Tetanus Surveillance and Epidemiology in the United States, 2001-2008

Background: Although environmental exposure to Clostridium tetani spores is ubiquitous, tetanus is almost completely preventable through immunization.  Routine immunization and wound care have resulted in a 95% decline in incidence since the 1940s.

Objectives: To describe surveillance and epidemiologic trends of tetanus in the US from 2001-2008.

Methods: We analyzed data from the National Notifiable Diseases Surveillance System for tetanus cases reported to the CDC from 2001 through 2008.

Results: During 2001 through 2008, 233 tetanus cases were reported, a 35% decrease when compared to cases reported during 1991 through 1998 (n=357).  The median age was 49 years (range 11 days-94 years) and 58.8% of cases were male.  One neonatal case was reported.  Thirty cases (12.9%) were reported as diabetic, and 27 (11.2%) as injecting drug users.  Immunization data were available for 92(40%) cases; 29 received ≥3 doses tetanus toxoid, 26 received 1 dose, and 37 were unimmunized.  One hundred and sixty seven (72%) cases identified an acute wound before onset, for which 61 (37%) sought medical care; 50% were puncture wounds to an extremity.  Twenty six deaths occurred among 197 cases with reported outcome; case fatality rate (CFR) =13.2%.  CFR was significantly higher in individuals age ≥65 years compared to those <65 (Attack Rate Ratio [ARR] =7.2, p<0.001), and in diabetics <65 years compared to nondiabetics <65 (ARR=6.5, p=0.03).  None of the fatal cases had received more than 1 vaccine dose before onset; however vaccination history was unknown or missing in 14 of 26 fatal cases.

Conclusions: The number of tetanus cases continues to decrease in the U.S., and 90% of cases reported known risk factors for disease.  Among cases, diabetics and individuals ≥65 are at increased risk of fatal disease, emphasizing the need to assure that these individuals are immunized.