Epidemiologic Notes and Reports Tetanus -- Kansas, 1993

In 1993, two tetanus cases * were reported to the Kansas Department of Health and Environment -- the first cases reported in the state since 1987. This report summarizes the findings of the case investigations.

Patient 1

On May 16, an 82-year-old man with a history of chronic obstructive pulmonary disease and recurrent pneumonia was taken to a hospital emergency department because of shortness of breath and inability to get out of bed. On May 15, he had had difficulty chewing and swallowing. Examination noted trismus ("lockjaw") and an abrasion on the right elbow, which resulted from a fall on May 14. The patient was admitted to the hospital with a diagnosis of tetanus. He had not been previously vaccinated with tetanus toxoid. Treatment included tetanus toxoid (0.5 cc) and tetanus immune globulin (TIG) (10,000 units).

While hospitalized, the patient experienced generalized tetanic spasms, followed by respiratory failure and pneumonia. He was placed on mechanical ventilation and treated with antibiotics, diuretics, and neuromuscular blocking agents. He recovered and was discharged on June 23. Inpatient hospital charges and physician fees totaled $151,492.

Patient 2

On August 15, a 57-year-old man with noninsulin-dependent diabetes sought treatment at an emergency department for a puncture wound to his foot that occurred when he stepped on a rusty nail earlier that day. Treatment in the emergency department included wound cleaning and administration of tetanus toxoid (0.5 cc).

On August 19, the man returned to the emergency department, reporting onset on August 18 of severe pain in the affected foot, fever, chills, and vomiting. He was hospitalized and treated for cellulitis. On August 20, he complained of pain and stiffness in his neck; he subsequently had a cardiopulmonary arrest, was resuscitated, and was placed on mechanical ventilation. Tetanus was diagnosed, and the patient was transferred to a tertiary-care facility. On August 21, he received TIG (500 units) and, on August 23, underwent additional wound debridement. During hospitalization, the patient experienced labile hypertension and cardiac arrhythmia. He remained on mechanical ventilation and died following a cardiac arrest on September 16.

Family members reported the patient had not previously been vaccinated with tetanus toxoid. Medical costs for treatment, transportation, and physician fees from the August 15 emergency department visit through the time of death totaled $145,329.

Reported by: J Hansen, M Goldsberry, Immunization Section, Bur of Disease Control, A Pelletier, MD, Acting State Epidemiologist, Kansas Dept of Health and Environment. National Immunization Program; Div of Field Epidemiology, Epidemiology Program Office, CDC.

Editorial Note

Editorial Note: Despite the availability of effective and inexpensive tetanus toxoid vaccines, cases of tetanus continue to occur in the United States. During 1989-1990, 117 tetanus cases were reported in the United States; of the 106 cases with known outcomes, 25 (24%) were fatal. All deaths occurred among persons aged greater than or equal to 40 years (1). Of 110 patients with known vaccination status, 34 (31%) were unvaccinated, and 53 (48%) had received an unknown number of doses of tetanus toxoid (1). The two tetanus cases described in this report are consistent with previous cases reported nationwide, which indicate that tetanus occurs primarily among older adults who typically are unvaccinated or have an unknown vaccination history (1-3).

Primary prevention of tetanus is accomplished through vaccination with diphtheria and tetanus toxoids and pertussis vaccine (DTP). For persons aged less than 7 years, the recommended vaccination schedule comprises doses at ages 2, 4, 6, and 12-18 months and 4-6 years (4); diphtheria and tetanus toxoids and acellular pertussis vaccine should be used for the fourth and fifth doses at age 15 months or older (4). For persons aged greater than or equal to 7 years, three doses of tetanus and diphtheria toxoids (Td) are recommended at an interval of 1-2 months between the first and second doses and 6-12 months between the second and third doses. Booster doses of Td should be administered every 10 years (4). Serologic surveys have demonstrated that 31%-71% of older adults lack protective levels of tetanus antibody (1).

Secondary prevention of tetanus, which varies with previous vaccination history, is accomplished postexposure through wound prophylaxis and administration of TIG and/or Td (4). Wounds should be cleaned and debrided as indicated. Persons with unknown or uncertain vaccination histories should be considered unvaccinated and should receive TIG (250 units intramuscularly) unless the wound is clean and minor (4). Tertiary treatment of tetanus includes appropriate medical care and the prompt administration of TIG (3000-6000 units) (5). The findings of the case investigations in this report suggest that 1) opportunities are being missed to review tetanus vaccination status of adults and administer appropriate vaccinations and 2) recommendations should be followed for appropriate postexposure treatment of severe puncture wounds.

The high costs of hospitalization for tetanus reflect the need for prolonged intensive care. In Kansas, public health clients pay an average of $3.30 per dose of Td; this charge comprises total vaccine and administration costs (Bureau of Disease Control, Kansas Department of Health and Environment, unpublished data, 1992). Based on the total hospitalization costs of the two tetanus cases reported in Kansas in 1993, nearly 90,000 doses of Td vaccine could have been administered in the state; however, this comparison does not constitute a cost-benefit analysis.

This report emphasizes the importance of preexposure tetanus prophylaxis, especially for older adults who may have never received a primary vaccination series of DTP or the recommended 10-year booster doses, and the importance of appropriate wound management. Because wounds that can result in tetanus often do not require a physician or emergency department visit, health-care providers should review the vaccination status of their patients at each contact and administer Td along with other indicated vaccines as appropriate (4).

References

1. Prevots R, Sutter RW, Strebel PM, Cochi SL, Hadler S. Tetanus surveillance -- United States, 1989-1990. In: CDC surveillance summaries (December). MMWR 1992;41(no. SS-8):1-9.

2. CDC. Tetanus -- Rutland County, Vermont, 1992. MMWR 1992;41:721-2.

3. CDC. Tetanus fatality -- Ohio, 1991. MMWR 1993;42:148-9.

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):2-6,16-7.

5. Committee on Infectious Diseases, American Academy of Pediatrics. Tetanus (lockjaw). In: Peter G, Lepow ML, McCracken GH, Phillips CF, eds. Report of the Committee on Infectious Diseases. Elk Grove Village, Illinois: American Academy of Pediatrics, 1991:465-70.

• Both met the Council of State and Territorial Epidemiologists/CDC clinical case definition for public health surveillance of tetanus: "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).

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