1. Tetanus Surveillance and Epidemiology in the United States, 2001-2008 CDC, Atlanta, GA 1 National Immunization Conference Atlanta, GA April 20, 2010 C. Thomas 1, T. Tiwari 1, T. Clark 1

2. Tetanus Potentially fatal disease –Clostridium tetani neurotoxin Risk factors –Acute wound, > 65 years, injection drug use, diabetes No naturally-acquired immunity Tetanus toxoid (TT) vaccine –Safe and immunogenic

3. ACIP Recommendations All individuals receive 3 doses TT to complete primary series –First immunization at 2 months Boosters recommended every 10 years –Individuals with tetanus prone wounds should receive booster if > 5 years since last dose

4. Objective Describe epidemiologic trends of tetanus in the United States from 2001-8 Review 2010 CSTE case definition

5. Methods Analyzed data from National Notifiable Diseases Surveillance System (NNDSS) Incidence Rates –Numerators: cases reported through NNDSS –Denominators: U.S. Census Bureau population estimates for 2001-8

6. CSTE Case Definition Clinical case definition –Acute onset of hypertonia and/or painful muscular contractions (usually of the muscles of the jaw and neck) and generalized muscle spasms without other apparent medical cause Case classification Confirmed – a clinically compatible case, as reported by a health-care professional

7. Results

8. Tetanus Incidence, 1947-2008 Source: Data from the National Notifiable Disease Surveillance System, Centers for Disease Control and Prevention, Atlanta, GA

9. Tetanus Incidence, 2001-8 Source: Data from the National Notifiable Disease Surveillance System, Centers for Disease Control and Prevention, Atlanta, GA

10. Descriptive Epidemiology Gender59% Male (137/233) Median Age50 yrs (11d to 94 yrs) Diabetes13% (30/233) Injection Drug Use (IDUs) 11% (27/233) Hospitalization Median stay 97% (191/196) 14 days (1-124) ICU Care Median stay 58% (111/191) 7 days (1-122)

11. Tetanus by Age, 2001-8

12. Neonatal Tetanus One nonfatal case in 2001 –Baby premature, born at home to foreign-born mother with unknown vaccination history –Transported immediately to hospital, onset 11 days after birth

13. Tetanus by Race, 2001-8 ^ Race reported in 77% (179/233 cases) n=146n=22 n=2 n=7

14. Tetanus by Ethnicity, 2001-8 n=140n=44n=28n=133

15. Tetanus by Ethnicity, 2001-8 n=140n=44n=28n=133

16. TT Vaccination Status TT History Reported (n=209)* Fatalities (n=24)** Unknown 56% (117) 54% (13) 0 Doses18% (37)33% (8) < 3 doses12% (26) 13% (3)^ 3+ doses 14% (29) + 0% (0) * TT history reported for 90% (209/233) cases + 76% (22/29) reported last dose more than 10 years before onset ** TT history reported for 92% (24/26)fatal cases ^ All cases reported TT history of 1 dose

17. TT Vaccination Status TT History Reported (n=209)* Fatalities (n=24)** Unknown 56% (117) 54% (13) 0 Doses18% (37)33% (8) < 3 doses12% (26) 13% (3)^ 3+ doses 14% (29) + 0% (0) * TT history reported for 90% (209/233) cases + 76% (22/29) reported last dose more than 10 years before onset ** TT history reported for 92% (24/26)fatal cases ^ All cases reported TT history of 1 dose

18. TT Vaccination Status Among 209 cases with vaccination history reported: 97% of all cases and 100% of fatal cases were inadequately vaccinated or vaccination history was unknown

19. Vaccination Status by Gender

20. Vaccination Status by Age

21. Acute Wounds Depth < 1 cm Punctures/Contamination Adequate TT Vaccination Sought Medical Care Appropriate Prophylaxis 72% (167/232*) 55% (39/71**) 68% (113/167) 2% (4/167) 37% (61/167) 4% (2/51**) * Does not include 1 neonatal tetanus case ** Based on cases with complete data

22. Other Wounds Chronic Wound or Infection 13%(29/232*) Injection Drug User 6%(14/232*) No wounds reported 9% (22/232*) * Does not include 1 neonatal tetanus case

23. Fatal Cases by Age, 2001-2008

24. CharacteristicCase Fatality Rate Adj. Odds Ratio* (95% CI) Age > 65 years < 65 years 32% 5% 7.4(2.7-20.5) 1.00 (Ref.) Diabetes Yes No 30% 10% 4.0(1.4-11.7) 1.00 (Ref.) Factors Associated with Fatal Disease *Variables not significant at 90% confidence included sex, Hispanic ethnicity, acute wound before onset, unknown TT History and injection drug use

25. CharacteristicCase Fatality Rate Adj. Odds Ratio* (95% CI) Age > 65 years < 65 years 32% 5% 7.4(2.7-20.5) 1.00 (Ref.) Diabetes Yes No 30% 10% 4.0(1.4-11.7) 1.00 (Ref.) Factors Associated with Fatal Disease *Variables not significant at 90% confidence included sex, Hispanic ethnicity, acute wound before onset, unknown TT History and injection drug use

26. Summary of Results Reported cases continue to decrease –Incidence highest in those > 65 years of age 91% report risk factors exclusive of age 97% cases unvaccinated or inadequately vaccinated Diabetics and those > 65 years of age at increased risk of fatal disease

27. 2009 CSTE Case Definition Clinical case definition –Acute onset of hypertonia and/or painful muscular contractions (usually of the muscles of the jaw and neck) and generalized muscle spasms without other apparent medical cause Case classification- Confirmed –a clinically compatible case, as reported by a health-care professional

28. 2010 CSTE Case Definition Clinical case definition –Acute onset of hypertonia and/or painful muscular contractions (usually of the muscles of the jaw and neck) and generalized muscle spasms without other apparent medical cause Case classification- Confirmed –a clinically compatible case, as reported by a health-care professional X

29. 2010 CSTE Case Definition Case classification Probable: –In the absence of a more likely diagnosis, an acute illness with Muscle spasms or hypertonia, AND Diagnosis of tetanus by a health care provider; –OR Death, with tetanus listed on the death certificate as the cause of death or a significant condition contributing to death

30. Recommendations Educate on importance of TT vaccination Encourage provider practices –Assess TT vaccination status routinely Complete primary series/boosters as needed –Provide appropriate tetanus prophylaxis as component of wound management -Provide TT for all wounded not up-to-date -Consider booster within 5 years for others Ensure updated case definition utilized

31. Acknowledgments Tejpratap Tiwari Tom Clark Nancy Messonnier Amanda Cohn Stacey Martin Shetul Shah Tracy Pondo Kristin Brown Pamela Srisvastava The findings and conclusions expressed in this presentation are those of the author and do not necessarily represent the views of the CDC.

33. Vaccination Coverage 2008 SurveyResults NIS Children96.2% children 19-35 mos had > 3 TT NIS Teen72.2% aged 13-17 > 1 TT after age 10 NHIS 64% aged 19-49 > 1 TT in last 10 yrs NHIS 62% aged 50-64 > 1 TT in last 10 yrs NHIS 52% aged > 65 > 1 TT in last 10 yrs

34. IDUs 16/27 (59%) were Hispanic Age ranged from 19-68 years 20/27 (74%) were male 23/27 (85%) were in 1 state –1 case each in 4 other states 4 cases practiced skin popping 2 cases were homeless, 11 were unemployed or occupation unknown

35. Acute Wound Type/Severity 51% (85/167) punctures –11% (19/167) stepped on a nail 20% (33/167) lacerations 11% (19/167) abrasions 46% (77/167) contaminated 41% (68/167) signs of infection 11% (19/167) devitalized, ischemic tissue 21% (35/167) no indication tetanus-prone

36. Wound Prophylaxis Guidelines TT History Clean, Minor WoundAll Other Wounds* TT TIG Unknown or <3 doses Yes NoYes > 3 dosesNo** NoNo *Such as but not limited to contaminated wounds, puncture wounds, avulsions ** Yes, if > 10 years since last TT dose ^ Yes, if > 5 years since last TT dose

37. Wound Prophylaxis (n=54) 59% (32/54) needed TT, did not receive 90%(26/29) TIG recommended, did not receive 4%(2/51) prophylaxis with TT and TIG could be evaluated and was in accordance with recommendations

38. Tetanus Differential Drug-induced dystonias Trismus due to dental infection Strychnine poisoning Malignant neuroleptic syndrome Stiff-man syndrome Source: UpToDate ®

39. Tetanus Case Reporting Passive system relies on physician report, no confirmatory lab results to notify public health officials of diagnosis Underreported: approx 19% of hospitalized tetanus cases are reported to CDC* *Estimate based on data from the Healthcare Cost and Utilization Project (HCUP)