Tetanus - Do you need the vaccine? Why?

What causes tetanus?
Tetanus is caused by a toxin (poison) produced by
a bacterium, Clostridium tetani. The C. tetani bacteria
cannot grow in the presence of oxygen. They
produce spores that are very difficult to kill as they
are resistant to heat and many chemical agents.
How does tetanus spread?
C. tetani spores can be found in the soil and in the
intestines and feces of many household and farm
animals and humans. The bacteria usually enter the
human body through a puncture (in the presence of
anaerobic [low oxygen] conditions, the spores will
germinate).
Tetanus is not spread from person to person.
How long does it take to show signs of tetanus after
being exposed?
The incubation period varies from 3-21 days, with
an average of eight days. The further the injury site
is from the central nervous system, the longer the
incubation period. The shorter the incubation period,
the higher the risk of death.
What are the symptoms of tetanus?
The symptoms of tetanus are caused by the tetanus
toxin acting on the central nervous system. In the
most common form of tetanus, the first sign is spasm
of the jaw muscles, followed by stiffness of the neck,
difficulty in swallowing, and stiffness of the abdominal
muscles.
Other signs include fever, sweating, elevated blood
pressure, and rapid heart rate. Spasms often occur,
which may last for several minutes and continue for
3-4 weeks. Complete recovery, if it occurs, may take
months.
How serious is tetanus?
Tetanus has a high fatality rate; during 1998-2000,
the case-fatality rate for reported tetanus in the
United States was 18%.
What are possible complications from tetanus?
Laryngospasm (spasm of the vocal cords) is a complication
that can lead to interference with breathing.
Patients can also break their spine or long bones
from convulsions. Other possible complications include
hypertension, abnormal heart rhythm, and
secondary infections, which are common because of
prolonged hospital stays.
Obviously, the high possibility of death is a major
complication.
How is tetanus diagnosed?
The diagnosis of tetanus is based on the clinical signs
and symptoms only. Laboratory diagnosis is not useful
as the C. tetani bacteria often cannot be recovered
from the wound of an individual who has tetanus,
and conversely, can be isolated from the skin of
an individual who does not have tetanus.
What kind of injuries might allow tetanus to enter
the body?
Tetanus bacilli live in the soil, so the most dangerous
kind of injury involves possible contamination
with dirt, animal feces, and manure. Although we
have traditionally worried about deep puncture
wounds, in reality many types of injuries can allow
tetanus bacilli to enter the body. In recent years, a
higher proportion of cases had minor wounds than
had major ones, probably because severe wounds
were more likely to be properly managed. People
have become infected with tetanus following surgery,
burns, lacerations, abrasions, crush wounds,
ear infections, dental infections, animal bites, abortion,
pregnancy, body piercing and tattooing, and
injection drug use. People can also get tetanus from
splinters.
I stepped on a nail in our yard. What should I do?
Any wound that may involve contamination with
tetanus bacilli should be attended to as soon as possible.
Treatment depends on your vaccination status
and the nature of the wound. In all cases, the wound
should be cleaned. Seek treatment immediately and
bring your immunization record with you.
With wounds that involve the possibility of tetanus
contamination, a patient with an unknown or incomplete
history of tetanus vaccination needs a tetanus-
and diphtheria-containing shot (Td or Tdap)
and a dose of tetanus immune globulin (TIG) as
soon as possible.
A person with a documented series of three tetanusand
diphtheria-containing shots (Td or Tdap) who
has received a booster dose within the last ten years
should be protected. However, to ensure adequate
protection, a booster dose of vaccine may still be
given if it has been more than five years since the
last dose and the wound is other than clean and
minor.
Is there a treatment for tetanus?
There is no “cure” for tetanus once a person develops
symptoms, just supportive treatment and management
of complications. The best “treatment” is
prevention through immunization.
How common is tetanus in the United States?
Tetanus first became a reportable disease in the late
1940s. At that time, there were 500-600 cases reported
per year. After the introduction of the tetanus
vaccine in the mid-1940s, reported cases of tetanus
dropped steadily.
During 1990-2001, a total of 534 cases of tetanus
were reported. Most (56%) of these cases occurred
among adults age 19-64 years and 38% were among
persons age 65 years or older.
Almost all cases of tetanus are in persons who have
never been vaccinated, or who completed their
childhood series, but did not have a booster dose in
the preceding 10 years.
What is neonatal tetanus?
Neonatal tetanus is a form of tetanus that occurs in
newborn infants, most often through the use of an
unsterile cutting instrument on the unhealed umbilical
stump. These babies usually have no temporary
immunity passed on from their mother because their
mother hasn’t been vaccinated and therefore has no
immunity.
Neonatal tetanus is very rare in the United States
(three cases reported during 1990-2004), but is
common in some developing countries. It causes
more than 215,000 deaths worldwide per year.
Can you get tetanus more than once?
Yes! Tetanus disease does not cause immunity because
so little of the potent toxin is required to cause
the disease. Persons recovering from tetanus should
begin or complete the vaccination series.
When did tetanus vaccine become available?
The first tetanus toxoid (inactivated toxin) was produced
in 1924 and was used successfully to prevent
tetanus in the armed services during World War II.
In the mid-1940s, tetanus vaccine was combined
with diphtheria toxoid and inactivated pertussis
bacteria to make the combination DTP vaccine for
routine childhood immunization.
In 1991, DTaP vaccine was licensed in the United
States. The pertussis component of this vaccine is a
more purified “acellular” version, which produces
fewer side effects.
In 2005, two new tetanus toxoid-diphtheria-acellular
pertussis (Tdap) vaccines were licensed. These
vaccines are the first pertussis-containing vaccines
that can be given to persons older than 7 years.
What kind of vaccine is the tetanus toxoid?
The tetanus vaccine is an inactivated toxin (poison)
called a toxoid. It is made by growing the bacteria
in a liquid medium and purifying and inactivating
the toxin. Because it is not a live vaccine, a person’s
immunity tends to decline with time, which is why
booster doses are recommended.
What’s the difference between all the vaccines containing
tetanus toxoid?
It’s like alphabet soup!
Tetanus toxoid is available as a single shot (TT) but
it rarely is given that way as it’s best to also provide
needed protection against other diseases at the same
time.
Children younger than age seven years receive DTaP
(tetanus, diphtheria, and acellular pertussis). If they
cannot receive the pertussis component of the combined
vaccine, they can receive DT (diphtheria and
tetanus toxoids for pediatric use). DTaP also can be
given as part of two different combination vaccines;
one includes DTaP, inactivated polio vaccine, and
hepatitis B vaccine, and another contains DTaP and
Hib vaccine.
Children ages seven years and older and adults
should be given a different formulation (i.e., Td or
Tdap).
How is this vaccine given?
The DTaP, DT, Td, and Tdap preparations are all
given as an injection in the muscle.
Who should get this vaccine?
Infants should receive DTaP vaccine (or DT-pediatric
if they cannot receive the pertussis component)
as part of their routine immunization. Adults should
be given a routine booster dose of Td every 10 years.
Adults without documentation of ever receiving the
basic series of tetanus and diphtheria toxoids should
first receive a primary series of three doses, properly
spaced. A single dose of Tdap is recommended for
persons age 11 years and older in place of one of the
Td doses, preferably the first one.
How many doses of DTaP vaccine are needed?
The usual schedule for infants is a series of four
doses given at two, four, six, and 15-18 months of
age. A fifth shot, or booster dose, is recommended
at 4-6 years of age, unless the fourth dose was given
late (after the fourth birthday).
When should adolescents and adults get vaccinated
against tetanus? Should they get vaccinated with Td
or Tdap?
Immunization experts recommend that the first dose
of Tdap be given at age 11-12 as a booster during
the routine adolescent immunization visit if the adolescent
has finished the childhood DTaP schedule
and has not already received a dose of Td or Tdap.
Adults should continue to receive a booster dose of
Td every ten years. Adults age 19-64 years who have
never received Tdap should receive a single dose of
Tdap to replace a single dose of Td so they can boost
their resistance to pertussis as well.
If someone experiences a deep or puncture wound,
or a wound contaminated with dirt, an additional
booster dose may be given if the last dose was more
than five years ago. It is important to keep an up-todate
record of all immunizations so that repeat
doses don’t become necessary. Although it is vital to
be adequately protected against tetanus, receiving
more doses than recommended can lead to increased
local reactions, such as painful swelling of
the arm.
Who recommends this vaccine?
The Centers for Disease Control and Prevention
(CDC), the American Academy of Pediatrics (AAP),
the American Academy of Family Physicians (AAFP),
and the American College of Physicians (ACP) all
recommend this vaccine.
How safe is this vaccine?
Most children have no serious reactions from the
combined DTaP vaccine. The most common reactions
are local reactions at the injection site, such as
soreness, redness, and swelling, especially after the
fifth dose. Other possible reactions may include
fussiness, fever, loss of appetite, tiredness, and vomiting.
The use of the more purified DTaP instead of
DTP has decreased these reactions substantially.
For adults receiving Td vaccine, localized non-serious
side effects are common (redness, soreness, etc.)
but are generally self-limiting and require no treatment.
What side effects have been reported with this vaccine?
Moderate to serious reactions are uncommon with
DTaP vaccine. Such reactions include crying for
three hours or more (up to about one child out of
1,000) and high fever (about one child out of
16,000). Most of these side effects are believed to be
due to the pertussis component of the vaccine, and
a child experiencing such a reaction may still be able
to be protected against tetanus and diphtheria with
the DT vaccine. More serious reactions, such as seizures,
are so rare that it is hard to tell if they are
caused by the vaccine.
As mentioned above, adults who received more than
the recommended doses of Td vaccine can experience
increased local reactions, such as painful swelling
of the arm. This is due to the high levels of tetanus
antibody in their blood.
The most frequently reported side effects following
vaccination with Tdap were headache, generalized
body aches, and tiredness.
Some of my patients describe having had a severe
reaction to something they were given for tetanus
many years ago. What could this be?
The allergic reactions these people experienced may
have actually been serum sickness, a reaction to
equine antitoxin. Equine antitoxin was the only
product available for the prevention of tetanus prior
to the mid 1940s. It was used for postexposure prophylaxis
until the late 1950s, when tetanus immune
globulin was introduced. Tetanus toxoid has never
contained any horse protein.
How effective is tetanus-diphtheria toxoid (Td)?
Td is close to 100% effective for persons receiving
the correct primary series (as a child or adult) and
a routine booster dose every ten years. It is felt that
Tdap vaccine will provide the same level of protection.
Who should NOT receive tetanus toxoid?
People who had a serious allergic reaction to one
dose of tetanus toxoid should not receive another.
Persons with a moderate or severe acute illness
should postpone receiving the vaccine until they are
improved. Most reactions to the combined DTaP
vaccine are due to the pertussis component. Please
see the “Pertussis” section for more information on
possible precautions to the use of this vaccine.
Can the vaccine cause tetanus?
No.