AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Acknowledgments
• Multimedia
• References

INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Acknowledgments
• Multimedia
• References

Background

Tetanus is an illness characterized by an acute onset of hypertonia, painful muscular contractions (usually of the muscles of the jaw and neck), and generalized muscle spasms without other apparent medical causes.

Although records from antiquity (5th century BC) contain descriptions of tetanus, it was Carle and Rattone in 1884 who first produced tetanus in animals. This was accomplished by injecting them with pus from a fatal human tetanus case. During that same year, Nicolaier produced tetanus in animals by injecting them with soil. In 1889, Kitasato isolated the organism from an infected human, showed that it produced disease when injected into animals, and reported that the toxin could be neutralized by specific antibodies. In 1897, Nocard demonstrated the protective effect of passively transferred antitoxin. Passive immunization in humans was used for treatment and prophylaxis during World War I. Tetanus toxoid was developed by Descombey in 1924. It was first widely used during World War II.

Despite widespread immunization of infants and children in the United States since the 1940s, tetanus still occurs in the United States. Currently, tetanus is a severe disease primarily of older adults who are unvaccinated or inadequately vaccinated. Worldwide, most reported cases of tetanus are the neonatal type. The last reported case of neonatal tetanus in the United States was in 1998; this was only the second case since 1989, and neither of the mothers had ever received tetanus vaccinations.

For more information, see Medscape's Vaccine Resource Center.

Pathophysiology

Clostridium tetani, an obligate anaerobic gram-positive bacillus, causes tetanus. This bacterium is nonencapsulated and forms spores, which are resistant to heat, desiccation, and disinfectants. The spores are ubiquitous and are found in soil, house dust, animal intestines, and human feces.

Spores that gain entry can persist in normal tissue for months to years. Under anaerobic conditions, these spores geminate and elaborate tetanospasmin and tetanolysin. Tetanolysin is not believed to be of any significance in the clinical course of tetanus. Tetanospasmin is a neurotoxin and causes the clinical manifestations of tetanus. Tetanospasmin that is released by the maturing bacilli is distributed via the lymphatic and vascular circulations to the end plates of all nerves. Tetanospasmin then enters the nervous system peripherally at the myoneural junction and is transported centripetally into neurons of the central nervous system (CNS). Per weight, tetanospasmin is one of the most potent toxins known. The estimated minimum 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.

These neurons become incapable of neurotransmitter release. The neurons, which release gamma-aminobutyric acid (GABA) and glycine, the major inhibitory neurotransmitters, are particularly sensitive to tetanospasmin, leading to failure of inhibition of motor reflex responses to sensory stimulation. This results in generalized contractions of the agonist and antagonist musculature characteristic of a tetanic spasm. The shortest peripheral nerves are the first to deliver the toxin to the CNS, which leads to the early symptoms of facial distortion and back and neck stiffness.

Once the toxin becomes fixed to neurons, it cannot be neutralized with antitoxin. Recovery of nerve function from tetanus toxins requires sprouting of new nerve terminals and formation of new synapses.

Frequency

United States

Reported incidence of tetanus has declined substantially since the mid 1940s because of the widespread use of tetanus immunizations (see Media file 1). Media file 2 shows the reported number of tetanus cases and average annual incidence rates, by state, in the United States from 1998-2000. An average of 43 cases was reported annually. Some suggest that only 40% of tetanus cases are reported to the Centers for Disease Control and Prevention (CDC). Media file 3 shows the number of tetanus cases reported, average annual incidence rates, and survival status of patients, by age group, from 1998-2000. The lowest average annual number of cases for a 3-year period in the United States was 41 cases per year during 1995-1997.

Of the 130 cases of tetanus reported in the United States from 1998-2000, California and Texas had the highest reported number of cases. All 50 states require that children be vaccinated prior to admission to public schools. More than 96% of children have received 3 or more diphtheria and tetanus toxoids plus pertussis (DTP) vaccinations by the time they begin school. The annual incidence of tetanus has dropped to fewer than 50 cases per year in the United States.

Heroin users, particularly persons who inject themselves subcutaneously, appear to be at high risk for tetanus. Quinine is used to dilute heroin and may support the growth of C tetani. The incidence of tetanus in people who use injection drugs increased 7.4%, from 3.6% of all cases in 1991-1994 to 11% of cases in 1995-1997. People who use injection drugs accounted for 15% of the tetanus cases in the United States from 1998-2000 (see Media file 4). Of the 19 people who used injection drugs and contracted tetanus from 1998-2000, only 1 reported an acute injury.

Most tetanus cases occur among people who are inadequately vaccinated and who sustain an acute injury.

International

Worldwide, tetanus is predominantly a disease of underdeveloped countries located in warm, damp climates. Tetanus affects all age groups, with the highest prevalence found in newborns and young people. In 1992, an estimated 578,000 infant deaths occurred due to neonatal tetanus. In 1998, 215,000 deaths occurred with more than 50% of these on the Africa continent. Tetanus is one of the target diseases of the World Health Organization Expanded Program on Immunization. Overall, the annual incidence of tetanus is 0.5-1 million cases.

Developed nations have incidences of tetanus similar to those observed in the United States. For instance, only 126 cases of tetanus were reported in England and Wales in 1984-1992.

Mortality/Morbidity

Overall, the mortality rate is approximately 45%. Clinical tetanus is less severe among patients who have a history of receiving a primary series of tetanus toxoid sometime during their life as compared with patients who are inadequately vaccinated or unvaccinated. The mortality rate in the United States is 6% for individuals who had previously received 1-2 doses of tetanus toxoid compared with 15% for individuals who were unvaccinated.

• The case-fatality ratio in the United States was 18% from 1998-2000 and 11% from 1995-1997; a case-fatality ratio of 91% was reported in 1947.
• The mortality rate is highest for people older than 60 years (40%) compared with those aged 20-59 years (8%). From 1998-2000, 75% of the deaths in the United States were in patients older than 60 years.
• The mortality rate is 30% for people who require mechanical ventilation but only 4% for those who do not.

Race

From 1998, the incidence of tetanus in the United States was highest among Hispanics (0.38 cases per million population), followed by whites (0.13 cases per million population), and then African Americans (0.12 cases per million population).

Sex

A difference in the levels of tetanus immunity exists between the sexes.

• Overall, men are believed to be better protected than women, perhaps because of additional vaccinations administered during military service or professional activities.
• In the United States from 1998-2000, the incidence of tetanus in males aged 59 years and younger was 2.8 times higher than in females in the same age range.
• In developing countries, women have an increased immunity where tetanus toxoid is administered to women of childbearing age to prevent neonatal tetanus.

Age

The incidence of tetanus increases with advancing age. From 1980 through 2000, 70% of reported cases of tetanus in the United States were among persons aged 40 years or older. Of all these patients, 36% are older than 59 years and only 9% are younger than 20 years.

CLINICAL

Section 3 of 11  

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• Clinical
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• Medication
• Follow-up
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• Multimedia
• References

History

• From 1995-2000, 81% of cases in the United States were generalized tetanus, 15% were localized, 3% were cephalic, and 1 case of neonatal tetanus was reported.
• Almost all reported cases of tetanus are in persons who have either never been vaccinated or who completed a primary series but have not had a booster in the preceding 10 years. From 1995-1997, 54% of the reported cases in the United States had an unknown tetanus vaccination history, 22% had no known previous tetanus vaccination, 9% had 1 previous dose, 3% had 2 previous doses, 3% had 3 previous doses, and 9% had 4 or more previous doses.
• The median incubation period is 7 days, and, for most cases (73%), incubation ranges from 4-14 days.
• • The incubation period is shorter than 4 days in 15% of cases and longer than 14 days in 12% of cases.
  • Patients with clinical manifestations occurring within 1 week of an injury have more severe clinical courses.
• Patients with generalized tetanus present with trismus (ie, lockjaw) in 75% of cases.
• • Other presenting complaints include stiffness, neck rigidity, dysphagia, restlessness, and reflex spasms.
  • Subsequently, muscle rigidity becomes the major manifestation.
  • Muscle rigidity spreads in a descending pattern from the jaw and facial muscles over the next 24-48 hours to the extensor muscles of the limbs.
  • Dysphagia occurs in moderately severe tetanus due to pharyngeal muscle spasms, and onset is usually insidious over several days.
  • Reflex spasms develop in most patients and can be triggered by minimal external stimuli such as noise, light, or touch. The spasms last seconds to minutes; become more intense; increase in frequency with disease progression; and can cause apnea, fractures, dislocations, and rhabdomyolysis.
  • Laryngeal spasms can occur at any time and can result in asphyxia.
  • Other symptoms include elevated temperature, sweating, elevated blood pressure, and episodic rapid heart rate.
• Sustained contraction of facial musculature produces a sneering grin expression known as risus sardonicus.

Physical

• The lower extremity is the site of antecedent acute injury in 52% of patients, the upper extremity is the site of antecedent injury in 34% of patients, and head or trunk is the site of antecedent injury in 5% of patients.
• Autonomic dysfunction in patients with severe tetanus manifests as extremes in blood pressure, dysrhythmias, and cardiac arrest.
• Neonatal tetanus presents with an inability to suck 3-10 days after birth. Presenting symptoms include irritability, excessive crying, grimaces, intense rigidity, and opisthotonus.
• Tetanic seizures may occur and portend a poor prognosis.
• • Frequency and severity of seizures are related to severity of the disease.
  • Seizures resemble epileptic seizures with the presence of a sudden burst of tonic contractions.
  • However, the patient does not lose consciousness and usually experiences severe pain.
  • Seizures frequently occur in the muscle groups causing opisthotonos, flexion and abduction of the arms, clenching of the fists against the thorax, and extension of the lower extremities.
• Localized tetanus is characterized by painful spasms of the group of muscles in close proximity to the site of injury. This disorder may persist for several weeks but is usually self-limiting.
• Cephalic tetanus is a rare form of the disease that is usually secondary to chronic otitis media or head trauma.
• • Cephalic tetanus is characterized by variable cranial nerve (CN) palsies; CN VII is most frequently involved.
  • Ophthalmoplegic tetanus is a variant that develops after penetrating eye injuries and results in CN III palsies and ptosis.
  • Patients with cephalic tetanus who are untreated progress to generalized tetanus.
• Patients with tetanus may present with abdominal tenderness and guarding, mimicking an acute abdomen. Exploratory laparotomies have been performed before the correct diagnosis was apparent.
• Tetanospasmin has a disinhibitory effect on the autonomic nervous system (ANS).
• • ANS dysfunction becomes progressively evident as the level of toxin in the CNS increases.
  • ANS disturbances, such as sweating, fluctuating blood pressure, episodic tachydysrhythmia, and increased release of catecholamines, are observed.
  • Drugs with beta-blocker effects have been used to control the cardiovascular manifestations of ANS instability, but they also have been associated with increased risk of sudden death.

Causes

• Only 12-14% of patients with tetanus in the United States have received a primary series of tetanus toxoid. During 1998-2000, only 6% of all patients with tetanus were known to be current with tetanus immunization, with no fatal cases reported among this group.
• • In 73% of patients with tetanus in the United States, tetanus occurred after an acute injury, including puncture wounds (50%), lacerations (33%), and abrasions (9%).
  • Of those who obtained medical treatment of their injury in the United States from 1998-2000, 96% were administered tetanus immune globulin as part of their treatment; 55% of patients required the use of assisted ventilation and 31% of these patients died.
  • Stepping on a nail accounted for 32% of the puncture wounds.
  • Tetanus can occur in burn victims; in patients receiving intramuscular injections; in persons obtaining a tattoo; and in persons with frostbite, dental infections (eg, periodontal abscesses), penetrating eye injuries, and umbilical stump infections.
  • Other reported risk factors include diabetes, chronic wounds (eg, skin ulcers, abscesses, gangrene), parenteral drug abuse, and recent surgery (4% of US cases).
  • Twelve percent of patients with tetanus in the United States from 1998-2000 had diabetes (with a mortality rate of 31%) compared with 2% during 1995-1997. Of these patients, 69% had acute injuries, while 25% had gangrene or a diabetic ulcer.
  • The median time interval between surgery and onset of tetanus is 7 days.
  • Tetanus has been reported after tooth extractions, root canal therapy, and intraoral soft tissue trauma.
• Worldwide risk factors for neonatal tetanus are as follows:
• • Unvaccinated mother, home delivery, and unhygienic cutting of the umbilical cord increase susceptibility to tetanus.
  • History of neonatal tetanus in a previous child is a risk factor for subsequent neonatal tetanus.
  • Potentially infectious substances applied to the umbilical stump (eg, animal dung, mud, clarified butter) are risk factors for neonates.
• Immunity from tetanus decreases with advancing age.
• • Serologic testing for immunity has revealed a low level among elderly individuals in the United States.
  • Approximately 50% of adults older than 50 years are nonimmune because they never were vaccinated or do not receive appropriate booster doses.
  • Prevalence of immunity to tetanus in the United States is greater than 80% for those aged 6-39 years but only 28% for persons older than 70 years.

DIFFERENTIALS

Section 4 of 11  

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Other Problems to be Considered

Intraoral disease
Odontogenic infections
Globus hystericus
Hepatic encephalopathy
Hysteria
Strychnine poisoning
Acute abdomen
Intracranial hemorrhage

WORKUP

Section 5 of 11  

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• Treatment
• Medication
• Follow-up
• Acknowledgments
• Multimedia
• References

Lab Studies

• No specific laboratory tests exist for determining the diagnosis of tetanus. The diagnosis is clinically based on the presence of trismus, dysphagia, generalized muscular rigidity, and/or spasm.
• Laboratory studies may demonstrate a moderate peripheral leukocytosis.

Other Tests

• An assay for antitoxin levels is not readily available. However, a level of 0.01 IU/mL or greater in serum is generally considered protective, making the diagnosis of tetanus less likely.
• Cerebrospinal fluid (CSF) study findings are usually within normal limits.

Procedures

• The spatula test is one diagnostic bedside test.
• • This simple test involves touching the oropharynx with a spatula or tongue blade.
  • This test typically elicits a gag reflex, and the patient tries to expel the spatula (ie, a negative test result).
  • If tetanus is present, patients develop a reflex spasm of the masseters and bite the spatula (ie, a positive test result).
  • In 400 patients, this test had a sensitivity of 94% and a specificity of 100%.
  • No adverse sequelae (eg, laryngeal spasm) from this procedure were reported.

TREATMENT

Section 6 of 11  

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• Follow-up
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Emergency Department Care

Treatment of tetanus is directed toward the treatment of muscle spasm, prevention of respiratory and metabolic complications, neutralization of circulating toxin to prevent the continued spread, and elimination of the source.

• Admit patients to the intensive care unit (ICU). Because of the risk of reflex spasms, maintain a dark and quiet environment for the patient. Avoid unnecessary procedures and manipulations.
• Seriously consider prophylactic intubation in all patients with moderate-to-severe clinical manifestations. Intubation and ventilation are required in 67% of patients.
• • Attempting endotracheal intubation may induce severe reflex laryngospasm; prepare for emergency surgical airway control. Rapid sequence intubation techniques (eg, with succinylcholine) are recommended to avoid this complication.
  • Perform tracheostomy in patients requiring intubation for more than 10 days. Tracheostomy has also been recommended after onset of the first generalized seizure.
  • Tetanus immune globulin (TIG) is recommended for treatment of tetanus. TIG can only help remove unbound tetanus toxin, but it cannot affect toxin bound to nerve endings. A single intramuscular dose of 3000-5000 units is generally recommended for children and adults, with part of the dose infiltrated around the wound if it can be identified.
• Surgical therapy includes debridement of wounds to remove organisms and to create an aerobic environment.
• • The current recommendation is to excise at least 2 cm of normal viable-appearing tissue around the wound margins.
  • Incise and drain abscesses.
  • Delay any wound manipulation until several hours after administration of antitoxin due to risk of releasing tetanospasmin into the bloodstream.

Consultations

• An intensive care medicine specialist should be the primary physician coordinating the patient's care.
• Consult a pulmonary medicine specialist after admission to the ICU for patients with severe respiratory symptoms or those requiring mechanical ventilation.
• Consult an anesthesiologist after admission to the ICU if intrathecal baclofen is to be administered.

MEDICATION

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Drugs used to treat muscle spasm, rigidity, and tetanic seizures include sedative-hypnotic agents, general anesthetics, centrally acting muscle relaxants, and neuromuscular blocking agents. Antibiotics are used to prevent multiplication of C tetani, thus halting production and release of toxins.

Drug Category: Anticonvulsants

Sedative-hypnotic agents are the mainstays of tetanus treatment. Benzodiazepines are the most effective primary agents for muscle spasm prevention and work by enhancing GABA inhibition. Diazepam is the most frequently studied and used drug. Diazepam reduces anxiety, produces sedation, and relaxes muscles.

Phenobarbital is another anticonvulsant that may be used to prolong effects of diazepam. Phenobarbital is also used to treat severe muscle spasms and provide sedation when neuromuscular blocking agents are used.

Drug Category: Skeletal muscle relaxants

These agents can inhibit both monosynaptic and polysynaptic reflexes at spinal level, possibly by hyperpolarization of afferent terminals.

Drug Category: Antitoxins

These agents are used to neutralize any toxin that has not reached the CNS.

Drug Category: Antibiotics

Administer to patients with clinical tetanus. However, efficacy is questioned. Theoretically, antibiotics may prevent multiplication of C tetani, thus halting production of toxin. Nevertheless, a study of 364 patients found no difference in fatality rates between patients who received antibiotics and those who did not. Penicillin G is the drug of choice. Metronidazole is considered by some to be a better drug. One study demonstrated a lower mortality for patients administered metronidazole compared with penicillin. Tetracycline is an alternative drug for patients who are allergic to penicillin or metronidazole. Large doses of antibiotics are recommended to favor diffusion into devitalized tissue.

Drug Category: Neuromuscular blocking agents

These agents inhibit the transmission of nerve impulses at neuromuscular junctions of skeletal muscles and/or autonomic ganglia.

FOLLOW-UP

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• Follow-up
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Further Inpatient Care

• Institute prevention measures for deep venous thrombosis, gastrointestinal ulcer, and decubitus ulcer.
• The maintenance of nutrition is extremely important and should be carried out in seriously ill patients via nasoduodenal tubes, gastrostomy tube feedings, or parenteral hyperalimentation.

Deterrence/Prevention

For related CME/CE activities, see CME/CE - Guidelines Issued on Pertussis, Tetanus, Diphtheria Prevention in Pregnant Women and Newborns and CME/CE - Adult Immunization Update.

• Prevention of tetanus is accomplished through vaccination with DTP or DTaP at ages 2, 4, 6, 12-18 months, and 4-6 years.
• For persons aged 7 years or older who have never been vaccinated against tetanus, diphtheria, or pertussis (no dose of DTP/DTaP/DT or Td), administer a series of 3 vaccinations containing tetanus and diphtheria toxoids.
• • The preferred schedule is a single dose of Tdap, followed by a dose of Td >4 weeks after Tdap and another dose of Td 6–12 months later. However, Tdap can substitute for any one of the doses of Td in the 3-dose primary series.
  • Alternatively, in situations in which the adult probably received vaccination against tetanus and diphtheria but cannot produce a record, vaccine providers may consider serologic testing for antibodies to tetanus and diphtheria toxin to avoid unnecessary vaccination. If tetanus and diphtheria antitoxin levels are each >0.1 IU/mL, previous vaccination with tetanus and diphtheria toxoid vaccine is presumed, and a single dose of Tdap is indicated.
  • Adults who received other incomplete vaccination series against tetanus and diphtheria should be vaccinated with Tdap and/or Td to complete a 3-dose primary series of tetanus and diphtheria toxoid-containing vaccines.
• Secondary prevention of tetanus is accomplished postexposure through appropriate wound cleansing and debridement and the administration of tetanus toxoid (Td, Tdap, DT, DPT, or DTaP as indicated) and human tetanus immune globulin (TIG), when indicated. Pediatric formulations (DT and DTaP) contain a similar amount of tetanus toxoid as adult Td, but contain 3-4 times as much diphtheria toxoid.
• • Consider the following wounds to be prone to tetanus: those present longer than 6 hours; deep (>1 cm); grossly contaminated; exposed to saliva or feces, stellate, and ischemic or infected (including abscesses); as well as avulsions, punctures, or crush injuries.
  • Of 2 licensed Tdap products, only Adacel is licensed and recommended for use in adults. Boostrix is licensed for persons aged 10–18 years and should not be administered to persons aged older than 19 years. DTaP and Tdap vaccines do not contain thimerosal as a preservative.
  • Administer Td or DTP intramuscularly to patients with tetanus-prone wounds if they are younger than 7 years and if it has been more than 5 years since their last dose of tetanus.
  • Administer TIG (250-500 U IM always in the opposite extremity of the toxoid) if patients previously have received fewer than 3 doses of tetanus toxoid and for patients aged 60 years or older.
  • In adults without tetanus-prone wounds, administer Td or Tdap to patients who previously have received fewer than 3 doses of tetanus toxoid or if more than 10 years have passed since their last dose. Tdap is preferred to Td for adults vaccinated more than 5 years earlier who require a tetanus toxoid as part of wound management and who have not previously received Tdap. For adults previously vaccinated with Tdap (after age 7 y), Td should be used if a tetanus toxoid-containing vaccine is indicated for wound care.
  • Review the immunization status for all patients who present to an ED for any care (regardless of chief complaint). Administer immunizations if a lapse of more than 10 years has occurred since their last booster.
• The Advisory Committee on Immunization Practices recommends vaccination at primary care visits for adolescents aged 11-12 years and for adults aged 50 years, review of vaccination histories, and updating of their tetanus vaccination status. This is in addition to recommending booster doses of tetanus-diphtheria toxoid every 10 years.
• Worldwide, neonatal tetanus may be eliminated by increasing immunizations in women of childbearing age, especially pregnant women, and by improving maternity care.
• • Tetanus toxoid twice during pregnancy (4-6 wk apart, preferably in the last 2 trimesters) and again at least 4 weeks before delivery is recommended for previously unimmunized gravid women.
  • Maternal antitetanus antibodies are passed to the fetus, and this passive immunity is effective for many months.

Complications

• Prior to 1954, asphyxia from tetanic spasms was the usual cause of death. However, with the advent of neuromuscular blockers, mechanical ventilation, and pharmacologic control of spasms, sudden cardiac death has become the leading cause of death. Sudden cardiac death has been attributed to excessive catecholamine productions, direct action of tetanospasmin, or tetanolysin on the myocardium.
• Nosocomial infections are common when hospitalization is prolonged. Secondary infections may include sepsis from decubitus ulcers, hospital-acquired pneumonias, and indwelling catheters. Pulmonary embolism is particularly a problem in drug users and elderly patients.
• Further complications include the following:
• • Long bone fractures
  • Glenohumeral joint and temporomandibular joint dislocations
  • Hypoxic injury and aspiration pneumonia is a common late complication of tetanus, found in 50–70% of autopsied cases.
  • Adverse effects of autonomic instability, including hypertension and cardiac dysrhythmias
  • Paralytic ileus, pressure sores, and urinary retention
  • Malnutrition and stress ulcers
  • Coma, nerve palsies, neuropathies, psychological aftereffects, and flexion contractures

Prognosis

• The prognosis is dependent on incubation period, time from spore inoculation to first symptom, and time from first symptom to first tetanic spasm.
• In general, shorter intervals indicate more severe tetanus and a poorer prognosis.
• Patients usually survive tetanus and return to their predisease state of health.
• Recovery is slow and usually occurs over 2-4 months.
• Some patients remain hypotonic.
• Clinical tetanus does not produce a state of immunity; therefore, patients who survive the disease require active immunization with tetanus toxoid to prevent a recurrence.

Patient Education

• For excellent patient education resources, visit eMedicine's Infections Center. Also, see eMedicine's patient education article Tetanus.

ACKNOWLEDGMENTS

Section 9 of 11  

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• Introduction
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• Differentials
• Workup
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• Medication
• Follow-up
• Acknowledgments
• Multimedia
• References

The authors and editors of eMedicine gratefully acknowledge the contributions of previous editor, Charles V Pollack, Jr, MD, to the development and writing of this article.

MULTIMEDIA

Section 10 of 11  

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Acknowledgments
• Multimedia
• References

Media file 1:  Tetanus Cases in US from 1947-2005. From Tetanus and Tetanus Toxoid: Epidemiology and Prevention of Vaccine-Preventable Diseases. National Immunization Program, Centers for Disease Control and Prevention. January 2006.
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Media type:  Graph

Media file 2:  Image from "Number of Tetanus Cases Reported and Average Annual Incidence Rates, by State." Pascual FB, McGinley EL, Zanardi LR, et al: Tetanus surveillance--United States, 1998--2000. MMWR Surveill Summ. 2003 Jun 20; 52(3): 1-8.
	View Full Size Image
Media type:  Graph

Media file 3:  Image from "Number of Tetanus Cases Reported, Average Annual Incidence Rates, and Survival Status of Patients, by Age Group." Pascual FB, McGinley EL, Zanardi LR, et al: Tetanus surveillance--United States, 1998--2000. MMWR Surveill Summ. 2003 Jun 20; 52(3): 1-8.
	View Full Size Image
Media type:  Graph

Media file 4:  Image from "Number of Tetanus Cases Reported Among Persons With Diabetes or Injection-Drug Use (IDU), by Age Group." Pascual FB, McGinley EL, Zanardi LR, et al: Tetanus surveillance--United States, 1998--2000. MMWR Surveill Summ. 2003 Jun 20; 52(3): 1-8.
	View Full Size Image
Media type:  Graph

Media file 5:  Age Distribution of Tetanus Case in the US from 1980-2003. From Tetanus and Tetanus Toxoid: Epidemiology and Prevention of Vaccine-Preventable Diseases. National Immunization Program, Centers for Disease Control and Prevention. January 2006.
	View Full Size Image
Media type:  Graph

Media file 6:  Tetanus Wound Management. From Tetanus and Tetanus Toxoid: Epidemiology and Prevention of Vaccine-Preventable Diseases. National Immunization Program, Centers for Disease Control and Prevention. January 2006.
	View Full Size Image
Media type:  Chart

REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Acknowledgments
• Multimedia
• References

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• Murphy SM, Hegarty DM, Feighery CS, et al. Tetanus immunity in elderly people. Age Ageing. Mar 1995;24(2):99-102. [Medline].
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Article Last Updated: Jul 25, 2008