Tetanus is a rare but often fatal disease that affects the central nervous system by causing painful and often violent muscular contractions. The earliest descriptions of the disease can be found in the medical papyri of ancient Egypt. The disease begins when the tetanus bacterium (Clostridium tetani ) enters the body, usually through a wound or cut that has come in contact with the spores of the bacterium. Tetanus spores are commonly found in soil, dust, and animal manure. Tetanus is a noncommunicable disease, meaning that it cannot be passed directly from one person to another.
Tetanus is uncommon in the United States, with nearly all cases occurring in adults who were not vaccinated as children, or in those who have not had a booster vaccination in 10 years.
In the United States, there are between 50 and 100 reported cases of tetanus a year. About 30% of cases are fatal. Most people who die of tetanus infections are over 50 years old.
Tetanus causes convulsive muscle spasms and rigidity that can lead to respiratory paralysis and death. It is sometimes called "lockjaw" because one of the most common symptoms is a stiff jaw that cannot be opened. Sometimes tetanus is localized, that is; it affects only the part of the body where the infection began. However, in almost all reported cases, tetanus spreads to the entire body. The incubation period from the time of the injury until the first symptoms appear ranges from five days to three weeks. Symptoms usually occur within eight to 12 days. The chance of death is increased when symptoms occur early.
Causes & symptoms
Tetanus is caused by a bacterium called Clostridium tetani, whose spores (the dormant form) are found in soil, street dust, and animal feces. The bacteria enter the body through cuts and abrasions but will multiply only in an environment that is anaerobic, or oxygen-free. Deep puncture wounds and wounds with a lot of dead tissue provide an oxygen-free environment for the bacteria to grow.
As C. tetani grows, it excretes a highly poisonous toxin called tetanospasmin into the bloodstream, spreading it throughout the nervous system. The infection is usually transmitted through deep puncture wounds or through cuts or scratches that are not cleaned well. Many people associate tetanus with rusty nails and other dirty objects, but any wound can be a source. Less common ways of getting tetanus are animal scratches and bites; surgical wounds; dental work; punctures caused by glass, thorns, needles, and splinters; and therapeutic abortion. Rare cases have been reported in people with no known wound or medical condition.
Neonatal tetanus in newborns can be caused by cutting the umbilical cord with an unsterile instrument or by improper care of the umbilical stump. Neonatal tetanus is less common in developed countries.
Tetanus toxin affects the nerve endings, causing a continuous stimulation of the muscles. Initial symptoms may include restlessness, irritability, a stiff neck, and difficulty swallowing. In about half of all cases, the first symptom is a stiff or "locked" jaw, which prevents patients from opening their mouths or swallowing. This symptom is also called trismus and results in a facial expression called risus sardonicus, which is a Latin phrase meaning "sardonic smile." Trismus is often followed by stiffness of the neck and other muscles throughout the body as well as uncontrollable spasms. Sometimes these convulsions, known as opisthotonos, are severe enough to cause broken bones. Other symptoms of tetanus include loss of appetite and drooling. People with localized tetanus experience pain and tingling only at the wound site and spasms in nearby muscles.
In the underdeveloped world, neonatal tetanus accounts for about one-half of tetanus deaths and is related to infection of the umbilical stump in a baby born of an unimmunized mother. In many cases the risk is increased by the mother's giving birth on a floor made of hardpacked soil. Worldwide, 800,000 children die of tetanus each year.
Tetanus is diagnosed by the clinical symptoms and a medical history that shows no tetanus immunization. Early diagnosis and treatment is crucial for recovery.
In general, the shorter the incubation period, the more severe the disease.
As traditional medical treatment revolves around drug therapy, traditional Chinese medicine herbal remedies are the most common alternative treatment for tetanus. Herbs that have sedative effects should be given to reduce the frequency of convulsions, along with herbs to fight the bacteria.
Tetanus and convulsions can be treated with a concoction made from the dried body of a long-nosed pit viper, called this drug Qi She in Mandarin. Chan Tui, or cicada slough (the skin the cicada sheds) is also helpful. Also helpful are the dried root of the Saposhnikovia divaricata, called divaricate saposhnikovia root, and jack-in-the-pulpit tuber, if it is treated to remove toxins.
There are several alternative treatments aimed at prevention of the disease.
Tetanus is a life-threatening disease. Patients diagnosed with it are usually hospitalized, usually in an intensive care ward. Treatment can take several weeks and includes antibiotics to kill the bacteria and shots of antitoxin to neutralize the toxin. It also includes antianxiety drugs to control muscle spasms or barbiturates for sedation. In severe cases, patients are placed on an artificial respirator. Recovery can take six weeks or more. After recovery, since the levels of circulating toxin are quite low, the patient must still be adequately immunized against this disease.
Full recovery is common in patients who can be kept alive during the most violent portion of the attacks. Yet up to 30% of tetanus victims in the United States die. Early diagnosis and treatment improves the prognosis. Neonatal tetanus, however, has a mortality rate of more than 90%.
Castor oil is a natural remedy that can be used to clean out a wound and prevent tetanus. When a wound is sustained, a cotton ball dunked in castor oil should be placed on the wound, and then fixed on the wound with a bandage. Castor oil has tremendous drawing power and can pull out rust and other infectious agents. The dressing should be changed every two hours the first day of treatment and twice a day for the next three days.
Tetanus is easily preventable through vaccination. All children should have a series of five doses of DTaP, a combined vaccine that offers protection against diphtheria, tetanus, and pertussis, before the age of seven. This measure is supported by numerous organizations, including the World Health Organization, the Centers for Disease Control and Prevention, the Advisory Committee on Immunization Practices, the Committee on Infectious Diseases of the American Academy of Pediatrics, and the American Academy of Family Physicians. Children in the United States will not be admitted to school without proof of this and other immunizations.
The DTaP vaccine should be given at ages two months, four months, six months, 15-18 months, and four to six years. DTaP is the preferred vaccine for children up to the age of seven in the United States; it has fewer side effects than DTP and can be used to complete a vaccination schedule begun with DTP. DTaP was first approved by the Food and Drug Administration in September 1996. In December 1996, it was approved for use in infants. Between age 11 and 13, children should have a booster, called Td, for diphtheria and tetanus.
Adults should have a Td booster every 10 years. Statistics from the Centers for Disease Control and Prevention show that fewer than half of Americans aged 60 and older have antibodies against tetanus. The Centers for Disease Control and Prevention suggests that adults be revaccinated at mid-decade birthdays (for example, at 45). Adults who have never been vaccinated against tetanus should get a series of three injections of Td over six to 12 months and then follow the 10-year booster shot schedule.
Side effects of the tetanus vaccine are minor: soreness, redness, or swelling at the site of the injection that appear any time from a few hours to two days after the vaccination and disappear in a day or two. Rare but serious side effects that require immediate treatment by a doctor are serious allergic reactions or deep, aching pain and muscle wasting in the upper arms. These symptoms could start from two days to four weeks after the shot and could continue for months.
For those who are averse to immunizations, tetanus immunity can be boosted naturally by taking vitamin E , according to a study from Tufts University in Medford, Massachusetts. To get the most benefit, 200 mg should be taken daily.
Keeping wounds and scratches clean is important in preventing infection. Since C. tetani grows only in the absence of oxygen, the wounds must be adequately cleaned of dead tissue and foreign substances. Run cool water over the wound and wash it with a mild soap. Dry it with a clean cloth or sterile gauze. To help prevent infection, apply an antibiotic cream or ointment and cover the wound with a bandage. Try the castor oil remedy. The longer a wound takes to heal, the greater the chance of infection. Consult a doctor if the wound doesn't heal, if it is red or warm, or if it drains or swells.
If the wounded individual does not have an adequate history of immunization, a doctor may administer a specific antitoxin (human tetanus immune globulin, TIG) to produce rapid levels of circulating antibody. The antitoxin is given at the same time as a dose of vaccine but at a separate site.
Some persons will report a history of significant allergy to "tetanus shots." In most cases, the reaction occurred in the remote past and was probably caused by antitoxin derived from horse serum. More recently, however, the use of aluminum as an adjuvant, or substance added to a vaccine to increase the body's immune response, has been associated with skin eruptions and swelling in hypersensitive individuals. In some cases, these persons can be safely vaccinated for tetanus with a graduated series of shots. Adverse reactions of any kind to tetanus vaccine should be reported to the Center for Biologics Evaluation and Research (CBER) of the Food and Drug Administration (FDA).
Evelyn, Nancy. The Herbal Medicine Chest. Trumansburg, N.Y.: The Crossing Press, 1986.
Magill's Medical Guide, edited by Tracy Irons-Georges. Englewood Cliffs, N.J.: Salem Press, 1998.
Baylor, N. W., W. Egan, and P. Richman. "Aluminum Salts in Vaccines—US Perspective." Vaccine 20 (May 31, 2002)(Supplement 3): S18-S23.
Quddus, A., et al. "Neonatal Tetanus: Mortality Rate and Risk Factors in Loralai District, Pakistan." International Journal of Epidemiology 31 (June 2002): 648-653.
Rennels, M. B., M. A. Deloria, M. E. Pichichero, et al. "Lack of Consistent Relationship Between Quantity of Aluminum in Diphtheria-Tetanus-Acellular Pertussis Vaccines and Rates of Extensive Swelling Reactions." Vaccine 20 (May 31, 2002)(Supplement 3): S44-S47.
Shin, D. H., J. H. Park, P. J. Jung, et al. "A Case of Maternal Tetanus in Korea." Journal of Korean Medical Science 17 (April 2002): 260-262.
Williams, A. N., et al. "Tetanus Immunisation in Hypersensitive Individuals." Journal of the Royal Army Medical Corps 148 (June 2002): 148-150.
Food and Drug Administration (FDA), Center for Biologics Evaluation and Research (CBER), 1401 Rockville Pike, Suite 200-N, Rockville, MD 20852. <www.fda.gov/cber>.
Centers for Disease Control and Prevention. "Tetanus & Diphtheria (Td) Vaccine." Healthtouch Online. http://www.healthtouch.com/bin/EContent_HT/showAllLfts.asp.
"Shots for Safety." National Institute on Aging Age Page. www.nih.gov/nia/health/pubpub/shots.htm.
"TCM Herbal Database." China-Med.net. http://www.chinamed.net/herb_search.html.
Rebecca J. Frey, PhD
"Tetanus." Gale Encyclopedia of Alternative Medicine. . Encyclopedia.com. (May 27, 2017). http://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/tetanus-2
"Tetanus." Gale Encyclopedia of Alternative Medicine. . Retrieved May 27, 2017 from Encyclopedia.com: http://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/tetanus-2
Tetanus is a rare but often fatal disease that affects the central nervous system by causing painful muscular contractions. It begins when tetanus bacteria enter the body, usually through a wound or cut exposed to contaminated soil. Tetanus is easily preventable through vaccination.
Tetanus is rare in the United States, with nearly all cases occurring in adults who were not vaccinated as children. About 100 cases are reported each year; 63% of these occur in people over the age of 50. The number of tetanus cases in the United States has steadily decreased since the 1940s (500 to 600 cases per year); the number of reported cases has remained at approximately 50 to 100 cases per year since the mid-1970s. In 1999, however, the lowest number of annual cases to date was reported (33, or 0.02 per 100,000).
Tetanus causes convulsive muscle spasms and rigidity that can lead to respiratory paralysis and death. It is sometimes called "lockjaw" because one of the most common symptoms is a stiff jaw, unable to be opened. Sometimes, tetanus affects only the part of the body where the infection began, but in almost all of reported cases, it spreads to the entire body. The incubation period from the time of the injury until the first symptoms appear ranges from two to 50 days. Symptoms usually occur within five to 10 days. When symptoms occur early, the chance of death is increased. Tetanus is not contagious.
Causes and symptoms
Tetanus is caused by a bacteria called Clostridium tetani, whose spores (the dormant form) are found in soil, street dust, and animal (or even human) feces. Tetanus spores germinate in the body, producing a highly poisonous neurotoxin in the blood, spreading to the nervous system. The infection is usually transmitted through deep puncture wounds or cuts or scratches that are not cleaned well. Between 1997 and 1999, approximately 64% of tetanus cases in the United States were associated with such wounds as punctures, lacerations, or abrasions. Many people associate tetanus with rusty nails and other dirty objects, but any wound can be a source. Less common ways of getting tetanus are animal scratches and bites, surgical wounds, dental work, and therapeutic abortion. About 18% of cases reported between 1997 and 1999 were a result of intravenous drug use. Cases have also been reported in people with no known wound or medical condition.
The first symptom of tetanus is often a stiff or "locked" jaw that prevents the patient from opening his/her mouth or swallowing. This is also called trismus and results in a facial expression called a sardonic smile (or risus sardonicus). Stiffness of the neck and other muscles throughout the body and uncontrollable spasms often follow. Sometimes these convulsions are severe enough to cause broken bones. The bacterial toxin (tetanospasmin ) affects the nerve endings, causing a continuous stimulation of muscles. Other symptoms include irritability, restlessness, loss of appetite, and drooling. People with tetanus that is localized experience pain and tingling only at the wound site and spasms in nearby muscles.
In the underdeveloped world, neonatal tetanus accounts for about one-half of tetanus deaths and is related to infection of the umbilical stump in a baby born of an unimmunized mother. The Centers for Disease Control and Prevention (CDC) estimate that over 270,000 deaths occur annually worldwide as a result of neonatal tetanus. In contrast, only two cases of neonatal tetanus in the United States were reported to the CDC between 1989 and 1999. Mothers who have been adequately immunized against tetanus protect their newborns by passing the antibody through the placenta.
Tetanus is diagnosed by the clinical symptoms and a medical history that shows no tetanus immunization. Early diagnosis and treatment is crucial to recovery from tetanus.
Tetanus is a life-threatening disease that requires immediate hospitalization, usually in an intensive care unit (ICU). Treatment can take several weeks and includes antibiotics to kill the bacteria and shots of antitoxin to neutralize the toxin. It also includes muscle-relaxing drugs to control muscle spasms or barbiturates for sedation. In severe cases, patients are placed on an artificial respirator. Recovery can take six weeks or more. After recovery, since the levels of circulating toxin are too low to stimulate natural antibody production, the patient must still be immunized against this disease to prevent reinfection.
Up to 30% of tetanus victims in the United States die. Early diagnosis and treatment improves the prognosis. Neonatal tetanus has a mortality rate of more than 90%.
Tetanus is easily preventable through vaccination. All children should have a series of five doses of DTaP, a combined vaccine that offers protection against diphtheria, tetanus, and pertussis, before the age of seven, according to the Centers for Disease Control and Prevention's national immunization guidelines, the Advisory Committee on Immunization Practices, the Committee on Infectious Diseases of the American Academy of Pediatrics, and the American Academy of Family Physicians. Children will not be admitted to school without proof of this and other immunizations.
The DTaP (diptheria, tetanus, accellular pertussis) vaccine should be given at ages two months, four months, six months, 15 to 18 months, and four to six years. DTaP is the preferred vaccine for children up to the age of seven in the United States; it has fewer side effects than DTP and can be used to complete a vaccination schedule begun with DTP. DTaP was first approved by the Food and Drug Administration (FDA) in September 1996. In December 1996, it was approved for use in infants. Between the ages of 11 and 13, children should have a booster for diphtheria and tetanus, called Td.
Adults should have a Td booster every 10 years. Statistics from the Centers for Disease Control and Prevention (CDC) show that fewer than half of Americans 60 years of age and older have antibodies against tetanus. The CDC suggests adults may be revaccinated at mid-decade birthdays (for example, 45, 55). Adults who have never been vaccinated against tetanus should get a series of three injections of Td over six to 12 months and then follow the 10-year booster shot schedule.
Side effects of the tetanus vaccine are minor: soreness, redness, or swelling at the site of the injection that appear anytime from a few hours to two days after the vaccination and go away in a day or two. Rare but serious side effects that require immediate treatment by a doctor are serious allergic reactions or deep, aching pain and muscle wasting in the upper arms. These symptoms could start from two days to four weeks after the shot and could continue for months.
In early 2001, a shortage of the tetanus vaccine became evident after the pharmaceutical company Wyeth-Ayerst Laboratories decided to stop production of the tetanus vaccine, leaving Aventis-Pasteur as the sole manufacturer of the vaccine. As a result, hospitals were provided with only a minimal amount of the drug on a weekly basis—enough to vaccinate patients with potentially infected wounds and other priority cases. Despite stepped-up production efforts on the part of the manufacturer, however, a spokesperson for Aventis-Pasteur predicted that the shortage would last until the end of 2001, as the vaccine takes 11 months to produce.
Keeping wounds and scratches clean is important in preventing infection. Since this organism grows only in the absence of oxygen, wounds must be adequately cleaned of dead tissue and foreign substances. Run cool water over the wound and wash it with a mild soap. Dry it with a clean cloth or sterile gauze. To help prevent infection, apply an antibiotic cream or ointment and cover the wound with a bandage. The longer a wound takes to heal, the greater the chance of infection. If the wound doesn't heal, or, it is red, warm, drains, or swells, consult a doctor.
Following a wound, to produce rapid levels of circulating antibody, a doctor may administer a specific antitoxin (human tetanus immune globulin, TIG) if the individual does not have an adequate history of immunization. The antitoxin is given at the same sitting as a dose of vaccine but at separate sites. Some individuals will report a history of significant allergy to "tetanus shots." In most cases, this occurred in the remote past and was probably due to the previous use of antitoxin derived from horse serum.
Clostridium — A genus of deadly bacteria that are responsible for tetanus and other serious diseases, including botulism and gangrene from war wounds. Clostridia thrives without oxygen.
DTaP— Diphtheria and tetanus toxoids and accellular pertussis combination vaccine.
DTP— Diphtheria, tetanus, and whole-cell pertussis vaccine.
Td— Tetanus and diphtheria vaccine.
Toxin— A poisonous substance that flows through the body.
Wound— Any injury that breaks the skin, including cuts, scratches, and puncture wounds.
Landers, Susan J. "Tetanus vaccine shortage leads to rationing." American Medical News. March 19, 2001. 〈http://www.ama-assn.org/sci-pubs/amnews/pick_01/hlsb0319.htm〉.
"Tetanus." Centers for Disease Control and Prevention. 〈http://www.cdc.gov/nip/publications/pink/tetanus.pdf〉.
"Tetanus." Gale Encyclopedia of Medicine, 3rd ed.. . Encyclopedia.com. (May 27, 2017). http://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/tetanus-1
"Tetanus." Gale Encyclopedia of Medicine, 3rd ed.. . Retrieved May 27, 2017 from Encyclopedia.com: http://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/tetanus-1
Tetanus, also called lockjaw, is a serious disease of the nervous system that can cause uncontrolled muscle spasms and death. It is caused by toxins (poisons) produced by the bacterium Clostridium tetani.
Tetanus occurs when the body is infected with spores of the bacterium C. tetani. This bacterium is found worldwide in soil and animal manure. The spores can remain alive in the soil for years and are resistant to heating and chemical destruction. They are more common in hot, damp environments than in cold or dry ones.
Once spores enter the body through a break in the skin, they begin producing bacteria. These bacteria multiply in areas where there is little oxygen present and produce a toxin that affects the nervous system. The toxin spreads along the nerves of the body, causing the nerves to fire (react). This results in muscle spasms and convulsions.
The bacteria that cause tetanus enter the body through a scrape, cut, or wound, in about 70 percent of cases. The most susceptible wounds are those that are caused by blunt trauma such as crushing or by bites . The bacteria can also enter at the site of a burn, bedsore, or frostbite , or be introduced into the body during surgery. In developing countries, newborns often contract tetanus from contaminated instruments used to tie off the umbilical cord after birth. Often the site where the bacteria enter is insignificant, does not become swollen or red, and does not require medical attention. Any time between two and 50 days later (most commonly between days seven and 21 days), the individual begins to show the signs of tetanus.
The severity of the disease is related to several factors:
- The sooner symptoms appear, the more severe the disease.
- If the point of entry was in the head or face, symptoms are more severe.
- The very young and the very old suffer more severe symptoms and higher death rates.
With almost universal vaccination starting in the 1940s, tetanus has become rare in the United States. Fewer than 50 cases have been reported annually since 1995. Worldwide, the disease is common, especially in newborns in developing parts of Asia, Africa, and South America where immunization is not universally available. The disease can affect individuals of any race, age, or gender.
Causes and symptoms
Since the incubation period can range from several days to many weeks, individuals often do not associate their initial symptoms with wound infection. The first sign of tetanus is a tightening of the jaw muscles that gives the disease its common name, lockjaw. This symptom is followed by waves of back spasms. The spasms then extend to the arms producing clenched fists and to the legs. Any stimulus, such as noise or light, can set off a round of convulsions. Other symptoms include drooling, increase in blood pressure (hypertension ), irregular heart beat, inability to open the mouth, high fever , kidney failure, and respiratory failure.
When to call the doctor
Tetanus is a medical emergency, and individuals should be taken to the emergency room as soon as symptoms are noticed. About 75 percent of individuals with tetanus are first seen by a dentist or oral surgeon for pain and stiffness in the jaw and mouth region.
Diagnosis of tetanus is based on presenting symptoms rather than laboratory tests. Less than one-third of the time can the bacteria that causes the disease be cultured from a wound.
Treatment begins immediately in the emergency room or intensive care unit of a hospital. There are five aspects of treatment. Initially the patient is placed in a dark, quiet room and given a sedative, usually a drug in the benzodiazepine family, through direct injection into a vein (IV) in an effort to reduce muscle spasms. A tube may be inserted in to the trachea (tracheotomy) in order to keep the airways open.
The second aspect of treatment is to clean and disinfect any wounds and remove any dead flesh.
The third aspect of treatment involves killing the bacteria producing the toxin using antimicrobial drugs given as an injection. The drug of choice is metronidazole (Flagyl), with penicillin the second choice.
Fourth, the toxin already circulating in the blood must be neutralized so that it causes no further damage to the nervous system. This is done with injections of human tetanus immunoglobulin (TIG).
Finally, complications of the disease are managed. This may involve IV fluid replacement, use of a respirator, or kidney dialysis. Contracting tetanus does not provide immunity against future infections, so tetanus immunizations are also given.
Individuals who develop symptoms within a few days of infection have close to a 100 percent mortality rate. The mortality rate for infections originating in the head and in newborns is also very high. The sooner an individual is treated, the more likely he or she is to survive. Overall, the death rate in the United States is 10 percent. Worldwide it is 45 percent. According the United States Centers for Disease Control, the average hospital stay is 16 days. Recovery for those who survive is normally complete after about four weeks.
Tetanus is completely preventable by immunization. The recommendation in the United States, as of 2004, is to immunize children against tetanus on the following schedule:
- initial vaccination at two months of age
- repeat at four months of age
- repeat at six months of age
- repeat at 12 to 15 months of age
- repeat at four to six years of age
- booster dose given every 10 years there after, normally at ages 15, 25, 35, etc.
Receiving the complete schedule of multiple vaccinations is necessary to ensure full protection. For children, vaccination against tetanus is normally included in a vaccine called DTaP that protects against diphtheria , tetanus, and whooping cough (acellular pertussis). Many school districts require proof of vaccination before a child may enroll.
Other prevention measures involve prompt cleaning and protection of wounds and hygiene measure such as washing well after exposure to soil containing animal manure. Sterile conditions during surgery also help prevent infection.
Food is not given by mouth to individuals who are having muscle spasms for fear they will breathe the food into their lungs. During this time, they are fed intravenously.
Some parents hesitate to vaccinate their children for religious reasons or because they fear side effects of the vaccination. The bacteria that cause tetanus are so common and the disease is so serious that protection against acquiring tetanus outweighs any risks associated with vaccination.
Intravenous —Into a vein; a needle is inserted into a vein in the back of the hand, inside the elbow, or some other location on the body. Fluids, nutrients, and drugs can be injected. Commonly called IV.
Toxin —A poisonous substance usually produced by a microorganism or plant.
Trachea —The windpipe. A tube composed of cartilage and membrane that extends from below the voice box into the chest where it splits into two branches, the bronchi, that lead to each lung.
Tracheotomy —An surgical procedure in which the surgeon cuts directly through the patient's neck into the windpipe below a blockage in order to keep the airway open.
Umbilical cord —The blood vessels that allow the developing baby to receive nutrition and oxygen from its mother; the blood vessels also eliminate the baby's waste products. One end of the umbilical cord is attached to the placenta and the other end is attached to the baby's belly button (umbilicus).
See also Vaccination.
Marx, John, et al. Rosen's Emergency Medicine: Concepts and Clinical Practice, 5th ed. St. Louis: Mosby, 2003.
Parker, James N., et al. Tetanus: A Medical Dictionary, Bibliography, and Annotated Research Guide to Internet References. Boulder, CO: netLibrary, 2004.
Roper, Martha H. "Tetanus Prophylaxis in the Emergency Department." Annals of Emergency Medicine 43, no. 3 (March 2004): 315–17.
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Tish Davidson, A.M.
"Tetanus." Gale Encyclopedia of Children's Health: Infancy through Adolescence. . Encyclopedia.com. (May 27, 2017). http://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/tetanus-0
"Tetanus." Gale Encyclopedia of Children's Health: Infancy through Adolescence. . Retrieved May 27, 2017 from Encyclopedia.com: http://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/tetanus-0
Tetanus, an acute infectious noncontagious disease caused by Clostridium tetani, is characterized by a prolonged illness associated with severe complications, including death. In industrialized countries, tetanus primarily affects elderly adults, while in developing countries, neonatal tetanus predominates and is a substantial major contributor to infant mortality. Elimination of tetanus, especially neonatal tetanus, through vaccination is a global public health priority.
Tetanus (lockjaw) is an acute neurologic disease that occurs when C. tetani spores infect a site of injury and produce a neurotoxin. Wounds accompanied by tissue injury and necrosis produce the anaerobic conditions necessary for bacterial replication and toxin production. The diagnosis is usually established clinically and supported by the epidemiologic setting. Major symptoms are spasm of the muscles of mastication (trismus or lockjaw) and generalized hyperreflexia, which produces painful and uncontrollable muscular contractions. Generalized spasms can occur, often induced by external sensory stimuli. The incubation period ranges from two days to two months, with an average of ten days. The course of illness may last several weeks (often requiring intubation) and subsides gradually in survivors.
The case fatality rate ranges between 10 and 90 percent. Survival is correlated with longer incubation periods and access to medical care. Shorter incubation periods are usually associated with heavily contaminated wounds, more serious disease, and worse outcomes. A wound history can be established in approximately 80 percent of tetanus patients in the United States; however, absence of a wound does not rule out tetanus. Laboratory confirmation of tetanus is difficult and may not be definitive. Culture of the wound may rarely yield C. tetani ; serology is often not helpful because disease can be caused by quantities of toxin insufficient to induce an immune response.
Neonatal tetanus (NT) is caused by unsanitary conditions during childbirth, specifically contamination of the umbilical stump. Neonatal tetanus can be prevented by education about the need for clean deliveries and immunization of women of childbearing age (including pregnant women).
Clostridium tetani is a normal inhabitant of soil and of animal and human intestines and occurs worldwide. Cases increase during warmer months in temperate climates, most likely because of increased outdoor activity. In the United States, an average of forty-six tetanus cases per year were reported to the Centers for Disease Control and Prevention (CDC) from 1990 to 1999, as compared to an average of sixty-seven cases in the 1980s.
In developing countries, neonatal tetanus is a leading cause of neonatal mortality, accounting for over 250,000 deaths annually. Neonatal tetanus has been called "the silent killer," since infants often die before their birth is recorded.
In the United States, five doses of tetanus toxoid are recommended at 2, 4, 6, and 18 months and between 4 and 6 years of age, most often administered with diphtheria toxoid and acellular pertussis vaccine (DTaP). Subsequent booster shots for tetanus, combined with diphtheria toxoid, are recommended every ten years. Less than one percent of tetanus cases recently reported in the United States were in persons with up-to-date immunizations.
There is no herd immunity for tetanus since C. tetani is not transmitted from person to person. Although tetanus is a highly preventable disease, all individuals remain at risk if they do not acquire and maintain immunity through vaccination and periodic boosters.
(see also: Communicable Disease Control; Immunizations )
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Bardenheier, B.; Prevots, D. R.; Khetsuriani, N.; and Wharton, M. (1998). "Tetanus Surveillance: United States, 1995–1997." In Centers for Disease Control Surveillance Summaries 47(SS-2):1–13.
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"Tetanus." Encyclopedia of Public Health. . Encyclopedia.com. (May 27, 2017). http://www.encyclopedia.com/education/encyclopedias-almanacs-transcripts-and-maps/tetanus
"Tetanus." Encyclopedia of Public Health. . Retrieved May 27, 2017 from Encyclopedia.com: http://www.encyclopedia.com/education/encyclopedias-almanacs-transcripts-and-maps/tetanus
Insight as to the mode of action of this toxin at the cellular level has interestingly first been gained from research on muscles of the crayfish. In contrast to the single excitatory innervation by motor axons in mammalian skeletal muscle, these invertebrate muscles have a twin innervation, one type of nerve fibre exciting, and the other inhibiting transmission at the neuromuscular junction. This inhibition does not occur through a process directly affecting the muscle fibre or indeed the ‘motor endplate’ of the neuromuscular junction. Instead, it depends on the release of a chemical transmitter ‘GABA’ which acts on the excitatory motor nerve terminals by opening a chemically-gated chloride channel; the effect of this is to reduce the amplitude of the action potential that reaches the terminal, thereby reducing the amount of excitatory transmitter (acetylcholine) released. As human and mammalian muscles lack such a mixed dual action, the muscular contractions must arise centrally in the axons or motor neuron cell bodies within the spinal cord or brain stem. Experiments show that tetanus toxin actually inhibits the release of GABA in the central nervous system. GABA normally damps downs the excitation of motor neurons; the effect of tetanus toxin is therefore to allow a now unchecked excitatory barrage to cause a sustained and uncontrollable discharge of motor neurons; this accounts in turn for the muscular contractions.
Because the muscle spasms may cause airway obstruction, such as by closing the jaw and the larynx, or may render the respiratory muscles functionally useless because contractions are sustained instead of rhythmic, tetanus is potentially fatal, but it can be treated successfully by antibiotic drugs. Meanwhile the patient may need to be sedated or, in more severe intoxication, to be paralysed by muscle relaxant drugs and artificially ventilated.
See also immunization; infectious diseases.
"tetanus." The Oxford Companion to the Body. . Encyclopedia.com. (May 27, 2017). http://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/tetanus
"tetanus." The Oxford Companion to the Body. . Retrieved May 27, 2017 from Encyclopedia.com: http://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/tetanus
tetanus (tĕt´nəs, –ənəs) or lockjaw, acute infectious disease of the central nervous system caused by the toxins of Clostridium tetani. The organism has a widespread distribution and is common in the soil, human and animal feces, and the digestive tracts of animals and humans; however, the toxin is destroyed by intestinal enzymes. Infection with the tetanus bacillus may follow any type of injury, whether incurred indoors or out, including nail puncture wounds, insect bites, splinter injuries, gunshot wounds, burns, lacerations, and fractures. Deep puncture wounds are most dangerous, since the bacillus thrives in an anaerobic environment.
The tetanus toxin, one of the most potent poisons known, acts on the motor nerves and causes muscle spasm at the site of infection and in other areas of the body. The most frequent symptom is stiffness of the jaw (lockjaw) and facial muscles. Difficulty in breathing and severe convulsions may ensue. The mortality rate is very high, especially in the very young and the aged; overall it is about 40%. Treatment with tetanus antitoxin should be started promptly in conjunction with human immune globulin. It is preferable, however, to prevent the disease by active immunization (including booster shots) with tetanus toxoid (see vaccination).
"tetanus." The Columbia Encyclopedia, 6th ed.. . Encyclopedia.com. (May 27, 2017). http://www.encyclopedia.com/reference/encyclopedias-almanacs-transcripts-and-maps/tetanus
"tetanus." The Columbia Encyclopedia, 6th ed.. . Retrieved May 27, 2017 from Encyclopedia.com: http://www.encyclopedia.com/reference/encyclopedias-almanacs-transcripts-and-maps/tetanus
Tetanus (pronounced TET-n-uhss) is an infection of the central nervous system (the brain and spinal cord). The disease is rare, but often fatal. It is caused when the bacterium Clostridium tetani (pronounced claw-STRID-eeum TEHT-uh-nee) enters the body. The bacterium often enters the body through wounds or cuts exposed to soil. Tetanus can easily be prevented through vaccination.
Tetanus is rare in the United States. For many years, a vaccine (pronounced vak-SEEN) has been available to protect against the disease and the vast majority of American children receive the vaccine. A vaccine is a substance that causes the body's immune system to build up resistance to a particular disease. Cases of tetanus usually occur in adults who were never vaccinated against tetanus.
Only about one hundred cases of tetanus are reported in the United States each year. Of this number, about 70 percent occur in people over the age of fifty. Most of those who die of tetanus are over the age of sixty.
Tetanus: Words to Know
- Central nervous system:
- A system of nerve cells in the brain and the spinal cord.
- Clostridium tetani :
- The bacterium that causes tetanus.
- A contraction of the muscles that can cause paralysis and/or shaking.
- A poison.
- A substance that causes the body's immune system to build up resistance to a particular disease.
Tetanus causes muscular spasms (tightening of the muscles) that can cause paralysis of the respiratory (breathing) system and lead to death. The disease is sometimes called lockjaw. The name comes from a common symptom of tetanus in which the jaw muscles become tight and rigid and a person is unable to open his or her mouth.
Sometimes tetanus affects only one part of the body but usually the infection spreads throughout the body until the entire body becomes paralyzed. The incubation period for tetanus is anywhere from two to fifty days. The incubation period is the time between infection and the first appearance of symptoms. When symptoms occur early, the chance of death is increased.
Tetanus is caused by a bacterium called Clostridium tetani. Bacterial spores (the inactive form of the bacterium) are found in soil, street dust, and animal feces. The spores are transmitted to humans through cuts in the skin. Once inside the body, the spores become active. As they grow, they release a toxin (poison) into the blood stream.
Cuts that have not been thoroughly cleaned are the major source of infection. But the disease can be transmitted in other ways also, such as animal scratches and bites, surgical wounds, and dental work.
The first symptom of tetanus is often a stiff or locked jaw. The patient is unable to open his or her mouth or to swallow. Stiffness soon spreads to the neck and other muscles of the body. The patient often goes into uncontrollable spasms (shaking). The spasms can become so severe as to cause broken bones. Other symptoms of tetanus include irritability, restlessness, loss of appetite, and drooling.
The symptoms of tetanus are quite distinctive and a doctor can usually diagnose the disease simply by observing the patient. Knowing whether or not the patient has had a tetanus vaccination also helps a doctor make their diagnosis.
EMIL ADOLF VON BEHRING
The vaccine against tetanus was discovered by the German bacteriologist Emil Adolf von Behring (1854–1917) in 1890. Behring was working at the time in the laboratory of the great bacteriologist Robert Koch. One of Behring's colleagues in Koch's laboratory was the Japanese bacteriologist Shibasaburo Kitasato.
Behring and Shibasaburo were especially interested in two terrible diseases, diphtheria and tetanus. Behring had an idea that a vaccine against both diseases might be possible by producing an "antitoxin" against them. He made the antitoxin in the following way:
First, he injected the bacteria that cause tetanus into an experimental animal, such as a rabbit. Then, he removed blood from the infected animal. Next, he injected that blood into a second animal, such as a horse. Finally, he removed blood from the second animal. From this blood, he made a vaccine to be used with humans.
Behring's idea was later developed more fully by his colleague Paul Ehrlich. The vaccine developed by Behring and Ehrlich later became part of the DPT (diphtheria/tetanus/pertussis) vaccine that nearly all young children receive today. For his invention of the vaccine, Behring was awarded the first Nobel Prize in medicine in physiology in 1901.
Tetanus is a life-threatening disease. It requires immediate hospitalization. Treatment consists of two main steps. First, the patient is given antibiotics to kill the bacteria. Second, injections of antitoxin are also given. An antitoxin is a substance that reacts with and destroys the bacterial toxin.
Patients may also need medication to control muscle spasms. In severe cases, the patient may have to be placed on artificial respiration. Recovery takes six weeks or more. After a patient is better, he or she should receive the tetanus vaccine to protect against future episodes of the disease.
Up to 30 percent of people with tetanus in the United States die. Early diagnosis and treatment improves the chance of survival. The death rate among young babies who develop the disease is more than 90 percent.
Tetanus can easily be prevented through vaccination. The usual method uses a combination of vaccines that protect against three diseases: tetanus, diphtheria, and pertussis (whooping cough; see whooping cough entry). The vaccine is given in five doses at the ages of two months, four months, six months, fifteen to eighteen months, and four to six years.
Adults should receive a booster shot against tetanus every ten years. A booster shot is a dose of the vaccine that renews a person's resistance to the disease. Adults who have never received a tetanus vaccination should begin one as soon as possible. The adult series consists of three injections over a six to twelve month period.
Side effects of the tetanus vaccine are minor. They include soreness, redness, and swelling at the site of the injection. The symptoms disappear with a few days.
Another way to prevent tetanus infections is to make sure that wounds and scratches are thoroughly cleaned. The tetanus bacterium grows only where there is no oxygen present. So a thorough cleaning of a wound will kill all bacteria. A wound should also be treated with an antibiotic cream and covered with a bandage. Wounds that don't heal should be examined by a doctor.
FOR MORE INFORMATION
Zamalu, Evelyn. "Adults Need Tetanus Shots, Too." FDA Consumer (July/August 1996): pp. 14–18.
"Childhood Infections: Tetanus." KidsHealth. [Online] http://www.KidsHealth.org (accessed December 10, 1997).
"Shots for Safety." [Online] http://www.nih.gov/nia/health/pubpub/shots.htm (accessed December 7, 1997).
"Taking Care of Cuts, Scrapes, and Minor Wounds: What Mom May Not Have Told You." [Online] http://www.mayo.ivi.com (accessed December 9, 1997).
"Tetanus & Diphtheria (Td) Vaccine." [Online] http://www.healthtouch.com/level1/leaflet/cdc181.htm (accessed December 10, 1997).
"Tetanus." UXL Complete Health Resource. . Encyclopedia.com. (May 27, 2017). http://www.encyclopedia.com/medicine/news-wires-white-papers-and-books/tetanus
"Tetanus." UXL Complete Health Resource. . Retrieved May 27, 2017 from Encyclopedia.com: http://www.encyclopedia.com/medicine/news-wires-white-papers-and-books/tetanus
—tetanic (tĕ-tan-ik) adj.
"tetanus." A Dictionary of Nursing. . Encyclopedia.com. (May 27, 2017). http://www.encyclopedia.com/caregiving/dictionaries-thesauruses-pictures-and-press-releases/tetanus
"tetanus." A Dictionary of Nursing. . Retrieved May 27, 2017 from Encyclopedia.com: http://www.encyclopedia.com/caregiving/dictionaries-thesauruses-pictures-and-press-releases/tetanus
- *central nervous system
- (SEN-trul NER-vus SIS-tem) is the part of the nervous system that includes the brain and spinal cord.
- (kon-VUL-shuns), also called seizures, are involuntary muscle contractions caused by electrical discharges within the brain and are usually accompanied by changes in consciousness.
for searching the Internet and other reference sources
Tetanus is a disease caused by infection with Clostridium tetani (klos-TRIH-dee-um teh-TAH-nye) bacteria, which are found all over the world in soil, dust, and some animal feces (FEE-seez, or bowel movements) and even on human skin. The bacteria can enter the body through any type of wound, such as a scratch or deep cut. Infection begins after bacterial spores* have moved deep within the body and become active. Clostridium tetani bacteria are anaerobic (ah-nuh-RO-bik), meaning that they grow best in places with very little oxygen—so the deeper they travel into the body, the better their chances to survive.
- are a temporarily inactive form of a germ enclosed in a protective shell.
Once tetanus spores become active, the bacteria begin producing a toxin (a poisonous substance) called tetanospasmin (teh-tuh-no-SPAZ-min), which attaches to the nerves around the area of the wound. The tetanus toxin also can spread and attach to the ends of nerves of the spinal cord and at neuromuscular junctions (where nerves meet muscles). The toxin blocks the release of a neurotransmitter (nur-o-trans-MIH-ter), a chemical that carries a signal from nerves to other nerves or muscles. This affects the messages that the muscles receive, resulting in severe muscle spasms* that can be powerful enough to tear muscles apart.
- (SPAH-zumz) are involuntary muscular tightenings or contractions.
There are three types of tetanus infection. Local tetanus is limited to the area of the wound; cephalic (seh-FAH-lik) tetanus is an uncommon form that affects the nerves of the face after a head injury or, rarely, a long-lasting ear infection; and generalized tetanus affects much of the body and accounts for the majority of tetanus cases. Neonatal tetanus is a generalized form of the infection that occurs in newborns. It is caused by bacteria contaminating the stump of the umbilical cord*, particularly if the cord has been cut with an instrument that has not been sterilized*.
- (um-BIH-lih-kul) cord is the flexible cord that connects a baby to the placenta, the organ that unites the unborn child to the mother’s uterus, the organ in which the baby develops.
- (STAIR-uh-lyze) is to eliminate all live bacteria or microorgranisms from something, usually through the use of heat, pressure, chemicals, or other antimicrobial agents.
Tetanus occurs around the world but is found frequently in densely populated areas that have hot, damp climates. The disease is rare in the United States, primarily because of vaccination. Nearly all reported cases of tetanus occur in people who have never been vaccinated or who have not had a booster shot in the previous 10 years. Neonatal tetanus infection is rare in developed countries because of improved surgical techniques, but there are hundreds of thousands of deaths from tetanus annually worldwide, mostly in developing countries. Intravenous* drug abusers, such as people who inject heroin, are at a higher risk of contracting the disease.
- (in-tra-VEE-nus), or IV, means within or through a vein. For example, medications, fluid, or other substances can be given through a needle or soft tube inserted through the skin’s surface directly into a vein.
Tetanus is not spread from person to person. Bacterial spores must enter a wound for the infection to spread.
Symptoms of tetanus appear from 3 to 21 days or longer after infection, but usually they develop within 7 days. In about 50 percent of generalized cases of tetanus, the first sign is trismus, or stiffness in the jaw muscles (also known as lockjaw), followed by a stiff neck, shoulder, or back; trouble swallowing; and fever. Spasms can soon spread to the abdominal* muscles, upper arms, and thighs. Other symptoms include sweating, high blood pressure, and periods of rapid heartbeat. The closer the infection is to the central nervous system, the sooner the symptoms appear. The earlier the symptoms begin to appear, the greater the risk of death.
- (ab-DAH-mih-nul) refers to the area of the body below the ribs and above the hips that contains the stomach, intestines, and other organs.
The diagnosis is made based on the presence of symptoms and the patient’s history (for example, getting a wound by stepping on a soil-contaminated nail). Laboratory tests are not useful in determining whether a patient has tetanus. A culture* of the wound can be done, but these cultures generally do not show the bacteria.
- (KUL-chur) is a test in which a sample of fluid or tissue from the body is placed in a dish containing material that supports the growth of certain organisms. Typically, within days the organisms will grow and can be identified.
Typically, tetanus infection is treated in a hospital. Treatment begins with giving the patient tetanus immune globulin* to control or reverse the effects of toxin that has not yet attached itself to nerve endings. Penicillin or other antibiotics also may be given to kill the bacteria. Cleaning the wound and removing dead tissue, in some cases by surgery, is important in ridding the body of invading bacteria. Muscle spasms can be treated with muscle relaxants. Respiratory system* support, provided by a respirator*, may be necessary to help maintain breathing if the respiratory muscles have been affected.
- *immune globulin
- (ih-MYOON GLAH-byoo-lin), also called gamma globulin, is the protein material that contains antibodies.
- *respiratory system ,
- or respiratory tract, includes the nose, mouth, throat, and lungs. It is the pathway through which air and gases are transported down into the lungs and back out of the body.
- is a machine that helps people breathe when they are unable to breathe adequately on their own.
Symptoms may last 3 to 4 weeks, although complete recovery can take several months. Tetanus can be mild, but in most cases the illness is severe and death may occur even after treatment has begun. Tetanus usually requires a long stay in the intensive care unit of the hospital.
Complications of the illness include spasms of the vocal cords and the muscles that control breathing, which can lead to difficulty breathing; fractures in the long bones or the spine from severe muscle spasms and convulsions; high blood pressure; abnormal heart rhythm; secondary infections, such as sepsis* and pneumonia (inflammation of the lung); a blood clot* in the lungs; and death. In the United States, 11 percent of reported tetanus cases are fatal. Unvaccinated children and the elderly are at greater risk of dying if they become infected with tetanus bacteria.
- is a potentially serious spreading of infection, usually bacterial, through the bloodstream and body.
- *blood clot
- is a thickening of the blood into a jelly-like substance that helps stop bleeding. Clotting of the blood within a blood vessel can lead to blockage of blood flow.
Immunization is the best means of preventing tetanus. The vaccination usually is given in combination with other vaccines: the DTaP (diphtheria*/tetanus/acellular pertussis*) form for children and the Td (tetanus/diphtheria) form for adults. A series of shots is required to develop immunity to tetanus toxin, followed by booster shots every 10 years. In some cases of unclean wounds, a booster will be given after the injury to help prevent tetanus.
- (dif-THEER-e-uh) is an infection of the lining of the upper respiratory tract (the nose and throat). It is a serious disease that can cause breathing difficulty and other complications, including death.
- (per-TUH-sis) is a bacterial infection of the respiratory tract that causes severe coughing.
Skin and Soft Tissue Infections
U.S. Centers for Disease Control and Prevention (CDC), 1600 Clifton Road, Atlanta, GA 30333. The CDC provides fact sheets and other information on tetanus at its website.
Telephone 800-311-3435 http://www.cdc.gov
KidsHealth.org. KidsHealth is a website created by the medical experts of the Nemours Foundation and is devoted to issues of children’s health. It contains articles on a variety of health topics, including tetanus.
"Tetanus (Lockjaw)." Complete Human Diseases and Conditions. . Encyclopedia.com. (May 27, 2017). http://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/tetanus-lockjaw
"Tetanus (Lockjaw)." Complete Human Diseases and Conditions. . Retrieved May 27, 2017 from Encyclopedia.com: http://www.encyclopedia.com/medicine/encyclopedias-almanacs-transcripts-and-maps/tetanus-lockjaw
1. A powerful sustained contraction of a voluntary muscle resulting from the summation of a series of rapid muscular contractions (twitches) that are induced by repeated stimulation of the muscle.
2. A disease caused by the bacterium Clostridium tetani, which generally enters the body via an open wound. A toxin produced by the bacterium irritates the nerves, which induce muscle spasms that begin in the jaw muscles (giving the disease the informal name of lockjaw).
"tetanus." A Dictionary of Biology. . Encyclopedia.com. (May 27, 2017). http://www.encyclopedia.com/science/dictionaries-thesauruses-pictures-and-press-releases/tetanus
"tetanus." A Dictionary of Biology. . Retrieved May 27, 2017 from Encyclopedia.com: http://www.encyclopedia.com/science/dictionaries-thesauruses-pictures-and-press-releases/tetanus
tet·a·nus / ˈtetn-əs/ • n. 1. a disease marked by rigidity and spasms of the voluntary muscles, caused by the bacterium Clostridium tetani. See also trismus. 2. Physiol. the prolonged contraction of a muscle caused by rapidly repeated stimuli. DERIVATIVES: tet·a·nize / -ˌīz/ v. tet·a·noid / -ˌoid/ adj.
"tetanus." The Oxford Pocket Dictionary of Current English. . Encyclopedia.com. (May 27, 2017). http://www.encyclopedia.com/humanities/dictionaries-thesauruses-pictures-and-press-releases/tetanus-0
"tetanus." The Oxford Pocket Dictionary of Current English. . Retrieved May 27, 2017 from Encyclopedia.com: http://www.encyclopedia.com/humanities/dictionaries-thesauruses-pictures-and-press-releases/tetanus-0
"tetanus." World Encyclopedia. . Encyclopedia.com. (May 27, 2017). http://www.encyclopedia.com/environment/encyclopedias-almanacs-transcripts-and-maps/tetanus
"tetanus." World Encyclopedia. . Retrieved May 27, 2017 from Encyclopedia.com: http://www.encyclopedia.com/environment/encyclopedias-almanacs-transcripts-and-maps/tetanus
"tetanus." The Concise Oxford Dictionary of English Etymology. . Encyclopedia.com. (May 27, 2017). http://www.encyclopedia.com/humanities/dictionaries-thesauruses-pictures-and-press-releases/tetanus-1
"tetanus." The Concise Oxford Dictionary of English Etymology. . Retrieved May 27, 2017 from Encyclopedia.com: http://www.encyclopedia.com/humanities/dictionaries-thesauruses-pictures-and-press-releases/tetanus-1
"tetanus." Oxford Dictionary of Rhymes. . Encyclopedia.com. (May 27, 2017). http://www.encyclopedia.com/humanities/dictionaries-thesauruses-pictures-and-press-releases/tetanus
"tetanus." Oxford Dictionary of Rhymes. . Retrieved May 27, 2017 from Encyclopedia.com: http://www.encyclopedia.com/humanities/dictionaries-thesauruses-pictures-and-press-releases/tetanus