Tetanus in an Unvaccinated Worker, Oregon, 2022: Three Emergency Visits Before a Diagnosis

In June 2022, a 42-year-old construction worker born in Mexico, who did not speak English, came to an Oregon emergency department with 2 days of difficulty opening his mouth and pain in his back, arms and neck.

Three visits

His vaccination history was not asked about until the third visit, when his family said he had recently stepped on a nail at work and had no known tetanus shots.

In hospital

He got intravenous metronidazole, tetanus immune globulin and the Tdap vaccine, but soon developed breathing trouble and was put on a ventilator, then moved to a larger hospital's ICU, where a small callus was found on the sole of his right foot.

• Day 13: tracheostomy.
• Through day 45: in intensive care.
• Day 48: tracheostomy removed.
• Day 50: discharged, able to speak, eat, drink and walk short distances.

About tetanus

Tetanus is caused by a nerve toxin made by Clostridium tetani, a bacterium common in soil that enters through open wounds. It is often life-threatening and can need months of care: in 2017, hospital care for an unvaccinated Oregon child with tetanus, over 57 days, cost more than $800,000.

It is preventable by vaccination:

Lessons

• Migrant workers may be at higher risk: their rate of work injuries has been found to be twice that of U.S.-born workers.
• Migrant populations often have lower vaccination coverage and more vaccine-preventable disease, and U.S. vaccination coverage is significantly lower among adults born abroad. In Mexico, the country of origin of the largest U.S. migrant population, 74% of 1-year-olds had three DTaP doses in 2022 (93% in the United States), and 78% had two measles-containing doses on time (85%).
• Vaccination coverage fell during the COVID-19 pandemic, so providers should watch for the return of vaccine-preventable diseases.
• Communication gaps delay care. Clinics should offer interpreters, and — because some Hispanic or Latino immigrants have limited health literacy — use written and spoken information, photonovelas (picture stories) and "teach-back" methods.
• Ask about vaccination history early, and offer vaccines promptly to anyone who can't show they are protected.

Sources

Based on Pierce C, Villamagna AH, Cieslak P, Liko J, "Notes from the Field: Tetanus in an Unvaccinated Man from Mexico — Oregon, 2022," MMWR Morbidity and Mortality Weekly Report, volume 72, Centers for Disease Control and Prevention; a work of the United States government in the public domain.