Global & Disaster Medicine

Archive for the ‘Tetanus’ Category

Tetanus in the wake of Florence

CDC

Pathogenesis

Clostridium tetani (C. tetani) spores usually enter the body through a wound or breach in the skin. Neonatal tetanus usually occurs because of umbilical stump infections. In the presence of anaerobic conditions, the spores germinate. The bacteria produce very potent toxins, most of which the blood stream and lymphatic system disseminate through the body. Toxins act at several sites within the central nervous system, including peripheral motor end plates, spinal cord, and brain, as well as in the sympathetic nervous system. Tetanus toxin causes the typical clinical manifestations of tetanus by interfering with the release of neurotransmitters and blocking inhibitor impulses. This leads to unopposed muscle contraction and spasm. Seizures may occur, and the autonomic nervous system may also be affected.

 

Risk Groups

Nearly all cases of tetanus in the United States today are among people who

  • Have never received a tetanus vaccine
  • Didn’t stay up to date on their 10-year booster shots

Tetanus Prevention after a Disaster

In most settings, a disaster does not increase the risk for tetanus. This includes earthquakes, hurricanes, floods, and tsunamis.

However, you can minimize the risk of tetanus among your patients who are disaster survivors and emergency responders by following routine vaccination recommendations and providing proper wound care.

Most reported cases occur in adults. From 2009–2015, more than 60% of the 197 reported cases were among people 20 through 64 years of age. In addition, a quarter of those reported cases were among people 65 years old or older. The risk of death from tetanus is highest among people 65 years old or older.

Diabetes, a history of immunosuppression, and intravenous drug use may be risk factors for tetanus. From 2009 through 2015, persons with diabetes was associated with 13% of all reported tetanus cases, and a quarter of all tetanus deaths. Intravenous drug users accounted for 6% of cases from 2009 through 2015.

 

Risk during Natural Disasters

In most settings, a disaster (e.g., earthquake, hurricane, flood, tsunami) does not increase the risk for tetanus. Minimize the risk of tetanus among your patients who are disaster survivors and emergency responders by following routine vaccination recommendations and providing proper wound care.

 

Symptoms and Diagnosis

Tetanus is a clinical syndrome without confirmatory laboratory tests. Characteristic symptoms of tetanus are painful muscular contractions, primarily of the masseter and neck muscles and secondarily of trunk muscles. Trismus, or lockjaw, is a common sign of tetanus (see generalized tetanus under Clinical Features). A common first sign suggestive of tetanus in older children and adults is abdominal rigidity, although rigidity is sometimes confined to the region of injury. Generalized spasms occur, frequently induced by sensory stimuli. History of an injury or apparent portal of entry may be lacking. The organism is rarely recovered from the site of infection.

Clinical Features

The incubation period ranges from 3 to 21 days, averaging about 10 days. In general, the further the injury site is from the central nervous system, the longer the incubation period. A shorter incubation period is associated with more severe disease, complications, and a higher chance of death. In neonatal tetanus, symptoms usually appear from 4 to 14 days after birth, averaging about 7 days.

There are three clinical forms of tetanus: generalized, localized, and cephalic.

Generalized Tetanus

Generalized tetanus is the most common form, accounting for more than 80% of cases. The most common initial sign is spasm of the muscles of the jaw or “lockjaw”. This may be followed by painful spasms in other muscle groups in the neck, trunk, and extremities and by generalized, seizure-like activity or convulsions in severe cases. Generalized tetanus can be accompanied by nervous system abnormalities, as well as a variety of complications related to severe spasm and prolonged hospitalization. The clinical course of generalized tetanus is variable and depends on the degree of prior immunity, the amount of toxin present, and the age and general health of the patient. Even with modern intensive care, generalized tetanus is associated with death rates of 10% to 20%.

Localized Tetanus

Localized tetanus is an unusual form of the disease consisting of muscle spasms in a confined area close to the site of the injury. Although localized tetanus often occurs in people with partial immunity and is usually mild, progression to generalized tetanus can occur.

Cephalic Tetanus

The rarest form, cephalic tetanus, is associated with lesions of the head or face and may also be associated with otitis media. The incubation period is short, usually 1 to 2 days. Unlike generalized and localized tetanus, cephalic tetanus results in flaccid cranial nerve palsies rather than spasm. Spasm of the jaw muscles may also be present. Like localized tetanus, cephalic tetanus can progress to the generalized form.

Complications of Tetanus

  • Laryngospasms
  • Fractures
  • Hypertension
  • Nosocomial infections
  • Pulmonary embolism
  • Aspiration pneumonia
  • Death

 

Treatment

Tetanus is a medical emergency requiring hospitalization, immediate treatment with human tetanus immune globulin (TIG), agents to control muscle spasm, aggressive wound care, antibiotics, and a tetanus toxoid booster. If tetanus immune globulin is unavailable, Immune Globulin Intravenous (IGIV) can be used.

A patent airway should be maintained and, depending on the severity of disease, endotracheal intubation or tracheostomy and mechanically assisted respiration may be lifesaving. Sedation and muscle relaxant drugs should be used as indicated to control muscle spasms. Agents to control autonomic nervous system instability may be required. Initiate active immunization concurrently with treatment.

Treatment of tetanus cases with TIG

A single dose of human TIG is recommended for treatment of persons with tetanus. Although the optimal therapeutic dose has not been established, experts recommend 500 international units (IU), which appears to be as effective as higher doses ranging from 3,000 to 6,000 IU and causes less discomfort.

Available preparations must be administered intramuscularly; TIG preparations available in the United States are not licensed or formulated for intrathecal or intravenous use.

Infiltration of part of the dose locally around the wound is recommended (see Red Book), although its efficacy has not been proven.

If TIG is not available, IGIV can be used at a dose of 200 to 400 milligrams per kilogram (mg/kg). However, the Food and Drug Administration has not approved IGIV for this use. In addition, anti- tetanus antibody content varies from lot to lot.

Vaccination during Recovery

Tetanus disease does not result in tetanus immunity. Active immunization with a tetanus toxoid-containing vaccine should begin or continue as soon as the person’s condition has stabilized.

 

Wound Management for Tetanus Prevention

Risk of tetanus disease depends on the type and condition of the wound and immune status of the patient. The following steps should be taken to prevent tetanus:

  • Assess the type of wound and provide appropriate wound care.
    Wounds may be clean or contaminated and dirty, superficial or deep and penetrating. Dirty wounds pose an increased risk for tetanus. Wounds should be considered dirty if contaminated with dirt, soil, feces, or saliva (e.g., animal or human bites). Penetrating or puncture wounds are considered contaminated and may pose a higher risk for tetanus. Wounds containing devitalized tissue (e.g., necrotic or gangrenous wounds), frostbite, crush injuries, avulsion fractures, and burns are particularly conducive for proliferation of C. tetani. All wounds should be cleaned, dirt or foreign material removed, and necrotic material removed or debrided.
  • Evaluate the immunization status of the patient. Unvaccinated persons should start and complete a primary series with an age-appropriate tetanus toxoid-containing vaccine (DTaP, TdaP, or Td) as currently recommended by CDC.Persons with unknown or uncertain history of receiving previous prior doses tetanus toxoid-containing vaccines should be considered to have had no previous tetanus toxoid-containing vaccine and a primary series should be completed. This is because early doses of toxoid may not induce adequate immunity, but only prime the immune system.Persons who have completed a 3-dose primary tetanus vaccination series:
    • If the last dose of a tetanus toxoid-containing vaccine was received less than 5 years earlier, they are considered protected against tetanus and do not require another dose of tetanus toxoid-containing vaccine as part of the current wound management.
    • If the last dose of a tetanus toxoid-containing vaccine was received 5 or more years earlier, then a booster dose of an age-appropriate tetanus toxoid-containing vaccine should be administered.
    • Rarely have cases of tetanus occurred in persons with a documented primary series of tetanus toxoid.
  • Assess need for administering TIG for prophylaxis.
    TIG provides temporary immunity by directly providing antitoxin. TIG can only help remove unbound tetanus toxin but cannot neutralize toxin that is already bound to nerve endings. Persons who have contaminated and dirty wounds and are either unvaccinated or have not received a primary series of tetanus toxoid-containing vaccines should receive TIG for prophylaxis. The dose of TIG for prophylaxis is 250 IU administered intramuscularly. People with HIV infection or severe immunodeficiency who have contaminated wounds (including minor wounds) should also receive TIG, regardless of their history of tetanus immunizations.
  • Do not use antibiotics for prophylaxis against tetanus.
    Antibiotic prophylaxis against tetanus is not recommended, but wounds should be observed for signs of infection and promptly treated if signs of infection are detected.

 

Guide to Tetanus Prophylaxis with TIG in Routine Wound Management

Guide to Tetanus Prophylaxis with TIG in Routine Wound Management
History of adsorbed tetanus toxoid-containing vaccines (doses) Clean, minor wound All other wounds*
DTaP, Tdap or Td TIG DTaP, Tdap or Td TIG
Unknown or <3 Yes No Yes Yes
≥3 No§ No No No

Footnotes

Abbreviations: DTaP = Diphtheria and Tetanus toxoids and acellular pertussis vaccine; Tdap = tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis; Td = tetanus and diphtheria toxoids; TIG = Tetanus immune globulin
*Such as, but not limited to, wounds contaminated with dirt, feces, soil, and saliva; puncture wounds; avulsions; and wounds resulting from missiles, crushing, burns, and frostbite.
† DTaP is recommended for children <7 years of age. Tdap is preferred to Td for persons aged 11 years or older who have not previously received Tdap. Persons aged 7 years or older who are not fully immunized against pertussis, tetanus, or diphtheria should receive one dose of Tdap for wound management and as part of the catch-up series.
‡ People with HIV infection or severe immunodeficiency who have contaminated wounds (including minor wounds) should also receive TIG, regardless of their history of tetanus immunizations.
§ Yes, if ≥10 years since the last tetanus toxoid-containing vaccine dose.
¶ Yes, if ≥5 years since the last tetanus toxoid-containing vaccine dose.

 

Prevention through Routine Vaccination

Since people cannot naturally acquire immunity to tetanus, the best way to prevent tetanus is to vaccinate your patients. CDC recommends tetanus vaccines for all babies and children, preteens and teens, and adults. See Diphtheria, Tetanus, and Pertussis Vaccination: Information for Healthcare Professionals for information on all tetanus vaccine recommendations by vaccine and age.

References

  1. Liang JL, Tiwari T, Moro P, et al. Prevention of Pertussis, Tetanus, and Diphtheria with Vaccines in the United States: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 2018;67(2):1–44.
  2. American Academy of Pediatrics. Tetanus. In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book®: 2015 Report of the Committee on Infectious Diseases. American Academy of Pediatrics; 2015; 773–8.
  3. Pink Book’s Chapter on Tetanus
    Epidemiology & Prevention of Vaccine-Preventable Diseases

CDC recommendations to healthcare providers treating patients in Puerto Rico and USVI, as well as those treating patients in the continental US who recently traveled in hurricane-affected areas during the period of September 2017 – March 2018.

CDC

Advice for Providers Treating Patients in or Recently Returned from Hurricane-Affected Areas, Including Puerto Rico and US Virgin Islands

Distributed via the CDC Health Alert Network
October 24, 2017, 1330 ET (1:30 PM ET)
CDCHAN-00408

Summary
The Centers for Disease Control and Prevention (CDC) is working with federal, state, territorial, and local agencies and global health partners in response to recent hurricanes. CDC is aware of media reports and anecdotal accounts of various infectious diseases in hurricane-affected areas, including Puerto Rico and the US Virgin Islands (USVI). Because of compromised drinking water and decreased access to safe water, food, and shelter, the conditions for outbreaks of infectious diseases exist.

The purpose of this HAN advisory is to remind clinicians assessing patients currently in or recently returned from hurricane-affected areas to be vigilant in looking for certain infectious diseases, including leptospirosis, dengue, hepatitis A, typhoid fever, vibriosis, and influenza. Additionally, this Advisory provides guidance to state and territorial health departments on enhanced disease reporting.

 

Background
Hurricanes Irma and Maria made landfall in Puerto Rico and USVI in September 2017, causing widespread flooding and devastation. Natural hazards associated with the storms continue to affect many areas. Infectious disease outbreaks of diarrheal and respiratory illnesses can occur when access to safe water and sewage systems are disrupted and personal hygiene is difficult to maintain. Additionally, vector borne diseases can occur due to increased mosquito breeding in standing water; both Puerto Rico and USVI are at risk for outbreaks of dengue, Zika, and chikungunya.

Health care providers and public health practitioners should be aware that post-hurricane environmental conditions may pose an increased risk for the spread of infectious diseases among patients in or recently returned from hurricane-affected areas; including leptospirosis, dengue, hepatitis A, typhoid fever, vibriosis, and influenza. The period of heightened risk may last through March 2018, based on current predictions of full restoration of power and safe water systems in Puerto Rico and USVI.

In addition, providers in health care facilities that have experienced water damage or contaminated water systems should be aware of the potential for increased risk of infections in those facilities due to invasive fungi, nontuberculous Mycobacterium species, Legionella species, and other Gram-negative bacteria associated with water (e.g., Pseudomonas), especially among critically ill or immunocompromised patients.

Cholera has not occurred in Puerto Rico or USVI in many decades and is not expected to occur post-hurricane.

 

Recommendations

These recommendations apply to healthcare providers treating patients in Puerto Rico and USVI, as well as those treating patients in the continental US who recently traveled in hurricane-affected areas (e.g., within the past 4 weeks), during the period of September 2017 – March 2018.

  • Health care providers and public health practitioners in hurricane-affected areas should look for community and healthcare-associated infectious diseases.
  • Health care providers in the continental US are encouraged to ask patients about recent travel (e.g., within the past 4 weeks) to hurricane-affected areas.
  • All healthcare providers should consider less common infectious disease etiologies in patients presenting with evidence of acute respiratory illness, gastroenteritis, renal or hepatic failure, wound infection, or other febrile illness. Some particularly important infectious diseases to consider include leptospirosis, dengue, hepatitis A, typhoid fever, vibriosis, and influenza.
  • In the context of limited laboratory resources in hurricane-affected areas, health care providers should contact their territorial or state health department if they need assistance with ordering specific diagnostic tests.
  • For certain conditions, such as leptospirosis, empiric therapy should be considered pending results of diagnostic tests— treatment for leptospirosis is most effective when initiated early in the disease process. Providers can contact their territorial or state health department or CDC for consultation.
  • Local health care providers are strongly encouraged to report patients for whom there is a high level of suspicion for leptospirosis, dengue, hepatitis A, typhoid, and vibriosis to their local health authorities, while awaiting laboratory confirmation.
  • Confirmed cases of leptospirosis, dengue, hepatitis A, typhoid fever, and vibriosis should be immediately reported to the territorial or state health department to facilitate public health investigation and, as appropriate, mitigate the risk of local transmission. While some of these conditions are not listed as reportable conditions in all states, they are conditions of public health importance and should be reported.

 

For More Information


Obstetric Tetanus in an Unvaccinated Amish Woman After a Home Birth Delivery

Yaffee AQ, Day DL, Bastin G, et al. Notes from the Field. Obstetric Tetanus in an Unvaccinated Woman After a Home Birth Delivery — Kentucky, 2016. MMWR Morb Mortal Wkly Rep 2017;66:307–308. DOI: http://dx.doi.org/10.15585/mmwr.mm6611a7.

Obstetric Tetanus in an Unvaccinated Woman After a Home Birth Delivery — Kentucky, 2016

Anna Q. Yaffee, MD1,2; David L. Day, DVM3; Glenda Bastin, MA3; Mary Powell, MPH4; Sandra Melendez4; Nancy Allen, MSN5; Julie Miracle1; Margaret Jones1; Robert Brawley, MD1 (View author affiliations)

On July 11, 2016, state and local health departments in Kentucky were notified of a case of obstetric tetanus in an unvaccinated woman. Obstetric tetanus, which occurs during pregnancy or within 6 weeks of the end of pregnancy, follows contamination of wounds with Clostridium tetani spores during pregnancy, or the use of contaminated tools or practices during nonsterile deliveries or abortions. CDC did not identify any cases of obstetric tetanus in the United States during 1972–2008 (1,2). State and local health departments in Kentucky investigated this case to identify risk factors and provide recommendations.

The patient, a woman aged 30 years, is a member of an Amish community. In late June, she delivered a child at home, assisted by an unlicensed community childbirth assistant. She had never received a vaccination for tetanus. Delivery was complicated by breech presentation, but no birth trauma, unsterile conditions, or other complications were reported. Nine days postpartum, the patient experienced facial numbness and neck pain, which progressed over 24 hours to stiff neck and jaw and difficulty swallowing and breathing. She was admitted to the hospital where a clinical diagnosis of tetanus was made, and 6,000 international units of tetanus immunoglobulin were administered intramuscularly. Endotracheal intubation and mechanical ventilation were required. Her hospital course was complicated by seizures and a need for prolonged respiratory support. After approximately a month, the patient was stable and discharged home.

The infant was monitored at home during the mother’s hospitalization. Tetanus immunoglobulin was recommended; however, the family declined treatment. A local advanced practice nurse performed weekly follow-up visits and noted no problems in the infant.

The close relationship between the local health department, health care providers, and the approximately 400-member Amish community facilitated contact with community leaders for an opportunity to discuss implementing Advisory Committee on Immunization Practices (ACIP) recommendations for tetanus immunization through a vaccination campaign. Door-to-door home visits in areas with vaccine-supportive community leaders were made by local health department staff members and the advanced practice nurse to explain the benefits of vaccination and provide vaccine. At the time of the campaign, there was one pregnant woman and one woman who was immediately postpartum in the community; both declined vaccination. Forty-seven (12%) persons were vaccinated, including 32 children aged ≤18 years. An age-appropriate diphtheria, tetanus, and pertussis vaccine (DTaP or Tdap) was administered to 30 (64%) of the 47 vaccine recipients. Because many community members reported having had pertussis disease and were opposed to receiving pertussis vaccine, 17 (36%) persons received age-appropriate tetanus and diphtheria toxoids without pertussis vaccine (DT or Td). Although none of the persons receiving vaccine had been previously vaccinated against any disease to date, none have agreed to complete the series because of little perceived ongoing vaccination need. Additional outreach initiatives are planned.

To prevent tetanus, ACIP recommends a 5-dose series of diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP) for children at ages 2, 4, 6, 15–18 months, and 4–6 years, followed by 1 dose of tetanus and diphtheria toxoids and acellular pertussis vaccine (Tdap) for adolescents aged 11–12 years. Previously vaccinated adults are recommended to receive routine booster doses of a tetanus-containing vaccine every 10 years, and unvaccinated adults should complete a 3-dose primary series (3,4). Pregnant women with unknown or incomplete tetanus vaccination histories should receive a series of 3 doses of tetanus and reduced diphtheria toxoids (Td) to protect against obstetric and neonatal tetanus (5). ACIP also recommends a dose of Tdap to all previously vaccinated pregnant women at 27 to 36 weeks’ gestation during each pregnancy, regardless of time of previous vaccination, to provide protection from pertussis to infants.

This case highlights the importance of tetanus vaccination for all persons as recommended by ACIP (5,6). Although Amish communities generally do not have religious objections to vaccination (7), preventive health care has not historically been accessed by this Amish community. Trust between the Amish community, local health department, and a familiar health care provider, as well as working within community members’ homes, and providing culturally appropriate education and recommendations through community leaders, facilitated vaccination of some persons. Ongoing outreach by health departments is beneficial to vulnerable, nonimmunized or underimmunized populations.

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Corresponding author: Anna Q. Yaffee, ayaffee@cdc.gov, 734-657-3581.

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1Kentucky Department for Public Health; 2Epidemic Intelligence Service, CDC; 3Lincoln Trail District Health Department, Elizabethtown, Kentucky; 4Louisville Metro Public Health and Wellness, Louisville, Kentucky; 5Central Medical Associates, Elizabethtown, Kentucky.

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References

  1. Murphy TV, Slade BA, Broder KR, et al. Advisory Committee on Immunization Practices (ACIP), CDC. Prevention of pertussis, tetanus, and diphtheria among pregnant and postpartum women and their infants recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2008;57(No. RR-4). PubMed
  2. CDC. Tetanus surveillance — United States, 2001-2008. MMWR Morb Mortal Wkly Rep 2011;60:365–9. PubMed
  3. CDC. Recommended immunization schedule for children and adolescents aged 18 years or younger—United States, 2017. Atlanta, GA: US Department of Health and Human Services, CDC; 2017. https://www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html
  4. CDC. Recommended immunization schedules for adults—United States, 2017. Atlanta, GA: US Department of Health and Human Services, CDC; 2017. https://www.cdc.gov/vaccines/schedules/hcp/adult.html
  5. CDC. Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) in pregnant women—Advisory Committee on Immunization Practices (ACIP), 2012. MMWR Morb Mortal Wkly Rep 2013;62:131–5. PubMed
  6. Advisory Committee for Immunization Practices. CDC. Tdap/Td ACIP vaccine recommendations. Atlanta, GA: Advisory Committee for Immunization Practices, CDC; 2014. https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/tdap-td.html
  7. Grabenstein JD. What the world’s religions teach, applied to vaccines and immune globulins. Vaccine 2013;31:2011–23. CrossRef PubMed

 


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