Overview
Tetanus is caused by bacterial spores that live in soil, dust, ash and manure. When they enter the body through a wound they produce one of the most powerful nerve poisons known, which makes muscles clamp and spasm painfully, starting with the jaw.
Unlike almost every other serious infection, tetanus does not pass from person to person. It is also almost entirely preventable, both by vaccination and by proper cleaning of wounds.
Disease Summary
- Category
- Infectious Disease
- Cause
- Clostridium tetani spores
- Transmission
- Not spread between people. Spores enter through wounds
- Body System
- Nervous System
- Preventable
- Yes
- Curable
- Yes
Symptoms
Common Symptoms
Symptoms usually begin 3 to 21 days after the spores enter the body, on average about 8 days. In newborns they appear between days 3 and 28 of life.
Jaw Cramping or Lockjaw
WHO describes jaw cramping or an inability to open the mouth. CDC states this is usually the first sign.
Muscle Spasms
WHO describes sudden painful muscle spasms, often in the back, abdomen and limbs, and often set off by a sudden noise or touch.
Muscle Stiffness
Stiffness of the neck and rigidity of the abdominal muscles follow the jaw symptoms.
Trouble Swallowing
Spasm of the swallowing muscles makes eating and drinking difficult and dangerous.
Seizures
Listed by both WHO and CDC among the symptoms of tetanus.
Fever and Sweating
Fever and heavy sweating accompany the muscle symptoms.
Changes in Blood Pressure or a Fast Heartbeat
The poison affects the nerves that control the heart and blood vessels as well as those that control muscles.
In Newborns, Inability to Suck or Feed
WHO states that spasms in a newborn are often preceded by an inability to suck or breastfeed, with excessive crying.
Danger Signs
Seek urgent medical attention immediately if any of the following symptoms develop.
Difficulty Breathing
Spasm of the voice box or the breathing muscles interferes with breathing and can be rapidly fatal.
Spasms Triggered by Noise or Touch
WHO describes sudden painful spasms often triggered by sudden noises. Patients are cared for in a quiet, darkened room for this reason.
Unstable Blood Pressure or Heart Rhythm
Instability of the heart and blood pressure is a recognised and dangerous feature.
A Newborn Who Stops Feeding and Becomes Rigid
WHO defines neonatal tetanus as a baby who fed and cried normally at first, then loses that ability between days 3 and 28 of life and becomes rigid or has spasms.
Bone Fractures From Spasm
CDC states that fractures of the spine or long bones can result from the sustained muscle contractions.
Diagnosis
A Clinical Diagnosis
WHO states that tetanus is diagnosed on clinical features and does not require laboratory confirmation. CDC states there is no laboratory test that can confirm or rule it out.
The Case Definition
An acute illness with muscle spasms or increased muscle tone, diagnosed by a health worker, with no alternative explanation.
The Newborn Definition
A baby who sucked and cried normally at first, lost that ability between days 3 and 28 of life, and became rigid or developed spasms.
Injury History and Timing
WHO gives an incubation of 3 to 21 days, with most cases developing within 14 days. The wound is sometimes minor and may already have healed.
Identifying the Form
Generalised tetanus accounts for most cases and begins with lockjaw. Local, head and newborn forms behave differently and are recognised separately.
Laboratory Tests
Wound Culture
Not diagnostic. CDC states the bacterium is recovered from wounds in only about 30% of cases, and is sometimes found in people who do not have tetanus.
Blood Antitoxin Level
Cannot exclude tetanus. CDC states that tetanus can occur even when protective levels of antitoxin are present.
Tests to Exclude Other Causes
Because the case definition requires no alternative explanation, tests are aimed at ruling out look-alikes such as low blood calcium or meningitis.
Wound Assessment at the Bedside
CDC classifies wounds as clean and minor, or dirty and major. This classification, not a laboratory test, decides whether a vaccine dose and tetanus immune globulin are needed.
Treatment
Tetanus Immune Globulin
WHO calls for immediate treatment with human tetanus immune globulin. It neutralises poison that has not yet attached to nerves. It cannot reverse what has already bound, which is why it is given at once.
Antibiotics
Eliminates the bacteria producing the poison. WHO lists antibiotics among the required components of treatment.
Wound Cleaning and Removal of Dead Tissue
WHO lists aggressive wound care. Removing dirt, foreign material and dead tissue takes away the oxygen-free conditions the spores need.
Control of Spasms and Airway Support
WHO lists medicines to control muscle spasms. Breathing support may be needed, and patients are nursed in a quiet, darkened room to reduce the triggers for spasm.
Vaccination During Recovery
WHO states plainly that people who recover from tetanus do not have natural immunity, so vaccination is part of the treatment.
Prevention
Complete the tetanus vaccine series
WHO recommends six doses of tetanus-containing vaccine in total for lifelong protection, beginning in infancy.
Keep boosters current
Protection fades. WHO recommends boosters in the second year of life, at 4 to 7 years and at 9 to 15 years, and many countries add adult boosters.
Vaccinate women of reproductive age
WHO states that newborn tetanus is prevented by immunising women of reproductive age, during or outside pregnancy.
Clean delivery and cord care
WHO lists clean delivery practices and proper care of the umbilical cord stump among the core prevention measures.
Clean every wound properly
CDC advises cleaning all wounds and removing dirt, foreign material and dead tissue. This applies to farm injuries, burns, animal bites and puncture wounds.
Get assessed after a dirty or deep wound
A vaccine dose or tetanus immune globulin may be needed depending on the wound and your vaccination history.
Risk Factors
Newborns and Mothers Without Vaccination
WHO states tetanus is particularly common and serious in newborn babies and pregnant women who lack sufficient immunisation.
- Babies born where the cord is cut or dressed with unsterile materials
- Infants of mothers who never received tetanus-containing vaccine
- Deliveries outside a health facility without clean delivery practices
- WHO reports that a small number of countries have yet to eliminate maternal and newborn tetanus
Adults Overdue for a Booster
CDC states most cases occur in unvaccinated adults or those who have not kept up with boosters.
- Adults who have never completed a primary series
- People whose last dose was many years ago
- People with an unknown vaccination history
- Anyone who has had tetanus before, since recovery gives no immunity
Older Adults and People With Other Conditions
CDC names these groups as facing elevated risk of severe disease.
- Adults aged 80 and over, in whom CDC reports the highest risk of death
- People living with diabetes
- People whose immune system is suppressed
- People who inject drugs
People With Tetanus-Prone Wounds
The wound type decides how much risk an injury carries.
- Wounds contaminated with soil, dust, manure or saliva
- Puncture wounds from nails, thorns or needles
- Burns, crush injuries and wounds with dead tissue
- Chronic sores, dental infections and animal bites
Complications
Spasm of the Voice Box and Breathing Failure
CDC states that spasm of the voice box or the breathing muscles interferes with breathing, and that mechanical ventilation may be necessary.
Fractures
CDC states that fractures of the spine or long bones may result from sustained muscle contractions.
Pneumonia From Inhaling Food or Saliva
CDC describes this as a common late complication of tetanus.
Unstable Blood Pressure and Heart Rhythm
Instability of the heart and circulation is a major cause of death in intensive care.
Blood Clots in the Lungs
Listed by CDC among the complications of a long period of immobility and illness.
Prolonged Recovery
CDC states muscle spasms persist for 3 to 4 weeks and full recovery may take months.
When to Seek Medical Care
Jaw Stiffness or Inability to Open the Mouth
This is the earliest reliable sign and it is an emergency. Do not wait to see whether it passes.
Any Muscle Spasms or Stiffness After a Wound
Spasms or rigidity following an injury, even a small one, need immediate assessment.
Difficulty Swallowing or Breathing
Both indicate the muscles of the throat and chest are affected.
Straight After a Dirty, Deep or Puncture Wound
Go even without symptoms. Cleaning the wound and, where indicated, a vaccine dose or immune globulin prevent the illness entirely.
A Newborn Who Stops Feeding or Becomes Rigid
WHO defines neonatal tetanus by exactly this change between days 3 and 28 of life. It is an emergency.
Prognosis
About One in Ten Reported Cases Is Fatal
CDC gives this figure even with modern intensive care, and states that risk is highest in people aged 80 and over.
Recovery Is Slow but Usually Complete
CDC states muscle spasms persist for 3 to 4 weeks and full recovery may take months. Those who recover generally do so fully.
Recovery Gives No Immunity
WHO states plainly that people who recover from tetanus do not have natural immunity, which is why vaccination is given during treatment.
Newborn Deaths Have Fallen Sharply
WHO reports an 84% reduction in neonatal tetanus deaths since 2000, achieved through maternal vaccination and clean delivery practices.
Differential Diagnosis
Poisoning With Certain Substances
Some poisons produce similar spasms but usually without the disturbance of blood pressure and heart rhythm seen in tetanus.
Meningitis
Causes neck stiffness early, but without the characteristic jaw locking and triggered spasms of tetanus.
Low Blood Calcium
Causes muscle spasms and is confirmed quickly by a blood test, which is why it is checked.
Dental or Throat Abscess
Can cause difficulty opening the mouth and swallowing, but from a localised infection rather than a body-wide illness.
Reactions to Certain Medicines
Some medicines cause muscle stiffness and spasm, separated by asking what the person has recently taken.
References
World Health Organization: Tetanus
WHO fact sheet on cause, symptoms, treatment, vaccination and newborn tetanus.
CDC: About Tetanus
How tetanus is acquired, its symptoms, complications and outcomes.
CDC: Clinical Overview of Tetanus
Clinical forms, diagnosis, treatment and risk factors.
CDC: Clinical Guidance for Wound Management to Prevent Tetanus
Wound classification and what treatment each type of wound requires.
Frequently Asked Questions
Can I catch tetanus from another person?
No. CDC states that people do not spread tetanus bacteria to other people, and WHO states it is not communicable between people. It is acquired when spores from soil, dust or manure get into the body through broken skin.
How soon after an injury would symptoms start?
WHO states symptoms appear between 3 and 21 days after infection, with most cases developing within 14 days. CDC gives an average of about 8 days. Newborn tetanus appears between days 3 and 28 of life.
Do I need a tetanus injection after a cut?
It depends on the wound and your vaccination history. CDC states that clean minor wounds do not pose a major risk, while dirty or major wounds do, including puncture wounds and wounds containing soil, dust or dead tissue. A health worker will decide based on when your last dose was.
How many tetanus vaccine doses do I need?
WHO recommends six doses of tetanus-containing vaccine in total for lifelong protection, three in infancy and three boosters in childhood and adolescence. Many countries also recommend adult boosters, so check your national schedule.
If I had tetanus once, am I protected?
No. WHO states plainly that people who recover from tetanus do not have natural immunity, and that vaccination is therefore given as part of the treatment.