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Tetanus

Queensland Health Guidelines for Public Health Units

Revision History

Version Date Changes
1.0 January 2011  Full revision of guideline
2.0 July 2018 Full revision of guideline
3.0 February 2019 Full revision of guideline

Infectious Agent

The agent is Clostridium tetani.

Notification Criteria

Confirmed case
A confirmed case requires either:

Laboratory definitive evidence OR clinical evidence.

Clinical evidence
A clinically compatible illness without other apparent cause.

Laboratory definitive evidence
Isolation of Clostridium tetani from a wound 1

Community outbreak criteria
2 or more associated cases.

Notification Procedure

Pathology Laboratories
To notify on laboratory suggestive evidence, by telephone or facsimile.

Attending Medical Practitioners/Medical Superintendents (or Delegates)
To notify on clinical diagnosis by telephone or facsimile.

Reporting to NOCS

Only confirmed cases should be reported. Cases with laboratory suggestive evidence in the absence of clinical evidence should be invalidated

Objectives of surveillance

To monitor the epidemiology of tetanus in Queensland.

Public Health significance and occurrence

In 2006, an estimated 290,000 people worldwide died of tetanus, mainly in Asia, Africa and South America. The disease is sporadic and relatively uncommon in most industrialised countries.

In Australia, tetanus is rare, occurring primarily in older adults who have never been vaccinated or who were vaccinated in the remote past. There were 24 notified cases of tetanus during 2001–2007. From 2008–2018 there were 42 notifications of tetanus in Australia, 11 of which were in Queensland.

The case-fatality rate in Australia is about 2%.

Clinical Features

An acute disease induced by the exotoxin of the tetanus bacillus, which grows anaerobically at the site of the injury. The disease is characterised by painful muscular contractions, rigidity and spasms, initially involving the jaw, neck and abdomen and then becoming generalised. Other symptoms include elevated temperature, sweating, elevated blood pressure, and episodic rapid heart rate. Case fatality ranges from 10% to 80% depending on age and quality of care available, and is highest in infants and the elderly.

Reservoir

Clostridium tetani is ubiquitous in the environment and are normal but harmless intestinal residents in horses and other animals. Spores in soil or fomites contaminated with faeces can contaminate wounds.

Mode of Transmission

Spores may be introduced through contaminated puncture wounds, lacerations, burns, trivial wounds or injected, contaminated street drugs.

Incubation Period

Usually 3 to 21 days, although it may range from one day to several months, with most cases occurring a mean of 7 – 10 days following exposure. Inoculation of spores in body locations distant from the central nervous system (e.g. the hands or feet) results in a longer incubation period than inoculation close to the central nervous system (e.g the head or neck).

In general, shorter incubation periods are associated with more heavily contaminated wounds, more severe disease, and a worse prognosis.

Period of Communicability

Not directly transmitted from person to person. Spores may remain viable for many years.

Susceptibility and Resistance

Since C. tetani spores cannot be eliminated from the environment, immunisation and proper treatment of wounds and traumatic injuries are crucial for tetanus prevention.

Anyone who has not been immunised against tetanus is at risk, in particular:

  • people who have regular contact with soil either in an occupational or leisure setting
  • intravenous drug users
  • people who acquire a high-risk wound

Active immunity is produced by vaccination with tetanus toxoid. Persons who have completed a primary course of three tetanus toxoid containing vaccines and at least two boosters do not require further boosters until age 50 as immunity is long-lasting.

Transient passive immunity follows injection of tetanus immune globulin (TIG) or tetanus antitoxin.

Recovery from tetanus does not result in immunity, therefore primary immunisation is indicated.

Management

Cases
Investigation
In consultation with the attending medical practitioner, ascertain the onset date and nature of symptoms.

Determine likely source of infection. High risk wounds include compound fractures, wounds contaminated with soil or manure, deep penetrating wounds, presence of foreign body (e.g. splinter), wounds involving extensive tissue injury or necrotic tissue such as burns or large contusions, injecting drug use, body piercing or surgical procedures under unhygienic conditions, replacement of an avulsed tooth, otitis media (ear infections), dental infection, animal bites, abortion, and pregnancy. No cause is found in about one third of cases.

For any recent wounds, determine how wounds were managed. (e.g. wound irrigation, topical disinfection, surgical debridement, immediate versus delayed wound closure, antibiotic treatment such as penicillin or metronidazole).

Determine tetanus immunisation history and whether tetanus immunoglobulin and/or tetanus toxoid was given appropriately after a high-risk wound.

Restriction
Not required.

Treatment
This is the responsibility of treating doctors but should include active immunisation of the case concurrently with treatment.

Counselling
Advise the case of the nature of the infection and its mode of transmission.

Contacts

Contact Tracing
No

Other control measures
In the event of a tetanus prone injury, a booster dose of tetanus vaccine should be given if 5 or more years have elapsed since the previous dose. Tetanus immunoglobulin can be considered for individuals who have previously had a severe adverse event following tetanus vaccine. Tetanus immunoglobulin should be given to all individuals with tetanus prone wounds who have not received at least 3 doses of tetanus vaccine.

Guide to Tetanus Prophylaxis in Wound Management

Whatever the immune status of a person with a tetanus-prone wound, local cleaning and disinfection and, where appropriate, surgical treatment of tetanus-prone wounds, must never be omitted. Antibiotic prophylaxis is not indicated for the prevention of tetanus; however, the use of antibiotics (such as penicillin, amoxicillin + clavulanate, or metronidazole) for preventing other bacterial infection of the wound is a matter for clinical judgement.

The current recommendations for vaccination following a tetanus prone wound are available in the Guide to tetanus prophylaxis in wound management table in the Australian Immunisation Handbook.

If indicated, as per the table, the recommended dose for TIG is 250 IU, to be given by IM injection as soon as practicable after the injury. If more than 24 hours have elapsed, 500 IU should be given. Because of its viscosity, TIG should be given to adults using a 21 gauge needle. For children, it can be given slowly using a 23 gauge needle. A tetanus toxoid-containing vaccine should be given at the same time in the opposite limb with a separate syringe, and arrangements should be made to complete the full course of tetanus toxoid-containing vaccinations.

TIG can be accessed through local Emergencies Departments.

Community outbreaks/epidemics

In the rare outbreak, consider contamination of injectable drugs.

Preventive measures

Educate the public on the necessity for complete immunisation with tetanus toxoid, the hazards of puncture wounds and closed injuries that are particularly liable to be complicated by tetanus, and the potential need after injury for active and/or passive prophylaxis.

Summary

Prepare a report of the investigation for the Communicable Diseases Branch, Queensland Health, on request.

References

Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-Preventable Diseases.(PDF, 364KB) Atkinson W, Wolfe S, Hamborsky J, McIntyre L, eds. 11th ed. Washington DC: Public Health Foundation, 2009.[accessed 20 January 2011].

Heymann, D (Ed).  2015. Control of Communicable Diseases Manual, 19th edition.  American Public Health Association: Washington.

NHMRC, The Australian Immunisation Handbook.

UpToDate

Notes

1 C. tetani is recovered from the wound in only 30% of cases. In the national case definition laboratory definitive evidence requires "prevention of positive tetanospasm in mouse test from such an isolate using specific tetanus antitoxin". However QHFSS advises that this test is no longer performed. As non-toxigenic strains of C. tetani exist, definitive laboratory diagnosis is therefore not currently possible.

Last updated: 5 February 2019