Symptoms:

• Jaw cramping

• Sudden, involuntary muscle spasms often in the back or stomach
• Painful muscle stiffness all over the body
• Trouble swallowing
• Seizures (jerking or staring)
• Headache
• Fever and sweating
• Changes in blood pressure and heart rate

If you think you may have these symptoms, talk with your doctor or healthcare provider.

Tetanus infection is dangerous and can lead to serious health complications, including:

• Paralysis (inability to move)

• Broken bones
• Difficulty breathing and swallowing
• Pneumonia (lung infection)
• Laryngospasm (tightening of the vocal cords)
• Pulmonary embolism (blockage of a lung artery)
• Death

Those more likely to have serious complications from tetanus are:

• Newborn babies
• Unvaccinated children and adults
• People living with chronic conditions

Tetanus does not spread from person to person.

The bacteria that cause tetanus can be found in soil, dust, manure, and other parts of the environment. It can get into the body by infecting cuts/sores on the skin, animal bites, and burns.

Some of the common ways people are infected with tetanus bacteria include:

• Cuts/wounds from rusty nails, needles, or other sharp objects
• Cuts/wounds contaminated with dirt, feces (poop), or saliva/spit
• Burns, frostbite, or crush injuries

Some less common ways that people can get infected include:

• Insect bites
• Dental infections
• Intravenous (IV) drug use

To help prevent tetanus, immediately clean and apply first aid to all cuts, scrapes, or other breaks in the skin and wash your hands often with soap and water.

If you think you have been exposed to tetanus bacteria and have not been vaccinated, immediately seek emergency care.

Getting vaccinated is the best way to protect yourself from tetanus. Tetanus shots are safe and effective at preventing severe infection.

The tetanus vaccine series, including booster doses, is nearly 100% effective in preventing tetanus. Nearly all cases of tetanus today are in people who never got a tetanus vaccine or did not receive a complete course of tetanus vaccines, or adults who didn't stay up to date on their 10-year booster shots.

There are three kinds of vaccines available in the United States to help protect against tetanus. All of these vaccines also provide protection against other diseases:

• DTaP vaccine: protects against diphtheria, tetanus, and pertussis
• Tdap vaccine: protects against tetanus, diphtheria, and pertussis
• Td vaccine: protects against tetanus and diphtheria

If you have insurance:

• Talk to your doctor or check with your local pharmacy to see what vaccines they offer.
• Most health insurance plans cover the cost of recommended vaccines for children and adults.

If you are uninsured or underinsured:

• Programs are available to help cover the cost of vaccines.
• Children 18 years or younger may receive vaccines at no cost through the Vaccines for Children (VFC) Program if they are:
  • Eligible for or are enrolled in Medi-Cal
  • American Indian or Alaskan Native
  • Uninsured (do not have health insurance)
  • Underinsured (private health insurance does not cover the full cost of vaccines)
• Adults who are uninsured or underinsured may be able to get free or low-cost vaccines at clinics enrolled in the Vaccines for Adults (VFA) program. For more information on who is eligible, read VFA Eligibility Based on Insurance Status.

Locating Vaccine Clinics:

• A list of free and low-cost clinics in Los Angeles County.
• Interactive county map to locate free and low-cost vaccine clinics.
• Call 1-833-540-0473 (Public Health InfoLine) for a list of free or low-cost vaccine clinics. This includes Vaccines for Children (VFC) provider locations that serve Medi-Cal eligible children and uninsured or underinsured adults.

• Immunization Schedules: Birth to 6 Years Old | 7 to 18 Years Old | 19 Years Old and Older (AAP & AAFP)
• What You Need to Know: DTaP (Diphtheria, Tetanus, Pertussis) | Tdap (Tetanus, Diphtheria, Pertussis) | Td (Tetanus, Diphtheria) | Multi-Vaccine (DTaP, Hib, Hepatitis B, Polio, PCV) (Immunize.org)
• Tetanus: Questions and Answers (Immunize.org)
• Tetanus (History of Vaccines)
• DTaP (Diphtheria, Tetanus, Pertussis) Vaccine (Voices for Vaccines)
• DTaP Vaccine: Preparing for Your Child's Well-Baby Visit (Voices for Vaccines)
• Paying for Vaccines (LACDPH)

Tetanus symptoms traditionally present as uncontrollable and painful muscle contractions, which can take the form of seizures or severe musculoskeletal cramping that contorts the body.

It can present in different clinical forms: Generalized, localized or neonatal.

• Generalized presentation of tetanus begins in the masseter and neck muscles, causing trismus (commonly known as “lockjaw”). Due to the anatomical structure within the neck, tetanus-caused trismus is often accompanied by difficulty swallowing, head jerking or staring, headaches, and fever. It can cause autonomic overactivity with sweating and tachycardia, profuse sweating and cardiac arrhythmias, and airway compromise. During generalized spasms, patients clench their fists, arch their back and abduct their arms. Spasms can be intensely painful.
• Localized tetanus is a result of a cut or a wound that is exposed to tetanus spores. In localized cases, the muscle contraction may be confined to the region of the injury.
• Neonatal tetanus is a form of generalized tetanus affecting newborn infants born to an unimmunized mother. Neonatal tetanus is usually the result of unsterile equipment used during the cutting of the umbilical stump and symptoms develop 5-7 days after birth. Neonates will refuse to feed and have difficulty crying, and then will proceed to have rigidity and spasms of their trunk.

Tetanus is not communicable from person-to-person, and therefore isolation for cases and quarantine for contacts is not necessary.

Please contact the LAC DPH Vaccine-Preventable Disease Control Program to report a case or obtain technical assistance with specimen collection or completion of forms for tetanus, or for any other vaccine-preventable disease.

Suspected or probable tetanus cases are to be reported within 7 calendar days from identification by electronic transmission (email or digital fax) or telephone per Title 17, California Code of Regulations (CCR), Section 2500.

• Weekdays Telephone: 8:30 am to 5:00 pm: Call 213-351-7800
• After Hours: Call 213-974-1234, option 8
• Email: vpdc@ph.lacounty.gov
• Fax Number: 213-351-2782

Please send the patient’s medical records and any available immunization records and/or laboratory results via secure email or fax.

• Diagnosis of tetanus is clinical. Healthcare providers diagnose tetanus by looking for and observing clinical signs and symptoms.
• C. tetani bacteria may be recovered from the wound site of a clinically diagnosed tetanus infection, but it has historically only been collected in 30% of cases. Culture results have shown to be unreliable in tetanus diagnostic confirmation, as false-positive and false-negative results are common. Laboratory identification of the organism depends primarily on the demonstration of toxin production in mice.
  • If collected, specimen should be stored using common bacterial transport media.

Pharmacologic Treatment:

• Human tetanus immune globulin (TIG, also known as HyperTET®) should be administered intramuscularly at the time of tetanus diagnosis. TIG can help to remove unbound tetanus toxin but cannot affect toxin already bound to nerve endings.
  • A single dose of 500 IU is recommended by most experts; this appears to be as effective as higher doses ranging from 3000-6000 IU and causes less discomfort.
  • TIG is not licensed or formulated for intrathecal or intravenous use.
• Intravenous immune globulin (IVIG) contains tetanus antitoxin and may be used if TIG is not available.
  • Administer intravenously at a dose of 200 to 400 mg/kg.
  • Note that IGIV is not approved by the FDA for this use, and anti-tetanus antibody concentration may vary from lot to lot.
• Equine antitoxin can be given intravenously but requires that the patient be tested for sensitivity and desensitized as needed, as it is associated with serious allergic side effects such as anaphylaxis and serum sickness. Use of equine antitoxin is not recommended when TIG or IVIG is available.
• Oral (or intravenous) metronidazole is effective in decreasing the number of vegetative forms of C. tetani and is the antimicrobial agent of choice. Administration is recommended for 7 to 10 days.
  • Parenteral penicillin G is an alternative treatment.

Clinical Treatment:

• Medical management of tetanus should prioritize wound cleaning through removal of all foreign material and necrotic tissue.
• If the patient is experiencing tetanic spasms, maintenance of an adequate airway is critical.
• Tetanus disease may not result in immunity because of the extreme potency of its toxin, so active immunization with tetanus toxoid should always occur once the person’s condition has stabilized.

The American Academy of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP) recommend routine tetanus vaccination across the lifespan. Children younger than 7 years of age should receive DTaP (diphtheria, tetanus, acellular pertussis), while older children and adults should receive Tdap (tetanus, diphtheria, acellular pertussis) or Td (tetanus and diphtheria). See the table below for a list of tetanus toxoid-containing vaccines and the recommended schedules.

Multiple combination vaccines containing tetanus toxoid are available for use. Use of combination vaccines are also useful in reducing the number of injections in a single visit.

Tetanus disease may not confer immunity. Unvaccinated or under-vaccinated persons recovering from tetanus should begin or complete their immunization series with tetanus toxoid during convalescence.

Adults

• Administer a single dose of Tdap to adults who have never received Tdap regardless of when they last received Td. This should be followed by a Tdap booster every 10 years.

Catch-Up Guidance for Children 4 Months through 18 Years

• Review the catch-up guidance for diphtheria, tetanus, and pertussis vaccination for children and adolescents whose vaccinations have been delayed.

Guidance for Td

• TdVax^TM has been discontinued and is no longer available in the U.S.
• A limited supply of TENIVAC® (Td) is still available, but due to constraints in vaccine supplies, vaccine providers should follow this guidance until the period of temporary ordering controls for Td vaccine ends:
  • Use Tdap vaccine in lieu of Td vaccine whenever possible while Td vaccine supplies are constrained.
  • Tdap vaccine is an acceptable alternative to Td vaccine, including when a tetanus booster is indicated for wound management.
  • Tdap vaccine isn't an acceptable alternative only when a person has a specific contraindication to pertussis-containing vaccines. Contraindications to DTaP and Tdap occur only very rarely, and in questioning about them, providers should probe whether a true contraindication actually exists. DTaP and Tdap contraindications are limited to only the following:
    • Severe allergic reaction (e.g., anaphylaxis) to a dose of DTaP or Tdap or to a vaccine component (Td) is a contraindication to DTaP, Tdap, or Td. Because of the importance of tetanus vaccination, people who experience anaphylactic reactions should be referred to an allergist to determine whether they have a specific allergy to tetanus toxoid and can be desensitized to tetanus toxoid.
    • Encephalopathy (e.g., coma, decreased level of consciousness, or prolonged seizures) not attributable to another identifiable cause within 7 days after administration of a previous dose of diphtheria and tetanus toxoids and pertussis vaccine (DTwP, DTaP, or Tdap) is a contraindication to the pertussis component.

Rates of tetanus are currently at a historical low in the United States. Vaccine trials have not previously included tetanus toxoid efficacy, but experts can infer efficacy from protective antitoxin levels. A complete vaccination series likely has a clinical efficacy of virtually 100% for tetanus. A complete series of tetanus vaccination is 4 doses for children younger than 7 years old and 3 doses for people 7 years old or older.

*Tetanus-containing vaccines can be administered with other vaccines.
**Because the pertussis antigens contained in INFANRIX and KINRIX are the same as those in PEDIARIX, these children should receive INFANRIX as their fourth dose of DTaP and either INFANRIX or KINRIX as their fifth dose of DTaP. KINRIX or Quadracel® may be used to complete the 4-dose IPV series.
***Preferred for American Indian and Alaska Native infants based on the Haemophilus influenzae type b (Hib) component.
† The recommended minimum age for dose 3 of VAXELIS® is 24 weeks, the minimum age for completion of the hepatitis B vaccine series.
†† KINRIX is approved only for dose 5 of DTaP and dose 4 of IPV.
††† Quadracel® is approved only for dose 5 of DTaP and dose 4 or 5 of IPV.
§ Children 7-9 years old who have never been vaccinated against pertussis, tetanus, or diphtheria should receive a series of three tetanus and diphtheria toxoid-containing vaccines, which includes at least one dose of Tdap.
‡ Either Tdap vaccine administered to a person 65 years old or older is immunogenic and would provide protection; a dose of either vaccine would be considered valid.
‡‡ Primary immunization with TENIVAC® consists of 3 doses, with the first 2 doses administered 2 months apart. The third dose is administered 6-8 months after the second dose.
‡‡‡ TENIVAC® may be used as a booster beginning at 11-12 years of age, and every 10 years thereafter.

Administration Data: California healthcare providers are required to report data on all valid immunizations that they administer to their patients into the California Immunization Registry (CAIR) within 2 weeks of administration per AB 1797.

Administration Errors: Healthcare providers are strongly recommended to report all vaccine administration errors to the Institute for Safe Medication Practices.

Adverse Events: Healthcare providers are required to report any adverse event on the reportable events list to the Vaccine Adverse Event Reporting System (VAERS) per HR 5546.

Storage and Handling: For general recommendations and guidance access the Vaccine Storage and Handling Job Aids.

• Checklist: Managing Patients Suspected of Having Tetanus (LAC DPH)
• Tetanus B-73 (LAC DPH)
• Tetanus Quicksheet (CDPH)
• Immunization Schedules: Birth to 18 Years (AAP) | 19 Years and Older (AAFP) | CA Healthcare Personnel (CDPH)
• Vaccine Information Statements (Immunize.org): DtaP | Tdap | Td | Multi-Vaccine
• Standing Orders for Administering: DTaP Vaccine to Children <7 Years Old | Tdap/Td to Children and Teens ≥7 Years Old | Td/Tdap Vaccine to Adults | Tdap During Pregnancy (Immunize.org)
• Tetanus (WHO)
• Los Angeles Health Alert Network (LAHAN) (LAC DPH)