Tetanus And Travel: Precautions For Travellers To Areas Where Tetanus Is Common

Overview

Tetanus, also known as "lockjaw," is a disease caused by the bacterium Clostridium tetani. This bacterium produces a potent toxin (a poisonous substance) that affects the nervous system, leading to severe muscle stiffness and painful spasms. Tetanus infection needs urgent treatment as it can cause paralysis, problems with breathing, and death.¹

Mass vaccination, particularly the combined diphtheria, tetanus and pertussis (whooping cough) vaccine (DTP, DTaP or Tdap), has significantly reduced the impact of tetanus. However, even with advances in medicine and specialised care, tetanus is still responsible for 1 death in every 10 people infected - which translates into 213,000 to 293,000 deaths globally each year.^1,2 

Tetanus still poses a large risk to public health, particularly in low-income settings such as sub-Saharan Africa and Southeast Asia, where vaccination rates tend to be low. Rural regions are more at risk due to residents having a higher chance of coming into contact with contaminated soil and animal waste, alongside limited access to healthcare.^4,5

Symptoms of tetanus infection

The spores produced by the bacterium enter the body through wounds, burns, puncture injuries, bites, or scratches. They produce a toxin that affects the nervous system, causing uncontrolled muscle spasms.^4,5

Symptoms of infection caused by Clostridium tetani include:

• Stiff muscles, especially in the jaw and neck
• Painful spasms
• Seizures (fits)
• Difficulty swallowing and/or breathing
• Fever
• Sweating
• High blood pressure
• Increased heart rate

How do I get tetanus?

The bacterial spores are found in the environment, particularly in soil, animal faeces, and dust. They usually enter the body through a wound or injury in the skin, such as cuts, scrapes, animal bites, burns, tattoo/piercing sites, or surgical wounds.

Tetanus can also be transmitted to newborns during birth (neonatal tetanus), particularly when the umbilical cord is cut with contaminated equipment. This is more predominant in births taking place outside of a hospital setting.^5,6

Although most people develop symptoms within 14 days of exposure, onset may range from 3 to 21 days. For neonatal tetanus, symptoms typically emerge between 4 to 14 days after birth, with an average onset of around 7 days.^5,6

There is a third form of tetanus (cephalic tetanus), which is extremely rare. Cephalic tetanus can affect one or more cranial nerves causing facial palsy (paralysis). Cephalic tetanus is most commonly caused by head trauma or otitis media (infection of the middle ear), and may or may not progress to generalised tetanus.

Travel-related tetanus infection

Individuals travelling to rural or resource-poor settings face a higher risk of tetanus infection, as there may be lower vaccination rates or limited access to healthcare services.

How to prevent tetanus infection while travelling

It is not possible to always avoid activities that may cause injuries while travelling. Instead, travellers must be prepared to manage accidents if they do occur. Ideally, travellers should know the location of nearby medical facilities and how to access them. Other important measures are described below.^4,5,6

• Vaccination is the best preventative measure. In the UK, the tetanus vaccine (combined with diphtheria and pertussis) is included in the NHS Vaccination Schedule and is given to children at 8, 12 and 16 weeks old, and again at 3 years old. A booster is usually given at 14 years old and every 10 years after
• Booster shots: everyone should have a tetanus booster every 10 years. For travellers, it is advisable to check if their tetanus vaccination is up to date. If necessary, a booster can be given before travelling, ideally at least 2 weeks beforehand
• Good hygiene: regular hand washing is one of the most important prevention measures. If hands are kept clean, there is less chance of infection in the case of injury
• Wound care: in the case of injury, thorough cleaning of the wound(s) is vital to prevent infection. If the wound is deep, has visible yellow tissue, or signs of infection (redness, pain, hot to touch, green leakage) develop, you should seek medical attention
• First aid kit: Some essential items can be very helpful in immediate care. These include normal saline or another liquid disinfectant, gauze, dressings and bandages, and an antibiotic ointment (please seek advice from your pharmacist or doctor)

How is tetanus treated?

Tetanus is always a medical emergency. If you injure yourself and you are not sure of your tetanus vaccination status, or you have an open wound, you should be seen by a nurse or doctor as soon as possible. In case of injury, the tetanus booster should be given up to 48 hours after the accident.

Tetanus is treated with immunoglobulins (antibodies) that neutralise the effect of the toxins, antibiotics to treat infection, and aseptic wound care. In more serious situations, you may need to stay in the hospital for a few days. If you start having muscle spasms, you may also receive medication to relax your muscles, relieve pain, and break any fever.^4,5,6

FAQs

Can everyone have the tetanus vaccine?

Most people can have the tetanus vaccine/booster, including those who are pregnant or breastfeeding. Contraindications to having the vaccine are:

• If you have had a serious allergic reaction (anaphylaxis) to a previous dose of the vaccine
• You are allergic to any ingredient in the vaccine

The vaccine may also not be appropriate if:

• You have been diagnosed with phenylketonuria, a rare genetic condition
• You have experienced seizures or suffer from a nervous system disorder
• If you have had Guillain-Barré syndrome

Please seek advice from a nurse or doctor if this is the case.⁷

Do I need a shot before travelling?

You may need a booster before you travel if you are travelling to an area with poor access to healthcare and your last vaccine was more than 10 years ago or you are not fully vaccinated (according to the NHS Vaccination Schedule).^5,6

Do I need a booster every 10 years?

Although a recent study suggests that boosters can offer up to 30 years of protection^2,7, more studies are needed to validate which factors play a major role in tetanus infection, including hygiene conditions and access to secondary healthcare. Tetanus is an emergency and, in some cases, fatal. The lack of evidence and the severity of the consequences of tetanus infection suggest that 10-year boosters are still advisable.^4,7

If I have been infected before - do I still need the vaccine?

Individuals who recover from tetanus do not develop natural immunity and are susceptible to reinfection. Thus, they still need to be vaccinated.

Is it safe to have another tetanus vaccine before the recommended 10 years?

Research shows that the tetanus vaccine can be safely given with a two-year (or more) interval between two shots.^8,9

What are the tetanus vaccine side effects?

The most common side effects include pain, redness and swelling in the injection site. Some people may also have a mild fever, headache, tiredness/ lethargy, nausea/vomiting, diarrhoea, or stomach pain.¹⁰

If I am scratched or bitten by an animal, should I get a booster?

Yes, if it has been more than five years since your last vaccination.^4,5,6

Is the tetanus vaccine free for travellers in the UK?

Yes, the vaccine is given for free through the NHS. Contact your GP for further information. You can also receive the vaccine privately at a pharmacy. Prices range from £30-50.⁶

Can I care for my wound at home if I have my tetanus shot up to date?

Yes, as long as your wound does not look infected and you do not have a fever.

Summary

• Tetanus continues to be prevalent in many parts of the world, especially where vaccination rates are low and medical care is limited
• Tetanus infection is a medical emergency that can result in serious injury or death
• Even when medical treatment is timely, tetanus still causes death in ~10% of cases
• The most common symptoms are jaw and neck stiffness, although there may be muscle spasms in other parts of the body
• Travellers should have up-to-date vaccines and treat wounds immediately
• If the wound looks infected or vaccination status is unknown, seeking medical attention is the priority