tetanus resurgence: vaccine hesitancy

 A recent article reviewed the resurgence of tetanus in the US that is associated with inadequate tetanus vaccine administration: see tetanus resurgence JAMA2026 in dropbox, or doi:10.1001/jama.2026.9347

A few background issues:

-- tetanus is ubiquitous in nature

-- clinical tetanus develops in humans when the spores of the Clostridium tetani bacteria germinate in anaerobic environments; the spores release the tetanus toxin tetanospasmin

    -- the typical scenario is having a contaminated or deep wound providing anaerobic conditions

    -- the diagnosis of tetanus is a clinical one: there are no diagnostic tests that support or rule out tetanus

-- this toxin affects the sympathetic nervous system by interfering with the release of neurotransmitters, resulting in sustained muscular contraction and spasms

-- this effect involves many different muscles, leading to respiratory failure from chest wall spasms, diaphragmatic dysfunction, laryngospasm and airway obstruction, trismus (lockjaw), autonomic nervous system dysfunction leading to hypertension and cardiac arrhythmias, aspiration pneumonia, bone fractures from muscle spasms, nosocomial infections, and pulmonary embolism

-- the incubation period ranges from 1 to 21 days, with the longer incubation being associated with the wound/ C. tetani entry being a further distance from the central nervous system

-- the clinical course is variable, from 1-4 weeks, but survivors can take months to recover

    -- since this toxin binds irreversibly to the neuromuscular binding sites, recovery depends on the creation of new neuromuscular connections and the degradation of the toxin

-- and there is a significant mortality rate from tetanus, unless tetanus immunogloblin is administered rapidly, along with a tetanus vaccine to prevent subsequent infections

-- there are three clinical types of tetanus:

    -- cephalic (head and neck injuries, characterized by cranial nerve palsies), the least common presentation

    -- localized (spasms confined to the area surrounding the site of injury)

    -- generalized (diffuse symptoms as above), the most common presentation

-- neonatal tetanus occurs when a mother is unvaccinated or undervaccinated against tetanus, so there is no passive transplacental transfer of antibodies to the infant to provide protection for them, especially in the context of nonsterile delivery and umbilical cord care

-- the US had essentially eliminated tetanus for many decades through the routine childhood immunization program

    -- tetanus has been a nationally notifiable disease since 1947

    -- the number of new cases and deaths declined since the introduction of the tetanus vaccine into the childhood immunization program in the late 1940s, with US tetanus cases having rapid declines of >95% and deaths by >99%

    -- my sporadic scrutiny of the CDC's annual MMWR summarizing reportable infection diseases over the decades revealed only a handful of tetanus cases, all related to those individuals not immunized and largely in immigrants from countries that had spotty public health systems and no aggressive immunization programs

-- there is no human-to-human transmission of C. tetani, which means that there is no herd immunity (ie, even if almost everyone is immune to tetanus from having received the vaccine, those few unvaccinated individuals are still subject to getting the infection)

a review of CDC report (doi:10.15585/mmwr. ss7501a1):

-- tetanus surveillance for 14 years from 2009-2023

-- total of 402 tetanus cases and 37 associated deaths from 47 states and the District of Columbia

    -- mean annual tetanus incidence: 0.08 cases and 0.008 deaths per 1 million population (ie one in ten who developed clinical tetanus died)

    -- 62% occurred in males, with male predominance in those <65yo, but female predominance if >80yo having tetanus incidence of 0.27 cases per 1 million population

    -- overall case fatality rate among persons with tetanus with known status was 12.4% (37 of 299 cases), with deaths mostly in older adults

 -- 45% of persons with tetanus who had a substantial wound sought medical attention prior to disease onset

    -- of those who were eligible for tetanus post-exposure prophylaxis, only 2.3% received the tetanus immune globulin (TIG) and 26% received the tetanus-toxoid-containing vaccine (TTCV) per the CDC recommendations.

    -- among those whose vaccination history was known, 43.9% had not received any TTCV doses (ie substantial gaps in coverage)

-- the current history in the US is highly problematic:

    -- in the US, after the Covid pandemic there has been a significant decline in immunizations overall (despite the fact that 1 million US individuals died from Covid and the vaccine prevented over 3 million more), with the CDC reporting a decline to 92.1% in DTap (diphtheria, tetanus, and pertussis) coverage in children in kindergarten during the 2024-2025 school year from the year before: https://www.cdc.gov/schoolvaxview/data/index.html

        -- and, MMR, DTaP, polio, and varicella vaccinations decreased in more than half the states vs the year before

        -- exemptions from one or more vaccines in those in kindergarten increased from 3.3% to 3.6%, resulting in 138,000 kindergartners being exempt from one or more vaccines in 2024-2025

-- the provisional count for 2025 is 38 tetanus cases, the highest of any year from 2009 to 2023

Report on current tetanus cases:

-- Four pediatric cases were reported to the CDC in 2024: https://www.cdc.gov/mmwr/volumes/75/wr/pdfs/mm7514a2-H.pdf, or doi:10. 15585/mmwr.mm7514a2

    -- patient A: age group (10-15yo), lives in city, unvaccinated, had likely exposure from compound ankle fracture, sought care when injured, parents declined TIG and TTCV, in hospital 8 days and received TIG and 1 dose of TTCV

    -- patient B: age group (5-9yo), lives outside city, unvaccinated, unknown likely exposure, not seen before tetanus symptoms, in hospital 31 days and received TIG and 2 doses of TTCV

    -- patient C: age group (1-4yo), lives in city, unvaccinated, had likely exposure of knee puncture from animal bone, sought care 8 days after being injured, parents declined TIG and TTCV, in hospital 16 days and received TIG and 4 doses of TTCV

    -- patient D: age group (10-15yo), lives outside city, unvaccinated, had likely exposure from crush injury from horse hoof while barefoot, did not seek care when injured, in hospital 45 days and received TIG and 2 doses of TTCV

        -- all had generalized tetanus with the common symptoms of back, neck and jaw pain; muscle spasms and rigidity; and difficulty walking

        -- none of them died; all were unvaccinated; those who went to the hospital after injury had parents who declined tetanus immunoglobulin (TIG) or future prophylaxis (TTCV)

        -- only one of them subsequently completed the recommended primary TTCV vaccination series

        -- at least two patients received post-discharge clinical care, including readmission for inpatient rehabilitation

            -- bottom line: terrible outcomes (fortunately no deaths) from not receiving initial childhood immunization, delays in wound care, lack of timely administration of TIG after the exposure and before the illness (per parental refusal)

so, it is hard for us as clinicians to see awful outcomes from a well-documented preventable illness. there are highly unfortunate current circumstances that have created this situation:

    -- "respected" governmental and other "authorities" have infiltrated the news and social media touting the disastrous effects of immunization and have undercut the authority of clinicians (who actually know the importance of vaccinations)

    -- many people do not listen to or read the strong evidence-based recommendations to perform the needed vaccinations

        -- by the way, it was notable that Mississippi, a reliably Republican state, was the US leader in the most aggressive childhood vaccination requirements in the country (99%, with country average of 91%), though kindergarten vaccination rates decreased in 2024-2026 to 97.5%

        -- notably, one of the 4 children above had no known "likely exposures" to tetanus, which should really reinforce the need for preventative vaccination early in life (one cannot rely on immediate care after a puncture wound....)

        -- this lack of confidence in clinicians even occurred after the children in the above 4 cases got this horrific disease, with 2 readmitted for inpatient rehabilitation; the parents did not even follow through on completing the vaccination series!!!

-- there are other important reasons for vaccine hesitancy, beyond the pervasive anti-vax rhetoric in the US:

    -- some people may have feared going to the hospital because of no or inadequate health insurance (an increasingly common problem) and were not able to deal with high bills

    -- some may have feared going to the hospital for concern of ICE agents arresting and deporting them

-- but it is hard to see the US devolve from being a country with a strong immunization program to at best a mediocre one based on thoughtless (ie anti-scientific) and destructive political interference

    -- we are clearly setting ourselves up as a cauldron for more avoidable severe diseases in the future

-- we will need a vigorous public health program in the (hopefully) near future to do the aggressive and broad education about the importance of childhood and later vaccinations. This will be a difficult task and require a lot of time to revert to having a strong national program to invigorate the public into accepting the vaccinations

-- and the current resurgence of two awful diseases, tetanus and measles, may well serve as the foundation for such a campaign

geoff

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