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Trends in Tetanus Epidemiology in the United States, 1972-2001

Trends in Tetanus Epidemiology in the United States, 1972-2001. Pamela Srivastava MS Bacterial Vaccine-Preventable Disease Branch, National Immunization Program Centers for Disease Control and Prevention March 2005. Tetanus Pathogenesis. • Caused by neurotoxin produced by

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Trends in Tetanus Epidemiology in the United States, 1972-2001

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  1. Trends in Tetanus Epidemiology in the United States, 1972-2001 Pamela Srivastava MS Bacterial Vaccine-Preventable Disease Branch, National Immunization Program Centers for Disease Control and Prevention March 2005

  2. Tetanus Pathogenesis • Caused by neurotoxin produced by Clostridium tetaniin anaerobic wounds • Tetanus spores are ubiquitous • soil • animal or human intestine/feces • skin surfaces • contaminated substances, including heroin

  3. Tetanus Clinical Presentation • Characterized by - muscle rigidity - painful muscle spasms • 3 types of tetanus (generalized, localized, cephalic) • Usually requires hospitalization, ICU care

  4. Tetanus Routine Vaccination/Immunity • A primary, 3-dose series + 1 booster provides immunity lasting approximately 10 years • Immunity following subsequent boosters lasts 10 - 20 years or more • Even incomplete immunization reduces disease severity and mortality

  5. Tetanus Surveillance • Passive reporting system • State health departments report weekly to the National Notifiable Diseases Surveillance System • Clinical diagnosis - no diagnostic laboratory tests • Approx 19% of hospitalized tetanus cases are reported to CDC* *Estimate based on data from the Healthcare Cost and Utilization Project (HCUP)

  6. 1972-2001 Tetanus in the United States: 1947-2004* 4.1/million CFR 91% 2004: 32 cases = 0.11 / million CFR 13% *2004 data not finalized

  7. Tetanus Epidemiology,30 years (1972-2001) 1837 cases reported: • 32 neonatal cases <1 month ∙ 7 deaths (CFR = 21.9%) • 1805 cases ≥ 1 year -512 deaths (CFR = 28.4%) -88% generalized, 12% localized, <1% cephalic

  8. Neonatal Tetanus, 1972-2001 38% were Hispanic, 34% were white 44% of mothers were unvaccinated, 44% of mothers received 1 dose

  9. Tetanus– Reported Cases and Annual Incidence, 1972-2001 CFR 38% CFR 25% CFR 17%

  10. 0 - 0 . 1 2 0 . 1 2 - 0 . 2 5 0 . 2 5 - 0 . 4 > 0 . 4 Average annual incidence (per million) 1972-1981 Tetanus Incidence by State 1972-1981 & 1992-2001 1992-2001

  11. Tetanus Incidence, by Region, 1972-2001 • The South had the sharpest decline in incidence, from 0.52 (1972 to 1981) to 0.17 (1992 to 2001)

  12. Tetanus Cases, by Season, 1972-2001

  13. Tetanus Incidence, by Gender, 1972-2001 Overall: Male 51%, Female 48%

  14. Tetanus Vaccination Status, 1972-2001

  15. Tetanus Cases and Deaths, by Age Group, 1972-2001 1-19 y 20-39 y 40-59 y 60+ y

  16. Tetanus Annual Incidenceby Age Group per million

  17. Tetanus Cases and IDUs, by Age Group, 1972-2001 1-19 y 20-39 y 40-59 y 60+ y

  18. Racial & Ethnic Distribution of Tetanus Cases: IDUs vs. Non-IDUs, 1972-2001 Hispanics make up 48% of tetanus cases in IDUs, compared to only 8.4% of cases in non-IDUs

  19. Tetanus Incidence, by Race/Ethnicity, 1972-2001 38% IDUs

  20. Tetanus in 20 to 39 year olds • Incidence rates have not decreased in the 20-39 yr age group • The outbreak of tetanus among IDUs on the West Coast does not account for this lack of decrease • When the IDUs are excluded, the proportion of Hispanics is the same as in other age groups

  21. Tetanus among Diabetics 1987-2001 • 13% (85/675) of all cases • 29% (37/128) of all deaths • CFR: 44% mortality (37/85) among diabetics

  22. Diabetes Tetanus Risk*, 1987-2001 • Overall incidence: diabetics 0.7 /million non-diabetics 0.2 /million • Age-adjusted relative risk for tetanus diabetics vs. non-diabetics 3.16 (2.51-3.99) • Age-adjusted relative risk for tetanus death diabetics vs. non-diabetics 4.41 (2.99-6.76) *Based on population estimates from the US Census and the NCHS Division of Diabetes Translation

  23. Acute Wounds, 1972-2001 • 76% (1366/1805) acute wounds • 38% punctures (nails & other sharp tools, splinters, body piercing & tattoos) • 42% lacerations or abrasions • 20% other (blunt trauma, crush injuries, burns, frostbite, surgeries, gunshots, animal bites/scratches)

  24. Non-Acute Wounds, 1972-2001 • 16% (285/1805) non-acute wounds • 34% chronic ulcers • 21% gangrene • 21% abscesses / cellulitis • 4% dental infections • 5% other infections • 15% injection drug use (IDU) only • 8% (154/1805) of all cases had no identifiable injury/lesion

  25. Impact of Tetanus • Severe - CFR 28% - 78% (518/668) hospitalized • Expensive* - Average cost per hospitalization: $84,277 (range $1718 - $925,315) - Total annual cost = $12,641,550 *Estimates based on HCUP data, 1988-2001

  26. Summary • Tetanus morbidity and mortality have decreased over the past 30 years • The elderly and diabetics are at increased risk for disease and death • Many cases did not have classic “tetanus prone” wounds

  27. Summary • Tetanus disease/mortality associated with inadequate vaccination • Racial/regional differences have disappeared • Neonatal tetanus virtually non-existent

  28. Recommendations • Public Health: • Collect more complete case data (especially vaccination history) • Clinicians: • Ensure all patients, especially diabetics, are up-to-date (pay attention to primary series) • Recognize that tetanus can occur even in absence of “tetanus-prone” wounds • Report cases

  29. Acknowledgments • State and Local Health Departments • Tetanus Team, National Immunization Program, CDC Kristin Brown Jufu Chen Katrina Kretsinger Martha Roper • National Immunization Program, CDC Rongping Zhang

  30. Tetanus is Preventable

  31. Regions

  32. Age-Specific Prevalence of Immunity by SexNHANES III 1988-1994 McQuillan et al. Ann Intern Med, May 2002; 136:660-666.

  33. Age-Specific Prevalence of ImmunityNHANES III 1988-1994 McQuillan et al. Ann Intern Med, May 2002; 136:660-666.

  34. Age-Specific Prevalence of Immunity by Sex 1988-94*& Reported Tetanus Cases 1988-94 *McQuillan et al. Ann Intern Med, May 2002; 136:660-666.

  35. Tetanus in the Elderly (>60 years),1972-2001 • 940/1805 (52%) of cases were >60 y • 379/512 (74%) of total deaths ; • CFR: 379/940 (40%) of cases ≥60 y died • 379/940 (40%) with no dose, 10/940 (1%) with >3 doses, 405/940 (43%) with missing dose

  36. Tetanus Incidence by Age Group, 1972-2001

  37. Tetanus Cases in Injection Drug Users, 1972-2001 Age Groups:

  38. Racial & Ethnic Distribution of Tetanus Cases: Diabetics vs. Non-Diabetics, 1987-2001 • Among the diabetic cases: 22% were African American and 21% were Hispanic compared to 12% and 16% respectively, among the non-diabetics

  39. Tetanus - Seasonal Trends, 1972-2001

  40. Tetanus in Diabetics, 1987-2001 • 72% of diabetics had acute wounds, compared to 76% of non-diabetics • Of the 18 diabetics with non-acute wounds, 44% (8) had ulcers and 39% (7) had gangrene—of the non-diabetics with non-acute wounds, 33% had ulcers and 20% had gangrene • 68% (44/65) diabetics insulin dependent

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