Tetanus (lockjaw)

Tetanus cannot be eradicated. The organism lives in the soil and will stay there, no matter how many people are vaccinated. Everything else follows from that single fact: that boosters are given lifelong, that protection is checked after an injury – and that tetanus of the newborn still costs tens of thousands of children their lives worldwide every year, although it would be entirely preventable.

Why this illness is different

Most of the organisms in the immunisation schedule are passed from person to person. Once enough people are vaccinated, such an organism finds no more hosts and disappears – that is how smallpox was eradicated, and that is what is intended for polio.

Clostridium tetani works differently. It lives in a dormant form in the soil, in dust and in the intestines of animals and humans. Its spores survive heat, dryness and disinfectants for years. It needs no transmission from person to person, and it has no interest in making anyone ill – the illness is a by-product.

From this it follows that there is no herd immunity for tetanus. Someone who is not vaccinated is not protected by the fact that others are. All protection here is individual.

How an infection arises

If spores get into a wound with little oxygen in it, they germinate and form a nerve poison – tetanospasmin, one of the most powerful poisons known at all. It travels along the nerve pathways to the spinal cord and there switches off the nerve cells that normally put a brake on muscle tension.

The result is tension with no brake. It typically begins in the face: spasm of the chewing muscles, so that the mouth can no longer be opened, and a distorted expression that looks like a grin. Then the neck, the back and the trunk follow. The spasms are triggered by sound, light and touch and are extraordinarily painful, with consciousness fully preserved.

It becomes life-threatening when the muscles of respiration are affected. Treatment takes place in intensive care, often over weeks. Even there mortality is ten to twenty per cent; without intensive care it is over eighty.

Important for understanding this: having had tetanus leaves no protection. The amount of poison that triggers the illness is too small to produce an immune response. Anyone who has survived tetanus has to be vaccinated afterwards – like everybody else.

The myth of the rusty nail

Rust has nothing to do with tetanus. The association arose because rusty objects typically lie outdoors and therefore come into contact with soil – the soil is the problem, not the rust.

Wounds with little oxygen are the ones at risk:

• deep puncture wounds, even small ones – a thorn while gardening is enough
• crush and laceration wounds with dead tissue
• dirty wounds containing soil, dust or street grime
• bite wounds
• burns and frostbite
• chronic wounds such as a leg ulcer

A cleanly bleeding cut, by contrast, is comparatively harmless, because it is well supplied with oxygen. The famous rusty nail is dangerous because it pierces deeply and carries soil with it – not because of the rust.

Tetanus in the newborn

Here lies the gynaecological core of this subject, and it is of considerable importance worldwide.

The umbilical stump of a newborn is a wound with little oxygen. If it is cut under unclean conditions or afterwards treated with soil, ash or cow dung – a traditional practice in some regions – spores get into it. The illness begins in the first or second week of life, usually with the child no longer being able to feed because the mouth cannot be opened.

Without treatment almost all affected children die. Even with care, mortality remains high. Until a few decades ago neonatal tetanus was one of the commonest causes of death in the first month of life worldwide.

It is prevented by two measures. The first is clean birth care: sterile cutting of the umbilical cord, clean hands, nothing applied to the stump. The second is vaccination of the mother – her antibodies cross the placenta to the child and protect it during exactly the period when it is at risk.

The World Health Organization has pursued the goal of eliminating neonatal tetanus for decades, and the progress is considerable: the number of deaths has fallen by more than ninety per cent since the 1980s. In fewer and fewer countries is it still regarded as a problem.

In Austria it has practically disappeared, because both conditions are met – birth care is sterile and the great majority of women are vaccinated. It is precisely this state of affairs, taken for granted, that is the result of a programme and not a fact of nature.

The “T” in the dTpa vaccine

In Austria every pregnant woman is recommended a dTpa vaccination between weeks 27 and 36. The reason for it is the whooping cough component; tetanus and diphtheria are part of the same vaccine because there is no whooping cough vaccine on its own.

For Austria the tetanus component above all means a booster that was due anyway. In countries without a reliable immunisation programme it is precisely this component that prevents neonatal tetanus – the same injection, two completely different meanings.

It is an inactivated vaccine containing a detoxified toxin, expressly licensed and recommended in pregnancy. It is given afresh in every pregnancy, regardless of the interval since the last booster; the minimum interval that otherwise applies does not apply here. More on this under whooping cough.

The immunisation schedule

For children the tetanus vaccination is part of the six-in-one vaccination in the first year of life, with doses in the third and fifth month of life and between the twelfth and the fourteenth, followed by boosters at primary school age and in adolescence.

For adults the rule is: every ten years, and from the age of 60 every five. A combination vaccine is used, because an isolated tetanus vaccination rarely makes sense – anyone boosting tetanus is boosting diphtheria at the same time, and often whooping cough as well.

If a booster has been missed, the series is continued and not begun again. Even after twenty or thirty years a single dose is enough, provided a basic course took place in childhood – immunological memory for tetanus is remarkably long-lived, even though measurable antibodies fall.

What happens after an injury

The decision follows two questions: what is the wound like, and when was the last vaccination?

The immunoglobulin in the last row consists of ready-made antibodies that work immediately. They are given into the area around the wound and into a different muscle from the vaccine, because otherwise they would neutralise one another. They bridge the weeks until the body's own protection has been built up.

The same scheme applies to pregnant women. Both the vaccine and the immunoglobulin can be used in pregnancy; a delay on account of the pregnancy would be a mistake.

Independently of all this, wound care includes thorough irrigation and the removal of foreign bodies and dead tissue. A well-treated wound deprives the organism of the low-oxygen environment it needs.

How long after the injury a vaccination is still worthwhile is a frequent question. The answer is: as early as possible, but still after one or two days. The incubation period is three days to three weeks, occasionally longer – so a window remains. Anyone who only thinks of it on the third day should therefore not do without it, but go.

How tetanus is diagnosed and treated

There is no laboratory test that makes the diagnosis. The organism often cannot be cultured from the wound, and antibodies say nothing about an acute illness. The diagnosis is made from the clinical picture: spasm of the chewing muscles, neck stiffness, painful spasms with consciousness fully preserved, triggered by stimuli from outside. Where suspicion is well-founded, treatment starts without waiting for confirmation.

Treatment consists of several parts that run in parallel: immunoglobulin, to catch toxin not yet bound; antibiotics, to stop further production; surgical cleaning of the wound; and above all intensive care with antispasmodic medication, often over weeks and in severe cases with artificial ventilation.

What has already bound to nerve cells cannot be removed. Recovery depends on those connections being slowly formed anew – which is why an episode of tetanus lasts weeks to months. Lasting damage is rather the exception if the acute phase is survived.

And that is why a basic course of vaccination follows recovery, as described above: someone who has come through tetanus is no better protected afterwards than before.

What is worth having in the medicine cabinet

Because most tetanus questions arise from an everyday injury, here is what actually helps – and what does not.

Worth having: sterile saline or clear tap water for thorough irrigation, sterile compresses, a wound antiseptic based on octenidine or polihexanide, plasters in various sizes, tweezers for foreign bodies. With a dirty wound, irrigation matters more than disinfection – it removes what the antiseptic would otherwise never reach.

Not worth doing: sealing wounds airtight when they are deep and dirty – that creates exactly the low-oxygen environment the organism needs. Equally: putting powder, ointments or home remedies into an open wound.

Belong with a doctor: deep puncture wounds, bite wounds, heavily contaminated wounds, wounds with visible foreign bodies, gaping wounds that need suturing, and any wound that becomes increasingly red, painful or warm after one or two days. In pregnancy this applies without qualification – there is no reason to wait longer with a wound just because you are pregnant.

Tolerability

The commonest reactions are local: pain, redness and swelling in the upper arm for one to two days. General reactions such as fatigue or slight fever occur and subside quickly.

Pronounced local reactions occur more often when a vaccination is given too soon after the last one – a reason to keep to the intended intervals where nothing speaks against it. In pregnancy and after an injury the benefit clearly outweighs this consideration.

A swollen, reddened upper arm is not an allergy but the intended reaction to the adjuvant the vaccine contains. Cooling and moving the arm help more than resting it.

After the birth: the child's navel

Because this text deals with neonatal tetanus at length, the practical side belongs with it – even though in Austria it is fortunately unspectacular.

The remainder of the umbilical cord dries out and falls off by itself after about five to fifteen days. Until then the rule is: keep it clean and dry. In concrete terms that means leaving the stump uncovered rather than dressing it, folding the nappy down below it so that it does not rub, and letting it get wet in the bath without scrubbing it – then patting it carefully dry.

Powder, ointments, oils, disinfectants and dressings of any kind are not recommended. The studies on this are unambiguous: keeping it dry heals faster than any treatment. In regions without clean birth care, by contrast, an antiseptic is applied to the stump, because the risk of infection there is a different one.

The navel should be looked at if the skin around it is red and hardened, if it smells, if pus comes out or if the child reacts with marked pain on being touched. A few drops of blood as it falls off, by contrast, are normal.

Travel and occupation

Before travelling, tetanus protection is checked regardless of the destination – the organism occurs everywhere, and the availability of immunoglobulin cannot be taken for granted outside Europe. If you are injured far from good care, protection that is up to date is what counts.

For work involving frequent contact with soil – gardening and agriculture, construction, animal husbandry – the same applies with greater emphasis. Anyone who regularly sustains small injuries should not have to ask the question about protection afresh each time.

For pregnant women in such occupations a second consideration comes in, one only indirectly connected with tetanus: contact with soil also means contact with the organism causing toxoplasmosis, which occurs in cat faeces and hence in garden soil. Gloves for gardening, washing your hands afterwards and washing home-grown vegetables therefore have a double justification. Toxoplasmosis status is determined at the first examination in the parent-child pass and repeated during the pregnancy if the result is negative.

How protection is measured

Unlike most vaccinations, tetanus protection can be measured well in the blood. An antibody level above 0.1 international units per millilitre counts as protective. That sounds practical – and is nevertheless rarely done.

The reason is a simple weighing-up. The measurement takes days, costs more than the vaccination and almost never changes what is done: if the level is low, the vaccination is given; if it is high, the extra dose would have done no harm. In the acute situation after an injury it is no option at all, because the result would come too late.

It is worthwhile in individual cases: in people with a weakened immune system, where it is unclear whether a response to vaccination came about at all, and occasionally in adults with no vaccination documentation whatsoever, when a complete series of three doses would otherwise have to be started.

For everyone else the vaccination record remains the decisive document – and where it is missing, the vaccination itself is the simpler answer than the measurement.

What happens next

In this practice the dTpa vaccination is discussed and given as part of antenatal care. Please bring your vaccination record – and if you cannot find it, that is no obstacle: in case of doubt the vaccination is given, because an extra dose where protection already exists is harmless. Arranging an appointment.