Notes from an R.N. -
124 cases in 3 years.
Read carefully. Still isn’t
written real well - I hate when they use %% and you don’t know the real
numbers. There are graphs on the
webpage with tiny, tiny writing that help a little. If they were graded on their writing skills presenting this type
of info they’d get a D.
That works out to be 41 cases in 1 year. One child with an insect bite. The key here for me is how many people DO
NOT GET TETANUS - aren’t vaccinated, aren’t up to date on vaccines, get insect
bites, work in the soil, etc. You have
to keep this all in perspective. Also a
lot of drug users here.
1. But the key
paragraph to me - which I didn’t know - was this....
“Tetanus remains a clinical diagnosis because
confirmatory laboratory tests are not available for routine use. Isolation of
the organism from wounds is neither sensitive nor specific: anaerobic cultures
of tissues or aspirates usually are not positive, and the organism might be
grown from wounds in the absence of clinical signs and symptoms of disease
(37-39).”
2. Also....”The number
of cases derived from passive reporting by physicians to local and state health
departments underestimates the true incidence of tetanus in the United States.
Completeness of reporting for tetanus mortality has been estimated at 40%,
while completeness of reporting for tetanus morbidity may be lower (36).
Although tetanus mortality reporting is incomplete, reported tetanus deaths are
representative of all tetanus deaths (36). Because fatal cases are more likely
to be reported than nonfatal ones, possible changes in reporting practices do
not appear to explain the decreased number of reported cases among older
adults, who are more likely to have severe disease.”
This paragraph doesn’t totally make sense but what I
get is that reporting for tetanus mortality is 40% and reporting of tetanus
morbidity (occurance) is less. SO IF
THE DOCS DON’T EVEN REPORT TETANUS, YOU THINK THEY REPORT VACCINE
REACTIONS?? The paragraph about tetanus
mortality being incomplete but the deaths are representative of all deaths -
how on earth do that know that. See
what I mean....
3. And this “Tetanus is
preventable through both routine vaccination and appropriate wound management. “
http://www.cdc.gov/epo/mmwr/preview/mmwrhtml/00053713.htm
July 03, 1998 / 47(SS-2);1-13
Barbara Bardenheier, M.P.H (1,2) D. Rebecca Prevots, Ph.D.,
M.P.H. (1) Nino Khetsuriani, Ph.D., M.D. (1) Melinda Wharton, M.D., M.P.H. (1)
(1) Epidemiology and
Surveillance Division
Problem/Conditions: Despite widespread availability of a
safe and effective vaccine against tetanus, 124 cases of the disease were
reported during 1995-1997. Only 13% of patients reported having received a
primary series of tetanus toxoid (TT) before disease onset. Of patients with
known illness outcome, the case-fatality ratio was 11%.
Reporting Period Covered: 1995-1997.
Description of System: Physician-diagnosed cases of
tetanus are reported by state and local health departments to CDC’s National
Notifiable Diseases Surveillance System. In addition, since 1965, supplemental
clinical and epidemiologic information for cases has been provided to CDC’s
National Immunization Program.
Results: From 1995 through 1997, a total of 124 cases of
tetanus were reported from 33 states and the District of Columbia, accounting
for an average annual incidence of 0.15 cases per 1,000,000 population. Sixty percent
of patients were aged 20-59 years; 35% were aged greater than or equal to 60
years; and 5% were aged less than 20 years, including one case of neonatal
tetanus. For adults aged greater than or equal to 60 years, the increased risk
for tetanus was nearly sevenfold that for persons aged 5-19 years and twofold
that for persons aged 20-59 years. The case-fatality ratio varied from 2.3% for
persons aged 20-39 years to 16% for persons aged 40-59 years and to 18% for
persons aged greater than or equal to 60 years. Only 13% of patients reported having received a primary series of
TT before disease onset. Previous vaccination status was directly related to
severity of disease, with the case-fatality ratio ranging from 6% for patients
who had received one to two doses to 15% for patients who were unvaccinated. No
deaths occurred among the 16 patients who previously had received three or more
doses. Tetanus occurred following an acute injury in 77% of patients, but only
41% sought medical care for their injury. All patients who sought care were
eligible for TT as part of wound prophylaxis, but only 39% received it. Tetanus
in injecting-drug users (IDUs) with no known acute injury comprised 11% of all
cases, compared with 3.6% during 1991-1994.
None of the IDU-associated tetanus cases occurred among persons who were
known to have been vaccinated. Sixty-nine percent of IDU-associated tetanus cases
were reported from California, and 77% of these cases occurred in heroin users.
Interpretation: Tetanus remains a severe disease that
primarily affects unvaccinated or inadequately vaccinated persons. Adults aged
greater than or equal to 60 years continue to be at highest risk for tetanus
and for severe disease. However, the overall incidence of tetanus has decreased
slightly since the late 1980s and early 1990s, from 0.20 to 0.15, a result primarily
of a decreased incidence among persons aged greater than or equal to 60 and
less than 20 years.
Actions Taken: Tetanus is preventable through both routine
vaccination and appropriate wound management. In addition to decennial booster
doses of diphtheria and tetanus toxoids during adult life, the Advisory
Committee on Immunization Practices (ACIP) recommends vaccination visits for
adolescents at age 11-12 years and for adults at age 50 years to enable
health-care providers to review vaccination histories and administer any needed
vaccine. Every contact with the health-care system, particularly among older
adults and IDUs, should be used to review and update vaccination status as
needed.
The reported incidence of tetanus morbidity and mortality
in the United States has declined substantially since the mid-1940s, when
tetanus toxoid became universally available (1). This decline has resulted from
a) widespread use of tetanus toxoid-containing vaccines (TT) for vaccination of
infants and children (e.g., as diphtheria and tetanus toxoids and pertussis
vaccine {DTP} or as diphtheria and tetanus toxoids for adult use {Td}), b) use
of TT and tetanus immune globulin (TIG) for postexposure prophylaxis in wound
treatment, and c) improved wound care management. In addition, increased rural
to urban migration (2), with consequent decreased exposure to tetanus spores,
may have contributed to the decline in tetanus mortality noted during the first
half of the century.
Vaccination coverage with TT among school-aged children
has improved substantially with the adoption and implementation of state
immunization requirements. Forty-nine of the 50 states and the District of
Columbia have passed legislation requiring that children be vaccinated for
tetanus before admission to school (3), and greater than 96% of school-aged
children have received three or more doses of DTP by the time they begin school
(4). In addition, among children aged 19-35 months, national vaccination
coverage with three or more doses of DTP has increased significantly (p less
than 0.05), from 83% in 1992 to 95% in 1996 (5).
National surveillance for tetanus is conducted to monitor
the epidemiology of the disease and to identify high-risk populations. In this
report, we describe the epidemiology of tetanus in the United States from 1995
through 1997 and update tetanus morbidity and mortality trends from 1947 to
1997.
National tetanus surveillance relies on reporting of
physician-diagnosed cases to state and local health departments. The diagnosis
of tetanus is based on the clinical judgment of the attending physician because
a laboratory test for definitive diagnosis of tetanus is not routinely available.
In 1990, the Council of State and Territorial Epidemiologists and CDC adopted
the following clinical case definition for public health surveillance for
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)”
(6).
State health departments report cases of tetanus on a
weekly basis to CDC’s National Notifiable Diseases Surveillance System (NNDSS).
CDC publishes the number of tetanus cases reported by each state to NNDSS on a
weekly basis and in an annual summary (1). In addition, since 1965, state
health departments have reported supplemental clinical and epidemiologic information
for cases to CDC’s National Immunization Program. This supplemental reporting
system provides CDC with information about the clinical history, presence and
nature of any associated risk factors, vaccination status of the patient, wound
care, and clinical management for each tetanus case (7). A summary of this
additional information is published approximately every 2-4 years (8-12).
During 1995-1997, a total of 124 tetanus cases with onset
during this period (i.e., 40 * cases in 1995, 36 in 1996, and 48 in 1997) were
reported to NNDSS. The annual average for this period was 41 cases, which is
the lowest annual average ever reported since national tetanus surveillance began
in 1947 (Figure_1) and is lower than the average of 50 cases reported from 1991
through 1994 (12). The incidence rate of 0.15 cases per million population
represents a slight decline from the rate of 0.2 cases per million population
reported from 1987 through 1994 (8-12) and a 96% decrease from the 3.9 cases
per million population reported for 1947. The overall case-fatality ratio also
has declined, from 91% in 1947 to 24% during 1989-1994 and to 11% during
1995-1997.
At least one case of tetanus was reported by each of 33
states, the District of Columbia, and New York City during 1995-1997
(Figure_2), and tetanus cases were reported all 3 years by 10 states
(California, Colorado, Florida, Illinois, Louisiana, Minnesota, New York,
Pennsylvania, Tennessee, and Texas). Of the 17 states with no reported cases,
seven (41%) were located in the Rocky Mountain and West North Central regions.
Tetanus incidence in these regions has historically been low (8-12). An
additional five states with no reported cases (29%) were located in New
England.
Data on age were reported for all 124 patients. Of these,
44 (35%) were aged greater than or equal to 60 years; 74 (60%) were aged 20-59
years; and six (5%) were aged less than 20 years, including one case of
neonatal tetanus and four patients aged 1-14 years (Figure_3). In contrast,
during 1991-1994, 54% were aged greater than or equal to 60 years (an annual average
of 25 cases) (12), and 41% were aged 20-59 years. During 1995-1997, the average
annual incidence among persons aged greater than or equal to 60 years was 0.33
cases per million population, a more than 12-fold increased risk compared with
that for persons aged 5-19 years (0.026 cases per million population), and a
nearly twofold increased risk compared with that for persons aged 20-59 years
(0.17 cases per million population) (Figure_3).
Data on sex were reported for all 124 patients; data on
race and ethnicity were reported for 120 (97%) of the 124 patients. Of the 124
cases, 74 (60%) were male. The female-to-male ratio among patients aged 20-59
years was 0.42; among patients aged greater than or equal to 60 years, the
ratio was 1.75. For persons aged 20-59 years, the incidence among males (0.24
cases per million population) was 2.4 times greater than that among females
(0.10 cases per million population). For persons aged greater than or equal to
60 years, incidence among males (0.28 cases per million population) was similar
to that among females (0.37 cases per million population). Incidence among whites was 0.15 cases per
million population; among Hispanics, 0.27; and among blacks, 0.09.
Supplemental clinical and epidemiologic information was
provided for 123 (99%) of the 124 reported tetanus cases. One case of neonatal
tetanus was reported in an infant who was delivered in 1995 in a hospital where
standard aseptic practices were used. The mother had immigrated from Mexico 8
years before delivery and had previously received only one tetanus vaccination
in Mexico at age 12 years. Since moving to the United States in 1987, she had
given birth to two other children in a hospital, and the index pregnancy
included five routine visits for prenatal care during the 6 weeks before
delivery. The family’s home in the United States was near a pasture where
cattle grazed. The infant recovered fully after a 2-month hospitalization (13).
The youngest non-neonatal tetanus case occurred in an
unvaccinated boy aged 3-1/2 years who had been stung by an insect. Because of
their religious beliefs, his parents initially refused medical care for the
tetanus and treated the child with herbal tea and carrot juice. The child had generalized
tetanus that required mechanical ventilation; he recovered after a 24-day
hospitalization.
Sixteen (13%) of the 122 non-neonatal patients with
supplemental data were reported to have received at least a primary series
(i.e., three or more doses) of TT before onset of illness (Table_1), including
two (40%) of the five non-neonatal patients aged less than 20 years. Three
(60%) of the non-neonatal patients aged less than 20 years were unvaccinated
because of their parents’ religious objections. The fourth case occurred in a
boy aged 14 years who was bitten by a dog and who had received his last dose 2
years previously. This patient did not seek medical care for his injury and was
later hospitalized with tetanus for 2 days. He did not require mechanical ventilation
and subsequently recovered. The fifth case occurred in a boy aged 15 years who
was in a moped crash; the interval since his last dose was 11 years. The
patient sought medical attention and received TT within 6 hours of his injury;
he was hospitalized 4 days and recovered without sequelae.
Of the 14 (11%) patients aged greater than or equal to 20
years who were known to have received a primary series, six reported receipt of
the last booster dose less than or equal to 10 years before onset of illness
and two within 5 years before onset of illness.
Fourteen deaths occurred among 122 patients with known
outcome, representing a case-fatality ratio of 11%. All tetanus-related deaths occurred
among patients aged greater than or equal to 25 years. The case-fatality ratio
varied from 2.3% among patients aged 20-39 years to 16% among patients aged
40-59 years and to 18% among patients aged greater than or equal to 60 years.
Previous vaccination status was directly related to disease severity: the
case-fatality ratio ranged from 6% for patients who had received one to two
doses of TT to 15% for patients who were unvaccinated. No deaths occurred among
the 16 patients who previously had received three or more doses (Table_1), and
only one patient required mechanical ventilation. Of these 16 patients, nine
had generalized tetanus, four had localized tetanus, and one had cephalic
tetanus. For two cases, the type of tetanus was unknown.
An acute injury sustained before onset of illness was
identified for 93 (77%) of the 120 tetanus cases with known injury status. Of
these cases, 46 (49%) occurred after puncture wounds, the most frequent type of
injury. Of the 33 patients for whom the circumstance of the puncture wound was
known, 13 (39%) had stepped on a nail. Other puncture wounds resulted from self-performed
body piercing (one case), self-performed tattooing (one case), animal bites,
and splinters. The case associated with body piercing occurred in a woman aged
27 years who pierced her umbilicus at home with a sterile 16-gauge needle. The
other most frequently reported types of acute injury were 20 (22%) lacerations
and 11 (12%) abrasions. Nine (10%) of the 93 patients with an acute injury also
reported injecting-drug use (IDU). An additional three patients had an acute
injury related to surgery performed 4-8 days before onset of illness; none of
these patients were known to have been vaccinated for tetanus. These patients
included a woman aged 63 years who underwent a hemorrhoidal banding procedure,
a man aged 41 years who had an implant inserted in his back, and a man aged 32
years who had knee surgery. All three patients were administered TIG
therapeutically and recovered.
The site of the antecedent acute injury was a lower
extremity in 43 (46%) patients, an upper extremity in 33 (35%) patients, and
the head or trunk in 11 (12%) patients. The injury site was not specified for
six patients. The environment in which the antecedent injury occurred was
reported for 85 patients. Of these patients, 20 (24%) were injured while at
home; 13 (15%) while indoors, other than at home; 33 (39%) while performing
outdoor farming or gardening activities; and 19 (22%) while engaged in other outdoor
activities. The median incubation period was 6 days (range: 0-73 days) for the
92 non-neonatal cases with an acute injury for which dates of injury and
illness onset were known. For 90 (98%) of these cases, the incubation period
was less than or equal to 30 days.
Information regarding medical care was reported for 88
patients who became ill with tetanus after sustaining an acute injury. Of these
patients, 36 (41%) obtained medical care for their injury, and all were
eligible to receive Td prophylaxis for wound management. TT was administered as
prophylaxis to only 14 patients (i.e., 39% of those who obtained medical care),
10 (71%) of whom received toxoid within 24 hours after the injury. The remaining 22 patients were eligible for
Td prophylaxis but did not receive it as recommended by the Advisory Committee
on Immunization Practices (ACIP). Of the 13 (43%) patients who sought medical
care and whose wounds were debrided, only three received the TIG indicated as
part of wound prophylaxis.
Twenty-nine non-neonatal cases unrelated to acute injury
were associated with underlying medical conditions, including chronic wounds or
IDU. Two patients had breast tissue necrosis secondary to breast cancer. Three patients
had diabetes, two of whom were insulin-dependent. Thirteen (43%) of the
patients without an acute injury were known to be IDUs (one of whom also had
insulin-dependent diabetes), representing 11% of all tetanus cases. The median
age of patients with IDU-associated tetanus was 43 years (range: 24-60 years);
11 (85%) were male. Vaccination history was known for three (23%) of the 13
IDU-associated patients, all of whom were unvaccinated. The overall
case-fatality ratio among IDU-associated cases was 15%. Nine (69%) of the 13
IDU-associated cases were reported from California. Of these cases, eight (89%)
were Hispanic, seven (78%) were male, and three (33%) were aged 20-29 years.
Although information on the types of drugs used is not routinely collected on
IDU-associated tetanus cases, seven of the patients with tetanus from
California were identified as heroin users (14).
The type of tetanus was reported for 100 (82%) of the 123
cases with supplemental information. Of these cases, 81 (81%) were generalized;
13 (13%), localized; and six (6%), cephalic. Therapeutic TIG administration for
treatment of clinical tetanus was reported for 108 (88%) patients, and the
exact dosage of TIG was specified for 80 (74%) patients. The median TIG dosage
used therapeutically was 3,000 IU; 75% of the patients received 1,000-4,000 IU
of TIG. The interval between onset of illness and TIG administration was known
for 102 (94%) of the patients who received TIG;
TIG was administered to 35 (34%) of these patients less
than 24 hours after onset of illness and to 40 (40%) patients 1-4 days after
onset. The case-fatality ratio for patients who received therapeutic treatment
within 24 hours was 9%, compared with 10% for those who received treatment
greater than 1 day after onset of illness. Information about illness outcome
was reported for 107 (99%) patients who received TIG; 11 (10%) of these patients
died. Two (20%) of the 10 patients who did not receive TIG died.
Length of hospitalization was reported for 98 (79%)
patients; the median duration was 11 days (range: 0-79 days). Of the 96
patients for whom the use of assisted ventilation was reported, 46 (48%)
received ventilation. Eighteen percent
of those who required ventilation died, compared with 6% of those who did not
require ventilation.
Tetanus remains a severe disease occurring primarily among
persons who are unvaccinated or inadequately vaccinated. Adults aged greater
than or equal to 60 years continue to be at highest risk for tetanus and for
severe disease. However, the overall incidence of tetanus has decreased
slightly since the late 1980s and early 1990s, from 0.20 to 0.15 cases per
million, a result primarily of a decreased incidence among persons aged greater
than or equal to 60 and less than 20 years. In addition, for the first time since
1973 (15), patients aged 20-59 years have accounted for a greater proportion of
cases (60%) than those aged greater than or equal to 60 years, with most (52%)
of these cases in the 20-49 year age group. This change in age distribution has
resulted from both an increase in the average annual number of cases among
persons aged 20-59 years and a decrease in the average annual number of cases
among persons aged greater than or equal to 60 and less than 20 years (12).
Older adults are at highest risk for tetanus because of
the low prevalence of immunity to tetanus in this population. Data obtained
from a national population-based serologic survey conducted during 1988-1991
indicate that the prevalence of immunity to tetanus in the United States is
lower in older age groups, from greater than 80% among persons aged 6-39 years
to 28% among persons aged greater than or equal to 70 years (16). The decreased
incidence among older adults during the 1990s may be in part related to
increases in tetanus vaccination among persons aged greater than or equal to 60
years. The National Health Interview Survey, a national probability sample,
ascertained a moderate increase in tetanus vaccination rates among older
adults; in 1991, 27% of persons aged greater than or equal to 65 years reported
that they had received a tetanus vaccination during the preceding 10 years. By
1995, this figure had increased to 36% (CDC, unpublished data). Although this
increase in tetanus vaccination does not entirely explain the twofold decreased
incidence in adults aged greater than or equal to 70 years, it suggests increased
compliance with current tetanus vaccination recommendations for adults (17).
Nonetheless, to further reduce the tetanus burden among older adults, improved
compliance with these recommendations is needed to increase population
immunity.
The disproportionate number of tetanus cases in the 20-59
year age group is in part related to an increased number of cases among IDUs,
particularly among Hispanics in California. Among patients aged 20-59 years,
IDUs comprised 27% of cases and 14% of cases with no acute injury. Overall,
IDUs comprised 18% of all cases; IDUs with no acute injury comprised 11% of all
cases. In contrast, from 1982 through 1994, the overall proportion of IDU-associated
cases ranged from 2.1% to 4.5% (8-12) **. The increase in the number of
IDU-associated tetanus cases is related to an increase in cases reported from
California; although California has reported most (59%) of these cases in the
United States since 1987, the number of IDU-associated cases reported from
California has increased steadily since the 1990s, particularly in recent years
(14). A disproportionate number of IDU-associated cases was last observed in
the United States among cases reported during 1970-1971 (18).
IDUs, particularly heroin users, have previously been
reported to be at high risk for tetanus both in the United States and elsewhere
(19-24). The high risk among IDUs is related to both increased exposure and susceptibility,
including: a) the high prevalence of abscesses, which favor anaerobic
conditions for bacterial growth, secondary to nonsterile injection practices
(25); b) subcutaneous injection (“skin popping”) (19,20,22); c) contamination
of the drug supply (20,21); and d) low prevalence of immunity (19,24). The
increased number of cases among Hispanic IDUs may be related to both low
prevalence of immunity to tetanus and exposure to contaminated heroin. A
national population-based seroprevalence survey conducted during 1988-1991
identified ethnic differences in tetanus immunity. Only 58% of
Mexican-Americans (the predominant Hispanic population in the Western region
{26}) had protective levels of tetanus antibodies, compared with 73% of
non-Hispanic whites and 68% of non- Hispanic blacks (16).
Most of the heroin supplied to the Southwest is available
in the resinous form called “black tar” (27,28); the use of black tar heroin
may be increasing in this region (29). A recent increase in cases of wound botulism
(an anaerobic bacterial infection caused by Clostridium botulinum) associated
with injecting black tar heroin has also been reported among drug users in
California (29). Whether the disproportionate number of IDU-associated cases
from California is because of an increase in black tar heroin use remains
unclear and requires further investigation (14). Among IDUs for whom drug
cessation strategies have not been successful, strategies to prevent cases of
tetanus among IDUs, include a) use of clean needles and sterile injection
technique (30) and b) assessment and updating of vaccination status as needed
during every contact with the medical-care system. ACIP recognizes that IDUs
are at increased risk for tetanus and recommends that they be kept up-to-date
with Td vaccinations (31).
The case of neonatal tetanus reported in 1995 was the
first reported since 1989 (32). Although nearly all tetanus cases in the United
States occur in adults, most reported tetanus cases worldwide occur in
neonates, with an estimated 490,000 deaths worldwide attributed to neonatal
tetanus in 1994 (33). The goal of worldwide neonatal tetanus elimination was
adopted by the World Health Assembly in 1989 (34). This goal has been defined
as less than one case per 1,000 live births in the presence of a functional
surveillance system. The key strategies are a) achievement and maintenance of
high vaccination coverage levels among women of childbearing age in high-risk areas
and b) promotion of clean delivery and cord-care practices (35). The two most
recent neonatal tetanus cases in the United States occurred among infants born
to immigrants in the United States in 1989 (32) and 1995 (13). The elimination of neonatal tetanus in the
United States can ultimately only be achieved through improved worldwide
coverage with at least two doses of TT among girls and women of childbearing
age.
National health objectives for the year 2000 include a
disease-elimination objective of no tetanus cases among persons aged less than
25 years. Three of the 12 cases among persons aged less than 25 years were
among children who had received no vaccines because their parents had religious
or philosophic objections to vaccination. Tetanus is not a communicable disease,
and the organism is ubiquitous in the environment; unlike other vaccine-preventable
diseases, there is no herd immunity to tetanus. As long as any child remains
susceptible to tetanus, cases of tetanus among children in the United States
can continue to occur.
The number of cases derived from passive reporting by
physicians to local and state health departments underestimates the true
incidence of tetanus in the United States. Completeness of reporting for
tetanus mortality has been estimated at 40%, while completeness of reporting
for tetanus morbidity may be lower (36). Although tetanus mortality reporting
is incomplete, reported tetanus deaths are representative of all tetanus deaths
(36). Because fatal cases are more likely to be reported than nonfatal ones, possible
changes in reporting practices do not appear to explain the decreased number of
reported cases among older adults, who are more likely to have severe disease.
Tetanus remains a clinical diagnosis because confirmatory
laboratory tests are not available for routine use. Isolation of the organism
from wounds is neither sensitive nor specific: anaerobic cultures of tissues or
aspirates usually are not positive, and the organism might be grown from wounds
in the absence of clinical signs and symptoms of disease (37-39).
Tetanus is preventable through both routine vaccination
and appropriate wound management. Vaccination with a primary series of three
doses of TT-containing vaccine and booster doses of Td every 10 years are
highly effective in preventing tetanus (40). During 1995-1997, only 13% of patients
were known to have completed a primary series with TT before onset of tetanus,
and only 47% of these had been vaccinated during the 10 years preceding onset
of tetanus. In addition, nearly two thirds of patients who sought medical care
following their injury did not receive prophylaxis as recommended by ACIP
(Table_2).
ACIP recommends that persons be routinely scheduled for a
vaccination visit at age 11-12 years (41) and age 50 years (42). Such visits
enable health-care providers to a) review the patient’s vaccination status, b) administer
Td as indicated, and c) determine whether a patient needs other vaccinations
(e.g., influenza and pneumococcal vaccinations). Because many patients with
tetanus did not have an acute injury and only 41% of those who did have an
acute injury sought medical care, every contact with the health-care system,
particularly among the elderly and IDUs, should be used to review and update
vaccination status as needed.
The authors thank Evelyn L. Finch and Barry I. Sirotkin
for data management and statistical support and Peter M. Strebel and Roland W.
Sutter (all four with CDC’s National Immunization Program, Atlanta, GA) for
their critical review of the manuscript; Cynthia D. O’Malley (California
Department of Health Services, Berkeley, CA) for her assistance with
surveillance data; and all reporting state and local health departments for
their efforts in conducting tetanus surveillance.
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One case with onset in 1994 was reported in 1995; this
case was included in a previous surveillance summary (12).
** During 1991-1994, although six of the seven
IDU-associated cases were initially reported as having an acute injury, further
investigation revealed that the only known injury was ongoing drug use.
Figure_1
Figure_2
Figure_3
Table_1
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TABLE 1. Tetanus toxoid vaccination status and deaths among
persons with
reported
tetanus, by vaccination status—United
States, 1995-1997
No.
Vaccination status No. (%) deaths
Unknown 66 (
53.7) 9
0 doses 27 (
21.5) 4
1 dose 11
( 9.1) 0
2 doses 4
( 3.3) 1
3 doses 4
( 3.3) 0
>=4 doses 12 ( 9.1)
0
Total 124 * (100.0) 14
*Outcome was unknown for two
patients.
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TABLE 2. Summarized
recommendations for the use of tetanus prophylaxis in routine wound management—Advisory
Committee on Immunization Practices (ACIP), 1991 (17)
Clean, minor wounds All other
wounds *
History of adsorbed
-------------------
------------------
tetanus toxoid Td + TIG
& Td TIG
Unknown or <3 doses Yes No Yes Yes>=3 doses
@ No ** No
No ++ No
·
Such as, but not limited to, wounds contaminated with
dirt, feces, soil, or saliva; puncture wounds; avulsions; and wounds resulting
from missiles, crushing, burns, or frostbite.
·
For children aged <7 years the diphtheria and
tetanus toxoids and acellular pertussis vaccines (DTaP) or the diphtheria and
tetanus toxoids and whole-cell pertussis vaccines (DTP) or pediatric diphtheria
and tetanus toxoids (DT), if pertussis vaccine is contraindicated is preferred
to tetanus toxoid (TT) alone. For persons aged>= 7 years, the tetanus and
diphtheria toxoids (Td) for adults is preferred to TT alone.
& TIG=tetanus immune globulin.
@ If only three doses of fluid toxoid have been received, a
fourth dose of
toxoid—preferably
an adsorbed toxoid—should be administered.
** Yes, if >10 years have elapsed since the last dose.
++ Yes, if >5 years have elapsed since the last dose.
More frequent
boosters are not needed
and can accentuate side effects.
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