Current Trends Tetanus -- United States, 1982-1984

From 1982 through 1984, 253 U.S. cases of tetanus were reported to the MMWR (88 in 1982, 91 in 1983, and 74 in 1984). Forty states and the District of Columbia reported at least one case; 19 states reported cases in all 3 years. The 10 states reporting no cases are located in the western and northeastern United States (Figure 4). The average annual incidence rate for 1982-1984 was 0.036 cases per 100,000 total population, compared to 0.39/100,000 in 1947, when national reporting began. The estimated average annual age-specific incidence rates progressively increased by age group, with a sevenfold increase from the 5- to 19-year to 20- to 29-year age group and a ninefold increase from the 20- to 29-year to 60 years and older age group (Table 4).

Case report forms for 234 (92%) patients with onset during these years provided information on demographic characteristics, immunization history, circumstances of injury or other medical condition, and tetanus prophylaxis used in wound management. Extrapolating from 229 patients for whom race was known, the estimated average annual incidence rate for whites was 0.033/100,000 (177 cases); for blacks, 0.059/100,000 (45 cases); and for all other races, 0.040/100,000 (seven cases).

One hundred fifty-nine (71%) of the 224 patients with known ages were 50 years of age or older; six (3%) were 1 month to 19 years of age; and 56 (25%) were 20-49 years of age (Table 5). Three cases of neonatal tetanus were reported (Texas--two; California--one); two of the mothers had no history of prior immunization, and the third had no history of completing primary immunization. All three infants survived. The remainder of this report covers 231 cases of tetanus that occurred among individuals ages 1 month and older.

The case-fatality rate was 26% (52% for patients 60 years of age and older and 13% for those under age 60). No deaths occurred among patients under 30 years of age.

Eleven (5%) of the 231 patients had received at least a primary series of tetanus toxoid* before onset (Table 6). Of these, three received their third dose of tetanus toxoid as part of wound prophylaxis, and three had not received a dose within the preceding 10 years. Two hundred fifteen patients (93%) had received fewer than two doses of toxoid before onset of illness or had received an unknown number of doses.

Tetanus occurred after an identified acute injury in 142 cases (72%). The most frequently reported acute injuries were puncture wounds (37%) and lacerations (35%). Injuries incurred indoors accounted for 41% of acute wounds; gardening and other outdoor injuries, for 39%; animal-associated injuries and major trauma, for 4% each; and other and unknown circumstances, for 12%. The median incubation period for the 166 tetanus patients with known interval between acute injury and onset was 8 days. One hundred thirty-one (92%) had an incubation period of 14 days or less. For 18 (13%) patients, the interval between wound and onset was reported to be 3 days or less. Tetanus toxoid was given as prophylaxis in wound management to 42 patients (25%) with acute wounds; two patients also received tetanus immune globulin (TIG). Of the 42 patients, 34 (81%) received prophylaxis within 3 days of the injury.

Fifty-six patients had acute wounds severe enough to require debridement after injury but before onset of tetanus. Based on the current recommendations of the Immunization Practices Advisory Committee (ACIP) for wound management (Table 7) (1), 55 of these patients were candidates for both Tetanus and Diphtheria Toxoids (Td) and TIG; none received TIG, and 22 (40%) received Td in the course of wound management. One patient was a candidate for Td only but did not receive tetanus toxoid.

Forty-eight 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 reported for five (2%) patients. A known acute injury, a chronic wound, or any other preexisting medical condition was not reported for 17 (7%) patients. Reported by Div of Immunization, Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: Following a steady decline in the average annual crude incidence rate of tetanus between 1947 and 1976, the rate has not changed substantially (Figure 5). The decline results both from immunization and careful wound management, since naturally acquired immunity against tetanus is undocumented in the United States. However, tetanus is a continuing health burden and has a high case-fatality ratio, primarily among the unimmunized and inadequately immunized. Approximately 95% of patients reported with tetanus during 1982-1984 had not received a primary series of tetanus toxoid. Vaccination with a primary series of three doses of tetanus toxoid and booster doses every 10 years is highly effective in preventing tetanus (2). Single-antigen tetanus toxoid is not recommended for use in routine immunization or in general wound management. The recommended preparation for individuals 7 years of age and older is Tetanus and Diphtheria Toxoids Adsorbed (For Adult Use) (Td). The recommended preparation for children before the seventh birthday is Diphtheria and Tetanus Toxoids and Pertussis Vaccine (DTP); Diphtheria and Tetanus Toxoids (For Pediatric Use) (DT) is recommended for children before the seventh birthday for whom pertussis antigen is contraindicated (1).

Tetanus cases are most frequently associated with acute wounds; most of these patients did not receive tetanus prophylaxis following the wound. It is uncertain what proportion of patients sought care for their wounds. Among tetanus patients in whom the associated wound was debrided, health-care contact did not result in the use of recommended Td/TIG. Underprophylaxis may have occurred in other tetanus patients who sought care (8). Primary immunization and routine maintenance of an up-to-date immunization status is necessary to prevent tetanus that is not associated with acute wounds or that occurs in persons who do not seek medical care for their wounds. Routine use of tetanus toxoid-containing preparations would also eliminate the need for, or simplify, tetanus prophylaxis in wound management for a given individual.

The relative absence of tetanus among persons 5-19 years of age reflects the success of the U.S. childhood vaccination program. Forty-seven states and the District of Columbia require primary immunization against tetanus for entry into school. Annual nationwide surveys indicate over 95% of children entering school since 1980 had received a primary series of tetanus immunizations. However, immunity levels in older populations are lower. In particular, serosurveys done since 1977 indicated that 49%-66% of persons 60 years of age or older lacked protective levels of circulating antitoxin antibody against tetanus (3-5). Expanded efforts to ensure that vaccination against tetanus is up-to-date in individuals of all ages could reduce further the remaining burden of tetanus in the United States. Efforts need to be directed primarily towards older adults, especially those 50 years of age and older who account for over 70% of current cases. One method to ensure adequate protection is to routinely provide booster doses of Td at mid-decade ages, i.e., 15 years, 25 years, 35 years, etc. Td is the only universally recommended immunization for individuals of all ages. As with tetanus, a substantial proportion of the remaining morbidity and mortality from other vaccine-preventable diseases now occurs among older adolescents and adults. The ACIP and the American College of Physicians have published recommendations for immunization of adults (6,7). All persons providing health care to older adolescents and adults should review the immunization status of patients and provide tetanus and diphtheria toxoids and, when indicated, measles, rubella, influenza, pneumococcal, and hepatitis B vaccines to persons found to be inadequately immunized.

References

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

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

3. Ruben FL, Nagel J, Fireman P. Antitoxin responses in the elderly to tetanus-diphtheria (TD) immunization. Am J Epidemiol 1978;108:145-9.

4. Crossley K, Irvine P, Warren JB, Lee BK, Mead K. Tetanus and diphtheria immunity in urban Minnesota adults. JAMA 1979;242:2298-3000.

5. Weiss BP, Strassburg MA, Feeley JC. Tetanus and diphtheria immunity in an elderly population in Los Angeles County. Am J Public Health 1983;73:802-4.

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

7. Committee on Immunization, American College of Physicians. Guide for adult immunization. Philadelphia, Pennsylvania: American College of Physicians, 1985.

8. 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. *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).

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