Tetanus -- Rutland County, Vermont, 1992

In July 1992, the Vermont Department of Health received a report of a case of tetanus. The last reported case of tetanus in Vermont was in 1987. This report summarizes the case investigation.

On July 12, a 31-year-old woman with left-sided face pain visited the emergency department of the hospital in Rutland. She was unable to open her mouth because of facial muscle spasms and had been unable to eat for 3-4 days because of severe pain and tightness of the jaw. Her attending physician noted trismus and risus sardonicus. She reported that on about July 5 she had walked barefoot in her garden and incurred a puncture wound at the base of her right great toe; she cleaned the wound and removed a few small pieces of wood but did not seek medical attention. On July 8, she had sought medical care from her primary-care physician for severe left-sided facial tightness and pain. She was treated with amoxicillin for presumptive sinusitis, but her condition worsened.

A presumptive diagnosis of tetanus was made in the emergency department, and the patient was admitted to the hospital. When the case was reported to the state health department, the patient's vaccination records were examined. School records indicated that she had been vaccinated with diphtheria and tetanus toxoids vaccine (DT) at ages 6 years 3 months, 6 years 5 months, and 8 years 3 months. Although she recalled receiving a tetanus booster at age 14 years, this could not be confirmed by school records or her physician.

On the basis of her clinical presentation and tetanus vaccination history, she was given tetanus toxoid, 3250 IU of tetanus immune globulin, and intravenous penicillin. Her puncture wound was thoroughly debrided; several additional small pieces of wood were removed. Although she was treated for muscle spasm, mechanical ventilation was not required. At the time of discharge 15 days later, she had difficulty performing simple tasks, such as tying shoelaces.

Reported by: S Brittain, MD, M Stickney, MD, Rutland Regional Medical Center, Rutland; M Terkla, M Segale, L Paulozzi, MD, R Houseknecht, PhD, State Epidemiologist, Vermont Dept of Health. Div of Field Epidemiology, Epidemiology Program Office; Div of Immunization, National Center for Prevention Svcs, CDC.

Editorial Note

Editorial Note: Tetanus is a clinical diagnosis based on acute onset of hypertonia and/or painful muscular contractions (usually of the muscles of the jaw and neck) and generalized muscle spasms without other apparent medical cause (as reported by a health professional) (1). Tetanus is caused by tetanospasmin, an exotoxin produced by Clostridium tetani spores, which are ubiquitous in the environment and enter the body usually through a wound; proliferation of bacilli under anaerobic conditions results in the production of tetanospasmin.

Worldwide, tetanus is a problem among nonimmunized or underimmunized persons. In developing countries, where aseptic perinatal care and vaccination programs may not reach all risk groups, tetanus is one of the most important causes of neonatal mortality (2). In comparison, tetanus has become rare in the United States. Universal childhood vaccination with diphtheria and tetanus toxoids and pertussis vaccine (DTP) and widespread use of tetanus toxoid combined with improved wound management have resulted in a decrease in tetanus reported in the United States from 560 cases in 1947 (when national surveillance began) to 57 cases in 1991 (3). Only one case of neonatal tetanus was reported to CDC during 1985- 1991 (CDC, unpublished data, 1992).

Tetanus toxoid is a highly effective vaccine. Protective levels of serum antitoxin are generally maintained for at least 10 years in properly vaccinated persons (4). After completion of a primary vaccination series, booster doses of tetanus toxoid combined with diphtheria toxoid (as Td) every 10 years are recommended by the Advisory Committee on Immunization Practices (4). Although the patient described in this report had received a complete primary series of tetanus vaccinations, there was no record indicating she had received booster doses.

Of the 109 tetanus patients for whom complete information was available for 1989 and 1990, 94% were aged greater than or equal to 20 years (CDC, unpublished data, 1992). Older persons are at greater risk for developing tetanus because many have never been vaccinated with a primary series of tetanus toxoid or with booster doses of tetanus toxoid. In 1989 and 1990, of the 57 persons with tetanus and known vaccination status, 45 (79%) had received fewer than three doses of DTP. Another eight (14%) persons had not received a booster dose in the 10 years preceding onset of illness (CDC, unpublished data, 1992).

Wounds such as that of the patient described in this report are common, especially during the summer months. Often such wounds are judged to not warrant a physician or emergency room visit. Establishment and maintenance of adequate tetanus antitoxin levels by administration of primary vaccination and routine booster vaccinations are the only means to avert tetanus. Internists, family practitioners, and other primary health-care providers who treat adults should use every opportunity to review the vaccination status of their patients and administer required vaccines.

References

1. CDC. Case definitions for public health surveillance. MMWR 1990;39(no. RR-13):38.

2. Cate TR. Clostridium tetani (tetanus). In: Mandell GL, Douglas RG, Bennett JE, eds. Principles and practice of infectious diseases. 3rd ed. New York: Churchill Livingstone Inc, 1990:1842-6.

3. CDC. Final 1991 reports of notifiable diseases. Notifiable diseases -- reported cases, by geographic division and area, United States, 1991. MMWR 1992;41:631,638.

4. ACIP. Diphtheria, tetanus, and pertussis: recommendations for vaccine use and other preventive measures -- recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR 1991;40(no. RR-10):2-8.

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