Tetanus is a serious but rare infection caused by bacteria. It usually occurs when a flesh wound becomes contaminated.
Without treatment, complications of tetanus are likely to develop, which can be fatal. However, vaccination and improvements in treatment mean deaths from tetanus are now rare in the UK. In England and Wales in 2011, there were only three recorded cases of tetanus.
What causes tetanus
Tetanus is caused by a type of bacteria called Clostridium tetani. The bacteria can live in many different substances including:
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.
Other symptoms of tetanus include:
muscle stiffness and spasms in the jaw muscles – often referred to as lockjaw
difficulty swallowing (dysphagia)
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.
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. The spatula will cause a gag reflex and you will try to push the spatula out of your mouth. If you have the infection, the spatula will cause your throat muscles to spasm and you to bite down onto the spatula.
If you have a deep wound that could become contaminated by 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 develop tetanus, 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.
The full course of the tetanus vaccination consists of five doses. The first three doses are given in the 5-in-1 vaccine for babies at two, three and four months of age.
This is followed by a booster of tetanus vaccine in the 4-in-1 pre-school booster jab which is given around four years of age.
And a final booster against tetanus is given to children betweeen 13 and 18 years of age as part of the 3-in-1 teenager booster.
After the full course of five injections, 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.
Tetanus vaccination for travel
Tetanus is found throughout the world. Any location where medical attention may not be available if you hurt yourself is considered a high-risk area.
A tetanus vaccination is usually recommended for anyone who:
has not been vaccinated before
has not been fully vaccinated (in the UK you should receive five doses of the tetanus vaccine)
is travelling to a country with limited medical facilities, and whose last dose of the tetanus vaccine was more than 10 years ago
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Symptoms of tetanus
The symptoms of tetanus usually develop within 4 to 21 days after infection with the Clostridium tetani bacteria (the incubation period). The average incubation period is about 10 days.
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
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 associated with a tetanus infection include:
high temperature (fever) of 38C (100.4F) or above
rapid heartbeat (tachycardia)
high blood pressure (hypertension)
If tetanus is not treated, it can cause serious complications that can be fatal, for example because of heart failure.
Causes of tetanus
Tetanus is caused by the Clostridium tetani bacterium.
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, a type of poison known as a neurotoxin. Tetanospasmin can slowly travel through nerves, until it reaches the spinal cord or brainstem.
The neurotoxin blocks the control of the nerve cells in the spinal cord and brainstem that control the muscles, causing them to be overactive. This leads to the muscle spasm and muscle stiffness associated with tetanus.
Cuts and wounds
One of the most common ways the tetanus bacteria enter the body is through a cut or a puncture wound. 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 caused by friction damage, such as the type of wound you would get after falling off a bike and scraping your knee
body piercings and tattoos (if unsterilised equipments is used)
Some groups of people, such as travellers and people who inject drugs, may be at increased risk of developing tetanus.
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.
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 medical care isn't available.
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.
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.
It is important that tetanus is treated quickly to prevent complications from developing.
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
Wounds that are vulnerable to a tetanus infection are called 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 (TIG) is a medication that contains antibodies that kill the tetanus bacteria. Antibodies are infection-fighting proteins. Tetanus immunoglobulin is given as an injection into a muscle and gives immediate, short-term protection against tetanus. It is thought to be safe to use in pregnant and breastfeeding women.
After having tetanus immunoglobulin, you are likely to have some short-term discomfort at the site of the injection. Other side effects are thought to be uncommon but may include:
shortness of breath
swelling of your face
Speak to the doctor in charge of your care if you develop any of these side effects.
Depending on whether your vaccinations are up to date, you may also be given a booster dose of the tetanus vaccine.
Treating tetanus symptoms
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 hospitals, where doctors with experience in treating tetanus are usually based.
The three main types of medication used to treat the symptoms of tetanus are:
neuromuscular blocking agents (NBAs)
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.
Side effects of sedatives include:
shaky movements and an unsteady walk (ataxia)
seeing or hearing things that are not real (hallucinations)
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).
You will be given muscle relaxants to stop your symptoms returning when your dose of sedatives are reduced.
Neuromuscular blocking agents (NBAs)
Neuromuscular blocking agents (NBAs) are a type of medication that block nerve signals 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.
A neuromuscular blocking agent called vecuronium is usually prescribed. Vecuronium causes paralysis of the muscles used for breathing, so assistance with breathing is provided before it can be given.
Preventing further spread of neurotoxins
Tetanus immunoglobulin 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 toxins being released.
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).
Complications of tetanus
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.
Like all very ill people, people with tetanus are at risk of a pulmonary embolism.
A 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.
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.