tetanus

Presentation evidence

Record individual observations before assigning a clinical form, including findings obscured by treatment.

1. Which jaw, neck, trunk, limb or cranial nerve findings were observed, by whom and when? provenance
2. Are abnormalities localized, generalized or cephalic, and what evidence supports that classification? definition
3. Which findings were unassessable because of sedation, paralysis or another examination limitation? measurement

Alternative explanations

Make the assessment of tetany, drug-related dystonia, poisoning, seizures and other causes explicit rather than applying an automatic symptom match.

1. Which alternative diagnoses were considered, and what evidence favors or weakens each? boundary
2. Who judged tetanus suspected or clinically diagnosed, and what observations supported that decision? provenance
3. Were laboratory results used to investigate alternatives without treating them as a definitive tetanus test? boundary

Portal and timeline

Retain multiple candidate exposures when necessary and distinguish unidentified entry from evidence of no exposure.

1. Which wounds, procedures, injections, cord-care events or head and ear lesions are plausible entry contexts? provenance
2. What interval separates each candidate event from the first symptom, and how uncertain are those dates? measurement

Immunization evidence

Link patient and, where relevant, maternal records to the episode and distinguish documentation from recall.

1. Which tetanus-containing vaccine doses and prior passive-immunization events are documented, reported or unknown? provenance
2. For a neonatal episode, what maternal immunization, birth and cord-care evidence is available? provenance
3. Which applicable guideline should interpret this history for subsequent prevention decisions? action

Motor burden trend

Compare observations using explicit time windows and treatment context; document naturally observed triggers without provoking spasms.

1. How have spasm frequency, duration, distribution and observed sensory triggers changed? measurement
2. When did generalized spasms first appear relative to the initial symptom? measurement
3. Could an apparent improvement reflect sedation or neuromuscular blockade rather than reduced disease activity? boundary

Urgent support needs

Tetanus requires hospital care; airway loss and autonomic instability are specific management concerns. [CDC clinical care](https://www.cdc.gov/tetanus/hcp/clinical-care/index.html)

1. What evidence indicates airway obstruction, impaired ventilation, unsafe swallowing or autonomic instability? measurement
2. What support is currently required, and which deterioration criteria trigger immediate escalation under the treating service's protocol? action

Intervention purpose and delivery

TIG acts on unbound toxin; wound care and antibiotics address the source. Record these as separate interventions. [CDC clinical care](https://www.cdc.gov/tetanus/hcp/clinical-care/index.html)

1. What antitoxin was prescribed and administered, at what time, dose and route, under whose authorization? provenance
2. What wound assessment, debridement or antimicrobial treatment was completed, pending or judged unnecessary? action
3. Which supply constraints, contraindications or uncertainties require specialist review? action

Support response

Record clinician-directed spasm control, autonomic management and respiratory support with response and adverse-effect assessments.

1. Which interventions target spasms, autonomic instability or ventilation, and what response has been observed? measurement
2. Which treatment changes or support reductions require clinician reassessment, and what evidence is needed? action

Resolution and residual effects

Record remaining spasm activity, swallowing or mobility limitations and linked complications without attributing every impairment to tetanus.

1. What sustained evidence supports resolution, including observations after symptom-suppressing treatment is reduced? measurement
2. Which residual impairments or complications require follow-up, and how certain is their relationship to tetanus? boundary

Post-episode follow-through

Recovery does not confer tetanus immunity; retain a vaccination review and follow-up plan. [CDC clinical care](https://www.cdc.gov/tetanus/hcp/clinical-care/index.html)

1. What vaccination plan has the responsible clinician established, and which doses remain outstanding? action
2. What jurisdiction-specific reporting definition and process apply, separately from the clinical diagnosis? boundary
3. Who owns outstanding rehabilitation, immunization and reporting tasks at episode closure? action

Kinds and varieties

Reported by the breadth pass; each item needs checking against its source before it becomes normative.

• generalized tetanus
• localized tetanus
• cephalic tetanus
• neonatal tetanus
• maternal tetanus

1. Which of these kinds and varieties hold for the sense of tetanus this model covers, and on what evidence? provenance

Identifiers and schemes

Reported by the breadth pass; each item needs checking against its source before it becomes normative.

• Wikidata - Q180744 - Item for tetanus as a disease (not the bacterium or the toxoid vaccine).
• ICD-10 - A33-A35 - A33 neonatal tetanus; A34 obstetrical tetanus; A35 other tetanus (including lockjaw).
• MeSH - D013742 - Heading Tetanus.
• SNOMED CT - 76902006 - Tetanus (disorder).

1. Which of these identifiers and schemes hold for the sense of tetanus this model covers, and on what evidence? provenance

Standards and regulation

Reported by the breadth pass; each item needs checking against its source before it becomes normative.

• WHO Position Paper on Tetanus Vaccines (updated February 2017) - World Health Organization / SAGE: six TTCV doses (three-dose primary series from 6 weeks, then boosters at 12-23 months, 4-7 years, and 9-15 years).
• Maternal and Neonatal Tetanus Elimination (MNTE) - WHO, UNICEF and UNFPA: neonatal tetanus no longer a public-health problem when incidence is below one case per 1,000 live births in every district.
• WHO neonatal tetanus surveillance definition - World Health Organization: an infant who sucked and cried normally in the first 2 days of life, then loses that ability between days 3 and 28 and becomes rigid or has spasms.
• ACIP recommendations for tetanus-toxoid-containing vaccines and wound prophylaxis (including TIG) - CDC Advisory Committee on Immunization Practices.
• US nationally notifiable disease surveillance for tetanus - CSTE/CDC (clinical case definition; no confirmatory laboratory criterion).

1. Which of these standards and regulation hold for the sense of tetanus this model covers, and on what evidence? provenance

Real-world use

Reported by the breadth pass; each item needs checking against its source before it becomes normative.

• Emergency and surgical wound care: classify the wound and immunization history, then give tetanus toxoid with or without tetanus immune globulin.
• Routine childhood immunization with TTCV combinations (DTP/DTaP, pentavalent and hexavalent products) and later Td or Tdap boosters.
• Antenatal and reproductive-age immunization so newborns have passive protection at birth (protection at birth / PAB).
• MNTE programmes: supplementary immunization of women of reproductive age, promotion of clean delivery and cord care, and neonatal tetanus case investigation.
• Hospital treatment of established disease: airway and spasm control, metronidazole, human TIG, and a full toxoid series at a different site because recovery does not confer immunity.

1. Which of these real-world use hold for the sense of tetanus this model covers, and on what evidence? provenance

Typical measurements

Reported by the breadth pass; each item needs checking against its source before it becomes normative.

• incubation period (non-neonatal) - 3-21 (average about 8) - days
• neonatal symptom onset after birth - 4-14 (average about 7) - days
• cephalic tetanus incubation - 1-2 - days
• share of cases that are generalized - >80 - %
• case fatality with modern intensive care (generalized tetanus) - 10-20 - %
• wound-culture recovery of C. tetani in clinically diagnosed tetanus - about 30 - %
• MNTE elimination threshold - <1 - neonatal tetanus cases per 1,000 live births per district
• global infant DTP3 coverage (2025, WHO) - 85 - %

1. Which of these typical measurements hold for the sense of tetanus this model covers, and on what evidence? provenance

Failure modes and hazards

Reported by the breadth pass; each item needs checking against its source before it becomes normative.

• Respiratory failure, laryngospasm and asphyxia from generalized spasms, including in neonates who stop sucking.
• Autonomic instability (hypertension, tachycardia, sweating) and secondary ICU complications such as pulmonary embolism and aspiration.
• Case fatality remains 10-20% even with intensive care; it is much higher without ventilation and in neonatal tetanus.
• Localized or cephalic disease can progress to generalized tetanus.
• Tetanospasmin already bound at nerve terminals cannot be neutralized; TIG only mops up circulating toxin.
• Recovery does not confer immunity, so unvaccinated survivors remain susceptible.
• Negative wound culture does not exclude tetanus (organism recovered in only about 30% of cases, and isolation can occur without disease).
• Unclean delivery or cord care in an unimmunized mother produces neonatal tetanus; missed infant doses or adult boosters leave injury-associated tetanus possible wherever spores exist.

1. Which of these failure modes and hazards hold for the sense of tetanus this model covers, and on what evidence? provenance

Regional variation

Reported by the breadth pass; each item needs checking against its source before it becomes normative.

• English common name lockjaw refers to masseter spasm (trismus), not a separate disease.
• As of July 2026 WHO reported eight countries still short of MNTE; neonatal tetanus is now rare in high-income settings such as the United States.
• Merck notes cephalic tetanus incidence highest in Africa and India.
• Infant primary-series calendars differ (examples in use: 6/10/14 weeks; 2/3/4 months; 3/4/5 months; 2/4/6 months).
• WHO recommends six lifetime TTCV doses through adolescence; many high-income schedules add adult Td/Tdap boosters about every 10 years.
• WHO asked countries to replace single-antigen tetanus toxoid (TT) with Td; nearly all had done so by December 2023.

1. Which of these regional variation hold for the sense of tetanus this model covers, and on what evidence? provenance

Neighbouring kinds and how to tell them apart

Reported by the breadth pass; each item needs checking against its source before it becomes normative.

• bacterial or viral meningoencephalitis - Tetanus keeps an intact sensorium and normal cerebrospinal fluid together with muscle spasms; meningoencephalitis typically alters consciousness and CSF.
• peritonsillar or retropharyngeal abscess (local trismus) - Trismus from a deep neck or tonsillar space infection has a focal ENT source on examination or imaging and lacks descending generalized rigidity and stimulus-triggered spasms.
• phenothiazine or other drug-induced dystonia (including neuroleptic malignant syndrome) - Drug history (neuroleptics/phenothiazines) and, when present, fever and rigidity of NMS; tetanus is a clinical syndrome after a wound or unclean birth in a person with incomplete TTCV history.
• Clostridium tetani colonization or a positive wound culture without tetanus - The organism can be isolated from people who do not have tetanus, and is missed in about 70% of true cases; diagnosis follows the clinical syndrome, not culture.

1. Which of these neighbouring kinds and how to tell them apart hold for the sense of tetanus this model covers, and on what evidence? provenance