Tetanus in the United States, 2009–2023

Tetanus is a serious, vaccine-preventable disease caused by a toxin from Clostridium tetani, a spore-forming bacterium found everywhere in the environment. It does not spread from person to person; the spores usually enter through a contaminated or deep wound, germinate where there is no oxygen, and produce tetanospasmin, the toxin behind the disease.

There are three clinical types: cephalic (rarest), linked to head and neck injuries and causing cranial nerve palsies; localized, with spasms near the injury; and generalized (most common), with trouble swallowing or breathing, widespread spasms, rigidity, seizures and trismus (lockjaw). Neonatal tetanus is a form of generalized tetanus. Symptoms appear 1 to 21 days after exposure — later the farther the wound is from the central nervous system. Complications include aspiration pneumonia, fractures from spasms, high blood pressure, laryngospasm, hospital-acquired infections, pulmonary embolism and death. The acute phase usually lasts 1–4 weeks. No laboratory test confirms or rules out tetanus; it is diagnosed from the clinical picture.

Tetanus has been nationally notifiable since 1947. Since vaccine entered the routine childhood schedule in the late 1940s, and a booster every ten years was recommended for everyone in the 1960s, reported cases have fallen by more than 95% and deaths by more than 99%. This CDC surveillance summary updates the picture for 2009–2023.

Cases and deaths

• 402 cases from 47 states and the District of Columbia, and 37 deaths from 16 states — an average of 26.8 cases (17–37) and 2.5 deaths (0–5) a year.
• Average annual incidence: 0.08 cases per million people, slightly below 2001–2008 (0.10) and far below the estimated global rate of 10.3 per million in 2019.
• 62.2% of patients were male (0.1 per million, against 0.06 for females). The average patient was 43 — 50 for females, 38 for males.
• Incidence was lowest among children and teens (0.05 per million) and highest at 80 and older (0.20). Below 65, males had higher rates; at 80 and older, women did (0.27, against 0.10 for men).
• By HHS region, incidence was highest in Regions 4 and 7 (0.11 each) and lowest in Region 2 (0.04).

Annual incidence of tetanus cases and deaths, United States, 2009–2023. CDC figure.

Vaccination and care

• Of 173 patients with known history, 76 (43.9%) had never received a tetanus toxoid–containing vaccine (TTCV). Of 80 who had at least one dose, 47 (58.8%) had their last dose 10 or more years before falling ill; the median gap was 12.5 years.
• Generalized tetanus accounted for 74.8% of cases with known type, localized 23.2% and cephalic 2.0%.
• 94.9% were hospitalized; of those, 65.0% needed intensive care and 41.9% mechanical ventilation.
• Three newborns had tetanus; all survived. Both whose details were known were born at home with a midwife to mothers with no record of tetanus vaccination.

Wounds

Most cases (86.8%) followed an acute wound — usually punctures (61.2%) or lacerations (19.8%), nearly all on an arm or leg — and 98.2% of wounds were tetanus-prone. Yet only 45.0% of people with wounds sought care before getting sick. Among those who should have received post-exposure protection, few did: a minority got the recommended vaccine, and just 1 of 44 (2.3%) got tetanus immune globulin (TIG).

Deaths

The average mortality rate was 0.008 per million. Vital status was known for 299 patients, of whom 37 died — a case-fatality rate of 12.4%, about 1 in 10. Depending on what happened to the patients with unknown outcomes, the true rate could lie between 9.2% and 34.8%.

• Median age at death was 80. Most deaths were among people 65 and older, and none among children; the case-fatality rate was 30.8% at 65–79 and 63.3% at 80 and older.
• 18.6% of female patients died and 8.3% of males, reflecting the higher incidence among the oldest women; within age groups, the risk of death was similar for both sexes. At 80 and older, mortality among women (0.133 per million) was about twice that among men (0.057).
• Cephalic tetanus was far deadlier (66.7%) than generalized (12.1%). Death came a median of 13 days after symptoms began.
• No one who had received three or more vaccine doses died. Two people who died had a dose within the previous 10 years, but both were over 80 with only one recorded dose, likely never completing the primary series.

Tetanus incidence and deaths by age group and sex, United States, 2009–2023. CDC figure.

What it means

Children have the lowest rates thanks to high coverage: more than 92% of children born in 2011–2021 had at least three DTaP doses by 35 months, and adolescent Tdap coverage has been above 88% since 2016. Adult booster coverage is far lower, 57%–70% in 2013–2022. The oldest adults were born before routine tetanus vaccination began in 1947. Men's higher rates at younger ages may reflect work and recreation exposures; older women's higher rates may reflect that men were vaccinated in military service, and a national survey found lower protection among older women.

The authors urged clinicians to keep children on the DTaP schedule, give adults Td or Tdap boosters every ten years — especially older adults and pregnant women, to protect newborns — and learn when wounds call for vaccine or TIG. People with significant wounds should clean them with soap and water and get prompt care. Surviving tetanus does not give immunity, so patients need all recommended doses as they recover.

Limitations: surveillance is passive, though tetanus is serious enough that few cases should be missed, and many reports lacked data such as vital status, wound details and vaccination history.

Sources

• Hughes MM, Amin AB, Rubis AB. "Tetanus Surveillance — United States, 2009–2023." MMWR Surveillance Summaries 2026;75(SS-1).
• The report gives different figures for the share of eligible patients who received the vaccine after a wound (26%, 28.6% and 31.6%) and for the share of deaths among people 65 and older (83.8% and 85%), so those shares are not given here.