Issue
Number 421
October 31, 2003
UNPROTECTED PEOPLE: Reports of
people who have suffered or died
from vaccine-preventable diseases
Reports #58-62:
TETANUS, A VIRTUALLY
PREVENTABLE DISEASE,
STILL ENDANGERS AND CLAIMS LIVES
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October 31, 2003
UNPROTECTED PEOPLE #58-62: TETANUS, A VIRTUALLY PREVENTABLE DISEASE, STILL
ENDANGERS AND CLAIMS LIVES
The Immunization Action Coalition (IAC) publishes articles about people who
have suffered or died from vaccine-preventable diseases and occasionally
devotes an "IAC EXPRESS" issue to such articles. In this issue, we present
five Unprotected People reports.
With this issue, IAC's editorial staff
inaugurates a new approach to presenting Unprotected People articles.
Instead of publishing an article about one person's experience with a
vaccine-preventable disease (VPD), we will offer a grouping of several
people's experiences with a single VPD. Some accounts will present detailed
information about one person's experience with the disease. Other accounts
will present only portions of one or more persons' experiences with the
disease. We think this approach will give readers a more comprehensive
picture of the VPD.
We have chosen tetanus as the topic of this Unprotected People issue for two
reasons: (1) During fall, many people are involved in activities, such as
yard clean-up and home repair, that put them at risk for tetanus, and (2)
the National Foundation for Infectious Diseases (NFID) and the National
Coalition for Adult Immunization launched the "Power of 10" campaign earlier
this year to increase adult and adolescent Td booster rates. Consequently,
it is now easy for health professionals to access free patient education
materials and other resources from the NFID website. (Go to
http://www.nfid.org or send an email
to powerof10@nfid.org)
We hope health professionals will tell their
vaccine-hesitant patients some of the stories recounted in this article as a
way of convincing them to protect themselves against tetanus and diphtheria
with a Td booster and to protect their children with the DTaP series. We
also hope health professionals will use "Power of 10" materials to help
educate their patients about the disease.
Check your email next Wednesday, November 5, when IAC will publish a
follow-up "Extra Edition." Using information culled from the federal
government, state health departments, and professional medical
organizations, we will present a number of resources on strategies for
increasing immunization rates among people of various ages, as well as
current patient- and professional-education materials on tetanus.
UNPROTECTED PEOPLE #58
Following are two articles published in the "Yorkshire Post," a British
newspaper. (1) Published February 26, 2003, "Tetanus Killed Woman After Fall
in Garden" relates the story of Sheila Creighton, a 61-year-old English
woman who sustained a face wound after falling on a bush in her garden in
March 2002. She died four weeks later. (2) Published March 26, 2003,
"Woman's Death Could Speed Action on Tetanus Vaccinations for Older People"
recounts how Mrs. Creighton's death spurred a member of Parliament [MP] to
call for promoting tetanus vaccination among older people.
IAC is grateful to the "Yorkshire Post" for permission to reprint both
articles; the "Yorkshire Post" holds the copyright on both.
***************************
TETANUS KILLED WOMAN AFTER FALL IN GARDEN
"Yorkshire Post" February 26, 2003
A rare disease, which has been largely wiped out in the UK thanks to
immunization, killed a 61-year-old woman after it got into her system
through a face wound.
Sheila Creighton fell on a bush in her garden, cutting her face. She was
taken to hospital where the wound was cleaned up and stitched. But she was
forced to seek further help when her face began to ache and she had
difficulty moving her jaw.
Several medical experts who saw Mrs. Creighton, most of whom had never seen
a case of tetanus before, failed to diagnose the disorder, which attacks the
nervous system, leads to spasms, and can kill.
It was only after she collapsed several days after the fall that tetanus was
diagnosed. She was treated in the intensive care unit at Pinderfields
Hospital, Wakefield, but efforts to save her failed and she died in April
last year [2002], four weeks after the fall.
An inquest in Huddersfield was told yesterday that the disease was extremely
rare in the UK. Figures for 1999 showed that there were only three reported
cases and only one resulted in death.
Deborah Tooley, specialist registrar in anesthetics and intensive care at
Pinderfields, who treated Mrs. Creighton in the later stages of the illness,
said [Mrs. Creighton] could not speak. But by asking her patient questions
[Ms. Tooley] had discovered Mrs. Creighton had had a tetanus jab in 1995.
Prior to that she indicated she hadn't been immunized for about 20 years.
But the inquest heard conflicting evidence that her GP notes showed she had
been immunized in 1991.
The hearing was told that if Mrs. Creighton of Milton Road, Liversedge, near
Dewsbury, hadn't been immunized for 20 years before 1995 she wouldn't have
been protected.
Pathologist Patricia Gudgeon concluded that Mrs. Creighton's death was due
to pneumonia and brain damage caused by tetanus, which entered her system
through a contaminated wound.
Mrs. Creighton was first treated at Dewsbury District Hospital on March 28
[2002].
Dr. Ed Walker, a specialist in emergency medicine at the hospital, said she
had a clean wound that was treated and dressed. Notes he was given showed
she had been vaccinated in 1995 and because of this and the type of wound he
had decided she did not need another. Yesterday, recording a verdict of
accidental death, West Yorkshire coroner Roger Whittaker said he couldn't
criticize the various medical experts who hadn't diagnosed tetanus. He said
they had made considered judgments. It wasn't until later that all the
symptoms materialized.
He called for a better system, which would allow doctors to quickly get
information about patients' immunization records.
Speaking after the inquest Mrs. Creighton's daughter Janet Creighton said
the family was keen to raise awareness of what could happen if people were
not immunized.
"We want to make people aware that this can happen and urge them to check
records with their doctors and make sure that they are covered. It could
happen to anybody," she said.
Mrs. Creighton's husband Ronald said his family had done research and it
appeared that those born before 1961 were especially at risk, because that
was when routine tetanus immunization began [in the UK].
***************************
WOMAN'S DEATH COULD SPEED ACTION ON TETANUS VACCINATIONS FOR OLDER PEOPLE
"Yorkshire Post" March 26, 2003
A concerted Government effort to raise awareness of the danger of tetanus to
older people was yesterday signaled after the death of a 61-year-old West
Yorkshire woman.
GP surgeries administering flu jabs across the country could be told to
check whether pensioners and older people are immunized. And there are plans
for a nationwide computerized record system which would tell doctors whether
a particular patient was protected against the very rare, but potentially
deadly disease.
Health Minister Hazel Blears confirmed the plans after Dewsbury MP Ann
Taylor raised the tragedy of her constituent Sheila Creighton who died in
April last year after falling on a bush in her garden in Liversedge and
cutting her face. She was taken to hospital where her wound was cleaned up
and stitched but later had difficulty moving her jaw.
Several days later she collapsed and was treated at the intensive care unit
at Pinderfields Hospital in Wakefield but died four weeks after her
accident.
As Mrs. Taylor yesterday recalled in a special debate at Westminster,
tetanus was not instantly diagnosed.
There was also doubt about when Mrs. Creighton had last been vaccinated. An
inquest, which recorded a verdict of accident, heard conflicting evidence
that she had been vaccinated in 1995 and 1991 as well as a having a much
earlier jab.
But Mrs. Taylor yesterday urged the Government to raise the awareness of the
dangers of tetanus, even though it was now an extremely rare disease in the
UK, and the need for older people to have booster jabs.
The Dewsbury MP acknowledged that since 1961, a program of tetanus jabs for
children had been carried out. And she was told by Ms. Blears that in
Calderdale and Kirklees, up to 96 percent of two-year-olds were
immunized--above the national average.
But Mrs. Taylor emphasized the need to raise
awareness of the need for protection among older people. Given the confusion
over Mrs. Creighton's immunization record when she was being treated, the
Dewsbury MP also raised the need for better patient records, a plea also
made by coroner Roger Whittaker at Mrs. Creighton's inquest.
Acknowledging that Mrs. Creighton's husband Ronnie had suffered "a great
loss," the Dewsbury MP urged the Government to ease some of the bereaved
family's anxieties by raising awareness about the potentially deadly
disease.
Ms. Blears, who extended her sympathy to Mrs.
Creighton's family, warned that although tetanus was now extremely rare in
the UK, it could not be eradicated completely as it was picked up from
spores in the soil.
*******************************
To access the two "Yorkshire Post" articles from the IAC website, go to:
http://www.immunize.org/stories/story58.htm
UNPROTECTED PEOPLE #59
Published in the January 2000 issue of "Discover" magazine, "Blindsided by
Tetanus" was written by Claire Panosian Dunavan, MD, professor of medicine
and infectious diseases, University of California at Los Angeles School of
Medicine. In the article, Dr. Dunavan relates her experience diagnosing and
treating Eduardo, an unvaccinated immigrant brought by police to a county
hospital with seizures thought to be the result of psychosis or a drug
overdose. Dr. Dunavan had previous experience treating a woman with tetanus;
her quick diagnosis of Eduardo's tetanus is one reason he survived his
ordeal with the disease.
IAC is grateful to "Discover" for permission to reprint the article, on
which "Discover" holds the copyright. We extend our thanks to Dr. Dunavan
for allowing us to make minor modifications to the article.
***************************
BLINDSIDED BY TETANUS: ARE YOU PSYCHOTIC, OVERDOSING, OR DID YOU JUST FORGET
YOUR BOOSTER SHOT?
By Claire Panosian Dunavan, MD
"Discover" January 2000
Eduardo rubbed his jaw and tried to open his mouth, wondering about the
tight muscles in his face and neck that had plagued him all day. Then he
noticed the flashing lights of a police cruiser in his rearview mirror. As
an illegal [immigrant] in a battered pickup without cash, driver's license,
or friends, Eduardo felt that this was becoming his worst nightmare.
Charged with weaving across lanes and driving an unregistered vehicle,
Eduardo spent the next two days in a holding cell. As the hours passed, his
cell mates noticed that he grew stiff, grinned oddly, and ignored his food.
Then, one of the guards saw him violently jerk his neck and torso. The guard
thought, "This guy's faking seizures to get out of jail." But Eduardo's
spasms persisted, and other prisoners began backing away from him. The staff
decided to pack him off to the county hospital's psychiatric unit.
During my years as the sole infectious diseases specialist at that small
county hospital in southern California, I wasn't called to the psychiatric
emergency room often. But when I was, the cases were never boring, [and this
case was no exception].
Eduardo posed a challenge. As I and the resident both knew--but the police
did not--psychosis and overdose were not the only conditions that could
produce a rigid neck and torso, a mute smile, and jerking movements. An
infection of the central nervous system was another possibility, and we'd
recently seen a few cases of mosquito-borne encephalitis in the area. "Como
esta?" I asked as I approached the young man lying on a gurney in a
curtained cubicle. The greeting was a courtesy. Eduardo was in no shape to
talk. Invisible pulleys had stretched his mouth into a tight smirk. But his
eyes were wide open, alert, and terrified--no sign of confusion or coma.
"Great--you got here fast!" The resident's voice rang out as he flung back
the curtain.
The sharp sound and sudden motion startled Eduardo. His head jerked back,
his shoulders and trunk arched up, and he gasped in pain. But he remained
conscious throughout the 15-second attack. That's not consistent with spasms
induced by brain disorders. This was no ordinary seizure. Suddenly the
diagnosis dawned on me. Twelve years earlier, as a medical volunteer in
Haiti, I had watched a rigid yet fully conscious pregnant woman arch her
body in just the same way.
She'd had tetanus.
"Get the ICU team here as soon as possible," I said to the resident. I spoke
softly to avoid startling Eduardo into another spasm. "The next time this
happens, he could stop breathing," I told the resident. "You make sure he
gets an airway. Meanwhile, I'll order up some antitoxin."
In the specialty of infectious diseases, few physical displays are as
dramatic as the spasms provoked by tetanus. Its cause is a protein toxin so
potent that many victims require months to recover from its effects, if they
survive at all.
But the toxin is not the ultimate perpetrator of tetanus. That honor is
reserved for the bacillus Clostridium tetani, which produces the toxin.
Excreted in the feces of animals and widely distributed in soil, mature C.
tetani resemble tennis rackets, bulging at one end with a hardy spore. It
doesn't always take an old nail puncturing a foot to get these into a human
host. All the bacteria need is a minor breach of the skin--a laceration, a
burn, or even an insect bite. And if they land in tissue that receives
little oxygen, they will thrive--multiplying and manufacturing their deadly
product.
Once secreted, the toxin molecule sneaks into the rootlike hairs of nerve
fibers, climbs toward the spinal cord, and binds itself to inhibitory
neurons, thus disrupting their function. That takes the brakes off the
peripheral nerve cells, and they start firing faster. The result is muscle
rigidity that typically begins in the head and neck, then moves to the chest
and abdomen, and eventually reaches the extremities.
Lockjaw, or trismus, is an early sign of tetanus. It means the toxin has
affected nerves in the masseters, or chewing muscles. Another early symptom
is risus sardonicus, a term from Roman times for the tetanus victim's
telltale smile, raised eyelids, and wrinkled forehead. The most vivid
hallmark of all is the wrenching spasms, which result when two opposing
muscle groups are simultaneously activated. The spasms can be triggered by
anything from a sudden noise, movement, or draft of air to such internal
stimuli as a full bladder or a cough.
Fortunately, most people in industrialized countries needn't worry that
everyday scratches and scrapes will yield an internal harvest of tetanus
toxin. Because they've received a series of tetanus vaccines in childhood as
well as the occasional tetanus booster, their bodies have plenty of
protective antibodies. Reported tetanus cases in the United States often
number no more than 100 a year.
But people in the developing world are less likely to receive tetanus
vaccines and they suffer the consequences. Tetanus kills an estimated
300,000 each year; almost all deaths occur in developing countries. Newborns
are particularly vulnerable. During the first few weeks of life, their only
defense against pathogens comes from antibodies imported from their mothers
. . . . Infants born to nonimmunized mothers are tetanus cases waiting to
happen. One dirty knife or soiled bandage on the umbilical stump is all it
takes. Today neonatal tetanus accounts for over half of the more than
500,000 cases worldwide.
In my quick exam of Eduardo, I hadn't seen a scratch. I suspected tetanus,
but there's no definitive diagnostic test for the disease because the toxin
hides away in the central nervous system. To confirm my suspicion, I needed
to exclude the possibility that another condition was mimicking tetanus
symptoms.
Tests of Eduardo's electrolytes were normal, which ruled out a low calcium
level as the cause of his spastic muscles. And Eduardo's spinal fluid showed
no signs of infection; that ruled out encephalitis or meningitis. And just
in case he was suffering from dystonia--a movement disorder triggered by
certain prescription drugs--he got a dose of diphenhydramine (Benadryl), the
usual antidote. That maneuver proved fruitless as well. The only remaining
tests were blood and urine assays for strychnine, and those results might
not be back for days. Tetanus was the leading contender.
"We'll start the antitoxin as soon as pharmacy brings it up," said the ICU
chief, taking me aside. "In the meantime, he's intubated, with diazepam
[Valium] by IV. Now what about antibiotics?"
Although Eduardo had no visible signs of infection, at least somewhere in
his tissues there must be C. tetani pumping out toxin. Penicillin was in
order. The drug would wipe out the toxin-producing bacteria. And we hoped
the antitoxin--antibodies culled from horses or humans immunized against
tetanus--would intercept the poisons in his blood and prevent his symptoms
from getting worse.
Unfortunately, its effects were far from Lazarus-like. Eduardo remained in
the ICU for a full month, while the toxin was slowly leached from his spinal
cord and brain. I was hoping for a full recovery, but sometimes tetanus so
damages nerves that muscles are left permanently weakened. Even muscle
relaxants, low lights, and tiptoeing doctors and nurses couldn't prevent
Eduardo's spasms, so we paralyzed his muscles and put him on a ventilator.
Thankfully, he made it through.
Several weeks after his discharge from the hospital, I saw Eduardo at a
follow-up visit. He was still thin and leaning on a cane. When I greeted him
in the hall, he seemed to remember me.
"Tetanus vaccine?" he responded laconically to my first eager question. "I
don't remember any vaccines in the village where I grew up."
I made a mental note to ask our nurse to vaccinate him. Ironically, so
little toxin is released during an infection that even a full-blown case of
tetanus builds no immunity against future attacks.
"What about an injury?" I persisted. "Usually a wound precedes tetanus."
"Ah, the soccer game," he mused. "A few weekends before I started getting
stiff, something sharp went right through the sole of my shoe. Glass, I
think." [This information let me put the last piece of the puzzle in place:
Eduardo's untreated puncture wound explained the cause of his tetanus
episode. Case closed.]
*********************************
To access this account from the IAC website, go to:
http://www.immunize.org/stories/story59.htm
UNPROTECTED PEOPLE #60
Published in the "British Medical Journal" on June 15, 2002, "Death from
Tetanus After a Pretibial Laceration" concerns a failure to follow
Department of Health guidelines for immunoprophylaxis in treating
tetanus-prone wounds. The article includes a case report, a table outlining
the guidelines, a brief discussion of tetanus immunization rates in the
U.K., characteristics of tetanus-prone wounds, and a report on the status of
wound management in U.K. emergency rooms. Excerpts from the case report and
the article's concluding paragraph follow.
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DEATH FROM TETANUS AFTER A PRETIBIAL LACERATION
By Oliver C.S. Cassell
"British Medical Journal" June 15, 2002
Case report
A 76-year-old woman fell in her garden and sustained a pretibial laceration.
Her wound was cleaned and approximated with Steri-strips . . . at an
emergency department. Her status for tetanus immunization at the time was
recorded as "?no previous tetanus injection," and a course of antitetanus
treatment was started. However, no immunoglobulin was given.
She returned one week later with a necrotic and malodorous wound. She was
unwell and complained of diffuse pains. She was admitted for debridement and
split skin grafting.
Her condition worsened. Twenty-four hours later she developed the signs and
symptoms of tetanus, with increasing jaw stiffness, opisthotonos, and
generalized limb spasticity. Cultures from the wound produced a heavy growth
of Clostridium tetanii. She was transferred to intensive care but died 22
days later. . . .
Conclusion
This case shows how the omission of the smallest detail can have a fatal
outcome. Complete management of an injured patient includes a full history
of tetanus immunization and adherence to the Department of Health's
immunoprophylaxis protocol.
***************************
To access the entire article from the "British Medical Journal" website, go
to:
http://bmj.bmjjournals.com/cgi/content/full/324/7351/1442
To access the article's opening paragraph and complete case report
from the IAC website, go to:
http://www.immunize.org/stories/story60.htm
UNPROTECTED PEOPLE #61
Published in "Morbidity and Mortality Weekly Report" March 6, 1998, "Tetanus
Among Injecting-Drug Users--California, 1997" summarizes the 27 tetanus
cases among injecting-drug users (IDUs) reported in California between
1987-1997 and presents two case reports. Following are excerpts from the
article.
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TETANUS AMONG INJECTING-DRUG USERS--CALIFORNIA, 1997
"Morbidity and Mortality Weekly Report" March 6, 1998
[Summary of cases]
The annual number of tetanus cases in IDUs in California has increased
steadily from one in 1987 to six in 1997. Of 67 cases of tetanus reported in
California during 1987-1997, a total of 27 (40%) occurred in IDUs. Of these
IDUs, 24 (89%) were Hispanic. Of the 27 cases of tetanus in IDUs, 24 (89%)
had no antecedent injuries other than drug injection. Abscesses were
observed at injection sites for 18 (69%) patients. Information about
injecting technique was provided for 14 patients, all of whom reported
subcutaneous injection (i.e., "skin popping"). All 10 patients for whom the
specific drug injected was reported had used heroin, either exclusively or
with other drugs. . . .
[Excerpts from the Editorial Note]
During 1987-1997, Hispanics constituted 60% of all patients with tetanus
reported in California and 89% of IDU-associated cases. Mexican Americans
are the predominant Hispanic population in California. A recent serologic
survey indicated that 58% of Mexican Americans, compared with 73% of
non-Hispanic whites, had protective levels of antibody to tetanus toxoid.
This increased susceptibility may, in part, explain the disproportionate
occurrence of tetanus among Hispanic IDUs.
Drug injection provides several potential sources for infection with C.
tetani, including the drug, its adulterants, injection equipment, and
unwashed skin. Although recommendations to prevent transmission of human
immunodeficiency virus among IDUs may limit infection from contaminated
injection equipment, these measures may not be effective against spores
inoculated from the skin or contained in the drug. Therefore, prevention
efforts should emphasize vaccination for tetanus.
Tetanus is almost entirely preventable through vaccination and appropriate
wound care, including administration of TIG [tetanus immune globulin] when
appropriate. A primary series of three doses of tetanus-diphtheria toxoid
(Td) and subsequent booster doses of Td every 10 years are highly effective
in preventing tetanus. IDUs have frequent contact with the medical system
but poorer continuity of care; each clinical encounter should be used for
assessment and, when needed, completion of tetanus vaccination.
****************************
To access the entire article from the MMWR website, go to:
http://www.cdc.gov/mmwr/preview/mmwrhtml/00051456.htm
To access the article, excluding references, from the IAC website, go to:
http://www.immunize.org/stories/story61.htm
UNPROTECTED PEOPLE #62
"Philosophic Objections to Vaccination as a Risk for Tetanus Among Children
Younger Than 15 Years" reviews the 15 cases of tetanus reported in the
United States in children younger than 15 years from 1992 to 2000. The
authors conclude that the majority of these children were unvaccinated
because their parents objected to vaccination on philosophic or religious
grounds. The article was published in the January 2002 issue of the journal
"Pediatrics," which holds the copyright. Excerpts from the abstract follow.
*************************
PHILOSOPHIC OBJECTIONS TO VACCINATION AS A RISK FOR TETANUS AMONG CHILDREN
YOUNGER THAN 15 YEARS
By Elizabeth Fair, MPH, Trudy V. Murphy, MD, Anne Golaz, MD, MPH, and
Melinda Wharton, MD, MPH
"Pediatrics" January 2002
Results. From 1992 through 2000, 15 cases of tetanus in children under 15
years of age were reported [to the National Notifiable Diseases Surveillance
System] from 11 states. Twelve cases were in boys. Two cases were in
neonates under 10 days of age; the other 13 cases were in children who
ranged in age from 3 to 14 years. The median length of hospitalization was
28 days; 8 children required mechanical ventilation. There were no deaths.
Twelve (80%) children were unprotected because of lack of vaccination,
including 1 neonate whose mother was not vaccinated. Among all unvaccinated
cases, objection to vaccination, either religious or philosophic, was the
reported reason for choosing not to vaccinate.
Conclusion. The majority of recent cases of tetanus among
children in the United States were in unvaccinated children whose parents
objected to vaccination. Parents who choose not to vaccinate their children
should be advised of the seriousness of the disease and be informed that
tetanus is not preventable by means other than vaccination.
*************************
To access a camera-ready (PDF) copy of the complete article from the
"Pediatrics" website, go to:
http://www.pediatrics.org/cgi/reprint/109/1/e2.pdf
To access the HTML version, go to:
http://www.pediatrics.org/cgi/content/full/109/1/e2
To access the complete abstract from the IAC website, go to:
http://www.immunize.org/stories/story62.htm
DISCLAIMER: The Immunization Action Coalition (IAC) publishes Unprotected
People reports for the purpose of making them available for our readers'
review. We have not verified the content of these reports, for which the
authors are solely responsible.
DO YOU KNOW OF PUBLISHED ARTICLES ABOUT UNPROTECTED PEOPLE? Please let us
know if you find articles or case reports about people who have suffered or
died from vaccine-preventable diseases that have appeared in the general or
scientific media. Send information about articles or case reports to "IAC
EXPRESS" by email to
admin@immunize.org or by fax to (651) 647-9131.
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