Research and analysis

Tetanus in England: 2020

Updated 1 June 2023

Applies to England

This article updates the Health protection report (HPR) Tetanus in England: 2019 (which presented surveillance data for England for that year), and reiterates current recommendations on diagnosis and clinical management of tetanus.

Key points arising from this report are that:

• tetanus is a potentially life-threatening but preventable infection and is very rare in the UK due to the success of the immunisation programme
• there were 7 cases and 2 deaths recorded between January to December 2020
• cases continue to occur predominantly in the elderly (those born before 1961)
• most cases are associated with domestic or work-related injuries

Data sources in England for the enhanced surveillance of tetanus include notifications, reference and NHS laboratory reports, death registrations, and individual case details such as vaccination history, source of infection and severity of disease obtained from hospital records and general practitioners.

Cases of tetanus are known to be under-reported. A comparison of surveillance data against hospital episode statistics between 2001 and 2014 suggested that tetanus was under-reported by 88% during that period with 67 additional cases identified in the hospital statistics that were not captured through enhanced surveillance (1).

Seven cases of clinical tetanus were identified in England between January and December 2020. This compares to 4 cases identified in 2019 and 7 cases in 2018. Tetanus is a notifiable disease in accordance with the amended Public Health (Control of Disease) Act 1984 and the accompanying regulations (SI 2010/659). However, only 1 case was notified as tetanus by healthcare professionals in England.

Six of the cases were between 56 and 87 years of age and 1 case was of unknown age. Four of the cases were male and 3 were female. Of the 6 cases where age was known, 5 were born before 1961 when routine childhood vaccination was introduced in the UK (1, 2).

Cases occurred in February, April, July, August, October and November. All had a history of domestic or work-related injury – 5 cases were injured in a home or garden, 1 case sustained an injury at work and 1 case had an injury about which the details were not specified.

Three cases presented with mild symptoms (grade 1), whilst 1 case had severe symptoms (grade 3a) and 1 case presented with moderate symptoms (grade 2) on admission and then progressed to very severe symptoms (grade 3b) – for 2 cases severity was unknown. All cases were hospitalised and 2 were admitted to intensive therapy units. The 2 severe cases died. Full details of grading of severity for clinical purposes are contained in Tetanus: guidance for health professionals, which was revised in 2019.

One of the cases was reported to have received 2 booster doses, however, the individual had not received a primary course. All the other individuals were either born before 1961 or did not have any vaccination history recorded. One individual with uncertain vaccine history was born outside of the UK but had lived in the UK for the last 50 years. Both fatal cases were born before 1961 and had an uncertain vaccination history.

One of the milder cases sought medical advice at the time of injury and was offered antibiotics. Of the 2 fatal cases, both sought medical advice at the time of injury. Both were offered antibiotics and 1 received a booster dose of tetanus toxoid. None of the cases that sought medical advice were offered post-exposure prophylaxis with intra-muscular tetanus immunoglobulin (IM-TIG) or human normal immunoglobulin (HNIG). Current recommendations are that all exposed individuals with unknown vaccination status be offered prophylaxis with TIG following a tetanus-prone wound.

After the onset of clinical symptoms when tetanus was diagnosed at hospital, all 7 of the cases received intravenous immunoglobulin (IVIG) or IM-TIG during their admission.

The 2 severe cases were confirmed with polymerase chain reaction (PCR) detection of the neurotoxin gene or by culture of Clostridium tetani from infected tissue samples. Pre-immunoglobulin blood samples from 2 cases and 2 post-immunoglobulin samples were sent to the Respiratory and Vaccine Preventable Bacteria Reference Unit (RVPBRU) for anti-tetanus antibody testing. But all 4 cases, including the 2 severe cases, were found to have levels of antibodies against tetanus that may be considered to confer protection – greater than 0.1 international units per millilitre (IU/mL) – at the time the sample was taken. The 2 severe cases had levels of antibodies only just above the 0.1 IU/ml threshold: 1 of these cases had their serum sample taken post-immunoglobulin and the other received a booster dose of tetanus toxoid at the time of injury. Serological testing is not a reliable indicator for diagnosis to confirm or to rule out tetanus.

Background, diagnosis and immunisation

Tetanus is a life-threatening but preventable disease caused by a neurotoxin (tetanospasmin, TS) produced by Clostridium tetani, an anaerobic spore-forming bacterium. Tetanus spores are widespread in the environment, including in soil, and can survive hostile conditions for long periods of time. Transmission occurs when spores are introduced into the body, often through a puncture wound but also through trivial, unnoticed wounds, chronic ulcers, injecting drug use, and occasionally through abdominal surgery.

Neonatal tetanus is still common in the developing world where the portal of entry is usually the umbilical stump, particularly if there is a cultural practice of applying animal dung to the umbilicus.

The infection is not transmitted from person to person. 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.

Tetanus immunisation was introduced in the 1950s and became part of the national routine childhood programme in 1961. Since then, vaccine coverage at 2 years of age has always exceeded 70% in England and Wales and since 2001 has been around or above 95%, the target coverage set by the World Health Organization (WHO).

The objective of the immunisation programme in the UK is to provide a minimum of 5 doses of tetanus-containing vaccine at appropriate intervals for all individuals. As there is no herd immunity effect, individual protection through vaccination is essential. In most circumstances, a total of 5 doses of vaccine at the appropriate intervals are considered to give satisfactory long-term protection, and routine boosters every 10 years are no longer recommended. Further details on tetanus immunisation information are available in the green book, chapter 30: Tetanus.

Clinical management

Recommendations for the treatment of suspected clinical tetanus and management of tetanus-prone wounds are contained in Tetanus: advice for health professionals.

Clinical management of tetanus includes administration of IVIG, wound debridement, antimicrobials including agents reliably active against anaerobes such as metronidazole, and vaccination with tetanus toxoid following recovery. The revised guidelines emphasise the clinical diagnosis of suspected tetanus. Three diagnostic laboratory tests are available to support diagnosis: detection of C. tetani from the infection site by PCR and culture, and detection of tetanus toxin in serum, using a bioassay.

Debridement of wounds is clinically beneficial and wound samples provide the diagnostic sample for the isolation of C. tetani or detection of toxin by PCR. However, a negative laboratory test does not rule out a case. The revised guidelines provide updated advice on treatment of clinical tetanus using IVIG and on the assessment and management of tetanus-prone wounds based on age and vaccination status.

The revised guidelines highlight that patients born before 1961 in the UK are unlikely to have completed a primary course and this should be taken into account as part of the risk assessment.

Since the supply of intramuscular tetanus immunoglobulin (IM-TIG) is limited, for tetanus-prone wounds requiring prophylactic IM-TIG, HNIG for subcutaneous use may be given intramuscularly as an alternative to TIG. Further details are provided in Tetanus: advice for health professionals.

References

1. Collins S, Amirthalingam G, Beeching NJ, and others (2015). Current epidemiology of tetanus in England, 2001 to 2014. Epidemiology and Infection: volume 144 number 16, pages 3,343 to 3,353.

2. Rushdy AA, White JM, Ramsay ME, Crowcroft NS (2003). Tetanus in England and Wales 1984 to 2000. Epidemiology and Infection: volume 144 number 16, pages 71 to 77.