Vaccine Preventable Diseases in Australia, 2005 to 2007

3.15 Tetanus

Page last updated: 24 December 2010

Tetanus is an acute disease resulting from the formation of exotoxin by Clostridium tetani, an anaerobic bacterium that grows at the site of injury and produces toxin with local and systemic neuromuscular effects. Tetanus spores are ubiquitous in the environment and can contaminate all types of wounds. The disease is characterised by painful muscle contractions, primarily of the masseter and neck muscles, secondarily of the trunk muscles. The case-fatality rate ranges from 10% to over 80%, with the highest rates in infants and the elderly.1

Case definitions


See Appendix 6.6 for pre-2004 definition

National definition from January 2004:2

Only confirmed cases are notifiable. Confirmed cases require either laboratory definitive evidence or clinical evidence.

  1. Laboratory definitive evidence
    • Isolation of Clostridium tetani from a wound in a compatible clinical setting and prevention of positive tetanospasm in mouse test from such an isolate using specific tetanus antitoxin.
  2. Clinical evidence
    • A clinically compatible illness without other apparent causes.

Hospitalisations and deaths

The ICD-10-AM/ICD-10 codes A34 (obstetrical tetanus) and A35 (other tetanus) were used to identify hospitalisations and deaths.

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Secular trends

There were 6 notifications of tetanus in the period January 2006 to December 2007 (an average annual notification rate of 0.01 per 100,000) (Table 3.15.1). Notifications for tetanus remained stable in 2006 and 2007, with 3 notifications annually. Between July 2005 and June 2007, there were 36 hospitalisations coded as tetanus (an average annual rate of 0.09 per 100,000). Hospitalisations for tetanus also remained relatively stable between 2005/2006 and 2006/2007; however, there has been a downward trend over the past decade (Figure 3.15.1).

Figure 3.15.1: Tetanus notifications and hospitalisations, Australia, 1993 to 2007,* by year of diagnosis or admission

Figure 3.15.1:  Tetanus notifications and hospitalisations, Australia, 1993 to 2007, by year of diagnosis or admission

* Notifications where the date of diagnosis was between January 1993 and December 2007; hospitalisations where the date of admission was between July 1993 and June 2007. Hospitalisation data for each financial year are plotted according to the year in which the financial year began.

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Severe morbidity and mortality

A total of 616 hospital bed days (average 308 per year) were recorded for patients with an ICD-10-AM code for tetanus over the 2 years July 2005 to June 2007. None of these were coded as obstetric tetanus (A34). Of the 36 separations, 20 (56%) had tetanus recorded as the principal diagnosis. The median length of stay in hospital was 3 days and varied with age. Adults aged ≥60 years had longer median lengths of stay (Table 3.15.1). In the review period 2005–2006, there was 1 death in the AIHW National Mortality Database with tetanus recorded as the underlying cause, in a person aged 87 years.

Table 3.15.1: Tetanus notifications, hospitalisations and deaths, Australia, 2005 to 2007,* by age group

Age group
2 years
2 years
(July 2005–June 2007)
LOS per admission
2 years
n Rate n (§) Rate (§) Median (§) n Rate
All ages

* Notifications where the date of diagnosis was between January 2006 and December 2007; hospitalisations where the date of separation was between July 2005 and June 2007; deaths where the death was recorded between January 2005 and December 2006.

† LOS = length of stay in hospital.

‡ Average annual age-specific rate per 100,000 population.

§ Principal diagnosis (hospitalisations).

n.p. Not published.

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Age and sex distribution

The majority of both the notified (5/6; 83%) and hospitalised (17/36; 67%) cases were aged ≥60 years. The youngest notified and hospitalised cases were aged 15–24 years. There was no difference in gender among notified cases, but there were fewer hospitalised female patients, with a male:female ratio of 1.3:1. In the ≥70 years age group, 69% of the hospitalised cases (11/16) were males.

For both notifications and hospitalisations, rates increased with increasing age (Figure 3.15.2). Males aged ≥70 years had the highest average annual hospitalisation rate (0.67 per 100,000).

Figure 3.15.2: Tetanus notification and hospitalisation rates, Australia, 2005 to 2007,* by age group

Figure 3.15.2:  Tetanus notification and hospitalisation rates, Australia, 2005 to 2007, by age group

* Notifications where the date of diagnosis was between January 2006 and December 2007; hospitalisations where the date of separation was between July 2005 and June 2007.

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Geographical distribution

Notification and hospitalisation rates varied over time and between states and territories (Appendices 6.2 and 6.3). However, there were too few cases in each jurisdiction to identify any trends.

Vaccination status

Two-thirds (4/6) of notified cases in the NNDSS in 2006–2007 were reported to be unvaccinated. A case aged 10–19 years was recorded as partially vaccinated for age. The final case had an unknown vaccination status.

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There has been a downward trend in tetanus hospitalisation rates, which remain higher than notification rates. It is likely that this discrepancy is primarily due to under-reporting, as well as multiple hospital admissions for one case and coding errors.3 Coding errors may have resulted from misclassification of other conditions as tetanus, especially where tetanus was not the principal diagnosis. Notifications of tetanus rely heavily on clinicians rather than laboratories, as laboratory confirmation of the diagnosis is rarely possible. Clinicians are known to under-notify hospitalised cases of disease,4 thus under-notification for tetanus is likely.

Tetanus is a disease of older adults. In Australia, booster doses of tetanus vaccine are thought to be poorly utilised, as is also noted in Canada and Switzerland.5,6 The major impetus for tetanus immunisation in adults is injury,5 but tetanus occurs in cases with trivial or no known injury and the definition of a ‘tetanus prone’ wound is unclear.7,8 International serosurveys and the Australian National Serosurvey have shown progressively lower levels of tetanus antibody in older age groups, particularly in women.9–13 Although the tetanus organism is ubiquitous in the environment, and the vaccine only provides individual level protection against the toxin, tetanus vaccination programs have had a significant impact on the disease burden in Australia. The current tetanus notification rate in Australia is similar to that in other developed countries.7,14–16 A tetanus booster is recommended at the age of 50 years unless a booster has been documented within the previous 10 years.17 While the data presented in this report suggest that this is an appropriate recommendation, strategies to improve vaccine uptake at this age need to be investigated. As both notifications and hospitalisations predominate in those aged ≥65 years, review of tetanus immunisation status at the time of annual influenza vaccination is clearly appropriate. Recent tetanus cases among injecting drug users in the United Kingdom and the USA demonstrate a younger population at risk from this preventable disease.15,18,19 Therefore, maintenance of immunity in young adults, through the scheduled booster dose at age 15–17 years, is also important.

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1. Tetanus. In: Heymann DL, ed. Control of Communicable Diseases Manual. 19th edn. Washington, DC: American Public Health Association, 2008.

2. Communicable Diseases Network Australia. Surveillance case definitions for the Australian National Notifiable Diseases Surveillance System. 2004. Available from: Accessed on 24 August 2009.

3. Quinn HE, McIntyre PB. Tetanus in the elderly – an important preventable disease in Australia. Vaccine 2007;25(7):1304–1309.

4. Bonacruz-Kazzi G, McIntyre P, Hanlon M, Menzies R. Diagnostic testing and discharge coding for whooping cough in a children’s hospital. J Paediatr Child Health 2003;39(8):586–590.

5. Skowronski DM, Pielak K, Remple VP, Halperin BA, Patrick DM, Naus M, et al. Adult tetanus, diphtheria and pertussis immunization: knowledge, beliefs, behavior and anticipated uptake. Vaccine 2004;23(3):353–361.

6. Bovier PA, Chamot E, Bouvier Gallacchi M, Loutan L. Importance of patients’ perceptions and general practitioners’ recommendations in understanding missed opportunities for immunisations in Swiss adults. Vaccine 2001;19(32):4760–4767.

7. Rushdy AA, White JM, Ramsay ME, Crowcroft NS. Tetanus in England and Wales, 1984–2000. Epidemiol Infect 2003;130(1):71–77.

8. Bowman C, Hearing S, Bewley J. Tetanus toxoid for adults [letter]. Lancet 1996;348(9042):1664.

9. Gidding HF, Backhouse JL, Burgess MA, Gilbert GL. Immunity to diphtheria and tetanus in Australia: a national serosurvey. Med J Aust 2005;183(6):301–304.

10. Maple PA, Jones CS, Wall EC, Vyse A, Edmunds WJ, Andrews NJ, et al. Immunity to diphtheria and tetanus in England and Wales. Vaccine 2000;19(2–3):167–173.

11. McQuillan GM, Kruszon-Moran D, Deforest A, Chu SY, Wharton M. Serologic immunity to diphtheria and tetanus in the United States. Ann Intern Med 2002;136(9):660–666.

12. Yuan L, Lau W, Thipphawong J, Kasenda M, Xie F, Bevilacqua J. Diphtheria and tetanus immunity among blood donors in Toronto. CMAJ 1997;156(7):985–990.

13. de Melker HE, van den Hof S, Berbers GA, Conyn-van Spaendonck MA. Evaluation of the national immunisation programme in the Netherlands: immunity to diphtheria, tetanus, poliomyelitis, measles, mumps, rubella and Haemophilus influenzae type b. Vaccine 2003;21(7–8):716–720.

14. Turnbull F, Baker M, Tsang B, Jarman J. Epidemiology of tetanus in New Zealand reinforces value of vaccination. New Zealand Public Health Report 2001;8(8):57–60.

15. Pascual FB, McGinley EL, Zanardi LR, Cortese MM, Murphy TV. Tetanus surveillance—United States, 1998–2000. MMWR Surveill Summ 2003;52(SS–3):1–8.

16. Public Health Agency of Canada. Notifiable diseases on-line. Tetanus. Available from: Accessed on 3 February 2009.

17. National Health and Medical Research Council. The Australian Immunisation Handbook. 9th edn. Canberra: Australian Government Department of Health and Ageing, 2008.

18. Health Protection Agency. Ongoing national outbreak of tetanus in injecting drug users. Commun Dis Rep CDR Wkly 2004;14(9):2–4. Available from: Accessed on 3 February 2009.

19. Savage EJ, Nash S, McGuinness A, Crowcroft NS. Audit of tetanus prevention knowledge and practices in accident and emergency departments in England. Emerg Med J 2007;24(6):417–421.

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