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Tetanus is uncommon in the U.S. but continues to have a substantial health impact in developing countries. The worldwide incidence of tetanus has been estimated at approximately 1 million cases per year, with a mortality rate of 20% to 30%.1 In response to high infant mortality rates in developing countries, the World Health Organization in 1989 initiated a campaign to eliminate neonatal tetanus by 1995. This initiative reduced tetanus mortality in infants by 78% to approximately 180,000 infant deaths in 2002.2 Despite substantial progress in the eradication of neonatal tetanus, the disease remains a substantial health problem, particularly in areas of Africa and Asia.2

The institution of widespread immunization programs for children, mechanization of agriculture, and use of chemical fertilizers rather than animal manure resulted in a decline in the annual incidence of tetanus in the U.S. to fewer than 50 cases per year.3 In the U.S., the majority of tetanus occurs in temperate areas, such as California, Texas, and Florida.3 Most patients who develop tetanus have inadequate immunity to the disease.3 Due to waning immunity and failure to receive routine boosters, only 31% of Americans >70 years old have adequate immunity to the disease.4 Although most cases of tetanus have historically occurred in older patients, there has been a decline in the disease among those over the age of 60 years old since the late 1990s. In addition, an increased incidence of tetanus in those aged 20 to 59 years old and in injection drug users in the late 1990s led to an increased proportion of tetanus in younger patients.3,5 Tetanus among children and neonatal tetanus is uncommon in the U.S. as well as in other developed countries. The case fatality rate is approximately 11%, with the elderly accounting for the majority of deaths.3

Most cases of tetanus in the U.S. are associated with an acute wound, and puncture wounds account for approximately half of cases.3 Most patients who develop tetanus do not seek medical care for their initial wound, and approximately 40% of those who seek care do not receive adequate tetanus prophylaxis.3 Diabetics and injection drug users are at increased risk of contracting tetanus.3

Tetanus is an acute, often fatal disease caused by wound contamination with Clostridium tetani, a motile, nonencapsulated anaerobic gram-positive rod. C. tetani exists in either a vegetative or a spore-forming state. The spores are ubiquitous in soil and in animal feces and are extremely resistant to destruction, surviving on environmental surfaces for years. In agricultural areas, adults may harbor the organism, and spores have been found on skin or in contaminated heroin.6 C. tetani is usually introduced into a wound in the spore-forming, noninvasive state but can germinate into a toxin-producing, vegetative form if tissue oxygen tension is reduced. Factors such as the presence of crushed, devitalized tissue, a foreign body, or the development of infection ...

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