Tetanus: Advice for Health Professionals

Overview

This Guidelines summary covers identifying, assessing, and managing tetanus. It does not include information on epidemiology or treatment with intravenous immunoglobulin or intramuscular tetanus immune globulin.

There is also a Guidelines summary on tetanus vaccination.

Causative Organism and Incubation Period

• Tetanus is caused by a neurotoxin produced by Clostridium tetani. C. tetani can be present in the gastrointestinal tract and faeces of horses and other animals, and the spores are widespread in the environment, including in soil
• Spores can survive hostile conditions for long periods of time, and human infection is acquired when C. tetani spores are introduced into wounds contaminated with soil. However, tetanus may also follow injecting drug use or abdominal surgery
• In some cases, no exposure is reported, and it is assumed that unnoticed minor wounds were the route of entry
• The incubation period of the disease is usually between 3 and 21 days, although it may range from 1 day to several months depending on the character, extent, and localisation of the wound.

Clinical Features

• The most common presentation of tetanus is generalised tetanus; however, two other forms, local and cephalic, are also described. Neonatal tetanus is also described, but has been eliminated in the UK for decades
• Generalised tetanus is characterised by trismus (lockjaw), tonic contractions, and spasms. Tonic contractions and spasms may lead to dysphagia, opisthotonos, and a rigid abdomen. In severe cases, they may cause respiratory difficulties. Autonomic instability is typical. Consciousness is not affected
• Localised tetanus is characterised by rigidity and spasms confined to the area around the site of the infection, and may be more common in partially immunised individuals. Localised symptoms can continue for weeks or may develop into generalised tetanus
• Cephalic tetanus is localised tetanus after a head or neck injury, involving primarily the musculature supplied by the cranial nerves.

Diagnosis

• Tetanus is primarily a clinical diagnosis. The key clinical features of generalised tetanus include at least two of the following:
  • trismus (painful muscular contractions, primarily of the masseter and neck muscles, leading to facial spasms)
  • painful muscular contractions of trunk muscles
  • generalised spasms, frequently position of opisthotonus.
• Severity can be graded as follows.

Grading of Severity

• Mild-to-moderate trismus and/or general spasticity, little or no dysphagia, no respiratory embarrassment.

Grade 2 (moderate)

• Moderate trismus and general spasticity, some dysphagia and respiratory embarrassment, and fleeting spasms occur.

• Severe trismus and general spasticity, severe dysphagia and respiratory difficulties, and severe and prolonged spasms (both spontaneous and on stimulation).

Grade 3b (very severe)

• As for severe tetanus, plus autonomic dysfunction, particularly sympathetic overdrive
• Localised tetanus can present with symptoms around the site of the wound.

Laboratory Testing to Support Clinical Diagnosis

• Laboratory tests are available to support clinical diagnosis. Although a serum sample should be taken before administering immunoglobulin, treatment of clinical cases of tetanus should never be delayed waiting for the laboratory result, and case management should proceed based on clinical review including clinical presentation, history of injury, and vaccination status.

Clinical Management

• Clinical management of suspected tetanus (including localised tetanus) includes:
  • early wound debridement
  • antimicrobials including agents reliably active against anaerobes, such as intravenous benzylpenicillin. Choice of antibiotics and doses should be discussed with your local microbiology team
  • intravenous immunoglobulin based on weight
  • vaccination with tetanus toxoid following recovery
  • supportive care (for example, benzodiazepines for muscle spasms, treatment of autonomic dysfunction, maintenance of ventilation, nursing in a quiet room).

Preventative Measures

Primary Prevention

• Effective protection against tetanus can be achieved through active immunisation with tetanus vaccine, which is a toxoid preparation
• A total of five doses of vaccine at the appropriate intervals are considered to provide lifelong immunity
• Single-antigen tetanus vaccine and combined tetanus/low-dose diphtheria vaccine have been replaced by the combined tetanus/low-dose diphtheria/inactivated polio vaccine for adults and adolescents for all routine uses in these age groups
• Recovery from tetanus may not result in immunity, and vaccination following tetanus is indicated. A full course of tetanus and diphtheria vaccines consists of five doses as shown in Table 1.

Table 1: Schedule of Tetanus and Diphtheria Vaccination

Occupational Health

• Tetanus is not transmitted from person to person, so those caring for patients with tetanus are not at risk of acquiring tetanus from the patient. However, like the general population, if they have not received the recommended five doses of tetanus-containing vaccine or are unsure about their vaccination status, they should check with their GP practice
• Employees in some occupations may be at increased risk of tetanus-prone wounds, so it is particularly important that occupational health providers check tetanus vaccination status.

Management of Tetanus-Prone Wounds

• Tetanus-prone wounds^[A] include:
  • puncture-type injuries acquired in a contaminated environment and likely therefore to contain tetanus spores,^[A] for example, gardening injuries
  • wounds containing foreign bodies, such as wood splinters^[A]
  • compound fractures
  • wounds or burns with systemic sepsis
  • certain animal bites and scratches^[B]
• High-risk tetanus-prone wounds include any of the above with either:
  • heavy contamination with material likely to contain tetanus spores, for example, soil, manure
  • wounds or burns that show extensive devitalised tissue
  • wounds or burns that require surgical intervention that is delayed for more than 6 hours are high risk, even if the contamination was not initially heavy
• Thorough cleaning of wounds is essential, and surgical debridement of devitalised tissue in high-risk, tetanus-prone wounds is crucial for prevention of tetanus. If the wound, burn, or injury fulfils the above high-risk criteria, intramuscular tetanus immune globulin or human normal immunoglobulin should be given to neutralise toxin. A reinforcing dose of tetanus-containing vaccine is recommended
• Treat tetanus-prone wounds with antibiotics (metronidazole, benzylpeniciilin, or coamoxiclav) depending on clinical severity with a view to preventing tetanus, and give a reinforcing dose of tetanus-containing vaccine
• Suspected cases of localised tetanus (where there is rigidity and/or spasms around the wound) should be treated as clinical cases as described in the sections on Diagnosis and Clinical Management, and not as a tetanus-prone injury. Further doses of vaccine should be administered as required to complete the recommended schedule to provide long-term protection.

Reporting

• Tetanus (local and generalised) is a notifiable disease. Doctors have a statutory duty to notify the ‘proper officer’ at their local council or local health protection team (HPT) of suspected cases
• Clinicians are requested to complete a notification form immediately on diagnosis of a suspected case without waiting for laboratory confirmation of a suspected infection. Diagnostic laboratories also have a statutory duty to report identification of C. tetani under the Health Protection (Notification) Regulations 2010
• Enhanced surveillance of tetanus for England is also carried out by the Immunisation and Vaccine Preventable Diseases Division, UK Health Security Agency. Consultants in communicable disease control or HPTs are requested to inform the National Surveillance Team of details of the case by completing the enhanced surveillance questionnaire and returning it to diphtheria_tetanus@ukhsa.gov.uk or phe.diphtheria.tetanus@nhs.net.

Footnotes

[A] Individual risk assessment is required and this list is not exhaustive. For example, a puncture wound from a discarded needle found in a park may be a tetanus-prone injury, but a needlestick injury in a medical environment is not.

[B] Although smaller bites from domestic pets are generally puncture injuries, animal saliva should not contain tetanus spores unless the animal has been rooting in soil or lives in an agricultural setting.