Current Trends Tetanus -- United States, 1987 and 1988

During 1987 and 1988, state health departments reported 101 cases of tetanus to the MMWR (48 in 1987 and 53 in 1988). The average annual incidence rate for 1987-1988 was 0.02 per 100,000 U.S. population, compared with 0.39 per 100,000 in 1947, when national reporting began. Thirty-five states reported at least one case of tetanus, and 13 states reported cases in both years. Five of the 15 states reporting no cases were in the Rocky Mountain region, a geographic distribution previously noted (1,2).

Case report forms on 99 patients provided demographic data and information on immunization history, injury or other medical conditions, tetanus prophylaxis used in wound management, and outcome. Of the 99 patients, 50 were male. Based on patients with known race, the estimated average annual incidence rate for whites (64 cases) was 0.15 per million; for blacks (21 cases), 0.34 per million; and for all other races combined (12 cases), 0.85 per million.

Sixty-seven of the 99 patients were greater than or equal to 50 years of age, and six were less than 20 years of age (Figure 1); incidence increased with age. No cases of neonatal tetanus were reported. Overall, the case-fatality rate was 21%.

Five patients reportedly received at least a primary series* of tetanus toxoid before disease onset (Table 1). Of these, two had received the last dose of tetanus toxoid 5-9 years before onset, and one person had received the last dose greater than 20 years earlier; for two patients, the interval since the last dose was unknown. Of the six patients less than 20 years of age, two had not received any doses of tetanus toxoid, one had received one dose, and three had completed the primary series. Of the 93 patients greater than or equal to 20 years of age, two were reported to have received at least three doses of tetanus toxoid, nine had received one or two doses, and 29 reported no prior doses of vaccine; for 53 patients, vaccination status was unknown.

Tetanus occurred after an identified acute injury in 74 persons. The most frequently reported acute injuries were puncture wounds (29%), lacerations (18%), and abrasions (13%). Most puncture wounds occurred after persons stepped on sharp objects such as nails and wood splinters. The injury site was a lower extremity in 41 (55%) cases, an upper extremity in 23 (31%) cases, the head or trunk in seven (9%) cases, and an unspecified site in three (4%) cases. Of the 61 patients whose circumstances of injury were known, 33% were injured indoors (three cases were associated with recent surgery), 41% during farming or gardening activities, and 26% in other outdoor settings. The youngest tetanus patient reported was a 2-year-old unvaccinated child whose hand had been injured by broken glass. The median incubation period for the 60 tetanus patients for whom a wound date and tetanus onset date were specified was 7 days. For five (8%) patients, the incubation period was greater than 14 days; for 11 (18%), less than or equal to 3 days.

Of the 73 patients who developed tetanus following an acute wound, 31 (42%) had sought medical care for the injury. Tetanus toxoid was given as prophylaxis in wound management to 16 patients (52%); 13 (81%) of these received toxoid within 4 days of the injury. Based on the current recommendations of the Immunization Practices Advisory Committee (ACIP) for the use of tetanus and diphtheria toxoids (Td) and Tetanus Immune Globulin (TIG) (3) in wound management (Table 2), 14 of the 15 patients who sought medical care for an acute injury but were not given Td should have received it.

Fourteen patients with acute wounds severe enough to have required prophylactic wound debridement were candidates for both Td and TIG (Table 2); eight (57%) received Td in the course of wound management, and none received TIG.

Fourteen cases were associated with chronic wounds or underlying medical conditions such as skin ulcers, abscesses, or gangrene. Ten of these occurred in patients with diabetes. A history of parenteral drug abuse was the only associated medical condition for six patients. No known acute injury, chronic wound, or other pre-existing medical condition was reported for four patients.

The median total TIG dosage used therapeutically after disease onset was 3500 international units (IU). Total TIG dosage ranged from 125 to 10,000 IU. Of the 85 patients who received TIG, 15 (18%) died. Of the 14 patients who did not receive TIG, five (36%) died.

For 78 patients, the type of tetanus was reported: 63 (81%) cases were generalized, nine (12%) were localized, and six (8%) were cephalic. Length of hospitalization was reported for 60 patients; the median duration was 15 days (range: 1-73 days). Of the 74 patients for whom the use or nonuse of assisted ventilation was reported, 48 (65%) required ventilation. Reported by: State and territorial epidemiologists. Div of Immunization, Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: The reported incidence rate of tetanus declined steadily between 1947 and 1976 (Figure 2). Since 1977, the incidence has continued to decline but at a slower rate. The decline has resulted from the widespread use of tetanus toxoid and improved wound management, including use of tetanus prophylaxis in emergency rooms. The 1990 Health Objectives for the Nation included a goal of less than 50 tetanus cases annually (4), a target achieved for the first time in 1987.

The nationwide tetanus surveillance system is a passive reporting system. However, because the clinical presentation of tetanus is distinct, it can be readily diagnosed and is hence more likely than many other diseases to be reported. Completeness of reporting of tetanus deaths to CDC was recently estimated at 40% (5), suggesting that the reported number of total tetanus cases is even further underreported. Although tetanus case report forms were completed on 98% of the cases reported to MMWR during 1987 and 1988, accuracy may have varied; for example, reports on immunization status were usually based on verbal history.

The epidemiology of reported tetanus in the United States during 1987 and 1988 was similar to that described previously for 1985 and 1986 (2). Tetanus remains a severe disease with a high case-fatality rate primarily among unimmunized and inadequately immunized adults.

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 (6). Acute wound-associated tetanus can be prevented by appropriate wound management, including active and/or passive immunization. Fifty-eight percent of tetanus patients with acute injuries did not seek medical care for their injuries; of those who did, 81% did not receive prophylaxis as recommended by ACIP guidelines. Of persons with injuries that can lead to tetanus, 1%-6% reportedly receive less than recommended prophylaxis (7,8). The only means of preventing tetanus not associated with acute wounds or tetanus in persons who do not seek medical care for their wounds is to ensure routine primary immunization and maintenance of immunization status.

In the United States, tetanus is primarily a disease of older adults. Thus, tetanus immunization efforts should be especially emphasized for persons aged greater than or equal to 50 years. Health-care practitioners who provide services to adolescents and adults should take every opportunity to review the immunization status of patients and provide, when indicated, Td and other vaccines such as hepatitis B, influenza, pneumococcal polysaccharide, and measles-mumps-rubella (9,10). Maintenance of protection against tetanus (and diphtheria) after the primary series can be achieved by routinely scheduling booster doses of Td at mid-decade ages, e.g., 15 years, 25 years, and 35 years.

References

1. CDC. Tetanus--United States, 1982-1984. MMWR

1985;34:602,607-11.

2. CDC. Tetanus--United States, 1985-1986. MMWR 1987;36:477-81. 3. ACIP. Diphtheria, tetanus, and pertussis: guidelines for vaccine prophylaxis and other preventive measures. MMWR 1985;34:405-14,419-26.

4. Public Health Service. Promoting health/preventing disease: objectives for the nation. Washington, DC: US Department of Health and Human Services, Public Health Service, 1980:22.

5. Sutter RW, Cochi SL, Brink EW, et al. Assessment of vital statistics and surveillance data for monitoring tetanus mortality, United States, 1979-1984. Am J Epidemiol 1990;131:132-42.

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

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

8. Brand DA, Acampora D, Gotlieb LD, et al. Adequacy of antitetanus prophylaxis in six hospital emergency rooms. N Engl J Med 1983;309:636-40.

9. ACIP. Adult immunization: recommendations of the Immunization Practices Advisory Com mittee (ACIP). MMWR 1984;33(no. 1S). 10. Committee on Immunization, American College of Physicians. Guide for adult immunization. Philadelphia: American College of Physicians, 1985. *Primary immunization against tetanus consists of three doses of tetanus toxoid, assuming at least 1 month between the first and second doses and at least 6 months between the second and third doses (3).

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