Tetanus -- United States, 1985-1986

During the period 1985-1986, the MMWR Morbidity Surveillance System received reports of 147 cases of tetanus in the United States (83 in 1985 and 64, provisionally, in 1986). Thirty-four states reported at least one case of tetanus, and 22 states reported cases in both years. The majority of the 16 states reporting no cases in these years are in the Rocky Mountain region. The provisional average annual incidence rate for 1985-1986 was 0.03/100,000 total population, compared with 0.39/100,000 in 1947, when national reporting began. Incidence increased by age group, with an eightfold increase between persons less than50 years of age and persons greater than or equal to50 (Table 1). Based on data for patients with known race, the estimated average annual incidence rate for whites was 0.03/100,000 (103 cases); for blacks, 0.06/100,000 (31 cases); and for all other races, 0.04/100,000 (6 cases).

Case report forms on 140 patients (95%) provided data on demographics, immunization history, circumstances of injury or other medical condition, and tetanus prophylaxis. Seventy-one percent (100) of the 140 cases occurred among persons greater than or equal to50 years of age, while 5% (7) occurred among persons less than20 years of age (Table 1). The youngest patient was 10 months of age. There were no cases of tetanus among neonates. Fifty-five percent (77) of the patients were male. The overall case-fatality ratio among the 137 patients for whom outcome is known was 31%. It was 42% for patients greater than or equal to50 years of age, and 5% for those less than50 years.

Nine patients (6%) were reported to have received at least a primary series of tetanus toxoid* prior to onset (Table 2). However, one of these received the third dose as part of wound prophylaxis, and three had not received a dose within the preceding 10 years. Four of the seven patients less than20 years of age had not received any doses of tetanus toxoid; the vaccine status of three was unknown. Two persons reported to have received at least a primary series of tetanus toxoid prior to onset died. One was a 61-year-old male whose most recent dose of toxoid was administered 20 years earlier. The other, the youngest fatality reported during the period 1985-1986, was a 26-year-old female who had no identifiable injury or associated condition and whose most recent dose of toxoid had been administered 8 years earlier.

Ninety-nine persons (71%) contracted tetanus after an identified acute injury. The most frequently reported acute injuries were puncture wounds (38%) and lacerations (37%). The circumstances of injury were known for 85 of the patients. Forty-eight percent of these wounds were incurred indoors; one was surgery-related; and the rest occurred during gardening or other outdoor activities. The median incubation period for the 75 patients with known date of injury was 7 days. Nine percent (7) had an incubation period of greater than14 days, and 12% (9) had an incubation period of less than or equal to3 days.

In view of reported immunization status and using the current recommendations of the Immunization Practices Advisory Committee (ACIP) for the use of tetanus and diphtheria toxoids (Td) and tetanus immune globulin (TIG) in wound management (Table 3) (1), all 99 patients who developed tetanus following an acute wound should have received at least Td prophylaxis**. Tetanus toxoid was given as prophylaxis for wound management to 20 patients (20%) with acute wounds; 13 (65%) of these received toxoid within 3 days of injury. How many of the 99 patients with acute wounds actually were seen by a medical provider prior to disease onset is not known.

Twenty-two patients had acute wounds severe enough to have required prophylactic wound debridement. Based on the ACIP recommendations for wound management, all of these patients were candidates for both Td and TIG (Table 3). However, none received TIG, and one (5%) received Td in the course of wound management.

Twenty-nine cases (21%) were associated with chronic wounds or underlying medical conditions such as skin ulcers, abscesses, or gangrene. A history of parenteral drug abuse was the only associated medical condition in three patients. No known acute injury, chronic wound, nor other pre-existing medical condition was reported for 12 (9%) patients.

Thirty-seven (31%) of the 121 patients who received TIG after onset of disease died. One received both TIG and equine tetanus antitoxin; the remainder received TIG alone. Total TIG dosages ranged from 75 to 22,000 international units (IU); the median was 3,000 IU. The 10-month-old patient received 75 IU and recovered. Reported by: State and Territorial Epidemiologists. Div of Immunization, Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: The incidence of tetanus has not changed substantially during the past decade, following the steady decline in the reported average annual crude incidence rate between 1947 and 1976 (Figure 1). The decline was attributed to both increasingly widespread immunization and improved wound management, including the use of tetanus prophylactic measures in emergency rooms.

The nationwide tetanus surveillance system is subject to limitations inherent in any reporting system. However, the clinical signs of tetanus are relatively dramatic and readily diagnosed; hence, tetanus is more likely than other diseases to be reported. Although case report forms were completed on 95% of the tetanus cases reported to the MMWR Morbidity Surveillance System during the period 1985-1986, the quality of the submitted information varied. Important data were occasionally omitted from the forms. More importantly, reported immunization status was usually based on verbal history and may not have been accurate.

The epidemiology of reported tetanus disease in the United States during the period 1985-1986 is essentially unchanged from that described previously for the period 1982-1984 (2). Tetanus remains a severe disease with a high case-fatality ratio occurring primarily among unimmunized and inadequately immunized adults. Data indicate that 94% of patients with reported cases of tetanus during 1985-1986 had not received at least a primary series of tetanus toxoid. The 1985-1986 case-fatality ratio of 31% is similar to the ratio of 26% reported during 1982-1984, but less than half the ratio of 66% reported during the period 1950-1959.

Tetanus is a completely preventable disease. Vaccination with a primary series of three doses of tetanus toxoid and booster doses every 10 years is highly effective in the prevention of tetanus (3). Acute wound-associated tetanus can be prevented by appropriate wound management, including active and/or passive immunization. As reported here, most tetanus patients with acute injuries have not received appropriate prophylaxis. One percent to 6% of persons with tetanus-prone injuries reportedly receive less than recommended prophylaxis (4,5). Tetanus cases that are not associated with acute wounds or that occur in persons who do not seek medical care for their wounds can be prevented only by routine primary immunization and maintenance of an up-to-date immunization status.

In the United States, tetanus is primarily a disease of older adults. Accelerated tetanus immunization efforts should be directed in particular to persons greater than or equal to50 years of age since this age group now accounts for over 70% of reported cases. All providers of health care to adolescents and adults should take every opportunity to review the immunization status of patients and provide, when indicated, tetanus and diphtheria toxoids and other vaccines such as hepatitis B, influenza, pneumococcal polysaccharide, measles, mumps, and rubella (6,7). One method of improving maintenance of protection against tetanus (as well as diphtheria) following the primary series is to schedule booster doses of Td routinely at mid-decade ages, i.e., 15 years of age, 25 years, 35 years, etc.

References

1. ACIP. Diphtheria, tetanus, and pertussis: guidelines for vaccine prophylaxis and other preventive measures. MMWR 1985;34:405-14,419-26.

2. CDC. Tetanus--United States, 1982-1984. MMWR 1985;34:602,607-11.

3. Edsall G. Specific prophylaxis of tetanus. JAMA 1959;171:417-27.

4. Giangrosso J, Smith RK. Misuse of tetanus immunoprophylaxis in wound care. Ann Emerg Med 1985;14:573-9.

5. Brand DA, Acampora D, Gottlieb LD, Glancy KE, Frazier WH. Adequacy of antitetanus prophylaxis in six hospital emergency rooms. N Engl J Med 1983;309:636-40.

6. ACIP. Adult immunization. MMWR 1985;33(1S):1S-68S.

7. Committee on Immunization, American College of Physicians. Guide for adult immunization. Philadelphia, Pennsylvania: American College of Physicians, 1985. *Primary immunization against tetanus consists of three doses of tetanus toxoid, assuming at least 1 month between doses 1 and 2 and at least 6 months between doses 2 and 3 (1). **Includes three patients who had acute, non-clean, non-minor wounds and had received greater than or equal to3 doses of tetanus toxoid but had not received a dose of toxoid within the previous 5 years.

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