What is tetanus, how can you get infected with it and how can you get vaccinated against it?

Tetanus is a bacterial infection caused by Clostridium tetani, a bacterium that lives in the intestines, and thus feces, of humans or other mammalian animals. Spores of the bacterium can survive in the environment and contaminate it. They are especially present on the ground and in dark sewage water.

There are 4 forms of tetanus that have different symptoms:

• generalized or systemic tetanus: the most widespread, common and severe form. A systemic infection that involves the entire body of the infected person. If not properly diagnosed and treated, it can lead to severe outcomes and even death;
• localized tetanus: less common, affecting a circumscribed area of the body, can evolve into generalized tetanus;
• encephalic tetanus: less common, localized in the cranial nerves, can evolve into generalized tetanus;
• neonatal tetanus: a rare form that affects infants in the first few days of life and can be fatal. If standardized hospital protocols for the Birth Pathway are properly applied, it is rare for infection of the unborn child to occur in Western/industrialized countries. More common, however, is newborn infection in developing countries of the Third and Fourth World, where bacterial tetanus infection can affect local populations as well as pregnant tourists and mothers traveling with infants.

Tetanus data today

"Although tetanus is a rare disease in Italy today (thanks to the mass vaccination campaign), every year there are still some incidents and deaths in our country due to this bacterial infection.

Ospedale San Raffaele has informed us that in Milan there have been 3 ascertained and reported cases of tetanus from 2009 to October 2023. Not a few when we think that vaccination is mandatory in Italy. While this figure may in fact appear unimportant in the eyes of a nonmedical reader, it is actually not at all relevant to us, infectiologists. With a population keeping up with vaccination and booster vaccination, cases in Italy should be zero. 

At the European level, the latest report available is from 2018. This paper brings out an alarming fact: out of 92 reported cases, 48 were confirmed. From 48 confirmed cases 36 were ascertained in Italy. Out of 48 European cases, 13 (26.5 percent) had a fatal outcome. That is, 13 people in 2018 lost their lives as a result of the untreated and non-prevented infection with vaccination and booster shots," stresses Dr. Canetti.

Tetanus contagion affects both the environment and human beings. Explains Dr. Canetti:

"Bacterial tetanus infection is contracted as a result of contamination of wounds (cuts and/or scratches/abrasions of the skin that show bleeding or not of the injured skin) by spores of the bacterium.

Infection can occur during farmland and livestock care, gardening, outdoor sports or hobbies, and manual labor. In all these cases, the spores of the bacterium could enter the body through the blood and lymphatic circulation (blood stream) and cause bacterial tetanus infection. Not infrequently, people with hand cuts or scratches caused by rusty iron objects are received in the Medical Guard and emergency rooms."

Symptoms may appear between the 3rd and 21st day after contact with the bacterium responsible for tetanus. The organs and districts most affected by tetanus symptoms are the autonomic nervous system and skeletal muscles. 

Let us look in detail at what 7 symptoms of generalized tetanus (also called systemic tetanus) are:

1. trismus: face and mouth are affected by involuntary contraction, i.e., spasms of the masticatory muscles (masseter muscles). In trismus, in particular, the cheeks and mouth are affected, but the neck is also affected. The result is the inability to open the mouth, which is pulled into a fixed grimace called “sardonic laughter.” It appears in 80% of cases of tetanus infection. The trismus symptom may persist until resolution of the condition, i.e., recovery from bacterial tetanus infection, or, in severe cases, until the inauspicious outcome (death).
2. fever;
3. plank abdomen (i.e., the involuntary contracture of the abdominal muscles that feel as rigid as a plank of wood), also called opisthotonos (from the Greek “tension that comes from behind”), is an involuntary and painful posture characterized by the arching of an individual's back. The patient assumes the characteristic “bridge” shape as a result of the muscle spasms present in tetanus infections affecting the skeleton: these are extrapyramidal effects involving severe spasticity and hyperextension and involving the head, neck, spine, and abdominal regions. Opisthotonos is reversible with appropriate antispastic therapy (muscle relaxants, CNS sedatives, etc.);
4. dysphagia, which is the difficulty in swallowing solid or liquid foods as a result of muscle contracture of the pharynx and glottis (oropharyngeal and esophageal muscles);
5. loss of consciousness;
6. cardiac arrhythmia (irregular heartbeat) and tachycardia (quickening of heartbeat);
7. profuse and heavy sweating.

"The emergency room or medical guard doctor, to whom one should turn immediately after wound contamination with soil and feces or sewage or following an animal bite can: 

• prescribe tetanus antibiotic (penicillin) therapy for several days;
• assess the need for administration of human tetanus immunoglobulin (Tig);
• evaluate for tetanus vaccination booster, if expired." 

What to do in case of getting infected on vacation?

"In such cases, travelers should go as soon as possible to the nearest Tourist Medical Guard (if the event occurs during a vacation outside their region of residence) or to any emergency room. Doctor on duty will decide whether to give the tetanus vaccination (if expired, he or she will give the booster; if the first vaccination is absent, the doctor will initiate the vaccine cycle to be continued upon return to one's country of origin) and, if necessary, will also administer (by intramuscular injection) a dose of tetanus immunoglobulin (Tig) in addition to prescribing antibiotics, if the doctor deems it appropriate. In the case of antibiotics, you will not be able to expose yourself to the sun."

"The whole population is required to have the tetanus vaccination: in Italy, it is a mandatory vaccination and is given to all children (from 2 months of age), according to the national vaccination schedule provided by the Ministry of Health and proposed to future parents by family doctors, midwives, pediatricians and other specialists," Dr. Canetti explains.

On mandatory tetanus vaccination, the doctor cites the current regulation: "As the regulation states, tetanus vaccination has been mandatory in Italy since 1968 for all newborns and since 1963 also for specific labor categories (Law No. 292 of March 5, 1963 on mandatory tetanus vaccination (G.U. March 27, 1963, No. 83), including workers in the metalworking sector (railroaders, seafarers, etc.)."

Tetanus vaccination schedule: booster every 10 years

"The tetanus vaccine schedule in Italy calls for the administration of 3 doses of vaccine over the first year of a child's life (or unvaccinated adult arriving in Italy from abroad): 

• the first dose of vaccine (or first vaccination or first vaccine cycle) is given at 2 months of age;
• the second dose after 6 to 8 weeks;
• the third dose after 6 months.

Once the first round of tetanus vaccination is completed, the booster dose, or first tetanus booster (also mandatory), is performed in children aged 8 to 10 years.  

Following this, every 10 years, one must go (without a prescription from the general practitioner) to a Vaccination Center to request free administration of:

• second tetanus booster at 18-19 years of age;
• third booster at 28-29 years of age;
• fourth booster at 38-39 years of age;
• fifth booster at 48-49 years of age;
• sixth booster at 58-59 years of age;
• seventh booster at 68-69 years of age, 

and so on every 10 years," Dr. Canetti explains, who reminds of the importance of the tetanus vaccination booster often forgotten by adult patients.

Symptoms and complaints after vaccine

Some may wonder if there are any side effects following tetanus vaccination or if there are any interactions between tetanus vaccine and drugs or whether or not sun exposure after vaccination or booster is allowed. Dr. Canetti responds to concerns and reassures that there are no known serious side effects as a result of tetanus vaccination.

"As for post-tetanus vaccine complaints, these can be common with any vaccination and are minor. They range: 

• from a red, swollen pimple to soreness at the injection site, with or without itching;
• from a slight rise in temperature or fever (above 37°), which resolves in 1 to 2 days, to a transient state of fatigue and in some cases transient nausea. 

There are no known interactions between the tetanus vaccine and other medications (in general, there is no need to discontinue current therapies; always consult your primary care physician for individualized therapeutic indications), and you can expose yourself to the sun after the vaccine with appropriate sun protection," Dr. Canetti concludes.