Tetanus is often considered a disease of the past, remembered mainly through childhood vaccinations and warnings about rusty nails. Yet despite being preventable with an effective vaccine, it continues to cause tens of thousands of deaths worldwide each year.
A comprehensive review published in The Lancet by Prof. Dr. Önder Ergönül and Dr. Selin Kolsuz from the Koç University İşbank Center for Infectious Diseases and the Department of Infectious Diseases and Clinical Microbiology at Koç University School of Medicine, together with Prof. Dr. J. Peter Figueroa from The University of the West Indies, examines why tetanus remains a global health problem.
The review brings together current knowledge on the global burden of tetanus, its underlying mechanisms, populations at increased risk, diagnostic and treatment approaches, and important questions that remain unresolved.
A disease that cannot be eradicated
Tetanus is caused by Clostridium tetani, a bacterium found in soil and animal feces. The bacterium produces highly resistant spores that can survive in the environment for long periods. Because these spores persist in nature, tetanus cannot be completely eradicated.
Unlike many infectious diseases, tetanus is not transmitted from person to person. Herd immunity therefore offers no protection: even in a highly vaccinated community, an individual whose immunity is insufficient may develop tetanus following a contaminated injury. Protection depends on each person maintaining adequate immunity.
The disease generally develops when bacterial spores enter the body through contaminated, deep, or improperly cleaned wounds. In tissues with low oxygen levels, the spores can become active and produce tetanospasmin, a potent neurotoxin.
Once the toxin reaches the nervous system, it blocks the signals that allow muscles to relax. This can result in muscle rigidity, painful spasms, difficulty swallowing, respiratory problems, and lockjaw, one of the disease’s most characteristic symptoms.
Once the toxin has bound to nerve tissue, it becomes difficult to neutralize. The antitoxin used in treatment can act only on toxin that has not yet attached to the nervous system, making early recognition and intervention crucial.
Risk extends beyond unvaccinated children
The authors emphasize that tetanus is not only a disease affecting unvaccinated children. Maternal and neonatal tetanus remains a serious concern in areas where access to health care is limited. Unhygienic delivery conditions, inadequate vaccination during pregnancy, and unsafe umbilical cord care can place newborns at particular risk.
Adults can also become vulnerable as immunity acquired through childhood vaccination declines over time. In high-income countries, cases are more frequently seen among older adults. People with diabetes, individuals with weakened immune systems, people who inject drugs, migrants, refugees, and populations affected by natural disasters may also face increased risk.
Earthquakes, floods, wars, and other crises can increase exposure to contaminated injuries while simultaneously disrupting access to wound care, vaccination, immunoglobulin, and other health services. The authors therefore underline that emergency health responses should include tetanus prevention alongside surgical and trauma care.
Diagnosis and treatment remain challenging
There is no simple laboratory test that can definitively confirm tetanus. Diagnosis is based largely on clinical findings such as muscle rigidity, painful spasms, lockjaw, swallowing difficulties, and respiratory symptoms.
However, tetanus can be mistaken for certain poisonings, medication-related spasms, dental abscesses, meningitis, stroke-like conditions, and other neurological disorders. Clinicians should therefore consider tetanus in patients with high-risk wounds or uncertain vaccination histories.
Treatment aims to stop bacterial growth in the wound, neutralize toxin that has not yet bound to nerve tissue, control muscle spasms, support breathing, and manage cardiovascular instability. It may involve wound cleaning and surgical debridement, antibiotics, tetanus immunoglobulin, medication to control spasms, and prolonged intensive care.
The review also identifies unresolved questions, including the comparative use of human- and equine-derived antitoxins, the most effective route for antitoxin administration, the management of autonomic nervous system instability, and which interventions most effectively improve survival.
Prevention requires a life-course approach
Although tetanus is vaccine-preventable, it will not disappear without sustained public health efforts. Immunity can decline, vaccination records may be incomplete, and inequalities in access to health care can leave populations unprotected.
Combating tetanus therefore requires more than childhood immunization. Vaccination during pregnancy, adult booster doses, appropriate wound care, targeted vaccination during disasters and migration, reliable vaccination records, early diagnosis, and access to intensive care are all essential.
The review’s central message is clear: the continued loss of life from a vaccine-preventable disease is not merely a medical issue, but also reflects inequalities in health systems, access to information, and preventive care.
Tetanus may be an old disease, but the effort required to prevent it remains as important as ever.