Posts Tagged ‘tetanus’

Tetanus: it hasn't disappeared, even here..

Monday, June 24th, 2013

We were at a fiftieth wedding anniversary party on a weekend night and ate, among other things, baked beans and chocolate cupcakes. So when I saw a dark splotch on a friend's arm I thought he'd spilled something on himself.

A rusty sharp piece of metal poises several dangers

A rusty sharp piece of metal poises several dangers

He said, "No, I scratched myself this morning on a rusty piece of metal."

"When did you have your last tetanus booster?"

"You know, I don't remember"

His physician is in solo practice and my friend was unsure of his weekend coverage, so I suggested going to the Urgent Care Clinic our local hospital runs. I nudged him buy showing a 1807 painting of a men with opisothonus, the most extreme muscle spasm one can imagine. At that point he showed me his contact information for his internist and I dialed the number and handed the phone back to him.

As it turned out his doc answers his own messages and told his patient that he had had boosters, but would check his record on the following Monday morning and then call him.

So why was I concerned? After all, the number of cases of tetanus, also called lockjaw, is very small in the United States, usually less than 40 to 60 a year.

That statement holds for most developed countries, but certainly not for the rest of the globe.

Worldwide it's quite a different matter with one source noting over 14,000 cases reported in 2011 and a 5-year death toll of 81,000 reported in 2008.

Still, that's a marked improvement over past years when estimates of a million deaths a year, mostly in Africa and Asia, were the rule. In the late 1980s the World Health Organization (WHO) estimated 787,000 newborns died of neonatal tetanus (NT). That's about 6.7 per every 1,000 live births.

The WHO has an ongoing campaign to eliminate maternal and neonatal (newborn) tetanus and by 2101 the number of NT deaths was estimated at 58,000, still enough souls to fill a mid-sized community, but 93% less than slightly over 20 years previous.

Yes, but a significant number of those who do get it die and having a dirty wound is clearly a risk factor for tetanus.

The tetanus bacteria, an anaerobic (capable of living without oxygen) rod-shaped organism, is found in soil and in the gut flora (the mass of bacteria living in the intestines) of animals and humans. Overall our bowels carry 100 trillion microorganisms, ten times a many as the entire number of cells in a human, with estimates of a hundred times the number of genes as our human genome possesses.

It is not transmitted from person to person, but is present throughout the environment and is commonly found in soil contaminated with manure, and animal and human feces. The incubation period is usually 7 to 8 days, but can range from 3 days to three weeks with shorter incubation timing being associated with heavily contaminated wounds.

Tetanus often begins with muscular stiffness in the jaw, e.g., lockjaw, followed by stiffness in the neck, difficulty swallowing, rigidity of the abdominal muscles, spasms, sweating and fever. Other complications can include vocal cord and/or repsiratory muscle spasm. In especially severe cases long bone or spine fractures can occur as a result of muscle spasms.

The Mayo Clinic's article on tetanus agrees that the tetanus vaccine has made the disease quite rare in developed countries, but notes there are still somewhere about a million cases every year elsewhere in the world (that's quite different from the number I mentioned above, but may represent older figures). There is no cure for this terrible disease and fatality rates, which used to range from 48% upward, are still close to 10% even in settings where modern supportive therapy is available. That may include antibiotics, bed rest in an environment with lights dimmed, noise kept at a minimum and temperature stabilized, drugs for muscle relaxation, sedation and debridement (localized surgery to clean the wound) & possibly tetanus immune globulin.

If no treatment is given, roughly 25% of those infected die and those rates are considerably higher in newborns (typically with umbilical cord infections) and in the elderly without adequate immunization. Yet, until quite recently, most recommendations for tetanus toxoid mention re-immunizing every 10 years until age 65, with no provision for those of us who are older. Below that age, studies of armed forces personnel have shown adequate protection for up to twelve years.

Over the past few years the recommendations for immunization in older adults (age 65 and up) have gradually changed. In late 2010, although there was no formally FDA approved Tdap (Tetanus, diphtheria and pertussis (whooping cough), vaccine for those in that age range, the CDC's Advisory Committee on Immunization Practices (ACIP) suggested Tdap be given to all 65+ adults who were in close contact with infants and others in that older age range could get Tdap. By early 2012 ACIP approved the use of Tdap in all older adults, with one product (Boostrix) being preferred but the use of either of the two kinds of Tdap available in the United States being valid.

Wound management recommendations have similarly changed recently. If more than 5 years have elapsed since the last tetanus booster (which may have been Td), then anyone who is 19 and older should get Tdap.

The last time I got a dirty puncture wound I thoroughly cleaned it and hurried off to the hospital's Urgent Care Clinic, shot record in my hand.

When did you last have a tetanus booster shot?

When did you last have a tetanus booster shot?

Between tetanus bacilli, flesh-eating strep, drug-resistant staph and all their compatriots I've changed my approach to outdoor work. Although I do much less of it than in years past, I still not infrequently come home with a dirty scratch. I really scrub my hands and occasionally add a topical antibiotic ointment and a band-aid.

I think you should ask your physician when your last tetanus booster was given and see what they'd suggest for supposedly minor cuts and punctures.

You may prevent one or another of the serious bacterial complications most of us have heard about happening, even in our own communities.



Vaccination/Immunization: Part 3 Adults and the disease risks some of us take

Saturday, February 16th, 2013

You need protection against viruses and bacteria that lurk out there

After reading a number of articles, I decided that Lynnette and I  are up to date on all our vaccinations, but many adult are not; the CDC on Feb 1, 2013, published an online review titled "Noninfluenza Vaccination Coverage Among Adults--United States 2011" that reveals a sad picture. The first two sentence sums it up, "Vaccinations are recommended throughout life to prevent vaccine-preventable diseases and their sequelae. Adult vaccination coverage, however, remains low for most routinely recommended vaccines and well below Healthy People 2020 targets."

I had only a vague idea what does Healthy People 2020 referred to, so I found the definition on a CDC website. 

In December of 2010 the Department of Health and Human Services (HHS) launched a multi-faceted ten-year program with four major goals for our American population: 1). Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death. 2). Achieve health equality, eliminate disparities, and improve the health of all groups. 3). Create social and physical environments that promote good health for all. 4). Promote quality of life, healthy development, and healthy behaviors across all life stages.

It's obviously a huge undertaking and HHS came up with 1,200 objectives (sic) organized into "topic areas" (42 of those) each covering something felt to be very important in our public health. That's too big of a chunk for me to even think of writing about today.

So in this post I'll focus on vaccinations for adults.

Every year an Advisory Committee on Immunization Practices is given the charge of reviewing and updating the recommendations for childhood vaccinations and also those for adults. The Annals of Internal Medicine published the adult schedule and comments on its changes January 29, 2013.

Let's go back to the non-influenza vaccination article; the discussion was on immunizations to protect us against tetanus, diphtheria and pertussis/whooping cough combined as Tdap; pneumococcal pneumonia, hepatitis A, hepatitis B, herpes zoster (AKA shingles), and the human papillomavirus (HPV).

The Tdap numbers were startling to me. Only 55.4 of adults over 65% are protected and <65% of adults from ages 19 to 64, but  fatality rates for tetanus are over 13%. Far too many people are taking chances with a terrible, but preventable disease. The American Geriatrics Society is urging all of us over age 65 to have the Tdap shot, to protect ourselves and our grandkids (from pertussis in the latter case).

I've written on pertussis, but to recap we're seeing more cases in the U.S. (22,550 were  reported in 2010 and many more, especially among the elderly, are never reported). There have been epidemics of pertussis in 2012-2013. If you think you're still immune to whooping cough  because you had the childhood vaccination five-shot series, you should know that an person's immunity wanes from 98% protection to 70% after five years have elapsed.

There hasn't been a case of diphtheria in this country since 2003, but lots of us travel to countries where that disease is endemic (regularly found) and the case-fatality rate for respiratory diphtheria is 5-10%.

The pneumoccocal vaccination rate for those in this country who are 19 to 64 and considered at high risk for this kind of infection (e.g., anyone whose immune system isn't at its best) is only a tad over 20%, while the 2011 figures for those of us over 65 are much higher, at 62.3% in 2011. Even in the older age group the data showed Caucasians have gotten this immunization much more commonly then Asians, Hispanics or blacks, all of whom had vaccination rates <50%.

I've had the herpes zoster shot, but I'm in the 15.8% (20111 figures) who've done so. I never wanted to have shingles after knowing two people who had prolonged excruciating pain from this disease.

HPV is the most common sexually-transmitted viral disease in the United States. The CDC says, "Almost every sexually active person will acquire HPV at some point in their lives." In doing so they increase their risk of certain cancers; in a major CDC study that covered everyone in the U.S. from 2004-2008 there were over 33,000 HPV-associated cancer cases per year.

There are a host of reasons people don't get vaccinated. The CDC has an article online that covers the topic of common misconceptions about the need to continue vaccination. Some people think that infectious diseases were being prevented by improvements in sanitation/hygiene even before immunizations were developed. Or they may believe that a majority of us have already been vaccinated so they don't need to (the herd immunity concept) or that certain "lots" of a particular vaccine are dangerous. Some think we've gotten rid of all the diseases that vaccines can prevent, so they reject having themselves get the shots.

Especially if "out there." in your case, means most of the world

Unfortunately, none of these concepts are valid and many of us travel to parts of the world that have much worse immunization statistics than America does. So, if we're not vaccinated before our trips, we run the risk of bringing home a disease and spreading it to others.

 There are some significant changes coming in the vaccination arena, but I'll save those for another time, including a few words on Hepatitis A and B. For now I'd suggest asking your physician is she/he thinks you're current in all the immunizations you need; that's especially true if you are planning a major trip somewhere outside the country.