Oregon's First Pediatric Tetanus Case in Over 30 Years Highlights Vaccination Refusal

A recent case study by investigators in Oregon details a 2017 pediatric tetanus case in an unvaccinated child, the state’s first such case in more than 30 years.

The report, published recently in the US Centers for Disease Control and Prevention’s (CDC) Morbidity and Mortality Weekly Report, describes a tetanus case in an unvaccinated Oregon child that occurred in 2017. An average of 30 cases occur in the United States each year, typically in individuals who have not received a full course of the tetanus vaccine and who have not gotten boosters.

Tetanus morbidity and mortality has declined in the United States since the 1940s, when tetanus toxoid-containing vaccines such as the diphtheria, tetanus, and pertussis (DTaP) vaccine became widely available. In the decades since, the United States has seen a 95% decline in the number of tetanus cases and a 99% decrease in the number of tetanus-related deaths. However, spores of the Clostridium tetani bacteria that cause tetanus still persist in soil, dust, and manure and can lead to an infection known as lockjaw if the bacteria comes into contact with exposed wounds, typically within 3 to 21 days.

“Unvaccinated or inadequately vaccinated persons are at risk for tetanus, irrespective of age, and recovery from tetanus disease does not confer immunity,” the study investigators wrote.

In the case study, investigators detail a tetanus infection in an unvaccinated 6-year-old boy that began after the child sustained an injury while playing outdoors on a farm. Although the wound was cleaned and sutured, 6 days after the injury the boy began to experience symptoms including jaw clenching, involuntary upper extremity muscle spasms, arching of the neck and back (opisthotonus), and breathing difficulty. His parents notified emergency medical services and the child was transported by air to a pediatric medical facility, where he was admitted to a pediatric intensive care unit and required sedation, endotracheal intubation, and mechanical ventilation.

The child received tetanus immune globulin and a dose of the DTaP vaccine, along with intravenous metronidazole, further wound care, and multiple continuous intravenous medication infusions to control his pain and blood pressure. On day 44 of his hospitalization, the boy was taken off ventilator support and was able to take sips of clear liquids. On day 57 he was transferred to a rehabilitation center, where he received an additional 17 days of care.

“The boy required 57 days of inpatient acute care, including 47 days in the intensive care unit. The inpatient charges totaled $811,929, excluding air transportation, inpatient rehabilitation, and ambulatory follow-up costs,” investigators explained. “The health care costs to treat this child’s preventable disease were approximately 72 times the mean cost of $11,143 for a US pediatric hospitalization. A recent report describing adult tetanus cases included hospital charges ranging from $22,229 to $1,024,672.”

Although the child was able to resume his normal activities 1 month after completing rehabilitation, his parents declined additional doses of DTaP or other vaccines. Under current recommendations, children receive a 5-dose series of the DTaP vaccine, with the first dose at 2 months of age and the fifth dose at 4 to 6 years of age. A booster of tetanus toxoids every 10 years is recommended for adults.