Lockjaw

Tetanus is a serious, acute (severe but short-lived) condition that is caused by infection with a bacterium known as Clostridium tetani.

As the Clostridium tetani bacterium is commonly found in the environment, tetanus can never be completely eradicated. In particular, the bacteria are often found in:

  • soil
  • dust
  • manure

The incubation period for a tetanus infection (the time between getting the infection and the onset of symptoms) is 4 to 21 days. The average incubation time is 10 days.

A tetanus infection must be treated quickly. If tetanus is not treated, it can be fatal. The condition cannot be passed from one person to another.

Tetanospasmin

The tetanus bacteria usually enter the body through a wound or cut in the skin. Once inside, the bacteria multiply and release a neurotoxin (poison) called tetanospasmin, which causes the symptoms of tetanus to develop.

Tetanospasmin can spread through the bloodstream, blocking the nerve signals from the spinal cord to the muscles. This causes muscle spasms (involuntary contractions) and rigidity (stiffness) throughout the body, particularly in the neck, face and jaw (lockjaw).

Due to its potential seriousness, tetanus is a notifiable condition. This means that when the condition is diagnosed, the doctor making the diagnosis must inform the local authority under the Public Health (Infectious Diseases) Regulations (1988).

How common is tetanus?

For over 50 years, babies and young children have been routinely vaccinated against tetanus as part of the national childhood vaccination programme. Therefore, in Ireland, tetanus infections are rare and most cases affect people over 65 who have not been vaccinated.

For example, from 1981 to 2009, there were 9 cases of tetanus in Ireland.

The highest number of tetanus cases during this period was in adults over 65 years of age. This is because people in this age category were not routinely vaccinated against tetanus as children.

Neonatal tetanus

In theese islands, there have been no cases of neonatal tetanus (tetanus in newborn babies) for over 30 years. However, in many developing countries, neonatal tetanus is still a public health problem. It is usually caused if the umbilical stump becomes infected when the umbilical cord is cut using unsterilised equipment.

One of the World Health Organization's aims was to eliminate neonatal tetanus worldwide by 1995. However, the condition has not yet been totally eradicated, but the number of countries reporting cases is steadily decreasing.

Tetanus vaccination

All young children are offered the tetanus vaccine as part of the routine childhood vaccination programme.

The tetanus vaccine encourages the body to create antibodies (infection-fighting cells) that provide a defence against tetanospasmin. This provides protection from the illness should you become infected with the tetanus bacteria.

The full course of the tetanus vaccine consists of five doses. The primary course consists of three injections, which provide protection against the infection for a number of years. The fourth and fifth doses are booster doses, which help maintain protection.

After the fifth dose, immunity remains for life and further boosters are not usually required, unless there is doubt about a person's vaccination history or you are travelling to a remote area of the world where treatment for a tetanus infection may not be readily available.

See Tetanus: prevention for more information and advice about the tetanus vaccination.

If you have been infected by the Clostridium tetani bacterium, you will usually start to develop the symptoms of tetanus around 10 days after the initial infection.

The incubation period for tetanus (the time between catching an infection and showing symptoms) is usually between 4 to 21 days, although in some cases it can be as little as one day or as long as several months.

Muscle stiffness and spasms

The main symptoms of tetanus are muscle spasms and muscular rigidity (stiffness). Stiffness is often first apparent in the face, with the 'chewing muscles' often being affected, which makes it difficult to open your mouth. This is sometimes called 'lockjaw'.

The muscle spasms then usually affect the neck area and the throat muscles, which can make swallowing difficult (dysphagia). You may also experience spasms in your facial muscles, which make it look as if you are grinning.

Muscle stiffness in the neck and chest can make breathing difficult. Sometimes, the abdominal muscles and the muscles of the arms and legs are also affected. Spasms in the back muscles can affect the spine which, in severe cases, can become arched backwards. This most commonly occurs in children with a tetanus infection.

Other symptoms

Other symptoms that are associated with a tetanus infection include:

  • a high temperature (fever) of 38C (100.4F) or above
  • sweating
  • a rapid heartbeat (tachycardia)
  • high blood pressure (hypertension)

Tetanus can be fatal

If it is not treated, tetanus can cause complications that can lead to death. Mortality rates are highest among infants and the elderly. Death can be caused by:

  • blood poisoning (septicaemia)
  • suffocation (asphyxia)
  • heart attack (cardiac arrest)
  • kidney failure

See Tetanus: complications for more information.

Stomach

The sac-like organ of the digestive system. It helps digest food by churning it and mixing it with acids to break it down into smaller pieces.

Spine

The spine supports the skeleton and surrounds and protects the delicate spinal cord and nerves. It is made up of 33 bones called the vertebrae.

Heart

The heart is a muscular organ that pumps blood around the body.

Kidney

Kidneys are a pair of bean-shaped organs located at the back of the abdomen, which remove waste and extra fluid from the blood and pass them out of the body as urine.

Tetanus is caused by the Clostridium tetani bacterium.

Clostridium tetani and tetanospasmin

Clostridium tetani spores can live for a long time outside the body and are widespread in the environment. They are commonly found in the manure of animals, such as horses and cows, and in contaminated soil.

After entering the body, the tetanus bacteria quickly multiply and release a neurotoxin (poison) called tetanospasmin. If tetanospasmin enters the bloodstream, it can spread around the body, causing the symptoms of tetanus to develop.

Tetanospasmin blocks the nerve signals that are sent from the brain to the spinal cord and then on to the muscles. This causes muscle spasms and muscle stiffness.

Cuts and wounds

One of the most common ways that tetanus bacteria can enter the body is through a cut (deep or superficial) or puncture wound. A minor gardening injury, such as a puncture wound from a rose thorn, can result in a tetanus infection developing.

The tetanus bacteria thrive and breed in places where there is little or no oxygen, which is why the infection often occurs in deep cuts and wounds. Therefore, to help prevent a tetanus infection developing, cuts and wounds should always be thoroughly cleaned.

Other entry points

As well as through cuts and wounds tetanus bacteria can enter the body as a result of:

  • burns
  • abrasions and lacerations
  • animal bites
  • intravenous drug use (where drugs are injected into a vein using dirty needles)
  • body piercing and tattoos (where unsterilised equipments is used)
  • circumcision (both male and female)

Risk groups

There are some groups of people who may be at increased risk of tetanus.

Travellers

If you are travelling abroad, make sure that your vaccinations are up to date, according to the schedule. Depending on where you are travelling, you may require additional doses of certain vaccinations. See the Health A-Z topic about Travel vaccinations for more information.

If you are travelling to a remote area where medical services may not be accessible and you had your last tetanus vaccine more than 10 years ago, you need to have a booster dose (even if you have already received the full five doses). This is a precautionary measure in case you get a tetanus-prone wound and tetanus immunoglobulin (TIG) is not available.

If you require protection from tetanus, diphtheria or polio and your last vaccine was more than 10 years ago, you will be given Td/IPV. See Tetanus - prevention for more information about the tetanus vaccine.

Other vulnerable groups

People who inject drugs have an increased risk of developing a tetanus infection and need to be protected against the condition. Booster doses should be given even if the person's vaccination status is unknown.

People whose jobs may expose them to tetanus, such as those who work in microbiology laboratories, are also at risk and should be fully vaccinated.

Tetanus is rare because the tetanus vaccine is part of the routine childhood immunisation programme.

As tetanus is a very rare condition in Ireland, many GPs will not see a patient with tetanus throughout their entire career. However, although it is rare, it is vital that tetanus is diagnosed as early as possible because it can be fatal if left untreated.

Diagnosing tetanus is usually straightforward because the symptoms are easily recognised. Few other conditions cause painful muscle spasms like tetanus. Therefore, a confident diagnosis can usually be made if someone has recently had a dirty wound and has painful muscle spasms and muscle stiffness.

Tetanus can sometimes be difficult to diagnose in intravenous drug users (people who inject drugs) because they often have many other medical problems. In such cases, a blood test may be used to confirm the diagnosis.

When to seek medical advice

As tetanus is serious and potentially fatal, it should always be treated as a medical emergency. See your GP immediately if you experience the symptoms of tetanus.

Seek medical advice straight away if you are abroad and you experience the symptoms of tetanus. If you are going abroad, ask your GP about any travel vaccinations you may require.

You will not usually require a tetanus vaccination if your vaccinations are up to date. However, if you plan to travel to areas where medical help may not be easily accessible, a booster vaccination may be recommended.

If you have a cut or a wound, it must be cleaned thoroughly to prevent infection. If you have a tetanus-prone wound, you must receive medical treatment as soon as possible.

Tetanus-prone wounds

A tetanus-prone wound is:

  • wounds or burns that require surgical intervention that is delayed for more than six hours
  • wounds or burns that show a significant degree of devitalised (removed) tissue or a puncture-type injury, particularly where there has been contact with soil or manure
  • wounds containing foreign bodies
  • compound fractures (serious fracture where the bone is exposed to infection)
  • wounds and burns in patients who have systemic sepsis (a fall in blood pressure resulting from a serious bacterial infection)

If a wound fulfils the above criteria and is considered to be high risk, tetanus immunoglobulin (TIG) should be given immediately, whatever the person's tetanus vaccination history. High risk is regarded as heavy contamination with material that is likely to contain tetanus spores or extensive devitalised tissue.

In such circumstances, TIG should be given as a precautionary measure because, at the moment, there is insufficient clinical evidence to support any alternative forms of treatment.

Tetanus immunoglobulin

Tetanus immunoglobulin (TIG) is a solution that contains antibodies (infection-fighting cells) that kill the tetanus bacteria. It is given as an intravenous injection (injection into a vein) and provides immediate, short-term protection against tetanus.

As TIG only offers short-term protection against tetanus, the amount of tetanus antibodies in your system will gradually decrease over time and replacement antibodies will not be created. Therefore, it is always a good idea to ensure that you are vaccinated against tetanus and that your vaccinations are fully up to date (see Tetanus: prevention).

When required, TIG and tetanus-containing vaccines should be given to pregnant women without delay. There is no evidence to suggest any risks to pregnant and breastfeeding women from these types of vaccines.

People whose immune systems are suppressed, such as those with HIV or who are having chemotherapy, should be given TIG and tetanus-containing vaccines when required. People with suppressed immune systems may not create a full amount of tetanus antibodies, so after they have made a full recovery, a booster dose should be considered.

Antibiotics

Antibiotics, such as penicillin and metronidazole, are sometimes used to treat tetanus infections. They work by preventing the Clostridium tetani bacterium from multiplying, stopping the tetanospasmin (neurotoxin) from spreading.

In cases where a person is allergic to penicillin or metronidazole, tetracycline may be used as an alternative antibiotic.

Treating muscle spasms

A number of different types of medication may be prescribed to treat muscle spasms and muscle stiffness, including:

  • anticonvulsants (sedatives)
  • muscle relaxants
  • neuromuscular blocking agents

Anticonvulsants

Anticonvulsants, such as diazepam (Valium), are often used to treat muscle spasms caused by a tetanus infection.

Diazepam

Diazepam is the most frequently used anticonvulsant for treating tetanus infections. Diazepam:

  • relaxes the muscles
  • reduces anxiety
  • works as a sedative

Diazepam should only be used for short periods of time because long-term use can lead to dependency. Withdrawal symptoms, such as anxiety, insomnia and loss of appetite, may occur if treatment with diazepam is stopped suddenly. Therefore, treatment should always be phased out gradually.

Diazepam can cause side effects including:

  • drowsiness
  • muscle weakness
  • reduced alertness

If you are prescribed diazepam, do not drive or operate heavy machinery, and avoid drinking alcohol as it is likely to make side effects worse.

If you are pregnant, do not take diazepam because it may harm the development of your baby. However, in exceptional circumstances where it is felt that the benefits of taking diazepam outweigh the risk to the foetus, diazepam may be recommended.

Do not breastfeed your baby while you are taking diazepam.

Phenobarbital

Phenobarbital is another type of anticonvulsant that is sometimes prescribed to treat tetanus. It can help prolong the effects of diazepam and is effective in treating severe muscle spasms.

As with diazepam, phenobarbital can cause withdrawal symptoms if it is stopped too quickly, so treatment should be stopped gradually. There are also a wide range of side effects associated with phenobarbital including:

  • drowsiness
  • irritability
  • depression
  • lack of concentration
  • shaky movements and an unsteady walk (ataxia)
  • hyperactivity
  • hallucinations (seeing or hearing things that are not real)
  • changes in blood cells
  • low blood pressure (hypotension)

If you are prescribed phenobarbital, do not drive or use heavy machinery, and avoid drinking alcohol.

As with most anticonvulsant medicines, phenobarbital carries a risk of causing developmental problems to an unborn baby. However, sometimes, uncontrolled seizures may carry a greater risk of harming the baby. Therefore, seek advice from your GP if you are pregnant or if you decide to try for a baby.

Do not breastfeed if you are taking phenobarbital.

Muscle relaxants

Baclofen (Lioresal) and dantrolene (Dantrium) are two muscle-relaxing medicines that are sometimes prescribed to help ease the symptoms of muscle stiffness and muscle spasms.

Baclofen

Baclofen is a muscle relaxant that works by suppressing (controlling) the nerve signals that are sent from the brain to the spinal cord. This reduces tension in the muscles.

Balcofen can cause a wide variety of side effects including:

  • drowsiness
  • headache
  • light headedness
  • confusion
  • mood swings
  • shaky movements and an unsteady walk (ataxia)
  • seizures (fits)
  • hallucinations (seeing or hearing things that are not real)
  • difficulty sleeping (insomnia)
  • nightmares
  • an increased need to pass urine
  • decreased blood pressure
  • visual disturbances

Balcofen can cause drowsiness. If you are prescribed it, do not drive or operate heavy machinery. Also avoid drinking alcohol because it is likely to make side effects, such as drowsiness, worse.

Balcofen is not usually recommended for use during pregnancy due to the potentially harmful effects it can have on the developing baby. However, sometimes it may be prescribed if it is thought that its use will outweigh the associated risks. Speak to GP about this.

Although balcofen passes into breast milk, at the normal prescribed doses it is not considered dangerous to the baby. However, if you are taking balcofen, discuss breastfeeding with your GP.

Dantrolene

Dantrolene is sometimes prescribed in cases of chronic (long-term) muscle spasticity (where your muscles are overly tight or rigid). It works by lowering the amount of calcium in the muscle cells, which reduces the muscle's sensitivity to nerve signals.

Some of the side effects associated with dantrolene include:

  • drowsiness
  • dizziness
  • headache
  • tiredness
  • confusion
  • depression
  • a skin rash
  • loss of appetite
  • diarrhoea
  • breathing difficulties
  • increased heartbeat (tachycardia)
  • visual and speech disturbances

If you are prescribed dantrolene, do not drive or operate heavy machinery and avoid drinking alcohol.

Dantrolene is not recommended for use by pregnant women or women who are breastfeeding. Seek further advice from your GP.

Neuromuscular blocking agents

Neuromuscular blocking agents block the signals that are transmitted from the nerves to the muscle fibres. This type of medication can be useful in helping control muscle spasms.

Vecuronium

Vecuronium is a neuromuscular blocking agent that is sometimes used during surgery as a muscle relaxant in addition to anaesthesia.

However, vecuronium is also effective at paralysing muscles, so it is sometimes prescribed to help control the muscle spasms that are a common symptom of a tetanus infection.

In pregnant women, there are no confirmed risks to the unborn baby associated with using vecuronium. Therefore, it may be prescribed if it is felt the benefits outweigh any potential risks to the foetus.

Surgery

In cases where a tetanus-prone wound is particularly large, it may be necessary to remove as much of the damaged and contaminated muscle as possible using a surgical procedure called debridement.

Debridement is the process of cleaning an open wound by removing foreign material, such as dirt and manure, as well as any dead tissue. In the case of a tetanus infection, debridement will limit the spread of the tetanospasmin toxin, allowing the wound to heal unhindered.

Nutrition and breathing

As a result of the increased muscle activity that is caused by tetanus, someone with the infection needs to consume a high amount of calories. An intake of 3,500-4000 calories is often required, plus 150g of protein a day.

If swallowing is difficult or not possible, it may be necessary to provide a liquid feed through a tube that is directly connected to the stomach or through a drip into a vein. Assistance with breathing may also be required.

How many people die from tetanus?

The World Health Organization (WHO) estimate that about 280,000 people die of tetanus worldwide each year, mostly in developing countries. Around 210,000 of these deaths are children.

 

In cases of severe tetanus infection, a number of possible complications can develop. Some of the complications that are associated with tetanus are outlined below.

Fractures

The repeated muscle spasms and convulsions that are caused by a tetanus infection may lead to fractures in the vertebrae, as well as in other bones.

Bone fractures can sometimes result in a condition called myositis ossificans circumscripta, which is where bone begins to form in the soft tissues, often around a joint.

See the Health A-Z topic about Fractures for more information.

Aspiration pneumonia

If you have a tetanus infection, muscle rigidity can make coughing and swallowing difficult. This can cause aspiration pneumonia to develop.

Aspiration pneumonia occurs as a result of inhaling the secretions or contents of the stomach, which can lead to a lower respiratory tract infection.

See the Health A-Z topics about Pneumonia and Respiratory tract infections for more information.

Laryngospasm

Laryngospasm is where the larynx (voice box) goes into a brief, temporary spasm that usually lasts 30-60 seconds. Laryngospasm prevents oxygen from reaching your lungs, making breathing difficult.

Following a laryngospasm attack, your vocal cords will usually relax and return to normal. However, in very severe cases, laryngospasm can lead to asphyxia (suffocation).

There is no medication to effectively treat laryngospasm, but sitting down and trying to relax your entire body may speed up recovery.

Tetanic seizures

Tetanic seizures are convulsions that are similar to epileptic fits. They can occur in severe cases of tetanus where the infection has spread to the brain. Someone with a severe tetanus infection may experience severe and frequent tetanic seizures.

Pulmonary embolism

A pulmonary embolism is a serious and potentially life-threatening condition. It is caused by a blockage in a blood vessel in the lungs that can affect breathing and circulation. It is, therefore, vital that treatment is given immediately in the form of anti-clotting medication and, if required, oxygen therapy.

See the Health A-Z topic about Pulmonary embolism for more information.

Acute renal failure

The severe muscle spasms that are associated with a tetanus infection can cause a condition known as rhabdomyolysis.

Rhabdomyolysis is where the skeletal muscles are rapidly destroyed, resulting in myoglobin (a muscle protein) leaking into the urine. This can lead to acute kidney failure.

See the Health A-Z topic about Kidney failure for more information.

Vaccination is the best way to prevent a tetanus infection from occurring. The complete course of the tetanus vaccination consists of five doses.

The vaccine allows your body to create antibodies against the tetanus toxin (tetanospasmin), providing protection from the illness if you are exposed to the Clostridium tetani bacterium in the future.

In Ireland, all children are routinely offered the tetanus vaccine as part of the childhood vaccination programme.

As an adult, if you are unsure about whether or not you have been fully vaccinated against tetanus, speak to your GP or practice nurse. They will be able to advise you about having a booster injection.

Primary vaccination

The primary course of the tetanus vaccination consists of three doses of the vaccine with a period of two months between each dose. This is given to babies at 2, 4 and 6 months of age as part of the 6 in 1 vaccine.

Babies who are born prematurely should be vaccinated at the appropriate age according to the vaccination schedule. There is no evidence that premature babies are at increased risk of having adverse reactions to vaccines.

Most children can have the vaccine. However, it should not be given to children who:

  • have had an anaphylactic reaction (a severe allergic reaction) to a previous dose
  • have had an anaphylactic reaction to any of the ingredients of the vaccine (including neomycin, streptomycin and polymyxin B, which may be present in small amounts)

If your child is unwell and has a high temperature (fever), postpone their vaccine until they have recovered. It is fine for your child to receive the vaccine if they have a minor illness, such as a cold or cough.

Side effects

Within 12 to 24 hours of having the vaccine, your child may experience some mild side effects, including:

  • discomfort, redness and swelling where the injection was given
  • a raised temperature

In very rare cases, babies experience more serious side effects around 24 to 48 hours after receiving the vaccine, including:

  • a very high temperature (fever)
  • febrile convulsions (a fit associated with a fever)
  • an unusually high-pitched cry
  • being floppy and less responsive than usual

Contact your GP immediately if your baby has a fit. They may have an illness that is unrelated to the vaccine. Whatever the cause, it is important to tell your GP. Babies usually fully recover after having a fit.

Do not delay having your baby vaccinated as doing so can increase their risk of having fits. It is very important to ensure that your child is vaccinated at the right age.

As with all vaccines, there is a rare possibility that the vaccine will cause anaphylaxis (a severe allergic reaction). Speak to your GP if you think your child has had a reaction to the vaccine.

Secondary immunisation

The first booster dose

Children aged 4 to 5 years are given a booster dose of tetanus vaccine as part of the 4 in 1 vaccine. The 4 in 1 vaccine is usually given in junior infants of primary school ( except in Sligo, Leitrim and Donegal where it is given by the GP).

The second booster dose

In 1st year of secondary school, students are given a booster dose of tetanus vaccine which is contained in theTDaP vaccine given to students.

 

Side effects

Most children have no problems after Tdap vaccines. A small number of children may have an area of soreness, swelling and redness where the injection was given. They may get a headache, nausea or a fever. If this happens you can give them paracetamol or ibuprofen. You should also give them plenty to drink. Make sure they are not too warm and that their clothes are not rubbing against the injection site.

Content provided by NHS Choices www.nhs.uk and adapted for Ireland by the Health A-Z.

Browse Health A-Z