COCA Now: Tetanus in Areas Affected by a Hurricane: Risk, Prevention, and Management Guidance for Clinicians

View this email as a webpage: https://content.govdelivery.com/accounts/USCDC/bulletins/20ee74a

COCA Now Banner

Tetanus in Areas Affected by a Hurricane: Risk, Prevention, and Management Guidance for Clinicians

    Summary

    Exposure to flood waters does not increase the risk of tetanus, so tetanus immunization campaigns are not needed for evacuees from flooding disasters. However, during evacuation and flood cleanup, emergency responders, cleanup workers, volunteers, and residents may be at increased risk for wounds, such as puncture to the skin, cuts, bruises, lacerations, scrapes, or other skin injuries that become contaminated with flood waters, human or animal waste, soil, dirt, or saliva. These workers and residents should make sure they are up-to-date with tetanus vaccination before starting cleanup activities.

    Clostridium tetani

    Tetanus or ‘lock-jaw’ is a toxin-mediated, noncommunicable, severe, and potentially fatal disease requiring emergency treatment. The disease is caused by an anaerobic bacteria, Clostridium tetani. Tetanus spores, ubiquitous in the environment, enter the body through any breach in the skin and can cause disease that is characterized by muscle spasms, particularly in unvaccinated or incompletely vaccinated people. Each year, about 30 cases of tetanus are reported in the United States. Nearly all cases of tetanus are among people who have either never received a tetanus vaccine, or have not completed the recommended childhood vaccination series, or adults who do not stay up to date with their 10-year booster shots.

    Tetanus is a medical emergency requiring hospitalization, immediate treatment with human tetanus immune globulin (TIG), agents to control muscle spasm, aggressive wound care, antibiotics, and a tetanus toxoid booster.

    History of an injury or apparent portal of entry may be lacking. The incubation period ranges from 3 to 21 days, averaging about 10 days. The clinical course of generalized tetanus is variable and depends on the degree of prior immunity, the amount of toxin present, and the age and general health of the patient. Even with modern intensive care, generalized tetanus is associated with death rates of 10% to 20%.

    Risk of Tetanus After Exposure to Flood Water

    Exposure to flood waters does not increase the risk of tetanus. However, some people impacted by floods and other disasters may have wounds such as puncture to the skin, cuts, bruises, lacerations, scrapes, or other skin injuries that become contaminated with flood waters, human or animal waste, soil, dirt, or saliva. Besides treatment of these wounds, the vaccination status of such persons should be assessed and an age-appropriate tetanus vaccine given, if needed. In some of these situations (e.g., patient with a contaminated wound), the clinician may decide that a tetanus vaccine is needed as early as 5 years since the last dose.

    Being up to date for tetanus vaccine can greatly simplify the treatment for any wound that might occur.

    Wound Management for Tetanus Prevention

    Risk of tetanus disease depends on the type and condition of the wound and the patient's immune status. The following steps should be taken to prevent tetanus:

    1. Assess the type of wound and provide appropriate wound care.
      Wounds may be simple, superficial, and clean. Other wounds such as those contaminated with dirt, feces, soil, and saliva; puncture wounds; avulsions; and wounds resulting from, crushing, and burns may pose a higher risk for tetanus. Wounds containing devitalized tissue (e.g., necrotic or gangrenous wounds), frostbite, crush injuries, avulsion fractures, and burns are particularly conducive for proliferation of C. tetani. All wounds should be cleaned, including removing dirt or foreign material, and removing or debriding any necrotic material.
    2. Evaluate the patient's immunization status. Unvaccinated persons with any type of wound should start and complete a primary series with an age-appropriate tetanus toxoid-containing vaccine (DTaP, Tdap, or Td) as CDC currently recommends. Persons with unknown or uncertain history of receiving previous prior doses of tetanus toxoid-containing vaccines should be considered to have had no previous tetanus toxoid-containing vaccine and a primary series should be completed. This is because early doses of toxoid may not induce adequate immunity, but only prime the immune system.
    3. Management of persons who have completed a 3-dose primary tetanus vaccination series. For persons with simple clean wounds, if the last dose of a tetanus toxoid-containing vaccine was received less than 10 years ago, they are considered protected against tetanus and do not require another dose of tetanus toxoid-containing vaccine as part of the current wound management. Otherwise, a booster dose should be administered. For persons with contaminated wounds, if the last dose of a tetanus toxoid-containing vaccine was received less than 5 years ago, they are considered protected against tetanus and do not require another dose of tetanus toxoid-containing vaccine as part of the current wound management. Otherwise, a booster dose should be administered.
    4. Assess need for administering tetanus immune globulin (TIG) for prophylaxis. TIG provides temporary immunity by directly providing antitoxin. TIG can only help remove unbound tetanus toxin but cannot neutralize toxin that is already bound to nerve endings. Persons who have contaminated and dirty wounds and are either unvaccinated, or have less than 3 doses of tetanus vaccines, should receive TIG for prophylaxis. The dose of TIG for prophylaxis is 250 IU administered intramuscularly. People with HIV infection regardless of CD4 count and immune status, or severe immunodeficiency who have contaminated wounds (including minor wounds) should also receive TIG, regardless of their history of tetanus immunizations.
    5. Do not use antibiotics for prophylaxis against tetanus. Antibiotic prophylaxis against tetanus is not recommended, but wounds should be observed for signs of infection and promptly treated if signs of infection are detected.     

    Diagnosis of Tetanus

    There is no laboratory test to confirm tetanus. The organism is rarely recovered from the site of infection. The diagnosis is based on clinical symptoms. Tetanus should be suspected in a person with a recent history of an open, contaminated wound, who develops localized muscle spasm around the wound, or spasm of muscles of the jaw, or generalized muscle spasms, particularly if the person is either unvaccinated, incompletely vaccinated, or not up to date with tetanus vaccinations. An obvious wound may be absent in about 10% cases.

    A common first sign suggestive of tetanus in older children and adults is abdominal rigidity, although rigidity is sometimes confined to the region of injury. Generalized spasms occur, frequently induced by sensory stimuli.

    Additional information on treatment and management of tetanus cases is available at: 

    • Tetanus for Clinicians: https://www.cdc.gov/tetanus/clinicians.html
    • American Academy of Pediatrics. Tetanus. In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book®: 2015 Report of the Committee on Infectious Diseases. American Academy of Pediatrics; 2015; 773–8.

    Further guidance on tetanus vaccination of responders and residents, can be found on the following CDC websites: