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Katherine L. Campbell, PhD1,2; Avnika B. Amin, PhD2,3; Jessica Goswitz, MPH4; Rebecca Betz, MS5; Stacey Moyer, MSN6; Jayne Griffith, MPH7; Kris K. Carter, DVM1,8; Christine Hahn, MD1; Michelle M. Hughes, PhD3 (
Summary
What is already known about this topic?
Because of high coverage with recommended tetanus toxoid–containing vaccine (TTCV), pediatric tetanus is rare in the United States; approximately four cases are reported annually.
What is added by this report?
Among four U.S. children who developed tetanus in 2024, none had completed a primary TTCV series, and none received TTCV or tetanus immunoglobulin (TIG) prophylaxis after their exposure and before illness onset. All four patients required hospitalization, ranging from 8 to 45 days, and two required additional rehabilitation care. Only one child completed the TTCV series after illness.
What are the implications for public health practice?
Completing a primary TTCV series and remaining up to date with TTCV vaccination are essential to preventing tetanus; patients with tetanus-prone wounds should receive timely administration of TTCV and TIG according to recommendations.
Related Materials
Tetanus is an acute neuromuscular disease mediated by a toxin produced by Clostridium tetani bacteria.* C. tetani spores are ubiquitous in the environment, including in soil, dust, and manure, and are often introduced into the body through an injury. C. tetani spores enter the body, germinate, and produce tetanospasmin, a potent neurotoxin that can cause severe, sometimes fatal, disease. Persons can help prevent tetanus by remaining up to date with recommended tetanus toxoid–containing vaccine (TTCV) and by receiving postwound prophylaxis for tetanus-prone wounds, including wound care and administration of TTCV or tetanus immunoglobulin (TIG); the treatment regimen is based on multiple clinical considerations (1). In the United States, pediatric tetanus is rare because of high coverage with recommended TTCV doses,† although pediatric TTCV vaccination coverage varies by state (1,2). A recent surveillance summary reported that among persons with tetanus whose vaccination history was known, 44% had not received a TTCV dose (1). During 2013–2023, an average of 4.4 U.S. pediatric tetanus cases were identified each year in the CDC National Notifiable Diseases Surveillance System (NNDSS) (1). In July 2024, the first pediatric case of tetanus in Idaho in >30 years was reported. Three other U.S. pediatric cases were reported in three other states in 2024. An investigation was initiated to understand patient characteristics and the circumstances under which these cases occurred, and to guide prevention efforts.
Data Source and Analysis
Four probable cases of tetanus among patients aged §
Patient Characteristics
Patient age groups ranged from
Exposure Route
Three patients with a hypothesized route of exposure had sustained their injury 7–10 days before symptom onset. Likely routes of exposure included 1) an ankle fracture (including traumatic injury to the overlying skin) during outdoor recreation, 2) a foot injury from a horse hoof while the child was barefoot, and 3) a knee puncture wound from an animal bone. The exposure mechanism for the fourth patient was unknown. Two of the patients (aged 5–9 and 10–15 years) did not seek medical care between the time the injury was sustained and the onset of tetanus. Two patients (aged All four patients experienced generalized tetanus. Common symptoms included back, neck, and jaw pain; muscle spasms and muscle rigidity; and difficulty walking. All patients were hospitalized (mean duration = 25 days; range = 8–45 days), and all received TIG for treatment and an initial TTCV dose for prevention of future disease. Two patients had documentation of receipt of a second TTCV dose; only one patient subsequently completed the recommended primary TTCV vaccination series. At least two patients received postdischarge clinical care, including readmission for inpatient rehabilitation. No deaths occurred.
Preliminary Conclusions and Actions
Tetanus can result in serious health consequences requiring extensive and costly medical care (3). Missed prevention opportunities for the children described in this report included failure to be vaccinated before the injury, delays in wound care, and lack of timely administration of TIG after exposure and before illness onset (3–5), including refusal. Tetanus disease is not transmitted person-to-person; therefore, herd immunity is not a feasible prevention strategy, nor does infection confer natural immunity: administration of TTCV is needed to prevent reinfection. Health care providers should discuss with parents the importance of being up to date with all recommended vaccines, including TTCV, and highlight the need for early medical care after a potentially contaminated wound occurs.¶ The need for prompt wound care is especially important in the case of environmentally contaminated or penetrating wounds; administration of TIG or TTCV when indicated should not be delayed, especially in unvaccinated or undervaccinated children.
Corresponding author: Michelle M. Hughes, mhughes7@cdc.gov.
1Idaho Department of Health and Welfare; 2Epidemic Intelligence Service, CDC; 3Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, CDC; 4Missouri Department of Health and Senior Services; 5Panhandle Health District, Hayden, Idaho; 6Wisconsin Department of Health Services; 7Minnesota Department of Health; 8Division of State and Local Readiness, Office of Readiness and Response, CDC.
All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. Rebecca Betz reports receipt of a subgrant from the Idaho Department of Health and Welfare. No other potential conflicts of interest were disclosed.
† TTCV is usually administered to children as a 5-dose series of diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP) beginning at age 2 months.
§ 45 C.F.R. part 46.102(l)(2), 21 C.F.R. part 56; 42 U.S.C. Sect. 241(d); 5 U.S.C. Sect. 552a; 44 U.S.C. Sect. 3501 et seq.
¶ A wound contaminated with dirt, feces, soil, or saliva; puncture wounds; avulsions; and wounds resulting from missiles, crushing, burns, and frostbite.
References
- Hughes MM, Amin AB, Rubis AB. Tetanus surveillance—United States, 2009–2023. MMWR Surveill Summ 2026;75(No. SS-1):1–11. https://www.cdc.gov/mmwr/volumes/75/ss/ss7501a1.htm
- Seither R, Yusuf OB, Dramann D, et al. Coverage with selected vaccines and exemption rates among children in kindergarten—United States, 2023–24 school year. MMWR Morb Mortal Wkly Rep 2024;73:925–32. https://doi.org/10.15585/mmwr.mm7341a3 PMID:39418212
- Guzman-Cottrill JA, Lancioni C, Eriksson C, Cho Y-J, Liko J. Notes from the field: tetanus in an unvaccinated child—Oregon, 2017. MMWR Morb Mortal Wkly Rep 2019;68:231–2. https://doi.org/10.15585/mmwr.mm6809a3 PMID:30845120
- Douvoyiannis M, Belamarich PF, Goldman DL. Tetanus after vaccine refusal and an opportunity for the pediatric infectious diseases specialist. Clin Pediatr (Phila) 2015;54:513–6. https://doi.org/10.1177/0009922814533411 PMID:24803630
- Johnson MG, Bradley KK, Mendus S, Burnsed L, Clinton R, Tiwari T. Vaccine-preventable disease among homeschooled children: two cases of tetanus in Oklahoma. Pediatrics 2013;132:e1686–9. https://doi.org/10.1542/peds.2013-1636 PMID:24218463
| Patient | Age group, yrs | Metro or nonmetro county* | TTCV status | Likely exposure route | Days from injury to illness | Sought care before illness | TIG and TTCV prophylaxis before illness | Days in hospital, TIG treatment and TTCV receipt † | Follow-up care after release |
|---|---|---|---|---|---|---|---|---|---|
| A | 10–15 | Metro | Unvaccinated | Compound ankle fracture from riding electric scooter | 8 | Yes, when injured | Offered by health care provider and declined by parents | 8 days, received TIG and 1 dose TTCV | Yes |
| B | 5–9 | Nonmetro | Unvaccinated | Unknown | Unknown | No | Did not seek care before illness onset | 31 days, received TIG and 2 doses TTCV | Unknown |
| C | 1–4 | Metro | Unvaccinated | Knee puncture from animal bone | 10 | Yes, 8 days after injury | Offered by health care provider and declined by parents | 16 days, received TIG and 4 doses TTCV | Yes |
| D | 10–15 | Nonmetro | Unvaccinated | Crush foot injury from horse hoof while barefoot | 7 | No | Did not seek care before illness onset | 45 days, received TIG and 2 doses TTCV | Unknown |
- County of patient’s residence. Metro versus nonmetro classification determined using the National Center for Health Statistics Urban-Rural Classification Scheme for Counties.
† All patients received first TTCV doses in the hospital for prevention of future tetanus. A diagnosis of tetanus does not confer immunity against future disease; persons who have had tetanus disease need to complete a TTCV series to be protected against future tetanus.
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