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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.

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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].

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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.

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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.

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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.]

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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.

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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.

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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.

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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.

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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.

 

Immunization Action Coalition1573 Selby AvenueSt. Paul MN 55104
E-mail: admin@immunize.org Web: http://www.immunize.org/
Tel: (651) 647-9009Fax: (651) 647-9131

This page was updated on October 31, 2003