1. Tetanus in Texas 2008-2009 Rachel Wiseman, MPH Texas Dept of State Health Services Infectious Disease Control Unit Diseases in Nature June 9, 2010

2. C. tetani Overview Clostridium tetani –anaerobic bacteria –produces an exotoxin Toxin is highly potent C. tetani spores widely found in soil, intestinal tract of animals, humans Not contagious

3. Infection C. tetani usually enters through a wound –Puncture wounds are higher risk Toxins disseminate through blood or lymph system Incubation period of 3-21 days –The shorter the incubation period, the more severe the clinical course –Average is 8 days

4. Clinical Features Generalized rigidity, starting in jaw or neck Difficulty swallowing Convulsive muscle spasms Recovery can take months

5. Complications and Treatment Complications –Laryngospasms/respiratory muscle spasms –Pulmonary embolism –Death Treatment –Tetanus immune globulin (IG) –Tetanus toxoid –Symptomatic supportive care

6. Tetanus Toxoid Passive immunization used for treatment/prophylaxis in WWI Toxoid used widely during WWII During the 1940s, tetanus toxoid was added to childhood immunization schedule Currently recommended at 2, 4, 6, 18 months, 4-6 years, 11-12 years and then every 10 years thereafter

7. Tetanus in Animals All warm-blooded animals –Horses and man most susceptible –Birds resistant Prevention –Vaccination is effective –Clean and disinfect wounds Treatment—sedatives, muscle relaxers, anti-toxins

8. Horses Stiffness in jaw, neck, hind limbs Spasms 3 rd eyelid may draw back Ears erect, tail stiff, nostrils dilate Sawhorse stance 80% fatality

9. Tetanus in Texas, 1995-2009

10. Risk Factors for Tetanus Over age 60 Male No recent vaccination history Acute trauma, especially puncture wound Diabetes IV drug use

11. Patient 1 40 year old White female Teacher Last tetanus toxoid received in 1988 9/1: Rock dug from fertilized soil lacerated lower left leg 10/7: Onset R side jaw pain 10/11: Presented to ER 10/13: Symptoms resolved

12. Patient 2 60 year old Black male No known toxoid history 7/29: Right aortofemoral bypass 8/17: Onset of uncontrolled jerking of all four extremities C. tetani found in graft site Unclear if given toxoid and/or IG Symptoms resolved by 8/28

13. Patient 3 52 year old Hispanic male No known vaccine history Meter reader for oil field wells 1/5 to 1/8: Splinter in right hand 1/15: Onset of jaw tightness, muscle spasms and pain

14. Patient 3, cont’d 1/18: Presented to ER (3 times!) 1/20: Hospital staff cannot open patient’s mouth; tetanus IG given 1/21: Put on ventilator Patient eventually recovered

15. Patient 4 45 year old Hispanic male Last toxoid at least 5 years ago 7/15: Struck left ankle against rock 7/16: Medical care sought for ankle –Ankle swollen, red, couldn’t bear weight –The wound was packed with cobwebs, covered in Vaseline and a “disinfectant”

16. Patient 4, cont’d 7/16-7/20, While at hospital: –Patient “seized” –Referred to ICU –Back spasms, difficulty opening jaw –Tetanus IG given –Patient sedated and put on vent 8/10: Still on vent

17. Lessons Learned Tetanus severity is variable An ICU stay and mechanical ventilation may be needed Spotty vaccination histories or no recent toxoid given Mostly wound-related

18. Summary Tetanus is preventable Tetanus is rare in Texas Rapid diagnosis and intervention may lessen severity