Disease
Tetanus is acquired through environmental exposure to the spores of Clostridium tetani, which are present in soil worldwide. The disease is caused by the action of a potent neurotoxin produced by the bacterium in dead tissue (e.g. dirty wounds). Clinical symptoms of tetanus are muscle spasms, initially of the muscles of mastication causing trismus or “lockjaw”, which results in a characteristic facial expression – risus sardonicus. Trismus can be followed by sustained spasm of the back muscles (opisthotonus) and by spasms of other muscles. Finally, mild external stimuli may trigger generalized, tetanic seizures, which contribute to the serious complications of tetanus (dysphagia, aspiration pneumonia) and lead to death unless intense supportive treatment is rapidly initiated.
Occurrence
Dirty wounds can become infected with the spores of Clostridium tetani anywhere in the world.
Risk for travellers
Every traveller should be fully protected against tetanus. Almost any form of injury, from a simple laceration to a motor-vehicle accident, can expose the individual to the spores.
Vaccine
Tetanus toxoid vaccine is available as single toxoid (TT), combined with diphtheria toxoid (DT) or low-dose diphtheria toxoid (Td), and combined with diphtheria and pertussis vaccines (whole pertussis wP or acellular pertussis aP) (DTwP, DTaP, or TdaP). In some countries, combination vaccines with Haemophilus infl uenzae type b and/or IPV exist. Vaccines containing DT are used for children under 7 years of age and dT-containing vaccines for those aged 7 years and over. Vaccine combinations containing diphtheria toxoid (D or d) and tetanus toxoid, rather than tetanus toxoid alone, should be used when immunization against tetanus is indicated.
A childhood immunization schedule of 5 doses is recommended. The primary series of 3 doses of DTP (DTwP or DTaP) should be given in infancy, with a booster dose of a tetanus toxoid-containing vaccine ideally at age 4–7 years and another booster in adolescence, e.g. at age 12–15 years. For adult travellers, an extra tetanus toxoid-containing dose will provide additional assurance of long-lasting, possibly lifelong, protection.
All travellers should be up to date with the vaccine before departure. The type of tetanus prophylaxis that is required following injury depends on the nature of the lesion and the history of previous immunizations. However, no booster is needed if the last dose of tetanus vaccine was given less than 5 (for dirty wounds) to 10 years (for clean wounds) previously.