None of four US children diagnosed as having tetanus in 2024 had completed a recommended primary tetanus toxoid–containing vaccine (TTCV) series, and none received TTCV or preventive tetanus immunoglobulin (TIG) between their exposure and symptom onset. 

And despite all four children requiring hospitalizations of eight to 45 days and two needing additional inpatient rehabilitation, only one completed the TTCV series after his or her illness, according to the findings of an investigation by the Centers for Disease Control and Prevention (CDC) and local health departments in four states.

The study, published yesterday in Morbidity and Mortality Weekly Report, describes the four cases, which included the first pediatric tetanus infection in Idaho in more than 30 years, as well as one case each in Minnesota, Missouri, and Wisconsin. The cases were identified through the National Notifiable Diseases Surveillance System.

Tetanus is a neuromuscular infection mediated by a toxin produced by Clostridium tetani bacteria. Ctetani spores are ubiquitous in the environment, being present in soil, dust, and manure, and often enter the body through wounds. In the body, the spores germinate and produce tetanospasmin, a potent neurotoxin that can cause a severe, even fatal, illness featuring lockjaw, muscle spasms, problems swallowing, fever, and stiffness in the abdomen, chest, and neck.

“Because of high coverage with recommended tetanus toxoid–containing vaccine (TTCV), pediatric tetanus is rare in the United States; approximately four cases are reported annually,” the authors noted. But “a recent surveillance summary reported that among persons with tetanus whose vaccination history was known, 44% had not received a TTCV dose” (see April 15 CIDRAP News story).

Parents refused post-injury vaccine, prophylaxis for 2 children

Two of the tetanus patients were in the 10- to 15-year age-group, and one each were in the one- to four-year and five- to nine-year groups. Two lived in metropolitan areas, and two were from non-metro areas. 

In one case, the likely exposure route was unknown, while one each were likely related to a compound ankle fracture from an electric-scooter accident, a knee puncture from an animal bone, and a crushing foot injury from a horse hoof while barefoot. 

The three patients with a known interval between the injury and illness sought care after seven to 10 days. Two patients didn’t seek medical care before illness onset, and the parents of two declined TTCV and TIG prophylaxis before symptom onset.

All four patients experienced generalized tetanus with symptoms such as back, neck, and jaw pain; muscle spasms and rigidity; and problems walking. All patients were hospitalized (average stay, 25 days) and were given TIG for treatment and an initial TTCV dose for prevention of future disease. 

Serious health consequences, costly care

Two patients had documented receipt of a second TTCV dose, but only one later completed the recommended vaccine series. At least two children received follow-up care, including readmission for inpatient rehabilitation. None of the four died.

Missed prevention opportunities for the children described in this report included failure to be vaccinated before the injury, delays in wound care, and lack of timely administration of TIG after exposure and before illness onset, including refusal.

“Tetanus can result in serious health consequences requiring extensive and costly medical care,” the researchers wrote. “Missed prevention opportunities for the children described in this report included failure to be vaccinated before the injury, delays in wound care, and lack of timely administration of TIG after exposure and before illness onset, including refusal.” 

Prompt wound care is particularly important if a patient sustains environmentally contaminated or penetrating wounds, the authors said. 

“Administration of TIG or TTCV when indicated should not be delayed, especially in unvaccinated or undervaccinated children,” they concluded. “Completing a primary TTCV series and remaining up to date with TTCV vaccination are essential to preventing tetanus; patients with tetanus-prone wounds should receive timely administration of TTCV and TIG according to recommendations.”