1. <Disease review>
Tetanus
감염 내과 / R3 이민혜

2. Introduction First described by Hippocrates
Etiology discovered in 1884 by Carle and Rattone
Passive immunization used for treatment and prophylaxis during World War I
Tetanus toxoid first widely used during World War II

3. Clostridium tetani Anaerobic gram-positive rod, spore forming bacteria
Spores found in soil, animal feces; may persist for months to years
Multiple toxins produced with growth of bacteria
Tetanospasmin estimated human lethal dose = 2.5ng/kg

4. Pathogenesis
Anaerobic conditions allow germination of spores and production of toxins
Toxin binds in central nervous system
Interferes with neurotransmitter release to block inhibitor impulses
Leads to unopposed muscle contraction and spasm

5. Epidemiology Reservoir : soil and intestine of animals and humans
Transmission : contaminated wounds, tissue injury
Temporal pattern : peak in summer or wet season
Communicability : not contagious

6. Epidemiology

7. Secular trends in the US

8. Incidence of tetanus in Korea
질병관리본부

9. Clinical features Incubation period; 8days (range, 3-21days)
Three clinical forms
Local (not common)
Cephalic (rare)
Generalized (most common)
Generalized tetanus : descending symptoms of trismus (lockjaw), difficulty swallowing, muscle rigidity, spasms
Spasms continue for 3-4 weeks; complete recovery may take months

10. Complications Laryngospasm Fractures Hypertension
Nosocomial infections
Pulmonary embolism
Aspiration pneumonia
Death

11. Diagnosis No laboratory findings characteristic of tetanus
The diagnosis is entirely clinical and does not depend upon bacteriologic confirmation
C. tetani
Wound in only 30% of cases
Can be isolated from patients who do not have tetanus

12. Medical management
Antimicrobial therapy : relatively minor role in the management of tetanus, universally recommended
Metronidazole(500mg IV every six to eight hours) : 7 to 10 days
Alternative : penicillin G(2 to 4 million units IV every four to six hours)
If tetanic spasms are occurring, supportive therapy and maintenance of an adequate airway are critical
Tetanus immune globulin (TIG) : recommended for persons with tetanus
Only help remove unbound tetanus toxin
It cannot affect toxin bound to nerve endings
A single intramuscular dose of 3,000 to 5,000 units
Intravenous immune globulin (IVIG) contains tetanus antitoxin and may be used if TIG is not available
Active immunization with tetanus toxoid should begin or continue as soon as the person’s condition has stabilized

13. Tetanus toxoid Formalin-inactivated tetanus toxin Schedule
3 or 4 doses + booster
Booster every 10 years
Efficacy; approximately 100%
Duration; approximately 10 years
Should be administered with diphtheria toxoid as DTaP, DT, Td, or Tdap
DTaP = Diphtheria and tetanus toxoids and acellular pertussis vaccine adsorbed
DT = Diphtheria, Tetanus toxoids - pediatric
Td = Tetanus & diphtheria toxoids - adult
Tdap = Tetanus & diphtheria toxoids and acellular pertussis vaccine

14. Td vs. Tdap JDT JADTP JDTPB Td vaccine Tdap vaccine
Used for many years
Protects against tetanus and diphtheria
Tdap vaccine
Licensed in 2005
First vaccine for adolescents and adults that protects against pertussis as well as tetanus and diphtheria
11~18 year-olds and adults should receive ONE DOSE of Tdap to replace a Td booster dose
JDT JADTP JDTPB

15. Td vs. Tdap JDT JADTP JDTPB Td vaccine Tdap vaccine
Used for many years
Protects against tetanus and diphtheria
Tdap vaccine
Licensed in 2005
First vaccine for adolescents and adults that protects against pertussis as well as tetanus and diphtheria
11~18 year-olds and adults should receive ONE DOSE of Tdap to replace a Td booster dose
JDT JADTP JDTPB

16. Wound management All wounds should be cleaned
Necrotic tissue and foreign material should be removed
Proper immunization plays the more important role

17. 표준 예방접종 일정표(소아용)

18. 2012년 대한감염학회 권장 성인예방접종표

19. 질환(상황)에 따른 성인예방접종 권장

20. 의료인에게 권장하는 예방접종