from 2009-2017.
-More than 60% of the 264 reported cases were among 20 through 64 of ages.
- Since 1990, the number of deaths from tetanus has fallen by 88%.
Here are the reports from 2018:

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The long term effects of this diseases are:
1. Tetanic seizure
2. Acute Renal Failure
3. Laryngospasm
4. Fracture
5. Hypertension
6. Nosocomial Infection
7. Pulmonary embolism
8. Aspiration Pneumonia
9. Death

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- Incubation period time from exposure to illness is usually between 3-21 days(average 10 days).
- It may range from one days to several months depending on the kind of  wounds.
- In General, Doctors see shorter incubation period when more heavily contaminated wounds, more serious diseases, and a worse outcomes (prognosis).

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Tetanus is an uncommon but very serious diseases caused by spores of bacteria found in the environment. - Being up to date, Vaccine is the best tool to prevent tetanus. CDC recommend several vaccine such as DTaP, DT, TdaP, Td.
- Most people who get Tetanus shots do not have serious problems but some side effects can occurs. Some  side effects are mild, but do not affect daily activities.

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2. T.P.S.P. M.D., P.L.M.D. M.P.H., & A.M.A.M.D. (2020, December 24). Pinkbook: Tetanus | CDC.

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Tejpratap S.P. Tiwari, MD; Pedro L. Moro, MD, MPH; and Anna M. Acosta, MD

Tetanus is an acute, often fatal, disease caused by an exotoxin produced by the bacterium Clostridium tetani. It is characterized by generalized rigidity and convulsive spasms of skeletal muscles. The muscle stiffness usually begins in the jaw (lockjaw) and neck and then becomes generalized.

Although records from antiquity (5th century BCE) contain clinical descriptions of tetanus, it was in 1884 when tetanus was first produced in animals by injecting them with pus from a fatal human tetanus case. During the same year, tetanus was produced in animals by injecting them with samples of soil. In 1889, Kitasato Shibasaburo isolated the organism from a human, showed that it produced disease when injected into animals, and reported that the toxin could be neutralized by specific antibodies. In 1897, Edmond Nocard demonstrated the protective effect of passively transferred antitoxin, and passive immunization in humans was used for treatment and prophylaxis during World War I. A method for inactivating tetanus toxin with formaldehyde was developed in the early 1920s. This led to the development of tetanus toxoid in 1924. It was first widely used during World War II.

Clostridium tetani

The C. tetani bacterium is a spore-forming, gram-positive, slender, anaerobic rod. The organism is sensitive to heat and cannot survive in the presence of oxygen. The spores, in contrast, are extremely resistant to heat and the usual antiseptics. They can survive autoclaving at 249.8°F (121°C) for 10 to 15 minutes. The spores are also relatively resistant to phenol and other chemical agents.

The spores are widely distributed in soil and in the intestines and feces of horses, sheep, cattle, dogs, cats, rats, guinea pigs, and chickens. Manure-treated soil may contain large numbers of spores. In agricultural areas, a significant number of human adults may harbor the organism. The spores can also be found on skin surfaces and in contaminated heroin.

C. tetani produces two exotoxins, tetanolysin and tetanospasmin. Tetanospasmin is a neurotoxin and causes the clinical manifestations of tetanus. On the basis of weight, tetanospasmin is one of the most potent toxins known: the estimated minimum human lethal dose is 2.5 nanograms per kilogram of body weight (a nanogram is one billionth of a gram) or 175 nanograms for a 70-kg (154 lb) human.

Pathogenesis

C. tetani usually enters the body through a wound. In the presence of anaerobic conditions, the spores germinate. Toxins are produced and disseminated via blood and lymphatics. Tetanospasmin, also referred to as tetanus toxin, acts at several sites within the central nervous system, including peripheral motor end plates, the spinal cord, and the brain, and in the sympathetic nervous system. The typical clinical manifestations of tetanus are caused when tetanus toxin interferes with the release of neurotransmitters, blocking inhibitor impulses. This leads to unopposed muscle contraction and spasm. Seizures may occur, and the autonomic nervous system may also be affected.

Clinical Features

The incubation period is usually about 8 days, with a usual range of 1 to 21 days. In general, the incubation period is longer the further the injury site is from the central nervous system. Shorter incubation periods are also associated with severe disease and a higher chance of death.

On the basis of clinical findings, three different forms of tetanus have been described. The most common type (more than 80% of reported cases) is generalized tetanus. The disease usually presents with a descending pattern. The first sign is trismus, or lockjaw, followed by stiffness of the neck, difficulty in swallowing, and rigidity of abdominal muscles. Other symptoms include elevated temperature, sweating, elevated blood pressure, and episodic rapid heart rate. Spasms may occur frequently and last for several minutes. Spasms continue for 3 to 4 weeks. Complete recovery may take months.

Localized tetanus is an uncommon form of the disease in which patients have persistent contraction of muscles in the same anatomic area as the injury. These contractions may persist for many weeks before gradually subsiding. Localized tetanus may precede the onset of generalized tetanus but is generally milder.

Cephalic tetanus is a rare form of the disease, occasionally occurring with otitis media in which C. tetani is present in the flora of the middle ear or following injuries to the head. There is involvement of the cranial nerves, especially in the facial area.

Neonatal tetanus is a form of generalized tetanus that occurs in newborn infants. Neonatal tetanus occurs in infants born without protective passive immunity because the mother is not immune. It usually occurs through infection of the unhealed umbilical stump, particularly when the stump is cut with an unsterile instrument. In neonatal tetanus, symptoms usually appear from 4 to 14 days after birth, averaging about 7 days.

Complications

Laryngospasm or spasm of the muscles of respiration leads to interference with breathing. Fractures of the spine or long bones may result from sustained contractions and convulsions. Hyperactivity of the autonomic nervous system may lead to hypertension or an abnormal heart rhythm.

Nosocomial infections are common because of prolonged hospitalization. Secondary infections may include sepsis from indwelling catheters, hospital-acquired pneumonias, and decubitus ulcers. Pulmonary embolism is particularly a problem in persons who use drugs and elderly patients. Aspiration pneumonia is a common late complication of tetanus, found in 50% to 70% of autopsied cases. In recent years, tetanus has been fatal in approximately 11% of reported cases. Cases most likely to be fatal are those occurring in persons age 60 years or older and unvaccinated persons. In about 20% of tetanus deaths, no obvious pathology is identified and death is attributed to the direct effects of tetanus toxin.

Laboratory Testing

The diagnosis of tetanus is entirely clinical and does not depend upon bacteriologic confirmation. C. tetani is recovered from the wound in only 30% of cases and can be isolated from patients who do not have tetanus. Laboratory identification of the organism depends most importantly on the demonstration of toxin production in mice.

Medical Management

All wounds should be cleaned. Necrotic tissue and foreign material should be removed. If tetanic spasms are occurring, supportive therapy and maintenance of an adequate airway are critical.

Tetanus immune globulin (TIG) is recommended for persons with tetanus. TIG can only help remove unbound tetanus toxin. It cannot affect toxin bound to nerve endings. A single intramuscular dose of 500 units is generally recommended for children and adults, with part of the dose infiltrated around the wound if it can be identified. Intravenous immune globulin (IVIG) contains tetanus antitoxin and may be used if TIG is not available.

Because of the extreme potency of the toxin, tetanus disease does not result in tetanus immunity. Active immunization with tetanus toxoid should begin or continue as soon as the person's condition has stabilized.

Antibiotic prophylaxis against tetanus is neither practical nor useful in managing wounds; immunization plays the more important role. The need for active immunization, with or without passive immunization, depends on the condition of the wound and the patient's immunization history. Rarely have cases of tetanus occurred in persons with a documented primary series of tetanus toxoid.

Persons with wounds that are neither clean nor minor, and who have had fewer than 3 prior doses of tetanus toxoid or have an unknown history of prior doses, should receive TIG as well as tetanus toxoid vaccine. This is because early doses of toxoid may prime the immune system but not induce immunity. TIG provides temporary immunity by directly providing antitoxin. This ensures that protective levels of antitoxin are achieved even if an immune response has not yet occurred.

Guide to Tetanus Prophylaxis with TIG in Routine Wound Management

*Such as, but not limited to, wounds contaminated with dirt, feces, soil, or saliva; puncture wounds; avulsions; and wounds resulting from missiles, crushing, burns, and frostbite.
†DTaP is recommended for children younger than age 7 years. Tdap is preferred to Td for persons age 11 years or older who have not previously received Tdap. Persons age 7 years or older who are not fully immunized against pertussis, tetanus, or diphtheria should receive one dose of Tdap (preferably the first) for wound management and as part of the catch-up series; if additional tetanus toxoid-containing doses are required, either Td or Tdap vaccine can be used.
§People with HIV infection or severe immunodeficiency who have contaminated wounds (including minor wounds) should also receive TIG, regardless of their history of tetanus immunizations.
¶Yes, if ≥10 years since the last tetanus toxoid-containing vaccine dose.
**Yes, if ≥5 years since the last tetanus toxoid-containing vaccine dose.

Epidemiology

Occurrence

Tetanus occurs worldwide but is most frequently encountered in densely populated regions in hot, damp climates with soil rich in organic matter.

Reservoir

Organisms are found primarily in the soil and intestinal tracts of animals and humans.

Mode of Transmission

Transmission is primarily by contaminated wounds (apparent and inapparent). The wound may be major or minor. In recent years, a higher proportion of tetanus cases had minor wounds, probably because severe wounds are more likely to be appropriately managed. Tetanus may follow elective surgery, burns, deep puncture wounds, crush wounds, otitis media, dental infection, and animal bites.

Communicability

Tetanus is not contagious from person-to-person. It is the only vaccine-preventable disease that is infectious but not contagious.

Secular Trends in the United States

A marked decrease in mortality from tetanus occurred from the early 1900s to the late 1940s. In the late 1940s, tetanus toxoid-containing vaccines were introduced into routine childhood vaccination and tetanus became a nationally notifiable disease. At that time, between 500-600 cases (approximately 0.4 cases per 100,000 population) were reported per year.

After the 1940s, reported tetanus incidence rates declined steadily. Since the mid-1970s, about 50 to 100 cases (approximately 0.05 cases per 100,000) have been reported annually in the United States. More recently, from 2009-2018, an average of 29 (range 18-37) cases were reported per year. Of the 297 cases reported during this 10-year timeframe, there were 19 deaths, all in adults age 55 years or older. In 2018, 23 tetanus cases were reported, with no deaths.

Among children born during 2016-2017, 93.3% had received at least 3 doses of DTaP vaccine by age 24 months, and 80.6% had received at least 4 doses of DTaP vaccine by age 24 months. Tdap coverage among adolescents age 13 through 17 years reached 90.2% in 2019. Coverage with tetanus toxoid vaccines among adults is lower; the estimates for any dose of a tetanus toxoid-containing vaccine (Td or Tdap) among adults was 63.4% in 2017.

Tetanus Toxoid-containing Vaccines

Tetanus toxoid is combined with diphtheria toxoid as diphtheria and tetanus toxoid (DT) vaccine or tetanus and diphtheria toxoid (Td [Tenivac and Tdvax]) vaccine. Tetanus toxoid is also combined with both diphtheria toxoid and acellular pertussis vaccine as DTaP (Infanrix and Daptacel) or Tdap (Boostrix and Adacel) vaccines. Td contains reduced amounts of diphtheria toxoid compared with DT. DTaP and Tdap contain the same pertussis components, but Tdap contains a reduced quantity of some pertussis antigens and diphtheria toxoid. Boostrix contains a reduced quantity of tetanus toxoid compared to Infanrix.

Children younger than age 7 years should receive DTaP vaccine or DT vaccine (in instances where the pertussis vaccine component is contraindicated or where the physician decides that pertussis vaccine is not to be administered). Persons age 7 years or older should receive Td vaccine or Tdap vaccine, even if they have not completed a series of DTaP or DT (Tdap would be off-label for children age 7 through 9 years, but is still recommended by ACIP). Tdap (Boostrix) is approved for persons age 10 years or older; Tdap (Adacel) is approved for persons age 10 through 64 years. DTP vaccines are combined diphtheria and tetanus toxoids and whole cell pertussis vaccine, but none are currently licensed in the United States.

There are five combination vaccines that contain DTaP vaccine. DTaP-HepB-IPV (Pediarix) is licensed for the first 3 doses of the DTaP series among children age 6 weeks through 6 years. DTaP-IPV/Hib (Pentacel) is licensed for the first 4 doses of the component vaccines among children age 6 weeks through 4 years. DTaP-IPV (Kinrix) is licensed only for the fifth dose of DTaP and fourth dose of IPV among children age 4 through 6 years. DTaP-IPV (Quadracel) is licensed only for the fourth dose of DTaP and fourth or fifth dose of IPV among age 4 through 6 years. DTaP-IPV-Hib-HepB (Vaxelis) is licensed for use in children age 6 weeks through 4 years but not yet available for use in the United States.

Characteristics

Tetanus toxoid-containing vaccines are administered by intramuscular injection. Each dose of tetanus toxoid-containing vaccines contains aluminum as an adjuvant but no preservative. DTaP-HepB-IPV (Pediarix), DTaP-IPV/Hib (Pentacel), DTaP-IPV-Hib-HepB (Vaxelis), DTaP-IPV (Kinrix), and DTaP-IPV (Quadracel) contain neomycin and polymyxin B as antibiotics. DTaP-IPV-Hib-HepB (Vaxelis) contains streptomycin as an antibiotic. DTaP-HepB-IPV (Pediarix) and DTaP-IPV-Hib-HepB (Vaxelis) vaccines contain yeast protein. Presentations of some tetanus toxoid-containing vaccines contain latex rubber.

Vaccination Schedule and Use

DTaP (Infanrix and Daptacel)

DTaP (diphtheria, tetanus toxoids, and acellular pertussis vaccine) is recommended for children age 6 weeks through 6 years. The routine schedule is a primary series of 3 doses at age 2, 4, and 6 months, a booster dose between age 15 through 18 months, and another booster dose between age 4 through 6 years (total of 5 doses). The first 3 doses should be given at 4- to 8-week intervals (minimum of 4 weeks). Dose 4 should follow dose 3 by no less than 6 months and should not be administered before age 12 months.

Dose 4 of both brands of DTaP is recommended to be administered at age 15 through 18 months (15 through 20 months for Daptacel). Dose 4 may be given as early as age 12 months if at least 6 months have elapsed since dose 3 and, in the opinion of the vaccine provider, the child is unlikely to return for an additional visit between age 15 through 18 months.

Children who received 4 doses before their fourth birthday should receive a fifth dose of DTaP before entering school. The fifth dose is not necessary (but may be given) if dose 4 in the series was given on or after the fourth birthday. Administering the fifth dose increases antibody levels and may decrease the risk of school-age children transmitting the disease to younger siblings who are not fully vaccinated.

If a child has a valid contraindication to pertussis vaccine, DT should be used to complete the vaccination series. If the child was younger than age 12 months when the first dose of DT was administered (as DTP, DTaP, or DT), the child should receive a total of 4 DT doses. If the child was age 12 months or older at the time the first dose of DT was administered, 3 doses (with dose 3 administered 6 through 12 months after dose 2) will complete the primary DT series. If dose 4 of DTP, DTaP, or DT is administered before the fourth birthday, a fifth dose is recommended at age 4 through 6 years.

DTaP-HepB-IPV (Pediarix)

DTaP-HepB-IPV vaccine is approved for use as a 3-dose series for children age 6 weeks through 6 years. It is administered to infants at age 2, 4, and 6 months. The minimum intervals for DTaP-HepB-IPV vaccine are determined by the DTaP component. The 3 doses must be separated by at least 4 weeks between doses. Because the minimum age for the first dose of DTaP-HepB-IPV vaccine is 6 weeks, this vaccine cannot be used for the birth dose of hepatitis B (HepB) vaccine. The final dose of DTaP-HepB-IPV vaccine should be administered at age 24 weeks or older, the minimum age for completion of the hepatitis B vaccine series. When DTaP-HepB-IPV vaccine is used to provide 3 doses at age 2, 4, and 6 months (based on the DTaP and IPV schedules), this will result in a 4-dose HepB vaccine series, which is acceptable.

DTaP-IPV/Hib (Pentacel)

DTaP-IPV/Hib vaccine is approved for use as a 4-dose series for children age 6 weeks through 4 years. It is administered to infants at age 2, 4, 6, and 15 through 18 months. The minimum intervals for DTaP-IPV/Hib vaccine are determined by the DTaP component. The first 3 doses must be separated by at least 4 weeks between doses. Dose 4 must be separated from dose 3 by at least 6 months, and should not be administered before age 12 months. When DTaP-IPV/Hib vaccine is used to provide 4 doses at age 2, 4, 6, and between 15 through 18 months (based on the DTaP and Hib schedules), an additional booster dose with IPV-stand alone or DTaP-IPV vaccine should be administered at age 4 through 6 years. This will result in a 5-dose IPV vaccine series, which is acceptable.

DTaP-IPV-Hib-HepB (Vaxelis)

DTaP-IPV-Hib-HepB is approved for use as a 3-dose series for children age 6 weeks through 4 years. It is administered to infants at age 2, 4, and 6 months. The minimum intervals for DTaP-IPV-Hib-HepB vaccine are determined by the DTaP component. The 3 doses must be separated by at least 4 weeks between doses. Because the minimum age for the first dose of DTaP-IPV-Hib-HepB vaccine is 6 weeks, this vaccine cannot be used for the birth dose of hepatitis B (HepB) vaccine. The final dose of DTaP-IPV-Hib-HepB vaccine should be administered at age 24 weeks or older, the minimum age for completion of the hepatitis B vaccine series. When DTaP-IPV-Hib-HepB vaccine is used to provide 3 doses at age 2, 4, and 6 months (based on the DTaP and IPV schedules), this will result in a 4-dose HepB vaccine series, which is acceptable.

DTaP-IPV (Kinrix)

DTaP-IPV (Kinrix) vaccine is approved only for dose 5 of DTaP vaccine and dose 4 of IPV vaccine in children age 4 through 6 years whose previous DTaP vaccine doses have been with Infanrix and/or Pediarix for dose 1, 2, and 3 and Infanrix for dose 4. However, if DTaP-IPV (Kinrix) vaccine is administered to children who received another brand of DTaP vaccine for prior DTaP vaccine doses, or if administered as dose 1, 2, 3, or 4 of the DTaP vaccine series or dose 1, 2, or 3 of the IPV vaccine series, the dose of DTaP-IPV (Kinrix) does not need to be repeated.

DTaP-IPV (Quadracel)

DTaP-IPV (Quadracel) vaccine is approved only for dose 5 of DTaP vaccine and dose 4 or 5 of IPV vaccine in children age 4 through 6 years who have received 4 doses of Pentacel and/or Daptacel vaccine. However, if DTaP-IPV (Quadracel) vaccine is administered to children who received another brand of DTaP vaccine for prior DTaP vaccines doses, or if administered as dose 1, 2, 3, or 4 of the DTaP vaccine series or dose 1, 2, or 3 of the IPV series, the dose of DTaP-IPV (Quadracel) does not need to be repeated.

Tdap (Boostrix and Adacel) and Td (Tenivac and Tdvax)

Both Tdap vaccines are approved by the FDA for a booster dose for persons who have completed the recommended childhood DTP/DTaP vaccination series. Boostrix is approved for persons age 10 years or older. Adacel is approved for a single dose in persons age 10 through 64 years. A second dose of Adacel is also licensed for administration 8 or more years after the first Tdap dose and for use for tetanus prophylaxis when indicated for wound management if at least 5 years have elapsed since the previous receipt of any tetanus toxoid-containing vaccine. Both Td vaccines are approved for use in persons age 7 years or older.

A single Tdap dose is recommended for adolescents age 11 through 18 years who have completed the recommended childhood DTP/DTaP vaccination series, preferably at age 11 through 12 years. Adults age 19 years or older who have not previously received Tdap should receive a single dose of Tdap. To reduce the burden of pertussis in infants, a dose of Tdap has been recommended during each pregnancy since 2012, although this practice is an off-label use.

All adolescents and adults should have received a primary series of at least 3 documented doses of tetanus and diphtheria toxoids-containing vaccine (i.e., DTaP, DTP, DT, or Td) during their lifetime. A person without such documentation should receive a series of 3 doses of tetanus- and diphtheria-containing vaccine. One of these doses, preferably the first, should be Tdap. The remaining 2 doses should be either Td or Tdap.

For persons age 7 to 9 years who receive a dose of Tdap as part of the catch-up series, an adolescent Tdap dose should be administered at age 11 through 12 years. If a Tdap dose is administered at age 10 years or older, the Tdap dose may count as the adolescent Tdap dose. Either brand of Tdap may be used.

Adults age 19 years or older who previously have not received Tdap should receive a single dose of Tdap to protect against pertussis and reduce the likelihood of transmission. For adults age 19 through 64 years, either brand of Tdap may be used. Adults age 65 years or older should be vaccinated with Boostrix, if feasible. However, either vaccine administered to a person age 65 years or older is immunogenic and would provide protection. A dose of either vaccine would be considered valid.

Adolescents and adults who have not previously received Tdap, and have or anticipate having close contact with an infant younger than age 12 months (e.g., parents, siblings, grandparents, child care providers, and health care personnel) should receive a single dose of Tdap to protect against pertussis. Ideally, these persons should receive Tdap at least 2 weeks before beginning close contact with the infant.

Health care personnel should receive a single dose of Tdap as soon as feasible if they have not previously received Tdap, regardless of the time since their most recent Td vaccination.

When Tdap is indicated (e.g., routine vaccination, catch-up vaccination, or pregnancy), it can be administered regardless of the interval since the last tetanus- or diphtheria-toxoid-containing vaccine. After receipt of Tdap, persons should continue to receive a dose of Td or Tdap for routine booster immunization against tetanus and diphtheria every 10 years unless needed sooner for tetanus prophylaxis as part of wound management.

Vaccination during Pregnancy

Pregnant women who have completed the childhood immunization schedule and were last vaccinated greater than 10 years previously should receive a booster dose of tetanus toxoid-containing vaccine to prevent neonatal tetanus. The risk for neonatal tetanus is minimal if a previously unvaccinated woman has received at least 2 properly spaced doses of a tetanus toxoid-containing vaccine during pregnancy; at least 1 of the doses administered during pregnancy should be Tdap, administered according to published guidance. If more than 1 dose is needed, either Td or Tdap may be used. The 3-dose primary series should be completed at the recommended intervals.

Immunogenicity and Vaccine Efficacy

After a primary series of 3 properly spaced doses of tetanus toxoid-containing vaccines in infants and a booster at 15 through 18 months of age or 3 properly spaced doses in adults, essentially all recipients achieve antitoxin levels considerably greater than the protective level of 0.1 IU/mL.

Efficacy of the tetanus toxoid has never been studied in a vaccine trial. It can be inferred from protective antitoxin levels that a complete tetanus toxoid series has an efficacy of almost 100%. In the series of 233 cases from 2001-2008, only 7 cases (3%) had received a complete tetanus toxoid series with the last dose within the last 10 years.

Antitoxin levels decrease with time. By 10 years after the last dose, most persons have antitoxin levels that only approach the minimal protective level. As a result, routine boosters are recommended every 10 years.

In a small percentage of individuals, antitoxin levels fall below the minimal protective level before 10 years have elapsed. To ensure adequate protective antitoxin levels, persons who sustain a wound that is other than clean and minor should receive a tetanus booster if more than 5 years have elapsed since their last dose.

Contraindications and Precautions to Vaccination

As with other vaccines, a history of a severe allergic reaction (anaphylaxis) to a vaccine component or following a prior dose is a contraindication to further doses. Moderate or severe acute illness (with or without fever) in a patient is considered a precaution to vaccination, although persons with minor illness may be vaccinated. If moderate to severe acute illness accompanies a wound that is neither clean nor minor, the risk of withholding tetanus-toxoid vaccine outweighs the risk of administering tetanus-toxoid vaccine, so the vaccine should be given as part of wound management.

Contraindications to combination vaccines that contain DTaP include the contraindications to the individual component vaccines (e.g., IPV, hepatitis B, Hib), but specific ingredients might differ. DTaP-HepB-IPV (Pediarix) and DTaP-IPV-Hib-HepB (Vaxelis) vaccines contain yeast. Presentations of some tetanus toxoid-containing vaccines contain latex rubber. DTaP-HepB-IPV (Pediarix), DTaP-IPV/Hib (Pentacel), DTaP-IPV-Hib-HepB (Vaxelis), DTaP-IPV (Kinrix), and DTaP-IPV (Quadracel) contain neomycin and polymyxin B. DTaP-IPV-Hib-HepB (Vaxelis) contains streptomycin.

Encephalopathy not attributable to another identifiable cause occurring within 7 days after vaccination with DTaP, DTP, or Tdap is a contraindication for DTaP and Tdap vaccination.

A progressive or unstable neurological disorder, uncontrolled seizures, or progressive encephalopathy is a precaution for DTaP and Tdap vaccination. For persons with a known or suspected neurologic condition, vaccination with DTaP or Tdap should be delayed until the condition has been evaluated, treatment initiated, and the condition stabilized. These conditions include the presence of an evolving neurologic disorder (e.g., uncontrolled epilepsy, infantile spasms, and progressive encephalopathy); a history of seizures that has not been evaluated; or a neurologic event that occurs between doses of vaccine. A family history of seizures or other neurologic diseases, or stable or resolved neurologic conditions (e.g., controlled idiopathic epilepsy, cerebral palsy, developmental delay), are neither contraindications nor precautions to DTaP or Tdap vaccination.

Guillain-Barré syndrome within 6 weeks after a previous dose of tetanus toxoid-containing vaccine is a precaution for DTaP, Tdap, DT, and Td vaccination.

A history of Arthus-type hypersensitivity reactions after a previous dose of diphtheria toxoid-containing or tetanus toxoid-containing vaccine is a precaution for DTaP, Tdap, DT, and Td vaccination; vaccination should be deferred until at least 10 years have elapsed since the last tetanus-toxoid-containing vaccine.

DTaP

Tdap, Td

Vaccine Safety

DTaP vaccine may cause local reactions, such as pain, redness, or swelling. Local reactions have been reported in 20% to 40% of children after each of the first 3 doses. Local reactions appear to be more frequent after the fourth and/or fifth doses. Mild systemic reactions such as drowsiness, fretfulness, and low-grade fever may also occur. Temperature of 101°F or higher is reported in 3% to 5% of DTaP recipients. These reactions are self-limited and can be managed with symptomatic treatment with acetaminophen or ibuprofen.

Moderate or severe systemic reactions (such as fever of 105°F or higher, febrile seizures, persistent crying lasting 3 hours or longer, and hypotonic-hyporesponsive episodes) have been reported after administration of DTaP, but occur less frequently than among children who received whole-cell DTP. Rates of moderate or severe systemic reactions vary by symptom and vaccine but generally occur in fewer than 1 in 10,000 doses.

Exaggerated local (Arthus-type) reactions are rarely reported but may occur following receipt of a vaccine containing diphtheria or tetanus toxoids.

The most common adverse reaction following vaccination with both brands of Tdap is a local reaction, such as pain (66% to 75%), redness (25%), or swelling (21%) at the site of injection. Temperature of 100.4°F or higher was reported by 1.4% to 5% of Tdap recipients and 1.1% to 5% of Td recipients. Tdap recipients also reported a variety of nonspecific systemic events, such as headache, fatigue and gastrointestinal symptoms.

The Institute of Medicine reported in 2011 that the evidence was inadequate to accept or reject a causal relation between receipt of diphtheria toxoid and tetanus toxoid-containing vaccine and encephalitis, encephalopathy, infantile spasms, seizures, ataxia, autism, acute disseminated encephalomyelitis, transverse myelitis, optic neuritis, onset of multiple sclerosis in adults, relapse of multiple sclerosis in adults, relapse of multiple sclerosis in children, Guillain-Barré syndrome, chronic inflammatory disseminated polyneuropathy, opsoclonus myoclonus syndrome, or Bell's palsy.

The most frequently reported adverse events after DTaP in the Vaccine Adverse Effect Reporting System (VAERS) and Vaccine Safety Datalink (VSD), two post-licensure surveillance systems, were consistent with observations from pre-licensure studies of these vaccines. When VAERS DTaP reports for each vaccine brand were compared individually with reports for all other inactivated vaccines in the VAERS database, no concerning patterns of adverse events were observed.

Routine VAERS surveillance for and VSD studies on adverse events following receipt of Tdap vaccines in persons aged 10 through 64 years have provided reassuring data consistent with the prelicensure clinical trial safety data and have not demonstrated any associations between Tdap and the following rare adverse events: encephalopathy-encephalitis-meningitis; paralytic syndromes; seizures; cranial nerve disorders; and Guillain-Barré syndrome.

Vaccine Storage and Handling

DTaP, Td, and Tdap vaccines should be maintained at refrigerator temperature between 2°C and 8°C (36°F and 46°F). Manufacturer package inserts contain additional information. For complete information on best practices and recommendations, please refer to CDC's Vaccine Storage and Handling Toolkit pdf icon [56 pages] .

Surveillance and Reporting of Tetanus

For information on guidance for state and local health department staff who are involved in surveillance activities for vaccine-preventable diseases, please consult the Manual for the Surveillance of Vaccine-Preventable Diseases.

Acknowledgements

The editors would like to acknowledge Fiona Havers, Susan Hariri, and Jennifer Liang for their contributions to this chapter.

Selected References

American Academy of Pediatrics. Tetanus. In: Kimberlin D, Brady M, Jackson M, et al., eds. Red Book: 2018 Report of the Committee on Infectious Diseases. 31st ed. Itasca, IL: American Academy of Pediatrics;2018:793-8.

CDC. Diphtheria, tetanus, and pertussis: Recommendations for vaccine use and other preventive measures. Recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR 1991;40(No. RR-10):1-28.

CDC. Pertussis vaccination: use of acellular pertussis vaccines among infants and young children. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1997;46(No. RR-7):1-25.

CDC. Preventing tetanus, diphtheria, and pertussis among adolescents: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccines. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2006;55(No. RR-3):1-34.

CDC. Preventing tetanus, diphtheria, and pertussis among adults: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccines. Recommendations of the Advisory Committee on Immunization Practices (ACIP) and Recommendation of ACIP, supported by the Healthcare Infection Control Practices Advisory Committee (HICPAC), for Use of Tdap Among Health-Care Personnel. MMWR 2006;55(No. RR-17):1-33.

CDC. Prevention of pertussis, tetanus, and diphtheria with vaccines in the United States: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2018;67(RR-2):1-44.

CDC. Updated Recommendations for Use of Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular Pertussis (Tdap) Vaccine from the Advisory Committee on Immunization Practices, 2010. MMWR

2011;60(No.1):13-5.

CDC. Use of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccines: updated recommendations of the Advisory Committee on Immunization Practices - United States, 2019. MMWR 2020;69(3):77-83.

Pascual F, McGinley E, Zanardi L, et al. Tetanus surveillance-United States, 1998-2000. MMWR 2003;52(No. SS-3):1-8.

Roper M, Wassilak S, Scobie H. Tetanus Toxoid. In: Plotkin S, Orenstein W, Offit P, et al., eds. Plotkin's Vaccines. 7th ed. Elsevier;2018:1052-79.

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epidemiology and prevention of tetanus vaccine

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Tejpratap S.P. Tiwari, MD; Pedro L. Moro, MD, MPH; and Anna M. Acosta, MD Tetanus is an acute, often fatal, disease caused by an exotoxin produced by the bacterium Clostridium tetani. It is characterized by generalized rigidity and convulsive spasms of skeletal muscles.

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1.  Bae, C., &amp; Bourget, D. (2020, May 28). Tetanus. StatPearls [Books].

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Continuing Education Activity

Tetanus is an infection characterized by muscle spasms and lockjaw, also called trismus. Toxins produced by Clostridium tetani are responsible for the characteristic presentation. The disease most commonly occurs in unvaccinated individuals or elderly patients with waning immunity. Vaccination campaigns have decreased the incidence of tetanus worldwide. This activity will review the most common modalities of tetanus transmission and presentation and illustrate the treatment approach according to current evidence. This activity will highlight the role of the interprofessional team in recognizing and treating patients with tetanus.
Objectives:

Explain the common ways in which tetanus is transmitted.

Identify the common presenting features of tetanus.

Review tetanus treatment strategies.

Explain how the facilitation of interprofessional team education and discussion can ensure the effective detection of tetanus and the need for subsequent evaluation and management.

Earn continuing education credits (CME/CE) on this topic.
Introduction

Tetanus is an infection characterized by a state of generalized hypertonia that manifests in the form of painful muscle spasms of the jaw and neck. The disease most commonly occurs in those who are not vaccinated or in the elderly with waning immunity. Currently, vaccination campaigns have decreased the incidence and prevalence of tetanus worldwide. The spasms from tetanus may last from minutes to weeks, with spasms starting in the face and then descending to the rest of the body. Symptoms are caused by toxins produced by the bacterium, Clostridium tetani. Based on the clinical features, there are four main types of tetanus:

Tetanus, a clinical diagnosis, has no particular laboratory test to confirm the diagnosis. Treatment includes tetanus immunoglobulin, antibiotic therapy, neuromuscular blockade, and supportive care for respiratory complications, autonomic instability, and muscle spasms. Full tetanus immunization is required after recovery from the disease. Long-term sequelae have been reported from survivors.[1][2][3][4]

Etiology

Tetanus is due to infection from the bacterium, Clostridium tetani, which is found in soil, dust, or animal feces. It is a gram-positive, spore-forming, obligate anaerobic bacillus. This bacteria and its spores are found worldwide, however, it is more frequently found in hot and wet climates where the soil is rich with organic matter.

C. tetani may enter the human body through wound puncture, laceration, skin breaks, or inoculation with an infected syringe or insect bites. Most common source of infection is a wound that is often trivial and may go unnoticed, such as a minor laceration from wood or metal splinters or thorns. High-risk populations include those that have not been vaccinated, intravenous drug users, and those who are immunosuppressed. Other causes of infection have been documented through surgical procedures, intramuscular injections, compound fractures, dental infections, and dog bites.[5][6][7]

Tetanus spores are durable and can survive for prolonged periods in certain environments. The source of infection, in most cases, is a wound, usually from a minor injury. A very common cause of tetanus is a lack of immunization. Even those who are vaccinated lose immunity with advancing age.

Tetanus can also develop as a consequence of chronic conditions such as abscesses and gangrene. Furthermore, burn patients and patients undergoing surgery can also acquire the infection.

Tetanus usually occurs in persons who are not immunized, partially immunized or fully immunized but lacking adequate booster doses.[8]

1. Septic cutting of the umbilical cord

2. Neonatal tetanus in a previous child

3. Infectious substances applied to the umbilical stump, such as animal dung, mud or other such material.

The risk factors for neonatal tetanus include the following:

Epidemiology

Although tetanus affects people of all ages; however, the highest prevalence is seen in newborns and young persons. [9]The World Health Organization (WHO) reports improvement in mortality rates from tetanus, associated with aggressive vaccination campaigns in recent years. The WHO estimates worldwide tetanus deaths in 1997 at around 275,000 with improved rates in 2011 at 14,132 cases. However, of these cases, the prevalence of tetanus is still disproportionately higher (some studies showing 135 times higher) in low-resource settings than rates in developed countries, with mortality rates of 20% to 45% with the infection. Mortality rates vary based on the availability of resources, notably mechanical ventilation, invasive blood pressure monitoring, and early treatment.[10]

The incidence of neonatal tetanus is decreasing due to routine vaccination worldwide, which is combined with other vaccines, pertussis, and diphtheria (DPT). The occurrence of tetanus among neonates is mostly due to incomplete vaccination of the infant. In 2013, approximately 84% of children less than 12 months of age had coverage of tetanus worldwide.

In high resource countries, such as the United States, cases of tetanus occur in the unimmunized or in the elderly who have decreased immunity over time. Intravenous drug users are also at risk owing to contaminated needles or drugs.

Tetanus is a disease of the underdeveloped world. It is more commonly found in areas where the soil is cultivated, in warm climates, and among males. It is also more frequently seen in neonates and children in the countries where there is no immunization program in place.[11]

Pathophysiology

C. tetani secretes the toxins, tetanospasmin, and tetanolysin, causing the characteristic "tetanic spasm," a generalized contraction of agonist and antagonistic muscles. Specifically, tetanospasmin affects the nerve and muscle motor endplate interaction, causing the clinical syndrome of rigidity, muscle spasms, and autonomic instability. On the other hand, tetanolysin damages the tissues.

At the site of inoculation, tetanus spores enter the body and germinate in the wound. [12] Germination needs particular anaerobic conditions, such as dead and devitalized tissue that has low oxidation-reduction potential. After germination, they release tetanospasmin into the bloodstream. [13] This toxin enters the presynaptic terminals in the neuromuscular endplate of motor neurons and inhibits neurotransmitter release of glycine and GABA. This paralyzes muscle fibers. Subsequently, this toxin, via retrograde axonal transport, travels to neurons in the central nervous system where it also inhibits neurotransmitter release; this occurs approximately 2 to 14 days after inoculation. Since glycine and GABA are major inhibitory neurotransmitters, cells fail to inhibit the motor reflex response to sensory stimulation, causing a tetanic spasm. This can cause such powerful unopposed muscle activity and contraction that bone fractures and muscle tears can occur.

The incubation period can last from one to 60 days but is, on average, around 7 to 10 days. Symptom severity depends on the distance from the central nervous system with more severe symptoms associated with shorter incubation periods. Once the neurotoxin enters the brainstem, autonomic dysfunction occurs, typically in the second week of symptom onset. With the loss of autonomic control, patients can present with labile blood pressure and heart rate, diaphoresis, bradyarrhythmias, and cardiac arrest. Symptoms can last for weeks to months with a mortality rate of 10% in those infected, it is even higher in those without prior vaccination. There have been frequent motor and long-term neuropsychiatric complications in survivors; however, many make full recoveries. [14]

History and Physical

The majority of cases of tetanus in the United States are reported in patients who are either unimmunized or partially immunized. The median period of incubation is 7 days and for majority cases, it is from 4 to 14 days. The patients sometimes recall the injury bot more commonly the injury goes unnoticed.

The clinical features of tetanus include lockjaw, grimace facial expression (risus sardonicus), generalized muscle spasms associated with severe pains, drooling, uncontrolled urination and defecation, and back arching spasm (opisthotonus) that may cause respiratory distress. Most commonly, trismus appears as the first symptom, with the progression of spasms throughout the rest of the body. Reflex spasms occur in most patients and can be triggered by nominal external stimuli, such as noise, touch, or light.

There are four forms of tetanus based on clinical findings: generalized, neonatal, localized, and cerebral tetanus.

Generalized tetanus is the most common form of tetanus, occurring in approximately 80% of cases. Patients present with a descending pattern of muscle spasms, first presenting with lockjaw, and risus sardonicus (rigid smile because of sustained contraction of facial musculature). This can progress to a stiff neck, difficulty swallowing, and rigid pectoral and calf muscles. These spasms can occur for up to 4 weeks, with full recovery taking months. Autonomic instability can also occur in these patients with fever, dysrhythmia, labile blood pressure and heart rate, respiratory difficulties, catecholamine excretion, and even early death.

Neonatal tetanus is a generalized form of tetanus that occurs in newborns of unimmunized mothers or from infection through a contaminated instrument when cutting the umbilical cord. Infants of immunized mothers generally do not get tetanus due to passive immunity from the mother. Those who are infected, exhibit irritability, poor feeding, facial grimacing, rigidity, and severe spastic contractions triggered by touch. There have been case reports of long-term consequences in survivors of neurodevelopmental impairments, behavioral problems, and deficits in gross motor and speech and language development.

Localized tetanus and cephalic tetanus are the rarest forms of tetanus. Localized tetanus is the persistent contraction of muscles at the site of injury that can persist for weeks. This type is uncommonly fatal; however, it can progress to the generalized form of tetanus, which is more life-threatening. Cephalic or cerebral tetanus is limited to the muscles and nerves of the head. Cephalic tetanus occurs most commonly after head trauma such as a skull fracture, head laceration, eye injury, dental procedures, otitis media, or from another injury site. It presents with neck stiffness, dysphagia, trismus, retracted eyelids, deviated gaze, and risus sardonicus. The facial nerve is most frequently involved. However, other cranial nerves can also be affected. These findings can lead to further complications such as broncho-aspiration, paralysis of respiratory and laryngeal muscles, and respiratory failure. This type can also progress to generalized tetanus.

Physical examination findings can vary significantly from one patient to another. Spatula test is one of the exam techniques that may provide a clue towards the diagnosis. It includes the stimulation of the posterior pharyngeal that elicits the reflex spasm of the masseter muscles causing the patient to bite down instead of the gag.

Autonomic involvement leads to hypertension and tachycardia alternating with hypotension and bradycardia. In extreme cases, cardiac arrest may also occur.

Patients may also present with abdominal tenderness and guarding, and that may be mistaken for acute abdomen by the providers. Historically, exploratory laparotomies have been performed before making the correct diagnosis.

Cephalic tetanus, although a rare form of tetanus, may present with various cranial nerve palsies. The most commonly involved nerve is cranial nerve 8th.

Evaluation

The diagnosis of tetanus is clinical with no particular laboratory test. Providers may find a positive wound culture and the isolation of the organism; however, this occurs in only 30% of cases. Key features to note when diagnosing tetanus include acute onset and muscle contractures with generalized spasms without any other medical cause. Some patients can recall a history of injury, but not all.

An assay for antitoxin levels, though not readily available, may help in excluding the possibility of tetanus. A serum antitoxin level of 0.01 IU/mL or higher is generally accepted as protective, making the possibility of tetanus less likely.

Spatula test that has been described before shows high specificity and sensitivity for the clinical diagnosis of tetanus. This involves using a soft-tipped instrument to touch the posterior pharyngeal wall. If this elicits an involuntary jaw contraction instead of the normal gag reflex, this suggests a positive test.

It is important to note that infections occur in people with no immunity or low-serum levels of anti-tetanus antibodies. Life-threatening complications from tetanus can occur and include pneumonia secondary to aspiration and laryngospasm, rhabdomyolysis, upper gastrointestinal bleed, cardiovascular instability such as transient cardiac arrest, tachycardia or bradycardia, arrhythmias, and hypertension, acute renal failure, and secondary wound infections. Mortality from the infection occurs from respiratory failure and cardiovascular collapse, associated with autonomic dysfunction.

Treatment / Management

1. Early intramuscular or intravenous administration of the human tetanus immunoglobulin (HTIG)

2. controlling various manifestations

The treatment of tetanus is based on the severity of the disease. However, all patients must have the following goals of treatment:

First-line treatment includes HTIG, which removes released tetanospasmin toxin; however, it does not affect the toxin that is already bound to the central nervous system. HTIG also shortens the course of illness and may help in reducing the severity. A dose of 500 U, either intramuscular or intravenous, is as effective as larger doses. HTIG is injected intrathecally, especially in cases of cerebral tetanus. In the case of generalized tetanus, therapeutic doses (3000-6000 U) are also recommended. Debridement of the wound will control the source of toxin production. [15]

Although toxins are the main cause of disease, metronidazole has been shown to slow the progression of the disease. Metronidazole has been shown to decrease mortality, as well. [16] Penicillin, which was used in the past for treatment, is no longer recommended after discovering that it may have synergistic effects with tetanospasmin. Antispasmodics such as benzodiazepines, baclofen, vecuronium, pancuronium, and propofol have been used based on the clinical scenario. Baclofen can also be given intrathecally and is found to be effective in controlling muscle rigidity.[17][18][19]

For more severe tetanus, patients are likely hospitalized in the intensive care unit (ICU) with sedation and mechanical ventilation, which can affect mortality and long-term sequelae. Tracheostomy is preferred because endotracheal tubes may be a stimulus for muscle spasms. Tracheostomy is also indicated in cases where intubation is required for more than 10 days.

Benzodiazepines are considered a cornerstone therapy for tetanus manifestations, and diazepam is the most frequently studied and utilized drug in this regard. It not only reduces anxiety but also causes sedation and relaxes muscles, thereby preventing lethal respiratory complications. Intravenous magnesium has been shown to prevent muscle spasm. Diazepam or midazolam, GABA-agonist benzodiazepines, are given as a continuous infusion to prevent respiratory or cardiovascular complications. To prevent spasms that last more than 5-10 seconds, diazepam should be administered IV, 10-40 mg every 1-8 hours. The dose of midazolam is 5-15 mg/hour IV.

Clinicians must also provide supportive care, especially for patients with autonomic instability (labile blood pressure, hyperpyrexia, hypothermia). Magnesium is often used in combination with benzodiazepines to manage these complications. [20] It should be given IV in the form of a bolus of 5g followed by a continuous infusion at a rate of 2-3 g/hour until the spasm control has been achieved. [21] During magnesium infusion, the patellar reflex needs to be monitored; if areflexia develops, the dose should be reduced. Morphine is often used to manage high blood pressure. Beta-blockers can cause hypotension and death. Esmolol in small doses can be used under strict monitoring.

Providing high-calorie diets to compensate for increased metabolic use from muscle contractions is also important.

Management of respiratory status, cardiovascular complications, and autonomic dysfunction is essential for survival. Moreover, all patients require full tetanus toxoid immunization at recovery; having the infection does not give future immunity.[22][23]

Differential Diagnosis

The only condition that mimics tetanus the most is strychnine poisoning. One of the typical symptoms of tetanus is trismus which may be present in many other conditions. Those conditions are mentioned below:

Prognosis

The prognosis after tetanus depends on the time from the first symptom to the first spasm. In general, with a short time to symptom manifestation, the prognosis is poor. The recovery after tetanus is slow and it can take months. Both neonatal and cephalic tetanus have a poor prognosis.

Some patients develop hypotonia and autonomic dysfunction that lasts for months or years. Even those who survive, need tetanus toxoid as the infection does not confer immunity.

Usually, patients survive this illness although recovery is slow and some patients may remain hypotonic.

Incubation - shorter than 7 days

Onset - less than 48 hours

Causes of tetanus - burns, surgical wounds, septic abortion, umbilical stump, compound fractures, or intramuscular injection

Temperature - more than 104 F (40 C)

Tachycardia - more than 120/min (150/min in neonates)

An established scale can be used to predict the prognosis of tetanus. One point is given for each of the following:

The total score indicates disease severity:

Complications

Vocal cord paralysis leading to respiratory distress

Autonomic dysfunction- leading to hypertension

Complications include contractions of respiratory muscles, vocal cords and other critical areas of the body. [24] Sympathetic overactivity is the most significant cause of tetanus-associated mortality in critical patients. Further complications include:

Consultations

1. Toxicology - to rule out strychnine poisoning

2. Neurology - to preclude other causes of seizures

3. Pulmonary medicine - for respiratory compromise and mechanical ventilation

4. Anesthesiology - for the administration of intrathecal drugs, such as baclofen.

The primary provider should be an intensivist as this is a disease that needs critical care and robust monitoring. However, the following specialties should be consulted in order to reduce morbidity and mortality:

Enhancing Healthcare Team Outcomes

Tetanus is a lethal infection, and it is best managed by an interprofessional team that includes an emergency department physician, nurse practitioner, infectious disease expert, neurologist, pulmonologist, and intensivist.

The treatment of tetanus is based on the severity of the disease. However, all patients must have early wound debridement, antibiotic therapy, early intramuscular or intravenous administration of the human tetanus immunoglobulin (HTIG), and neuromuscular blockade. Patients with severe symptoms should be admitted to the ICU for close monitoring and mechanical ventilation. Healthcare providers must also provide supportive care, especially for patients with autonomic instability (labile blood pressure, hyperpyrexia, hypothermia). Moreover, all patients require full tetanus toxoid immunization at recovery. For those who are treated with tetanus toxoid, recovery is assured, but the rehabilitation may take weeks or months.[25]

Healthcare workers, including nurses and pharmacists, must emphasize the importance of immunization.

The tetanus vaccination has been considered as a routine vaccine in addition to pneumococci and influenza vaccines among older adults. Protection against tetanus by vaccines is essential because there is no natural immunity against tetanus. The tetanospasmin toxin is very lethal and will cause death before initiating an immune response. After recovery from an infection, patients must receive full immunity. In addition, post-exposure prophylaxis can also be provided through tetanus toxoid with or without tetanus immunoglobulin intravenous or intramuscular, depending on the wound.

Only with an interprofessional approach with regular education of the public can the morbidity and mortality of tetanus be lowered.

Continuing Education / Review Questions

References

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Tetanus is an infection characterized by a state of generalized hypertonia that manifests in the form of painful muscle spasms of the jaw and neck. The disease most commonly occurs in those who are not vaccinated or in the elderly with waning immunity. Currently, vaccination campaigns have decreased the incidence and prevalence of tetanus worldwide.

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3. H.C.L. (2021, January 3). Toxigenic clostridia. Clin. Microbiol. Rev. 3:66–98.

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Species/Subspecies:

Clostridium tetani

Categories:

Causes hemolysis; spore forming; motile

Etymology:

Genus name: a small spindle.
Species epithet: of a tension (of tetanus which refers to the tension in the muscles which is caused by tetanus).

Significance:

[Very important]

Taxonomy:

Macromorphology (smell):

C. tetani produces a very faint growth on FAA plates. Single colonies can hardly be observed, but a thin film of bacteria can often be discerned, because the bacteria swarm on moist agar plates. On dryer blood agar single medium sized colonies may be formed (4-6 mm in diameter). These colonies are flat, translucent and grayish with an irregular margin. A thin zone of β-hemolysis can often be observed around colonies on blood agar.

Gram +/Gram -:

G+ (old cultures may appear as G-)

Fermentation of carbohydrates:

D-glucose

lactose

maltose

L-rhamnose

sucrose

-

-

-

-

-

L-arabinose

cellobiose

D-mannitol

salicin

trehalose

-

-

-

-

-

glycerol

inulin

raffinose

D-sorbitol

starch

-

-

-

-

-

Other carbohydrates: C. tetani does not form acid by fermentation of carbohydrates.

Reservoir:

C. tetani can be found in soil (particularly manured) and can be isolated from the gut of different animal species.

Disease:

Tetanus

Hosts

Disease

Clinical picture

Horse

Tetanus

Spastic paralysis, increased muscle stiffness, rigid motions, convulsions, strong reaction to external stimuli, difficulties to eat, prolapse of third eyelid, and finally paralysis of respiratory muscles

Cattle

Tetanus

Muscle contractions, spasms, tremors, straight tail, ceased rumen function, stiff legs, collapse

Humans

Tetanus

Painful muscle contractions beginning with the face ("risus sardonicus" = sardonic smile) and neck, followed by torso and extremities. The cramps are often triggered by external stimuli and cause strangle.

Virulence Factors:

C. tetani produces two exotoxins, tetanolysin and tetanospasmin, which are encoded by plasmid born genes. Tetanospasmin is a neurotoxin, which is similar to botulinum toxin in structure and mode of action, but they act on different parts of the nervous system. Tetanospasmin blocks the inhibitory nerve impulses by interfering with the release of neurotransmitters (glycine and γ-aminobutyric acid) and this in turn leads to a spastic paralysis. C.f. Clostridium botulinum.

The lethal dose of tetanospasmin for humans is approximately 2.5 ng/kg of body weight. Of natural toxins, only the botulinum toxin is more potent. Tetanolysin has a local necrotizing effect, which may facilitate the spread of C. tetani.

Genome Sequence:

Acc-no

Strain

Size (bp)

Genome

NC_004557

E88

2 799 251

1c + 1c

16S rRNA Seq.:

Acc-no

Strain

Number of NT

Operon

X74770

NCTC 279

1 515

6

Taxonomy/phylogeny:

C. tetani belongs, together with about 80 other Clostridium spp., to cluster I, which use to be regarded as genus Clostridium sensu stricto. There are about 100 additional species described.

Reference(s):
No. 33

Link:
Botulinum + Tetanus Toxin Mechanism

Updated:

2021-01-03

# data[].attributes.attachment_link.description
Species/Subspecies: Clostridium tetani Categories: Causes hemolysis; spore forming; motile Etymology: Genus name: a small spindle. Species epithet: of a tension (of tetanus which refers to the tension in the muscles which is caused by tetanus). Significance: [Very important] Taxonomy: Macromorphology (smell): C. tetani produces a very faint growth on FAA plates.