Tetanus Deaths Still Happening in the U.S., CDC Report Shows

Despite tetanus being preventable with vaccination, cases continue to occur in the U.S., with deaths mostly affecting older adults, the CDC reported.

From 2009 through 2023, there were 402 tetanus cases reported to the CDC in 47 states and the District of Columbia, with 16 states reporting 37 tetanus-associated deaths, wrote Michelle Hughes, PhD, of the CDC’s National Center for Immunization and Respiratory Diseases, and colleagues in Morbidity and Mortality Weekly Report Surveillance Summaries.

On average, there were 26.8 reported tetanus cases and 2.5 deaths annually, with a mean annual incidence of 0.08 cases and 0.008 deaths per 1 million population. The case-fatality rate was 12.4% among people with tetanus whose vital status was known.

Most tetanus deaths (85%) occurred in adults ages 65 and older, with a case-fatality rate of 30.8% in those ages 65-79 and 63.3% in those ages 80 and older.

Tetanus infections are caused by the spore-forming bacterium Clostridium tetani, with exposure typically occurring through deep or contaminated wounds. Symptoms include generalized spasms, rigidity, seizures, and lockjaw, and severe complications can include aspiration pneumonia, hypertension, pulmonary embolism, and death. Nearly everyone (94.9%) with reported tetanus was hospitalized. Prevention measures for those with at-risk wounds include tetanus toxoid-containing vaccine (TTCV) and tetanus immune globulin.

“Despite being preventable, tetanus remains a risk for those who are unvaccinated, undervaccinated, or who do not receive recommended wound management,” Hughes and colleagues wrote. “Sustained routine vaccination with TTCV and prompt identification and management of tetanus-prone injuries are essential to preserving the current low incidence of this potentially fatal disease.”

Of note, reported tetanus cases have dropped more than 95% since the introduction of routine childhood tetanus vaccination in the late 1940s, and deaths have declined more than 99%. The current U.S. incidence rate is far below the estimated global incidence of 10.3 cases per 1 million in 2019.

A majority of tetanus cases occurred in men (62.2%), and mean age was 43 years. Incidence rates were greater in men than women in every age cohort to age 64, and equal at ages 65-79, at 0.09 per 1 million. However, incidence flipped in those ages 80 and older, with an incidence rate of 0.27 per 1 million in women versus a rate of 0.10 per 1 million in men.

Tetanus incidence was greatest among those ages 80 and older, at 0.20 cases per 1 million population, and lowest among children and adolescents ages 17 and younger, at 0.05 cases per 1 million population. The high risk among the elderly may reflect that they were born before the primary series of tetanus vaccines was recommended for routine use in 1947.

Case-fatality rates were greater in men than women in every age cohort from 18 to 80 years and older. In contrast to the high case-fatality rates in older adults, the rate in adults ages 18-34 was 1.2%.

“The increased tetanus incidence and associated deaths among older age groups, especially women, suggest waning of vaccine-induced immunity and underscore the need for focused vaccination and wound care prevention efforts among these groups,” Hughes and team wrote.

In tetanus cases in which vaccination status was known, 43.9% occurred in people who didn’t have a documented history of tetanus vaccination. Vaccination status wasn’t known in 57% of the 402 cases. Among those who developed tetanus but had received at least one dose of tetanus vaccine, 58.8% had their most recent dose at least 10 years before tetanus onset. None of the tetanus deaths occurred in people who had had at least three doses of a tetanus vaccine.

Of the reported tetanus cases, 86.8% were linked to an acute wound, but only 45% of people with wounds sought medical care.

Study limitations included the passive nature of surveillance, which may have led to underreporting of cases.