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Current Case Definition for Surveillance
The clinical case definition of tetanus is: "Acute onset of hypertonia and/or painful muscular contractions (usually of the muscles of the jaw and neck) and generalized muscles spasms without other apparent medical cause." Cases meeting the clinical case definition, as reported by a health care professional, are considered confirmed.
Although passive immunization with tetanus antitoxin was used during World War I, tetanus toxoid was first produced in 1924, used extensively in the armed services during World War II, and introduced into routine childhood immunization in the late 1940's. Essentially all recipients achieve protective antitoxin levels after completing a series of four properly spaced doses of toxoid (or three doses in those seven years old or older). Most persons have antitoxin levels that approach the minimal protective level by ten years after the last dose; thus, routine boosters are recommended every ten years. Cases of tetanus in fully immunized persons whose last dose of toxoid was within the last 10 years are extremely rare.
In Maryland, tetanus immunization is required by law for entry into pre-school programs, and kindergarten through grade twelve. Based on the 1998/99 retrospective kindergarten survey, an estimated 78% of children in Maryland had received four doses of DTP by 24 months of age, (compared to 60% in the 1988/89 survey).
Historical Trends (see graphs below)
The maximum number of tetanus cases ever reported during any one year in Maryland was 43 in 1928. There has been a steady decline in the five-year mean tetanus rates since 1928. From 1967 to 1998 no more than three cases per year have been reported in Maryland, with only 36 cases for the thirty-year period. Although tetanus has been a relatively rare disease in Maryland, even in the pre-vaccine era, the case fatality rate remains approximately 30% (in the United States). Almost all reported cases of tetanus in the United States are in persons who either have never been vaccinated or who completed a primary series but have not received a booster in the preceding 10 years.
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