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Home Eurosurveillance Monthly Release  2002: Volume 7/ Issue 7 Article 2
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Eurosurveillance, Volume 7, Issue 7, 01 July 2002
Scientific review
Two recent cases of severe tetanus

Citation style for this article: Two recent cases of severe tetanus. Euro Surveill. 2002;7(7):pii=356. Available online:


Two cases of severe tetanus in women aged 61 years with histories of incomplete vaccination were notified in April 2002, the first cases reported sofar this year (1).

The first case from West Yorkshire developed symptoms eight days after sustaining a head injury from a fall down stairs. Neither tetanus toxoid nor immunoglobulin was given at the time of her injury, which required stitches. She was admitted to intensive care four days later with respiratory and cardiac arrest, and severe trismus, and died two and a half weeks later. Only one dose of tetanus toxoid given eight years ago was shown in her medical records.


The second case from Suffolk presented to her general practitioner (GP) with classical symptoms of jaw stiffness and facial spasms. Three days prior to this she suffered a deep scratch on her forearm while gardening. The patient reported that she had suffered a mild episode of tetanus as a teenager, over 40 years ago, and her symptoms with this episode were so similar that she had correctly self-diagnosed tetanus before seeing her GP. Following admission to intensive care she had protracted muscular spasms and autonomic symptoms, and required repeated intravenous infusions of tetanus immunoglobulin. Tetanus antitoxin levels were tested in an admission blood sample at the PHLS Respiratory and Systemic Infection Laboratory, and were below protective levels. Cultures of swabs taken from the wound grew Clostridium tetani were confirmed by the Anaerobe Reference Unit in Cardiff.

Following the first infection the patient had received one vaccination in the mid-1970s, but had a mild adverse reaction to the vaccination and so had not received further doses. The patient is now improving and, as the only contraindication to vaccination against tetanus is anaphylaxis, has been started on a primary course of vaccination. Immunity does not necessarily develop following tetanus disease and so the only protection against future infections is by vaccination. Patients who have had tetanus should be vaccinated when they have recovered sufficiently.

Herd immunity plays no part in tetanus control. High vaccination coverage in the childhood vaccination programme and opportunistic vaccination of those with histories of incomplete vaccination are required to ensure high levels of immunity in the whole population (2). Opportunistic vaccination should include groups such as those born before vaccination programmes were implemented and new arrivals with uncertain or incomplete vaccination histories. Tetanus vaccination coverage in most European Union member states including the UK, is good. Five doses of tetanus toxoid-containing vaccine are thought to give life-long protection – routine ten-yearly boosters are no longer recommended in the United Kingdom. Prompt and appropriate post-exposure prophylaxis is an important control measure. Doctors working in accident and emergency medicine need to maintain systems for providing post-exposure prophylaxis for tetanus and should preferably provide a vaccine that also includes an appropriate dose of diphtheria toxoid.

Attendance at accident and emergency offers a good opportunity to check vaccination status: liaison with GPs will be required to ensure the completion of a vaccination course in unvaccinated individuals. This should be a good topic for audit of local practice.

Since 1930, most tetanus cases in the United Kingdom have occurred in older people, mainly women, who had never been vaccinated (3-5). Between two and seven tetanus cases per year occur in England and Wales. Family doctors should ensure that all their patients are fully vaccinated, targeting those born before 1961.

Reprinted from CDR Weekly, 2002; 12 (18): 2-3


1. Department of Health. Immunisation against infectious disease. London: HMSO, 1996.

2. PHLS CDSC. Tetanus surveillance: England and Wales, 1981-3. BMJ 1985; 290: 696-7.

3. Galbraith NS, Forbes P, Tillett H. National surveillance of tetanus in England and Wales 1930-79. J Infect 1981; 3: 181-91.

4. CDSC. Tetanus surveillance in England and Wales. Commun Dis Rep CDR Wkly 1982; (07): 3-5.


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