General Information

Tetanus is caused by a neurotoxin produced by Clostridium tetani, an anaerobic spore forming bacillus. Tetanus spores are widespread in the environment, including in soil, and can survive hostile conditions for long periods of time.  Hence tetanus disease can be eliminated by vaccination but never eradicated. Transmission occurs when spores are introduced into the body, often through a puncture wound but also through trivial, unnoticed wounds, through injecting drug use, and occasionally through abdominal surgery. The infection is not passed from person to person and there is no herd immunity. The incubation period of the disease is usually between three and 21 days, although it may range from one day to several months, depending on the character, extent, and localisation of the wound.

The first symptoms of tetanus are stiff muscles near the wound (or injection site) followed by stiffening of other muscles and of the jaw until the patient can't open their mouth ('lockjaw'). This can be followed by frequent and painful spasms. The illness can progress for about 2 weeks. The muscle spasms can affect the patient's breathing and heart, which can be fatal.

The disease is completely preventable through adequate immunisation and wound management. Tetanus immunisation was introduced in the 1950s and became part of the national routine childhood programme in 1961.  Five doses of vaccine are now considered to give adequate immunity and routine boosters every ten years are no longer necessary ( Department of Health. Green Book chapter: Tetanus ).

• Immunisation schedule
• Completed Primary Courses at Two Years of Age: England and Wales, 1966 - 1977, England only 1978 onwards
  

Tetanus is usually confirmed by a clinical diagnosis alone, although three diagnostic laboratory tests are available:

1. Tetanus toxin in a serum sample: provides laboratory confirmation of a clinical diagnosis of tetanus, however, failure to detect toxin in serum does not negate a clinical diagnosis.
2. Isolation of tetanus bacillus from infection site: C. tetani is only very rarely recovered from the infection site.
3. Tetanus toxin antibodies in serum: demonstrating low levels or absent antibody to tetanus toxoid may provide laboratory evidence in support of a clinical diagnosis.
   The first two tests may provide laboratory confirmation, whereas the third can only support the diagnosis.

Enhanced surveillance for tetanus incorporates data from notifications, reference and NHS laboratories, death registration, and individual case details such as vaccination history, source of infection, and severity of disease obtained from hospital records and from general practitioners.

Tetanus is now a rare disease and the small number of cases that occurred prior to 2003, about ten per year, were generally confined to unimmunised people aged over 64 years (Rushdy AA, White JM , Ramsay ME, Crowcroft NS . Tetanus in England and Wales 1984-2000. Epidemiol Infect 2003; 130: 71-7).  During 2003 a cluster of tetanus cases occurred in injecting drug users; between July 2003 and September 2004, 25 tetanus cases were reported in injecting drug users; two of these patients died.  Cases continue to occur sporadically; advice for injecting drug users is available on the guidelines page.