Non-Neonatal Tetanus In Quebec, Canada, 1990-2008

Background:  Despite very high vaccine coverage against tetanus in children plus recommendation for booster doses in adults, sporadic cases of tetanus continue to occur in Quebec, Canada. 

Objectives:  We estimated the incidence of tetanus in Quebec, reviewed its clinical presentation, and identified risk factors associated with its occurrence.

Methods:  Using hospitalization database and notifiable disease registry, we identified all tetanus cases that occurred between April 1^st, 1990 and March 31^st, 2008. Medical charts were reviewed by three independent reviewers.

Results:  Among 36 potential cases identified, 23 were confirmed as tetanus (21 with medical charts available for review) for an average of 1.2 cases yearly and an incidence of 0.17 per million person-years. Both sexes were equally represented, but men were younger at diagnosis (39 vs. 54 years of age).  Possible source of infection could be identified in 19/21 cases (90%): traumatic injury and/or chronic wound. Only 11/19 (58%) sought medical care. The majority of cases (81%) occurred in patients who were not up-to-date with their immunisation, of which 5 (24%) had never been immunized. Among the 21 cases requiring ≥1 dose of vaccine and the 18 needing immunoglobulin as part of post-exposure prophylaxis, only 38% and 22% respectively received the prophylaxis at first medical consultation; 46% and 25% for those with at least one traumatic injury and 16% and 16% for cases with chronic wound or no wound at all. When they left hospital, all cases had received immunoglobulin, but 2 persons (10%) still needed their vaccine dose.

Conclusions:  We identified failures at all steps of care. Most cases were not adequately immunized, or failed to seek medical care or were not administered the correct course of post-exposure prophylaxis.