Tetanus Didn’t Leave Us, We Left Tetanus
What Is Tetanus?
Tetanus, also called lock jaw, is a bacterial disease caused by the organism Clostridium tetani. The disease is caused when tetanus bacteria, which can be found in soil laden with animal manure, invade the body through a deep wound, which doesn’t bleed efficiently or lacks oxygen.
Bleeding is one way a wound cleanses itself.
Tetanus is an anaerobic bacteria, meaning it can survive without oxygen. If the conditions are met, the bacteria produces a toxin, or poison, that attacks the nervous system and causes the hallmark signs of tetanus:
- muscles become tight
- the neck and jaw muscles could lock
- severe muscle spasms
- painful muscle stiffness
- trouble swallowing
- seizures
- fever and sweating
A wound that is cleaned, bleeds, and has oxygen exposure is unlikely to be the conditions for tetanus to thrive.
The likelihood of tetanus is greatest following deep, dirty puncture wounds where there is little bleeding and an absence of oxygen.
Interestingly, the vaccine against tetanus contains not pieces of the bacteria, but rather the toxin, hence the tetanus vaccines (Dtap, Tdap, Td) are all toxoid vaccines.
Tetanus Before and After Vaccines
Historically, tetanus was more common on farms due to the abundance of manure, in the context of accidents and injuries inherent to the farming industry.
In larger cities, tetanus infections were more common prior to the invention of the automobile, which replaced horses with vehicles that did not excrete tons of manure each day onto the city streets.
In the late 1800s and early 1900s, the streets of big cities like New York were literally filled with manure from horses, which would have harbored tetanus spores. On any given day, nearly 200,000 horses would traverse the streets, moving around millions of inhabitants. Just one horse produces between 10 and 15 kilograms of manure each day. It’s not hard to imagine why people were so ill back then.
According to the CDC, before widespread use of the vaccine in the late 1940s, there was an average of 580 cases of tetanus and an average of 472 deaths from tetanus reported.
According to a 1957 report, the incidence of tetanus had changed very little since 1947 when morbidity data were first published. In 1955, there were 462 cases and 265 deaths registered in the United States. So despite vaccination introduction in the late 1940s and early 1950s, the cases and deaths only marginally declined during this time.
The report acknowledged that historically, at least 10% of tetanus cases were postoperative or surgical tetanus. Another portion of tetanus cases were due to drug addicts using unsterilized needles, syringes, or contaminated drugs:
“In a one and one-half year period ending in July, 1954, Levinson reported that 12 of 22 adult tetanus cases treated at Cook County Hospital, Chicago, had been heroin addicts.”
According to the report, the largest category of tetanus cases were those following injury, and the most frequent injuries were puncture wounds, emphasizing the importance of improving medical practices on minor wounds and lacerations in the prevention of tetanus.
The paper summarizes that:
“despite the advent of improved preventive and therapeutic methods, the incidence of tetanus has shown little change.”
Fast forward to 2017, a total of 33 tetanus cases and 2 deaths were reported in the United States. Vaccination status was known for 72 (27%) of 264 tetanus cases reported from 2009 through 2017. A total of 18 (25%) had received 3 or more doses of tetanus toxoid. The remaining patients were either unvaccinated or had received fewer than 3 doses of tetanus toxoid. Why don’t they break this down further for us?
From 2009 through 2017, a total of 264 cases and 19 deaths from tetanus were reported in the United States. Sixty (23%) cases were in persons 65 years of age or older, 168 (64%) were in persons 20 through 64 years of age, and 36 (13%) were in persons younger than 20 years, including 3 cases of neonatal tetanus. All tetanus-related deaths occurred among patients >55 years of age.
By these numbers, a child living today in the United States has very little risk of developing tetanus. Essentially zero.
Not to complicate things, but there is no diagnostic laboratory test for tetanus; the diagnosis is entirely clinical. C. tetani is recovered from wounds in only about 30% of cases, and the organism is sometimes isolated from patients who do not have tetanus, according to the CDC.
So What Really Happened To Tetanus?
I’m not an epidemiologist, but let’s look at every part of the picture and see how everything connects. Is there anything else that explains the decrease in reported tetanus?
- Lifestyle shift from farming communities to urban areas and suburban cities
- Horses replaced by automobiles
- Safer methods of farming, more automated
- Improved surgical techniques and wound cleaning
- Introduction of antibiotics and antiseptics
- Advances in birth practices
Tetanus is not communicable. It’s not contagious. It’s directly related to soil and manure (and a deep, dirty wound that isn’t cleaned well).
In the 1950s, thirteen Southern States accounted for all neonatal tetanus deaths, and non-white deaths greatly outnumbered white deaths. These are also States that currently have a higher infant and maternal mortality than all other States. Is this just an effect of tetanus distribution, is subsequent reduction in tetanus simply an effect of vaccination–or could it have more to do with inequalities in medical care, living conditions, birth practices, or a tendency to assign presumptive causes of death based on prejudices? Since there is no diagnostic test for tetanus, was this a subjective or presumptive diagnosis?
Most cases of neonatal tetanus at this time were the result of tetanus contamination of the umbilical stump, following a home delivery, unattended by even a midwife, among the Black community, and in Texas, among the Hispanic community, according to this report. This is a very specific set of risk factors that does not represent every family today.
Tetanus vaccination
According to the CDC, widespread vaccination against tetanus didn’t begin until the late 1940s. And before widespread use of the vaccine, there was an average of 580 cases of tetanus and an average of 472 deaths from tetanus reported.
Most tetanus deaths were people over aged 60 (1 or 2 deaths per 100,000 people).
By comparison, today:
- 161 per 100,000 people die of cancer
- 12 per 100,000 people die in auto accidents
- 3 per 100,000 die of lightening
When a vaccine is “introduced” there is not 100% vaccine uptake or coverage. When the DPT first rolled out in 1948, it had a coverage level around 55%. The tetanus shot by itself would have been lower.
When the DPT vaccine came out, it was marketed to infants. But the typical tetanus case was in adults, and the average age of death was over 60 years old. So, exactly how does a shot in a baby prevent a death in an over 60 year old?
What’s even more concerning, is that in developing countries, including countries that have rigorous vaccination programs, there are still thousands of tetanus deaths in the first month of life due to poor sanitary conditions and hygiene.
In 2015, in developing nations approximately 34,000 newborns died from neonatal tetanus, a 96% reduction from 1988 when an estimated 787,000 newborn babies died of tetanus within their first month of life.
Many of these infants are undergoing circumcision with unsterile equipment or improper umbilical cord clamping with unsterile equipment or no access to clean running water.
Vaccination doesn’t prevent an infant from being exposed to tetanus, and it doesn’t guarantee an infant will survive once it develops a tetanus infection. This can ONLY be prevented by proper hygiene and cleaning of wounds.
However, we should not use statistics from developing, third world countries to justify public health policies in a highly developed first world nation.
A study looked at the levels of tetanus antitoxin antibodies in new mothers and found similar levels of antibodies in infants of unvaccinated mothers and vaccinated mothers. That study also found that vaccinating a pregnant woman interfered with her neonates response to subsequent DTP vaccinations:
It was found that the percentage of protective infants born from non-immunized and immunized mothers were 95.4 and 100 respectively. The transplacental tetanus immunity in infants of immunized mothers was higher than those of non-immunized mothers, however, it was significantly reduced in both groups of infants within two months. After the first dose of DTP vaccine, infants born from non-immunized mothers were able to respond well in producing antibody whereas the infants from immunized mothers were not.
As always, there is a lot more to the story, a lot more to the picture. Most likely, in the United States, the incidence of tetanus declined more so because of shifts in population and improvements in first aid wound cleaning, hygiene and the discovery of antibiotics.
Remember, at this time, syringes were being reused between people. I have a hard time assigning too much credit to “sharing needles” when we already know a hepatitis c outbreak among baby boomers was started from this very thing.
