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Unprotected People Reports: Tetanus |
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Tetanus Among Injecting-Drug Users--California, 1997 |
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| Click here for a fully-formatted PDF version
of this report |
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| The Immunization Action Coalition (IAC)
publishes articles about people who have suffered or died from
vaccine-preventable diseases and periodically devotes an “IAC Express”
issue to such an article. This is the 61st in our series. |
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| It was published in “Morbidity and
Mortality Weekly Report” March 6, 1998, and is reprinted below in its
entirety with the exception of references. |
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During 1997, 47 cases of tetanus were provisionally reported in the United
States; 11 of these were reported from California. Of these 11, six (55%)
occurred among injecting-drug users (IDUs). The substantial proportion of
cases among IDUs prompted a review of reported tetanus cases in
California. This report summarizes reported cases of tetanus in IDUs in
California during 1987-1997 and presents two case reports for 1997.
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.
Case Reports
Case #1
In June 1997, the California
Department of Health Services received a report of tetanus in a
59-year-old Hispanic woman who had injected heroin intermittently
throughout her life. She had resumed daily heroin injection 2 years before
onset of disease. On June 18, she sought treatment for opisthotonos at a
local emergency department. Tetanus was diagnosed, and she was
hospitalized that day. She had multiple abscesses at injection sites on
her arms and feet. Despite mechanical ventilation and treatment with
tetanus immune globulin (TIG), she died on June 23. Her tetanus
vaccination status was unknown. She had had access to sterile syringes,
alcohol, and other supplies for injections because her husband was
diabetic. Her family indicated she had used hygienic technique when
injecting and had not shared injecting equipment.
Case #2
On July 17, 1997, a 45-year-old
Hispanic man who had injected heroin subcutaneously five times a day
sought treatment at a local emergency department because of respiratory
failure and tremors. He reported having used diazepam in an attempt at
detoxification, and he was hospitalized that day with a diagnosis of drug
withdrawal. He had persistent spasms, and tetanus was diagnosed on July
21. TIG was administered, and he was placed on mechanical ventilation.
Clostridium subterminale and Staphylococcus aureus were cultured from a
wound on his right arm. He was hospitalized for 13 weeks, including 4
weeks in a rehabilitation hospital, then released. His tetanus vaccination
history was unknown.
Reported by: CD O'Malley, PhD, E White, R
Schechter, MD, NJ Smith, MD, Immunization Br, Div of Communicable Disease
Control; SH Waterman, MD, State Epidemiologist, California Dept of Health
Svcs.
Editorial Note:
When the anaerobe C. tetani
colonizes devitalized tissue, the exotoxin tetanospasmin is disseminated
to inhibitory motor neurons, resulting in tetanus. The spastic paralysis
of tetanus can persist for several weeks. Predisposing wounds include open
fractures, abrasions, abscesses, and punctures. The diagnosis is usually
made clinically. Patients often require mechanical ventilation, and the
case-fatality rate is 25%.
Tetanus among IDUs has been reported
previously, and the Advisory Committee on Immunization Practices considers
IDUs to be at high risk for tetanus. In California, subcutaneous injection
of Mexican black tar heroin has been associated with a recent increase of
wound botulism caused by infection with C. botulinum. The annual number of
wound botulism cases reported in California increased from one in 1990 to
23 in 1995. During this period, all but one case occurred among IDUs. Both
the spastic paralysis of tetanus and the flaccid paralysis of wound
botulism are caused by ubiquitous anaerobic soil bacteria.
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.
Tetanus cases are reported to local and
state health departments through a passive reporting system, and both
cases and risk factors probably are underreported. Drug use preceding
tetanus may be underestimated because of limited reporting by patients or
clinicians.
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 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 article from the website of the Centers for Disease Control
and Prevention, go to: http://www.cdc.gov/mmwr/preview/mmwrhtml/00051456.htm
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| 10/31/03 • REPORT #61 |
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| 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 this
report. |
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