Tetanus is a worldwide spread disease, which is caused by the poison (toxin) of a bacterium (Clostridium tetani). Since these bacteria are widespread almost everywhere, it is almost impossible to avoid them. However, there is a way to protect oneself – the tetanus vaccination.
Tetanus is still a serious problem in many parts of the world, but especially in low-income countries or regions with low vaccination coverage rates and where births often occur in unsanitary conditions. Tetanus neonatorum is an important cause of infant mortality in developing countries. WHO estimates that in 2018 (the latest year for which estimates are available), 25.000 newborns died from tetanus. This represents a reduction of 88% compared to the year 2000.
In 2018, 92 tetanus cases were reported in Europe (EU/EEA), of which 48 were confirmed. The number of reported cases was similar to 2017. Adults 65 and older were the most affected age group, with women accounting for most cases. Illnesses occurred more frequently during warmer months, which are associated with higher levels of outdoor activity. The current epidemiology of tetanus in the EU/EEA may be explained by lower vaccination protection or declining immunity in older populations. Due to the severity of tetanus, it is necessary to maintain high vaccination rates in all age groups and continue to implement strategies to protect specific groups, especially the elderly, in countries with higher rates of the disease.
According to the cause of death statistics, 3 people died in 2019 as a result of tetanus infection.
The causative agent of tetanus is a bacterium – Clostridium tetani – which, in the form of its extremely resistant permanent forms (spores), is found practically everywhere, z.B. in soil, in dirt, in street dust but also in feces of humans and animals.
Tetanus spores can be in the soil. (© Goran Bogicevic – Fotolia.com)
The spores can also occasionally be detected on clothing or in house dust. The pathogen is commonly found in densely populated areas with hot and humid climates and in soil rich in organic matter. There is no direct person-to-person infection. As a result of the global spread of the pathogen, eradication of tetanus is impossible, as is prevention of the disease through hygienic measures alone.
The tetanus pathogens enter the body via wounds (z.B. (e.g. stabbing, biting or crushing injuries, frostbite or scalding wounds) in the body. These wounds do not have to be large, trivial scrapes and scratches can be enough. In the absence of oxygen, often deep in the ties, the spores germinate and develop into bacteria capable of reproducing, producing a nerve toxin.
Infection can only be direct, i.e. a person with tetanus cannot infect other people. In some developing countries, tetanus occurs in newborns (tetanus neonatorum) because one of the country's typical rituals is to place soil or even cow dung on the fresh umbilical wound.
Symptoms& Disease pattern
The first signs of the disease, such as restlessness, sleep disturbances, sweating and a general feeling of illness, usually appear gradually 4 – 14 days after infection.
Then there are persistent muscle tensions, which typically begin in the chewing muscles. The mouth can only be opened to a limited extent, or not at all. This muscular rigidity is triggered by the toxin produced by the bacteria. It is distributed throughout the body via blood and lymphatic pathways and enters the central nervous system. Here it binds to nerve cells. Disrupts regulated muscle function. The muscle tension spreads over the mimic musculature of the face and gives the patient a facial expression as if he were grinning (Risus sardonicus): he wears wrinkles on the forehead, the palpebral fire is narrowed and the mouth is drawn wide. Speaking and swallowing become difficult and increasingly impossible. Gradually, the muscles of the neck, back, abdomen and limbs are also affected. Muscle strains result in excruciating pain experienced while fully conscious. Within three days, there are also seizure-like, very painful muscle spasms, which can be triggered by external stimuli such as touch, sound, or light.
In infants delivered by inadequately immunized mothers with poorly sanitized umbilical care, the neonatal form of tetanus i.d.R. outbreak in the first two weeks of life. Babies appear stiff, suffer from weakness in drinking and convulsions. In developing countries, this form of tetanus is responsible for many infant deaths.
Bone fractures may occur as a result of the exceptionally strong muscle cramps. Cramps of the intestinal and bladder muscles lead to constipation and the inability to pass urine. If the respiratory musculature is affected, additional diseases of the lungs may occur, such as.B. an inflammation; in the worst case, death occurs by suffocation. The heart can also be damaged, resulting in arrhythmias, ventricular fibrillation or even cardiac arrest. A survived tetanus disease does not provide protection against a new infection – only the vaccination can do that.
The diagnosis is made on the basis of the signs of the disease. Stiff muscles or muscle spasms as a result of a wound injury, with the patient fully conscious, are considered definite signs of. In very rare cases, toxin detection may be performed to confirm the diagnosis.
Therapy aims, on the one hand, to ensure the survival of the sick person through intensive medical measures and, on the other hand, to stop the multiplication of the pathogens and the spread of the toxin. Therefore, the wound is generously excised and given an open wound treatment to create an oxygen-rich environment where bacteria do not feel comfortable. In addition, antibiotics in high doses should kill the pathogens. The infected person is injected with tetanus immunoglobulin, i.e. tetanus antibodies, to intercept the toxin still circulating in the bloodstream (passive immunization).
Intensive medical care, including ventilation and the administration of anticonvulsant medications, is essential. Sedatives are also administered so that the patient does not have to witness his or her condition while fully conscious. Careful monitoring and nursing care and a quiet environment to avoid inducing unnecessary convulsions are added to the mix. Even with intensive medical treatment, about 10 – 20% of patients die. Without such treatment, up to 70% die, and in very young and very old patients, almost 100% die.
There is only one measure that protects against tetanus with absolute certainty, and that is vaccination. Minimizing the risk of injury is a possible preventive measure against tetanus, but a rather unrealistic one.
In June 2020, the STIKO approved the vaccination schedule for the Basic immunization simplified (with Six-dose vaccine: diphtheria, hepatitis B, Hib [Haemophilus influenzae type b], pertussis, polio [poliomyelitis] and Tetanus [tetanus]): Infants should now be vaccinated with 3 doses of vaccine (instead of 4 previously) at 2, 4 and 11 months of age (2+1 schedule).
Premature infants, born before 37 weeks of age, may die. The vaccine should be administered to children born in the second week of pregnancy, but they should continue to receive 4 doses of vaccine at 2, 3, 4 and 11 months of age (3+1 vaccination schedule). Likewise, infants who have already reached 2. Those who received the second vaccine dose before 4 months of age should be vaccinated according to the old schedule of 4 doses (3+1 schedule).
For a safe vaccination protection with this vaccination scheme it is especially important that the child receives the first dose of the vaccination series early at the age of 8 weeks and gets the following vaccinations at the recommended times at the age of 4 and 11 months. Between the ages of 2. and 3. Vaccine dose is to be kept an interval of at least 6 months (therefore the designation "2+1"). The vaccination series should be shot around the first birthday (protection in kindergarten).
A booster vaccination in the sixth year of life is recommended by the Standing Commission on Vaccination (STIKO). Also the Booster vaccination between the 10. and 17. Year of life should not be forgotten. Further booster vaccinations every 10 years maintain the protective effect even in adulthood.