Tetanus

Tetanus is a bacterial infection that leads to painful muscle contractions, typically beginning in the jaw and then progressing to the rest of the body. In recent years, tetanus has been fatal ‘in approximately 11% of reported cases’.¹

Globally 38,000 people died from tetanus in 2017. Around half (49%) were younger than five years old.

The vaccine against tetanus allowed massive progress in controlling the disease. The result — 89 percent reduction in tetanus cases and deaths since 1990.

Tetanus is a disease caused by the toxin of a bacterium. There are two ways by which the disease can be contracted:

• Tetanus can be contracted from dirt that enters through wounds, and can ultimately cause paralysis and death.
• When mothers or newborns contract tetanus through wounds during birth, this is called maternal/neonatal tetanus (MNT). It can be prevented by immunizing the mother who passes the immunity on to her newborn for a few days after birth.

This entry presents a global overview on tetanus and MNT, presenting data on cases and deaths, and explaining transmission, prevention and the efforts to eliminate tetanus.

Over the past three decades we have seen a significant fall in the number of deaths from tetanus globally. You can see this in the visualization. In 1990, 314,000 people died due to tetanus while in 2019 there were less than 35,000 deaths — that’s an 87% reduction. 

The visualization also shows that the majority of tetanus cases in the past and today occur in children under the age of 5. However, if you switch the relative toggle on the bottom left of the chart, you’ll see that the proportion of cases in children has also fallen, from 76% in 1990 to just below half (49%) in 2017. 

Notably, if you switch the country in the chart to any high-income region, e.g. Central Europe, you will see that tetanus in children is almost absent in those places. This is in large part due to a highly effective childhood vaccine that we have available for this disease.

Today the majority of new cases of tetanus occur in South Asia and Sub-Saharan Africa. As the chart shows, these two regions account for 82% of all tetanus cases globally. 

Similarly, 77% of all deaths from tetanus, 29,500 lives lost, occur in South Asia and Sub-Saharan Africa.

However, even though South Asia still sees more cases of tetanus than any other region, in just three decades the incidence rate in the region has fallen 14-fold, from close to half a million cases in 1990 to 33,000 in 2017. 

The map here shows the rates of new tetanus infections by country. By clicking the play button you can see how this changed over time. In 1990, Nepal, Eritrea, Pakistan and Afghanistan had the highest rates of tetanus in the world; all above 70 cases per 100,000 people.

By 2017, just two countries, South Sudan and Somalia, had the rates of tetanus cases greater than 10 per 100,000 people.

You can see the change for individual countries by clicking on them or by selecting the “chart” tab at the bottom. In the bottom left corner of the “chart” tab different countries, as well as global data can be selected.

In the chart you see death rates from tetanus by country. This is given as the number of tetanus deaths per 100,000 individuals, and is age-standardized to allow for comparisons between countries and over time.

You can view the total number of deaths by country here.

Today we have an effective vaccine against tetanus. The vaccine is referred to as DTP and it contains ingredients that protect not only from tetanus but also from diphtheria and pertussis.

Prior to 1980, the number of tetanus cases had already declined in developed countries with good hygiene and immunization programmes. Since then, the global number of cases of tetanus and global coverage of vaccination against tetanus were monitored and allow a comparison.

As the coverage of tetanus vaccination increased, the number of tetanus cases declined. In the graph, tetanus cases are plotted against the number of people vaccinated.

Two different data sets on the number of tetanus cases are available. Starting in 1980 the WHO reported the number of confirmed tetanus cases. However, it’s estimated that less than 10 percent of all cases are reported and confirmed. The Global Burden of Disease project has estimated the actual number (not just the confirmed) of tetanus cases from 1990. Both data sets agree that tetanus cases decreased as more and more people were vaccinated against tetanus.

WHO recommends DTP vaccination of babies and subsequent follow-ups in childhood, teenage and adult years. In countries with good vaccination programmes tetanus has been largely eliminated.²

In the graph you can see how global tetanus vaccine coverage increased rapidly from 38 percent to 77 percent between 1983 and 1990. Since then it has further increased to 86 percent in 2015. 

If a person gets infected with tetanus-causing bacteria, treatment involves antibiotics, antitoxin against the bacterial toxin, and spasm-controlling drugs. Tetanus survivors still need to be vaccinated as the infection does not result in immunity to the disease.

Tetanus that affects newborns and their mothers is referred to as Maternal and Neonatal Tetanus (MNT). The World Health Organisation has estimated that 787,000 newborns have died as a result of MNT in 1988. By 2015 this number has been reduced by 96% to 34,019 deaths.³

Maternal and neonatal tetanus cases are linked to inequality in access to healthcare services. Because tetanus bacteria spores are present in the environment, clean birth delivery services are essential for protection of mothers and newborns during delivery. If environment in which birth is delivered is not hygenic, mothers can contract tetanus through tissue damage during delivery and newborns can get tetanus through umbilical stump . Vaccination of mothers and newborns protects from MNT and most cases of MNT occur in places where vaccine coverage is insufficient.

In the map you can see how the distribution of neonatal tetanus cases changed across the world since 1980.

In 1988 the WHO declared the goal to eliminate neonatal tetanus by 1995.

The elimination standard was set to 1 case of MNT per 1000 live births. Due to slow progress, this goal was pushed back to 2000, then 2005 and eventually no specific goal was set. Instead the organizations Kiwanis and UNICEF partnered in 2010 to form the ELIMINATE project which aims to eliminate tetanus in the remaining 39 countries.⁴

The international service organization Kiwanis records the latest progress towards MNT elimination on its project website.

In 2019 47 countries eliminated MNT and 12 countries still have rates of MNT above the set 1 in 1000 standard. These countries are shown on the map here.

Tetanus is caused by the toxin of a bacterium, Clostridium tetani, found in human and animal faeces, soil and street dust. The bacteria enter the body through wounds. Seven to 14 days after infection, a toxin is released from the bacteria and enters nerves responsible for movement and alters their activity. Specifically it prevents the release of the signaling substance GABA from nerve cells. Symptoms include, muscle stiffness, “lockjaws” (paralysis of the jaw), spasms, back pain and difficulties breathing. Tetanus is lethal in 13.2% of cases overall (including cases with and without treatment).

Tetanus is one of the rare diseases that is infectious but not contagious or communicable. One can become infected with it, e.g. through dirt that enters wounds, but not transmit the disease to other people (“communicate” it).

Even if the number of tetanus cases were reduced to zero at one point in the future tetanus would not be eradicated. As the disease-causing bacteria can be found in soil, unvaccinated people can become reinfected at any time. Continued vaccination efforts are therefore necessary to control tetanus. As a result tetanus is one of the very few infectious diseases that are not eradicable. For definitions of the words infectious, communicable, eradication and elimination, please see the definition section.

Differences in WHO and IHME figures

When comparing the number of new cases per year (incidence) as reported by the WHO and the IHME we can see a significant difference. The comparison between these figures are shown in the chart.

This difference occurs because the WHO only reports confirmed cases; cases that are unreported in any given country and cases that are reported in a country that does not submit its data to the WHO, are not included in the dataset.

The IHME provides estimates which not only include confirmed cases but also estimates of unreported cases. Its figures are therefore always higher than those reported by the WHO.

World Health Organization (WHO)

• • Data: Data on tetanus cases, neonatal tetanus cases and DTP3 vaccination coverage
  • Geographical coverage: Global – by country and WHO region for cases, global for vaccination coverage
  • Time span: Available from 1980 onwards
  • Available at: Online here.

Institute of Health Metrics and Evaluation (IHME), Global Burden of Disease (GBD)

• • Data: Number of cases, deaths and death rates
  • Geographical coverage: Global, across all regions and countries
  • Time span: Available from 1990 onwards
  • Available at: Online here

Kiwanis

• • Data: Tetanus elimination status of countries
  • Geographical coverage: Global, by country
  • Time span: 2018
  • Available at: Online here