Research and analysis

Tetanus in England: 2021

Updated 1 June 2023

Applies to England

This article updates the report Tetanus in England: 2020 (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 severe, potentially life-threatening but preventable infection and is very rare in the UK due to the success of the immunisation programme
• there were 11 cases and 1 death recorded between January to December 2021 which is higher than the usual cases per year over previous years
• most cases are associated with domestic or work-related injuries
• all cases were partially or non-immunised
• it is essential to take a full tetanus vaccination history (including primary and boosters) and exposed individuals with an unknown vaccination status should be offered prophylaxis with TIG along with tetanus vaccine following a tetanus-prone wound to prevent tetanus

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 GPs.

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).

There were 11 cases of clinical tetanus identified in England between January and December 2021. This compares to 7 cases identified in 2020 and 4 cases in 2019. 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.

Of the cases, 6 were female and 5 were male. The cases ranged in age from 19 to 87 years, with 6 of the cases aged above 73 years – these 6 cases were born before 1961, when routine childhood vaccination was introduced in the UK (1, 2).

Most cases occurred between July and September and had a history of domestic or work-related injury – 6 cases were injured in a home or garden, 2 cases sustained injuries in the street, 2 cases were injured at work and one case had a wound relating to intravenous drug use.

Two cases presented with mild symptoms (grade 1), 2 cases with moderate symptoms (grade 2), whilst one case had severe symptoms (grade 3a) and 3 cases had very severe symptoms (grade 3b) – for 3 cases severity was unknown. All cases were hospitalised (including one case hospitalised for the initial injury and later presenting with tetanus symptoms, and another with protracted course) and 6 were admitted to intensive therapy units. One of the very severe cases died. Full details of grading of severity for clinical purposes are contained in Tetanus: guidance for health professionals, current guidelines that were revised in 2019.

One of the cases was reported to have received their full primary course, however, the individual had not received a booster in the previous 10 years, whilst one of the severe cases had records showing an incomplete primary course and no further boosters. All the other individuals were either born before 1961 or did not have any vaccination history recorded – 2 individuals with uncertain vaccine history were born outside of the UK. The fatal case was born before 1961 and had one known dose given within the past 5 years.

At the time of injury, 4 cases sought medical advice of which 2 cases received antibiotics – the fatal case did not receive antibiotics nor a dose of tetanus toxoid at the time of injury. 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, 10 cases were recorded as receiving intravenous immunoglobulin (IVIG) during their admission.

There were 4 cases 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 9 cases were sent to the Respiratory and Vaccine Preventable Bacteria Reference Unit (RVPBRU) for anti-tetanus antibody testing – in 2 cases it is unclear whether the sample was taken pre- or post-IVIG administration. Samples tested from 6 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. 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 C. 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 one 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.

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 – 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: guidance 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. The revised guidelines emphasise the clinical diagnosis of suspected tetanus. Laboratory diagnostic tests are ancillary – the most useful test is detection of C. tetani from the infection site by PCR and culture.

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 the revised guidelines (1).

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.