Research and analysis

Tetanus in England: 2022

Updated 1 June 2023

Applies to England

This report updates Tetanus in England: 2021 (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 4 cases recorded between January to December 2022; there were no fatalities
• all cases were associated with domestic or work-related injuries
• most cases were only partially vaccinated or of unknown vaccination status

Case histories reported here, and in earlier years, underline the fact that tetanus is under-reported; health practitioners may be unaware of the statutory duty to report cases.

Where an individual presents with a suspected tetanus-prone wound, it is essential that a full tetanus vaccination history is taken (including primary and boosters) and that those with an unknown vaccination status should be offered prophylaxis with tetanus immunoglobulin (TIG) along with tetanus vaccine, as specified in the Green book, chapter 30: tetanus. See also the ‘Clinical management’ section below.

Surveillance and recent epidemiology

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 4 cases of clinical tetanus identified in England between January and December 2022. This compares to 11 cases identified in 2021 and 7 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, none of the 2022 cases was notified as tetanus by healthcare professionals in England.

The cases ranged in age from 23 to 72 years, with 2 cases born before 1961 when routine childhood vaccination was introduced in the UK (1, 2). Only 1 case was male. Cases occurred in February, March, April and June. All had a history of domestic or work-related injury; 2 cases were injured while gardening, 1 case sustained a bite from a feral cat and 1 had a minor injury from work.

One case presented with mild symptoms (grade 1) and 2 cases with moderate symptoms (grade 2); 1 had severe tetanus (3A). All cases were hospitalised and 1 was admitted to the intensive therapy unit (ITU); there were no fatalities.

Full details of grading of severity for clinical purposes are contained in the current guidance on the treatment of tetanus cases and management of tetanus-prone wounds (3). See also the ‘Clinical management’ section below.

One of the moderate cases was reported to have received their full primary course, with the final booster administered in the previous 10 years; the mild case believed themselves to be immunised but they were born outside of the UK and therefore vaccination history could not be verified. The remaining individuals were born before the introduction of childhood vaccination for tetanus in 1961: 1 moderate case had 2 boosters on record, neither of which were administered in the previous 10 years; the severe case had no tetanus vaccines recorded.

Only 1 case sought medical advice at the time of injury (the following day) and received antibiotics and a booster dose of tetanus toxoid; the case was not offered the recommended post-exposure prophylaxis with intra-muscular tetanus immunoglobulin (IM-TIG) or human normal immunoglobulin (HNIG) (3). After the onset of clinical symptoms, when tetanus was diagnosed at hospital, all 4 cases received intravenous immunoglobulin (IVIG) during their admission.

No cases were confirmed with polymerase chain reaction (PCR) detection of the neurotoxin gene or by culture of Clostridium tetani as no samples from infected tissue were collected. Serological testing is not a reliable indicator for diagnosis – to confirm or to rule out tetanus (3).

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 (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. Routine boosters every 10 years are no longer recommended; however, immunity to tetanus wanes over time and therefore additional boosters may be recommended in specific circumstances. Further information on tetanus immunisation is 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 (3), last revised in 2019.

Clinical management of tetanus includes:

• administration of IVIG
• wound debridement (medical cleaning and removal of any dead, damaged or infected tissue)
• antimicrobials including agents reliably active against anaerobes such as metronidazole
• vaccination with tetanus toxoid

This current guidance emphasises 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 guidance provides 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, including a tetanus booster if one has not been administered in the previous 10 years.

The guidance also highlights 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 current guidance for health professionals (3).

References

1. Collins S, Amirthalingam G, Beeching NJ, and others (2016). ‘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.

3. Public Health England (2019). ‘Tetanus: guidance for health professionals’.