Discover tetanus symptoms, prevention tips, and treatment options. Stay informed and protect yourself with Meri Sehat.

Tetanus (Lockjaw)

Overview

Tetanus is a bacterial infection caused by Clostridium tetani. When the bacteria invade the body, it produces a toxin that causes continuous and painful muscle contractions. As a result of these contractions, the neck and jaw muscles lock; hence the name &ldquo;lockjaw&rdquo;<a href="#accordion">[1]</a>.

&nbsp;

There are records of tetanus-like diseases dating all the way back to the 5th century BCE. The disease was further researched and the causative agent was isolated by Kitasato Shibasaburo in 1889. The very first vaccine was created by Edmond Nocard in 1897, but it wasn&rsquo;t administered until World War I. Despite the fact that the disease has been documented a long time ago; progress regarding consolidating effective prevention strategies is still underway<a href="#accordion">[2]</a>.

Tetanus is more prevalent in low-income countries than in high-income countries. For instance, in the US, there are barely 30 reported cases every year, which mostly include people who did not get tetanus vaccinations<a href="#accordion">[3]</a>. Contrastingly, in low income countries we see more cases of tetanus and unfortunately a higher mortality rate as well.

For e.g., in Pakistan, there are around 213,000-293,000 deaths due to tetanus recorded each year with 5-7% of them being neonatal deaths and 5% being maternal deaths worldwide<a href="#accordion">[4]</a>. These figures could be attributed to several factors including inadequate immunization coverage and underreporting.

With regard to inadequate immunization coverage, Pakistan unfortunately is one of the 34 countries around the world that have not achieved the global elimination target set by WHO for the elimination of neonatal tetanus<a href="#accordion">[5]</a>. Moreover, only 60-74% of vaccination coverage was reported in the past decade indicating the need for raising public awareness and implementing effective mass immunization programs<a href="#accordion">[6]</a>.&nbsp;

&nbsp;

There are 4 types of tetanus<a href="#accordion">[7]</a><a href="#accordion">[8]</a>:&nbsp;

&nbsp;

<ul>
	<li>
	<h5>Generalized</h5>
	</li>
</ul>

80% of tetanus cases fall within the generalized category. The onset of symptoms takes around 10 days after getting infected. In generalized tetanus, the symptoms start mild and then slowly progress toward severity. Generalized tetanus starts off by affecting the jaw and then the muscle spasms affect the neck and other parts of the body. The individual may have trouble swallowing due to prolonged contraction of facial muscles. This prolonged contraction of facial muscles also causes risus sardonicus (raised eyebrows and a peculiar distorted grin due to facial muscle spasms).&nbsp;

&nbsp;

<ul>
	<li>
	<h5>Neonatal</h5>
	</li>
</ul>

Generalized tetanus in newborns is referred to as neonatal tetanus. The main culprit of the disease, apart from the causative bacteria itself, is an unvaccinated mother. The bacteria are mostly transferred while the umbilical cord is being cut using unsterilized equipment. Newborns start showing symptoms like irritability, inability to suck or feed, and muscle rigidity along with spasms. Neonatal tetanus is difficult to diagnose&nbsp;and can be fatal if left undiagnosed and untreated.&nbsp;

&nbsp;

<ul>
	<li>
	<h5>Localized</h5>
	</li>
</ul>

​​​​​​​Localized tetanus refers to muscle spasms in a confined area. This type of tetanus mostly occurs due to exposed skin and injured areas. The bacteria enters the system through the site of injury and starts producing its toxin there. This causes muscle spasms to occur in that specific area near the injury. It can occur in people who have been immunized against it before&nbsp;but are currently immunocompromised. The disease starts off mild and slowly progresses toward generalized tetanus.&nbsp;

&nbsp;

<ul>
	<li>
	<h5>Cerebral Tetanus</h5>
	</li>
</ul>

​​​​​​​Also known as cephalic tetanus, it is restricted to the muscles of the head. This type of tetanus is characterized by the paralysis of one or multiple cranial nerves. Cephalic tetanus is very rare; it accounts for only 1-3% of the total cases of tetanus. Most cephalic tetanus cases worsen and transform into general tetanus.

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Signs And Symptoms

After infection, the onset of symptoms usually takes around 7-10 days, however, it can even take up to a month. The symptoms include:

&nbsp;

<ul>
	<li>Stiff muscles</li>
	<li>Muscle spasms</li>
	<li>Locked jaw</li>
	<li>Difficulty&nbsp;swallowing</li>
	<li>Rigid facial muscles&nbsp;</li>
	<li>Trouble breathing</li>
	<li>Bloody stools</li>
	<li>High fever</li>
	<li>Severe headache</li>
	<li>Sore Throat</li>
	<li>Excessive sweating</li>
</ul>

&nbsp;

Note: Opisthotonus (back arching due to muscle spasms) may be seen in tetanus patients, however, this abnormal posture can also be seen in many diseases e.g. meningitis, cerebral palsy, rabies. Since opisthotonus is life-threatening and is associated with serious health complications, it is recommended to seek medical attention immediately.&nbsp;

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Causes

The causative bacterium for tetanus is called Clostridium tetani. The anaerobic gram-positive bacteria have been around for decades and cannot be eradicated from the environment due to their spore-forming capabilities that enable them to withstand extreme temperatures. The bacteria produce a toxin that triggers all the muscle-contracting effects experienced in tetanus.&nbsp;

C. tetani is commonly found in soil and enters the human body through injuries and broken skin. After the bacteria&rsquo;s entry into the body through the site of injury, it multiplies and produces tetanospasmin and tetanolysin.&nbsp;

Tetanolysin plays a role in providing a base for the infection, while Tetanospasmin interferes with the release of acetylcholine in the nervous system and is responsible for irregular muscle spasms and even flaccid paralysis.&nbsp;

The toxins also affect the spinal cord and the brain stem, and cause inhibition of GABA and glycine neurotransmitters, leading to hyperactivity and involuntary contractions<a href="#accordion">[9]</a>.&nbsp;

In addition to injuries of any kind, the bacteria can be contracted through:

<ul>
	<li>Soil, stool, or spit contaminating open wounds</li>
	<li>A contaminated object causes wounds</li>
	<li>Surgical procedures</li>
	<li>Improper use of IV&nbsp;</li>
</ul>

&nbsp;

Diagnosis

The diagnosis for tetanus includes taking the patient&rsquo;s vaccination history and patient examination for signs and symptoms e.g. locked jaw, risus sardonicus.

Normally, tests are not ordered and on the rare occasion where they are, the point is to observe the adverse reactions of the tetanus vaccine or possible humoral immunodeficiency. An antibody test can determine the body&rsquo;s response to the vaccine, but even this test has its deficiencies and cannot be relied upon solely for diagnosis.&nbsp;

Differential diagnosis is the only useful option for tetanus. PCR and bioassays detect the toxin of clostridium tetani but the test itself requires a certain well-equipped facility, which is difficult to provide in the low-income areas where this disease is highly prevalent.&nbsp;

&nbsp;

Treatment

The treatment varies according to the severity of your symptoms. It is targeted towards multiple aspects of the disease, like:

<ul>
	<li>Symptomatic therapy to reduce muscle contractions</li>
	<li>Removing or neutralizing unbound toxin</li>
	<li>Stopping further production of the toxin</li>
</ul>

&nbsp;

The treatment involve multiple types of medications including:&nbsp;

<ul>
	<li>Antimicrobials: These are used to eliminate the toxin produced by the bacteria. Initially, Penicillin G was used for this purpose, but now Metronidazole is preferred due to its improved antimicrobial activity.&nbsp;</li>
	<li>Vaccine: Tetanus immune globulin (TIG) is used to treat tetanus. TIG removes unbound toxins&nbsp;but is ineffective against the toxin that is bound to the nerve endings.&nbsp;</li>
	<li>Benzodiazepines: Benzodiazepines are used for the symptomatic treatment of tetanus. These drugs are commonly used for anxiety and are known to exert relaxing and sedating effects. In the case of tetanus, they are effective in reducing muscle contractions<a href="#accordion">[10]</a>.&nbsp;</li>
</ul>

&nbsp;

Depending on the type of tetanus, there can be several complications, including:

<ul>
	<li>Acute Breathing Issues &ndash; Vocal cords tighten especially during spasms</li>
	<li>Pulmonary Embolism &ndash; Blockage of the main artery or its branches by a blood clot</li>
	<li>Severe Generalized Spasms &ndash; Leading to fractures in the body</li>
	<li><a href="https://www.merisehat.pk/disease/pneumonia" target="_blank">Pneumonia</a></li>
	<li>Blockage Of Airways Or Nerve Damage &ndash; This can&nbsp;cause death</li>
</ul>

&nbsp;

This include:

<ul>
	<li>Being unvaccinated (biggest risk factor)</li>
	<li>Immunocompromised individuals</li>
	<li>Not getting 10-year booster shots</li>
	<li>Injuries and wounds being exposed to soil or a contaminated object&nbsp;</li>
	<li>Skin lesions in people with diabetes</li>
	<li>Natural disasters;&nbsp;tetanus is likely to occur in regions that suffer a natural disaster and the risk is increased if the immunization rates within the afflicted region are low. For example,&nbsp;the Aceh province in Indonesia faced a huge outbreak of tetanus after the 2004 tsunami.</li>
</ul>

&nbsp;

The key to preventing tetanus is vaccination. Mass vaccination programs for tetanus exist worldwide. One of the main areas of focus is the eradication of neonatal tetanus. This requires the vaccination of adults and children of all ages. Unlike popular belief, these vaccinations are not just a one-time thing. You would require a booster dose once in a while, particularly whenever you are traveling to a country where tetanus is highly prevalent<a href="#accordion">[11]</a>.&nbsp;

Other than this, immediate disinfection of wounds and the usage of sterilized products during the delivery of babies is crucial. The vaccine commonly given also involves immunization for diphtheria and acellular pertussis. DTaP comprises a total of 5 shots to be given after certain periods of time. Some children are unable to tolerate the acellular pertussis vaccine and hence are only administered DT<a href="#accordion">[12]</a>.

&nbsp;

UNICEF officials focus on the urgency of immunization in South Asian countries, including Pakistan and India. Pakistan was on top of the list of countries in which children were not getting their first dose of DTP from 2019 to 2020. The tide changed when Pakistan bounced back during the COVID times and the number of zero-dose children was drastically reduced. WHO and UNICEF also praised Pakistan for its commitment<a href="#accordion">[13]</a>.

&nbsp;

Key Points

<ul><li>Tetanus is a bacterial infection caused by Clostridium tetani. It causes severe muscle contractions and may even lead to a locked jaw.</li><li>There are a total of 4 types of tetanus: generalized, cephalic, localized, and neonatal tetanus.</li><li>The symptoms of tetanus include: locked jaw, difficulty breathing, difficulty swallowing, fever, headache, sore throat, etc.</li><li>When the causative bacteria invades our body, it tends to produce a toxin that acts on the nerve endings and acetylcholine, thereby, causing increased muscle contractions.</li><li>There are no tests to diagnose tetanus that would give accurate results. PCR and bioassays do give promising results but are associated with high cost, elaborate infrastructures and skilled expertise. Efforts are needed to devise cost effective diagnostic modalities that can be utilized in rural areas.&nbsp;&nbsp;</li><li>The main risk factor is not getting vaccinated and, likewise, the biggest preventive measure is getting vaccinated.</li><li>Pakistan is on the road towards ensuring that there are no zero-dose children, eliminating neonatal tetanus from the country.</li><li>Neonatal tetanus is a notification priority disease in Pakistan and any presenting cases should be notified to the concerned authorities immediately.</li></ul>

[1] Tetanus disease (lockjaw). Centers for Disease Control and Prevention.

[2] Pinkbook: Tetanus. Centers for Disease Control and Prevention.

[3] About tetanus disease (Lockjaw). Centers for Disease Control and Prevention.

[4] Disease factsheet about tetanus. European Centre for Disease Prevention and Control.

[5] Tetanus – Federal Directorate of Immunization, Pakistan.

[6] Lambo JA, Nagulesapillai T. Neonatal tetanus elimination in Pakistan: Progress and challenges. International Journal of Infectious Diseases. 2012;16(12).

[7] Tetanus. Mayo Clinic.

[8] Alhaji MA, Abdulhafiz U, Atuanya CI, Bukar FL. Cephalic tetanus: A case report. Case Reports in Infectious Diseases. 2011;2011:1-2.

[9] George EK, De Jesus O, Vivekanandan R. Clostridium Tetani. [Updated 2022 May 23]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-.

[10] Patrick B Hinfey MD. Tetanus Treatment &amp; Management: Approach considerations, initial supportive therapy and wound care, pharmacologic therapy. Tetanus Treatment &amp; Management: Approach Considerations, Initial Supportive Therapy and Wound Care, Pharmacologic Therapy.