Tetanus - The Last Bastion of Belief - Part 1
Informed Consent - Choose Wisely
I got a call this week from a friend who was a bit panicked. His 3yo, unvaccinated grandson had stepped on a nail. Should he get a tetanus shot? I asked a few questions:
Was the nail new or old and rusty?
Was he barefoot? Was he walking in the dirt?
Was it a deep puncture?
Did it bleed?
Well, as it turns out, it was a clean, new nail. It had scratched the skin, not even enough to slightly bleed. I told him to wash it with warm soapy water. Let the water run profusely for a few minutes and then apply some Neosporin ointment.
I then asked, “If he had scratched or cut himself in any other way, would you have been asking about a tetanus shot?” His answer was a sheepish, “No. I wouldn’t have given it a second thought.”
What is tetanus?
Tetanus is an illness is characterized by rigidity and spasms of skeletal muscles, specifically the muscles of the face and neck. Slight movement can cause severe spasms, called trismus, and clamping of the masseter muscles (lockjaw.) The spasms are excruciatingly painful and often uncontrollable, which can lead to an inability to breathe, drink, or eat. This is why the cause of death from severe tetanus is often respiratory arrest.
Tetanus is caused by a toxin released by the bacterium Clostridium tetani, a microbe that is widely distributed in the environment, and commonly found in the intestinal flora of domestic animals, horses, chickens, and even in the GI tracts of man.
C. tetani exists as a spore that can enter the body through a cut or a wound. The tissues at highest risk are dirty wounds caused by a severe burn or a crush injury. When the spore germinates under anaerobic conditions (areas with low oxygen), it releases a toxin called tetanospasmin, the second most potent toxin known to humans, surpassed only by botulism toxin.
Once tetanospasmin is released, it slowly dissipates through the tissues until it reaches a synapse at a nerve junction. According to CDC data, the incubation period — the time from exposure to the onset of tetanus illness — averages 10 days but can range from 3 to 21 days or even several months later.
Note the time frame: On average, becoming ill with tetanus takes 10 to 14 days, but it can be even longer. There’s no reason to panic, drop everything and go screeching off to the ER for a tetanus shot.
How common is tetanus?
The majority of reported tetanus cases are in 3rd world countries and are associated with unhygienic birth practices and unsterile abortions. How common is tetanus in the US? (Pink Book on Secular Trends.)
Since the mid-1970s, there have been between 50 and 100 cases per year.
Between 1987 and 1988, only 101 cases were reported to the CDC.
Between 2001 and 2008, only 233 cases were reported (29 cases per year). The overall case-fatality rate among the vaccinated, the unvaccinated, AND those with unknown vaccination history was estimated at 13.2%.
In fact, of the 233 cases, 5 people had >3 shots; 24 people had four or more tetanus shots. MMWR Morb Mortal Wkly Rep 2011; 60:365–9. (Table 2)
In 2018, only 23 cases were reported with no deaths. That sounds like a magnificent track record for tetanus shots, but even before the tetanus shots were routinely available, there were only 500 to 600 cases/per year in the US – with a population in the 100s of millions. Hmm.
The Pink Book
The CDC publishes a manual regarding childhood infections every few years called “The Pink Book.” Now in its 14th edition, the Pink Book is a well-organized, concise compendium of information used by healthcare providers. It covers all the routinely given pediatric and adult vaccines with information and stats about the infections that are being vaccinated against. All of the chapters are free and downloadable as pdf files. If you’re new to pediatric vaccination schedules, this is a good place to start. You will get an overview of all the infections, all in one place. Just keep in mind it is written from a very pro-vaccine perspective.
The following information about tetanus was mostly taken from Chapter 14: Tetanus, in the Pink Book.
Types of Tetanus
Based on clinical findings, there are four different forms of tetanus.
1. GENERALIZED TETANUS: This is the most common type (more than 80% of reported cases). The first sign is trismus, or lockjaw, followed by stiffness of the neck, difficulty in swallowing, and rigidity of abdominal muscles. Spasms may occur frequently and last for several minutes. Spasms continue for 3 to 4 weeks. Complete recovery may take months.
2. LOCALIZED TETANUS: This uncommon form of tetanus presents as persistent muscle contractions in the same area as the injury where the spores most likely entered. These contractions may persist for many weeks before gradually subsiding. Local tetanus is generally mild; only about 1% of cases are fatal.
3. CEPHALIC TETANUS: This rare form involves the muscles and cranial nerves in the facial area. It is most usually associated with a head injury, especially a skull fracture. This form of tetanus is more likely than other forms of tetanus to be fatal, carrying a 15-30% fatality rate.
4. NEONATAL TETANUS: This form of generalized tetanus occurs in newborn infants. It occurs when the umbilical stump is cut with an unsterile instrument. Symptoms begin about 7 days after birth. Infants often die due to airway compromise and inability to feed. In 2000, neonatal tetanus was responsible for about 215,000 deaths worldwide.
Many of you have probably seen the picture of an infant who has advanced neonatal tetanus. We are shown this picture over and over again...as a warning of what could happen if you don’t give your infant a tetanus shot – at 2, 4, and 6 months of age.
But we don’t use unsterile blades to cut the umbilical cord in First World countries. Nor do we treat the umbilical stump with clay or cow dung, which is done in many African countries. Nonetheless, we inject US infants with three doses of DTaP – containing tetanus toxoid, pertussis toxoid, formaldehyde and aluminum – by the time they are six months of age.
But wait…. Isn’t tetanus 100% fatal?
Once the toxin has done damage to the nerve cell, it can take weeks or months for the synapse to FULLY RECOVER. In one study, patients took one to seven months, depending on the severity of symptoms, before they FULLY RECOVERED and were able to return to work following treatment for tetanus.
In 1980, a study was published of 50 survivors of tetanus infection. 29 patients said they had regained normal health and 45 of the 50 had returned to full employment. Additionally 9 of the 50 said they were still improving and 12 considered that their health permanently impaired, mostly due psychological memories of the seriousness of the illness.
REF: Flowers, MW and Edmondson, RS. “Long-term recovery from tetanus: a study of 50 survivors.” Br Med J. Feb 2;280(6210):303-5. 1980.
Don’t get me wrong. Tetanus is a serious disease. You want to clean out every wound and do what you can to prevent it. But it is not, repeat, NOT routinely fatal. Rabies is routinely fatal; tetanus is not.
What about Diphtheria?
Every pertussis and every tetanus shot also has a dose of diphtheria toxoid. Other vaccines, including the H. influenza b (HiB), also contain diphtheria antigens.
Diphtheria is nearly nonexistent in the United States, with no cases reported from 2008 to 2012. In fact, only 5 cases of diphtheria have been reported in the US in the last 15 years, making it less common than tularemia, plague, cholera, or anthrax. Serious adverse events after vaccination against tetanus and diphtheria are uncommon, but they do occur. When multiplied by an estimated 16 million doses of tetanus and diphtheria (Td) vaccine administered annually in the United States, approximately 25 severe allergic events and 80–160 cases of brachial plexus neuritis could occur. We are very much over-vaccinating for diphtheria.
Be sure to check back next week for TETANUS – PART 2
In the meantime, to learn more about Tetanus shots and many other childhood vaccinations, go here.
I knew someone who became a paraplegic after having taken a tetanus shot. She was probably in her early 30s at the time, so tragic. I have never forgotten that.