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Tetanus

Introduction

Tetanus is a serious but rare infection caused by bacteria. It usually occurs when a flesh wound becomes contaminated. If it is not treated, tetanus may lead to complications, which can be fatal.

However, vaccination and improvements in treatment mean that deaths from tetanus are now very rare in the UK. In England in 2009, there were no recorded deaths from tetanus.

Causes

Tetanus is caused by a type of bacteria called Clostridium tetani. The bacteria can live in many different substances including:

  • soil
  • house dust
  • animal and human waste, such as manure 

The tetanus bacteria usually enter the body through a wound in the skin or a serious burn. Once inside, they multiply and release a powerful type of poison, known as a neurotoxin.

The neurotoxin disrupts the normal workings of the nerves, causing symptoms such as stiffness and muscle spasms.

Read more about the causes of tetanus and who is at risk.

Other symptoms of tetanus include:

  • muscle stiffness and spasms in the jaw muscles – this is often referred to as lockjaw
  • difficulty swallowing

Treating tetanus

If you have a deep wound that could become contaminated by the tetanus bacteria and you have been vaccinated, you will be given a medication called tetanus immunoglobulin (TIG) as a precaution.

If you have not been vaccinated and you develop a tetanus infection, you will need to be admitted to hospital for treatment. Treatment usually involves a combination of medications, such as antibiotics, muscle relaxants and antitoxins, to combat the effects of the infection.

A ventilator (a machine to assist with breathing) can be used to help prevent suffocation.

Most people survive the infection, although it can take up to four months to make a full recovery.

Read more about treating tetanus.

Tetanus vaccination

A vaccination to protect against tetanus is given as part of the NHS childhood vaccination programme.

The full course of the tetanus vaccination consists of five doses. The first three doses are given during early childhood. This is followed by two booster doses. The first booster dose is given at around four years of age. The second one is given 10 years later.

After the full course, you should have lifelong immunity against tetanus. However, if you or your child has a deep wound, it's best to get medical advice. 

If you are not sure whether you've had the full course, for example because you were born in another country, contact your GP for advice.

Read more about preventing tetanus

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Symptoms

Nowadays, most tetanus cases occur in people who:

  • were never vaccinated against the infection
  • did not complete the entire vaccination schedule (three initial injections followed by two booster doses that are given 10 years apart)
  • inject illegal drugs such as heroin

The time it takes for symptoms of tetanus to develop after infection with the Clostridium tetani bacteria (the incubation period) is usually 4 to 21 days. The average incubation period is about 10 days.

Muscle spasms and stiffness

Stiffness in your jaw muscles is usually the first symptom of tetanus to develop. This is sometimes known as lockjaw. It can make it difficult for you to open your mouth. 

Muscle spasms and stiffness spread from your jaw into your neck and limbs over 24 to 72 hours.

Muscle spasms in your neck can make swallowing difficult (dysphagia). In the most serious cases, severe breathing difficulties could develop. This may lead to suffocation.

Other symptoms

Other symptoms that are associated with a tetanus infection include:

  • high temperature (fever) of 38C (100.4F) or above
  • sweating
  • rapid heartbeat (tachycardia)
  • high blood pressure (hypertension)

Tetanus can be fatal

If tetanus is not treated, it can cause serious complications that can lead to death, for example because of heart failure.

Read more about complications of tetanus.

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Causes

Tetanus is caused by the Clostridium tetani bacterium.

Clostridium tetani and tetanospasmin

Clostridium tetani spores can live for a long time outside the body and are widespread in the environment. They are commonly found in the manure of animals such as horses and cows, and in contaminated soil.

After they enter the body, the tetanus bacteria quickly multiply and release tetanospasmin. This is a type of poison known as a neurotoxin. If tetanospasmin enters the bloodstream, it can spread around the body, causing the symptoms of tetanus to develop.

Neurotoxins block the nerve signals that are sent from the brain to the spinal cord and then on to the muscles. This causes the muscle spasms and muscle stiffness associated with tetanus.

Cuts and wounds

One of the most common ways that tetanus bacteria can enter the body is through a cut or a puncture wound, such as the type of wound you would get after stepping on a nail. Even minor puncture wounds, such as piercing your skin with the thorn of a rose, could allow the bacteria to enter your body.

Tetanus bacteria thrive and breed in places where there is little or no oxygen. This is why the infection often occurs in deep cuts and wounds. To help prevent a tetanus infection developing, always ensure that cuts and wounds are thoroughly cleaned.

Other entry points

As well as entering the body through cuts and wounds, the tetanus bacteria can also enter through:

  • lacerations – tears or splits in the skin caused by blunt trauma such as a blow to the skin, or a sharp object such as a knife or broken glass
  • abrasions – wounds that are caused by friction damage, such as the type of wound you would get after falling off a bike and scraping your knee
  • burns 
  • animal bites 
  • body piercings and tattoos (if unsterilised equipments is used)
  • eye injuries

Risk groups

Some groups of people, such as travellers and people who inject drugs, may be at increased risk of developing tetanus.

Travellers

If you are travelling abroad, make sure your vaccinations are up to date, according to the UK schedule. Depending on where you are travelling, you may need additional doses of certain vaccinations.

Read more about travel vaccinations.

If you are travelling to a remote area where medical services may not be easily accessible, and you had your last tetanus vaccine more than 10 years ago, you need to have a booster dose (even if you have already had the full five doses). This is done as a precaution, in case you get a wound that is vulnerable to a tetanus infection and you cannot get suitable medical care.

Read more about the tetanus vaccine.

Injecting drug users

People who inject illegal drugs such as heroin or methamphetamine have an increased risk of developing tetanus. Drug dealers often mix these types of drugs with a chemical called quinine. Quinine can be contaminated by the tetanus bacteria.

For example, in England during 2003 and 2004, an outbreak of 20 cases of tetanus was linked to a contaminated batch of heroin.

Neonatal tetanus

Neonatal tetanus is a type of tetanus that affects newborn babies. It develops when the umbilical cord is cut with a knife or a similar tool that has been contaminated by the tetanus bacteria.

Neonatal tetanus usually only occurs in the poorest parts of the world, where there is limited or no access to maternity services.

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Diagnosis

Diagnosing tetanus is usually straightforward because the symptoms are easily recognised. Few other conditions cause painful muscle spasms like tetanus.

A confident diagnosis can usually be made if someone has recently had a wound or similar injury and has painful muscle spasms and muscle stiffness.

Spatula test

A spatula test can help confirm tetanus if there is any doubt about the diagnosis. It involves inserting a spatula into the back of your throat.

If you do not have the infection, the spatula will cause a gag reflex and you will try to push the spatula out of your mouth. However, if the tetanus infection is present, the spatula will cause your throat muscles to spasm and you will bite down onto the spatula.

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Treatment

There are two types of treatment for tetanus:

  • preventative treatment - for people who are thought to be fully or partially vaccinated against tetanus and who have an injury that makes them vulnerable to a tetanus infection
  • symptomatic treatment - for people who have developed the symptoms of an active tetanus infection

Preventative treatment

Wounds that are vulnerable to a tetanus infection are called tetanus-prone wounds.

Tetanus-prone wounds

Tetanus-prone wounds include:

  • wounds or burns that required surgery to repair, but access to surgery was delayed for six hours or more
  • wounds or burns that cause a significant amount of tissue loss
  • puncture injuries, particularly if they may have become contaminated with soil or manure
  • wounds that contain foreign bodies, such as an animal’s tooth
  • severe bone fractures that may have left the bones vulnerable to infection
  • wounds and burns in patients who have systemic sepsis (a fall in blood pressure as a result of a serious bacterial infection)

Medication called tetanus immunoglobulin (TIG) is recommended if you have a tetanus-prone wound and there is a high risk that it could be contaminated by tetanus bacteria. This might be the case if the wound came into contact with soil or animal waste.

The use of TIG is recommended even if your vaccinations are up to date. There may be a very small chance that the vaccine did not give you total immunity against tetanus.

Tetanus immunoglobulin

Tetanus immunoglobulin (TIG) is a medication that contains antibodies that kill the tetanus bacteria. Antibodies are infection-fighting cells. TIG is given as an injection into a muscle and gives immediate, short-term protection against tetanus. TIG is thought to be safe to use in pregnant and breastfeeding women.

After having TIG, it is likely that you will have some short-term discomfort at the site of the injection. Other side effects are thought to be uncommon but may include:

  • chest pain
  • shortness of breath
  • dizziness
  • swelling of your face
  • mouth ulcers
  • shaking
  • joint pains

If you develop any of these uncommon side effects after having TIG, speak to the doctor in charge of your care for advice.

Depending on your vaccination status, you may also be given a booster dose of the tetanus vaccine.

Symptomatic treatment

If someone develops the symptoms of tetanus, they will need to be admitted to hospital.

Because tetanus is rare in the UK, an infected person may be transferred to one of the larger NHS hospitals, where doctors with experience in treating tetanus are usually based.

The two main goals in treating tetanus are:

  • to prevent the further spread of the neurotoxins (poisons) into the nerve tissue
  • to provide relief from the symptoms of muscle spasms and stiffness

Preventing further spread of neurotoxins

TIG can be used to prevent the tetanospasmin neurotoxin causing further damage and disruption to your nervous system. Antibiotics such as penicillin (or metronidazole if you are allergic to penicillin) are also used to try to kill any bacteria and prevent any further toxin release. 

Providing relief from symptoms

Three main types of medication are used to treat the symptoms of tetanus. They are:

  • sedatives
  • muscle relaxants
  • neuromuscular blocking agents (NBAs)

Sedatives

Sedatives are a type of medication that make you feel physically and mentally relaxed. They relax the muscles, which can help relieve and prevent muscle stiffness.

Types of sedatives that are used to treat tetanus include diazepam and phenobarbital.

Side effects of diazepam include:

  • drowsiness
  • muscle weakness
  • reduced alertness

Side effects of phenobarbital include:

  • drowsiness
  • irritability
  • depression
  • lack of concentration
  • shaky movements and an unsteady walk (ataxia)
  • hyperactivity
  • seeing or hearing things that are not real (hallucinations)

Muscle relaxants

Muscle relaxants are a type of medication that help relax the muscles. They are often used when treatment with sedatives is withdrawn (sedatives can be addictive so they are not usually recommended as a long-term treatment).

Your dose of sedatives will be gradually reduced and you will be given muscle relaxants to stop your symptoms returning.

Baclofen and dantrolene are two muscle relaxants that might be prescribed.

Neuromuscular blocking agents (NBAs)

Neuromuscular blocking agents (NBAs) are a type of medication that block nerve signals which are sent from the brain to the muscles. This leads to an inability to move certain muscles (paralysis), which can be useful in people with severe muscle spasms and stiffness.

An NBA called vecuronium is usually used. Vecuronium will cause paralysis of the muscles used for breathing, so assistance with breathing will be provided before it can be given.

Surgery

If a tetanus-prone wound is particularly large, it may be necessary to remove as much of the damaged and contaminated muscle as possible using a surgical procedure called debridement.

Debridement involves cleaning an open wound by removing foreign material, such as dirt and manure, as well as any dead tissue. In the case of a tetanus infection, debridement will remove any remaining tetanus bacteria.

Nutrition and breathing

The increased muscle activity caused by tetanus means that a person with the infection needs to consume a high amount of calories. An intake of 3,500 to 4,000 calories a day is often required, plus 150g of protein a day.

If swallowing is difficult or not possible, it may be necessary to give a liquid feed through a tube connected to the stomach or through a drip into a vein. Help with breathing may also be required using a ventilator (a machine that helps you breathe).

Pregnancy and breastfeeding

It is unclear whether any of the medications mentioned here are safe to take during pregnancy or when breastfeeding.

The main reason for the uncertainty is that it would not be ethical to test medication on pregnant or breastfeeding women in case it caused harm to their baby.

However, due to the very serious nature of tetanus and the risk of serious complications, the potential benefit of treatment may outweigh any risks

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Complications

If a tetanus infection is severe, several possible complications can develop.

Sudden cardiac death

Sudden cardiac death is the most serious complication of tetanus. It is a leading cause of death in people with the condition.

Sudden cardiac death is where the heart suddenly stops beating. It can occur for a variety of reasons and usually only happens in people who are already very ill with tetanus (in an intensive care unit).

Sudden cardiac death is not the same as a heart attack, which is where the flow of blood to the heart becomes restricted, causing the muscles of the heart to become damaged.

Pulmonary embolism

Like all very ill people, people with tetanus are at risk of a pulmonary embolism.

pulmonary embolism is a serious and potentially life-threatening condition. It is caused by a blockage in a blood vessel in the lungs that can affect breathing and circulation. Therefore, it is vital that anti-clotting medication and, if necessary, oxygen therapy are given immediately.

Read more about treating pulmonary embolisms.

Aspiration pneumonia

As people with tetanus have difficulty swallowing (dysphagia) because of muscle stiffness and spasms, there is a risk that small amounts of saliva could fall down into their lungs. This can cause an infection known as aspiration pneumonia.

Aspiration pneumonia is treated with antibiotics.

Acute kidney failure

The severe muscle spasms associated with a tetanus infection can cause a condition known as rhabdomyolysis.

In rhabdomyolysis, muscle tissues are broken down, causing a protein called myoglobin to leak into the urine. This can cause acute kidney failure, where the kidneys suddenly lose most or all of their functions.

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Prevention

Vaccination is the best way to prevent a tetanus infection. A complete course of tetanus vaccination consists of five doses.

The vaccine allows your body to create antibodies against the tetanus toxin (tetanospasmin). This protects you from the illness if you are exposed to the Clostridium tetani bacterium in the future.

In the UK, all children are routinely offered the tetanus vaccine as part of the NHS childhood vaccination programme.

If you are not sure whether you have been fully vaccinated against tetanus, speak to your GP or practice nurse. They will be able to advise you about having a booster injection.

Primary vaccination

The primary course of the tetanus vaccination consists of three doses of the vaccine. The doses are given one month apart.

The DTaP/IPV/Hib vaccine

The tetanus vaccine forms part of the combined DTaP/IPV/Hib vaccination. This provides protection against:

  • diphtheria (D) – an infection that can cause breathing difficulties
  • tetanus (T)
  • pertussis (whooping cough) (aP) – a type of infection that can cause prolonged and severe bouts of coughing
  • polio (IPV or inactivated polio vaccine) – an infection that usually causes mild flu-like symptoms, but can occasionally cause more serious symptoms such as loss of normal muscle function
  • Hib (haemophilus influenzae type b) – a bacterial infection that can cause a number of serious illnesses such as pneumoniablood poisoning and meningitis

It is recommended that the DTaP/IPV/Hib vaccination is given to babies at two, three and four months of age. However, it can be given at any stage between two months and 10 years of age.

If the primary course is interrupted, it should be resumed (but not repeated) with an interval of one month between the remaining doses.

Babies who are born prematurely should be vaccinated at the appropriate age according to the vaccination schedule. There is no evidence that premature babies are at increased risk of having adverse reactions to vaccines.

Most children can have the DTaP/IPV/Hib vaccine. However, it should not be given to children who:

  • have had a severe allergic reaction (anaphylaxis) to a previous dose
  • have had an anaphylactic reaction to any component of the vaccine (including neomycin, streptomycin and polymyxin B, which may be present in small amounts)

If your child is unwell and has a high temperature, postpone their DTaP/IPV/Hib vaccine until they have recovered. It is fine for your child to have the vaccine if they have a minor illness, such as a cold or cough.

Side effects

Within 12 to 24 hours of having the DTaP/IPV/Hib vaccine, your child may experience some mild side effects, including:

  • swelling and redness at the site of the injection
  • a small lump at the site of the injection, which may last for a few weeks
  • a slightly raised temperature
  • some sickness or diarrhoea
  • your child may be irritable and miserable

In very rare cases (less than 1 in 1,000), babies can have more serious side effects around 24 to 48 hours after receiving the DTaP/IPV/Hib vaccine, including:

  • a very high temperature
  • febrile convulsions (a seizure associated with a fever)
  • an unusually high-pitched cry
  • being floppy and less responsive than usual

Contact your GP immediately if your baby has a fit. They may have an illness that is unrelated to the vaccine. Whatever the cause, it is important to tell your GP. Babies usually fully recover after having a fit.

Do not delay having your baby vaccinated as doing so can increase their risk of having fits. It is very important to ensure that your child is vaccinated at the right age.

As with all vaccines, there is a rare possibility that the DTaP/IPV/Hib vaccine will cause anaphylaxis (a severe allergic reaction). However, the risk is less than one in a million.

The potential risk of vaccination is far outweighed by the benefits of being protected against serious diseases, such as tetanus.

Speak to your GP or call NHS Direct  Wales on 0845 46 47 if you think your child has had a reaction to the DTaP/IPV/Hib vaccine.

Secondary immunisation

The first booster dose

Children under the age of 10 should be given the first tetanus booster combined with the diphtheria, pertussis and polio vaccines (DTaP/IPV or dTaP/IPV). Ideally, the first tetanus booster should be given three years after the primary course is completed. This is usually when a child is three-and-a-half to five years of age.

If the primary vaccination was delayed, the first booster dose can be given at the scheduled time, as long as the third primary dose was given at least one year before. This allows the child to get back on to the routine schedule.

The DTaP/IPV vaccine should be used for children under the age of 10.

Children over 10 who have had three doses of the primary vaccination, with the last dose received at least five years ago, should be given the first tetanus booster combined with the diphtheria and polio vaccines (Td/IPV).

The second booster dose

Ideally, the second booster dose (Td/IPV) should be given 10 years after the first booster dose. However, if previous doses were delayed, the second booster dose can be given at the scheduled time, as long as at least five years have passed since the first booster dose was given. This is the last scheduled opportunity to ensure long-term protection.

The Td/IPV vaccine

Td/IPV is recommended for children who are 13–18 years old. Td/IPV is a booster vaccine that tops up protection against three different illnesses:

  • tetanus (T)
  • diphtheria (d)
  • polio (IPV or inactivated polio vaccine)

After having a Td/IPV vaccine, your child may experience some swelling and redness at the site of the injection. A small, painless lump may also develop, although it will usually disappear after a few weeks.

More serious side effects are less common, but may include:

  • a high temperature (fever) of 38C (100.4F) or above
  • headaches
  • dizziness
  • nausea and vomiting
  • swollen glands
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Q&A

Do I need a tetanus jab (vaccine) after an accident or injury?

You may need a tetanus jab (vaccine) if the injury has broken your skin and your tetanus vaccinations aren’t up to date.

Tetanus

Tetanus is a serious condition. If treated, it’s usually a short-term condition. However, without treatment, tetanus can be fatal.

Tetanus is caused by infection with Clostridium tetani bacteria. These bacteria can enter your body through a wound or cut in your skin. They are often found in soil and manure.

UK vaccination programme

The UK has a vaccination programme against tetanus.

A full course of tetanus vaccination consists of five doses of the vaccine. This should be enough to give you long-term protection from tetanus. However, if you’re not sure how many doses you’ve received, you may need a booster dose after an injury that breaks your skin.

If you’ve definitely received five doses of the tetanus vaccine, you are fully vaccinated and don’t need a booster dose.  

See Prevention for more information.

Risk of tetanus

You may have a higher risk of being infected with tetanus if the wound:

  • is deep
  • gets dirty with soil or manure

However, even small wounds, such as a prick from a thorn, can allow enough bacteria to get into your body to cause tetanus. See Causes for more information.

If you’ve got a cut or a wound, you should clean it thoroughly as soon as possible to prevent infection. As long as you’re fully vaccinated, you won’t need another tetanus jab. If you don’t know whether you’re fully vaccinated, see your GP as you may need a booster dose. 

If you have a tetanus-prone wound, you should get medical treatment as soon as possible, even if you’ve been fully vaccinated.

What are tetanus-prone wounds?

The Department of Health defines tetanus-prone wounds as:

  • wounds or burns that need surgery that is delayed for more than six hours 
  • wounds or burns where a significant amount of tissue has been removed, or puncture-type injuries (such as animal bites), particularly if they have had contact with soil or manure
  • wounds containing foreign bodies (any substance that shouldn’t be there, such as dust or dirt)
  • compound fractures (serious fractures where the bone is exposed and prone to infection)
  • wounds and burns in people who have systemic sepsis (a fall in blood pressure resulting from a serious bacterial infection)

If you have a tetanus-prone wound, you’ll need treatment with tetanus immunoglobulin (TIG). This is a solution containing antibodies (infection-fighting cells) that kill the tetanus bacteria.

You will need TIG even if you’re fully vaccinated against tetanus.

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