Tetanus Surveillance — United States, 2009–2023

Tetanus remains rare in the United States, underscoring the success of current vaccination policies and programs (11,12). Incidence during 2009–2023 (0.08 cases per 1 million population) was slightly lower than that reported during the previous surveillance period of 2001–2008 (0.10 cases per 1 million); the incidence of U.S. tetanus cases during this period was >100 times lower than the estimated global incidence of 10.3 cases per 1 million in 2019 (6,13). Tetanus primarily affects adults, with 86% of all cases occurring among adults aged ≥18 years. However, the median age of tetanus patients (40 years) during 2009–2023 was lower than that during 2001–2008 (49 years) (6). Tetanus incidence among adults aged ≥80 years is higher than for all other age groups. This cohort was born before the primary series of tetanus toxoid vaccines was recommended for routine use in 1947. The lowest incidence among children compared with other ages likely reflects the impact of high coverage with recommended tetanus immunizations for children and adolescents: for children, routine childhood diphtheria and tetanus toxoids, and acellular pertussis (DTaP) vaccines (>92% coverage with ≥3 doses by age 35 months for those born during 2011–2021) and for adolescents, adolescent tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine (Tdap) boosters (>76% coverage among adolescents aged 13–17 years during 2009–2024 [>88% since 2016]) (14,15). Adult coverage with a combined tetanus and diphtheria toxoid vaccine or Tdap is substantially lower (57%–70% during 2013–2022) than that among children or adolescents (16). Although TTCVs are recommended in childhood and as decennial boosters throughout life, older adults might have missed opportunities for booster vaccination.

Tetanus incidence in the United States varies by age, with sex modifying this association. Overall, among persons aged 17), or to persistence of antibodies among men; findings from a national serosurvey of tetanus reported lower seroprotection among older women compared with men (18). Sex differences might be also due to variations in wound frequency and clinical wound management. However, tetanus incidence worldwide remains higher among males than females throughout the lifespan (13).

Tetanus is a serious and life-threatening disease. Ninety-five percent of patients with reported tetanus are hospitalized. Approximately 1 in 10 persons who develop tetanus in the United States will die. The risk for death increases with increasing age: 85% of tetanus deaths occurred among adults aged ≥65 years. The higher incidence of death among females than among males is likely driven by the higher overall incidence of tetanus among women in the oldest age groups compared with men. Although females experience higher tetanus-associated mortality, the CFR stratified by age is similar among males and females, indicating that the risk for death among males and females who contract tetanus is similar.

Although neonatal tetanus is extraordinarily rare in the United States, cases still occur. Among neonates with known birth information, in the two cases where deliveries occurred at home, the lack of maternal TTCV vaccination combined with nonsterile delivery setting likely contributed to the development of neonatal tetanus. Worldwide, particularly in low-income countries, neonatal tetanus remains a substantial cause of morbidity and mortality after unhygienic deliveries in settings with low TTCV coverage and lacking skilled birth attendants; approximately 8,000 neonatal tetanus cases were reported worldwide in 2021 (19,20).

Tetanus and tetanus deaths are preventable through routine vaccination and recommended wound care and management (21). Approximately one half of patients with tetanus had no documented history of ever having received a TTCV, and the majority who had received ≥1 TTCV dose most recently received it ≥10 years before tetanus onset. No deaths were reported among patients with documented receipt of ≥3 TTCV doses. The two persons who died who had received a TTCV in the preceding 10 years did not have records indicating completion of their primary series, underscoring the importance of completing the primary series, in addition to decennial boosters, for protection. These findings are consistent with previous studies that reported less favorable outcomes among persons with tetanus who failed to complete the full childhood vaccination series or remain up-to-date (22,23). Although the large majority of persons with tetanus who had wounds had a tetanus-prone wound, fewer than one half sought medical care before disease onset. TTCV was indicated for nearly all patients, and TIG was indicated for approximately 75%. However, only approximately one third received TTCV, and one in 50 received TIG. Among those whose vital status was known, no patient died who received TIG prophylaxis, and one patient who received TTCV prophylaxis died, highlighting the importance of receipt of prompt and recommended treatment to reduce the risk for death.

Despite the rarity of tetanus, vigilance among clinicians is critical, and providers might benefit from continuing education regarding the indications for TTCV and TIG in wound management. These findings are consistent with those in the 2001–2008 surveillance report, which indicated that further education and support are needed for persons with wounds to ensure that they seek care. In addition, health care providers should ensure that their patients’ TTCV doses are up-to-date and follow treatment guidelines to determine the need for TIG and TTCV (24). For patients with tetanus, receiving all recommended TTCV doses during recovery is critical because contracting and surviving tetanus does not confer immunity to future infection (1).