Transcript Tetanus

Trends in Tetanus Epidemiology in
the United States, 1972-2001
Pamela Srivastava MS
Bacterial Vaccine-Preventable Disease
Branch, National Immunization Program
Centers for Disease Control and
Prevention
March 2005
Tetanus
Pathogenesis
• Caused by neurotoxin produced by
Clostridium tetani in anaerobic wounds
• Tetanus spores are ubiquitous
– soil
– animal or human intestine/feces
– skin surfaces
– contaminated substances, including
heroin
Tetanus
Clinical Presentation
• Characterized by
- muscle rigidity
- painful muscle spasms
• 3 types of tetanus (generalized,
localized, cephalic)
• Usually requires hospitalization,
ICU care
Tetanus
Routine Vaccination/Immunity
• A primary, 3-dose series + 1 booster
provides immunity lasting approximately
10 years
• Immunity following subsequent boosters
lasts 10 - 20 years or more
• Even incomplete immunization reduces
disease severity and mortality
Tetanus
Surveillance
• Passive reporting system
• State health departments report weekly to the
National Notifiable Diseases Surveillance
System
• Clinical diagnosis - no diagnostic laboratory
tests
• Approx 19% of hospitalized tetanus cases are
reported to CDC*
*Estimate based on data from the Healthcare Cost and Utilization Project (HCUP)
Tetanus in the United States:
1947-2004*
5
4.1/million
per million
4
1972-2001
CFR 91%
3
Incidence
Mortality
2
1
2004:
32 cases =
0.11 / million
CFR
13%
0
1947
1960
*2004 data not finalized
1970
1980
1990
2000
Tetanus Epidemiology,
30 years (1972-2001)
1837 cases reported:
• 32 neonatal cases <1 month
∙ 7 deaths (CFR = 21.9%)
• 1805 cases ≥ 1 year
- 512 deaths (CFR = 28.4%)
- 88% generalized, 12% localized,
<1% cephalic
Neonatal Tetanus, 1972-2001
30
Cases
25
20
15
10
5
0
1972-1981
1982-1991
1992-2001
38% were Hispanic, 34% were white
44% of mothers were unvaccinated, 44% of mothers received 1 dose
Tetanus– Reported Cases and Annual
Incidence, 1972-2001
CFR 38%
0.6
CFR 25%
Cases
100
CFR 17%
0.5
80
0.4
60
0.3
40
0.2
20
0.1
0
0.0
1972
1977
1982
1987
1992
Year
cases
incidence
1997
Incidence per million
120
Average annual incidence
(per million)
0 - 0.12
0.12 - 0.25
0.25 - 0.4
> 0.4
1972-1981
Tetanus
Incidence
by State
1972-1981
&
1992-2001
1992-2001
Tetanus Incidence, by Region, 1972-2001
0.6
Northeast
MidWest
South
West
per million
0.5
0.4
0.3
0.2
0.1
0.0
72-81
82-91
92-01
• The South had the sharpest decline in incidence, from 0.52
(1972 to 1981) to 0.17 (1992 to 2001)
Tetanus Cases, by Season, 1972-2001
300
250
Cases
200
Winter
Spring
Summer
Fall
150
100
50
0
72-81
82-91
92-01
Tetanus Incidence, by Gender,
1972-2001
0.40
0.35
Male
Female
per million
0.30
0.25
0.20
0.15
0.10
0.05
0.00
1972-1981
1982-1991
1992-2001
Overall: Male 51%, Female 48%
Tetanus Vaccination Status, 1972-2001
Vaccination
History
Unknown
Reported
Cases
39% (712)
Reported
Fatalities
38% (273)
Not vaccinated 34% (611)
28% (173)
Vaccinated,
< 3 doses
3+ doses
21% (369)
17% (62)
6% (113)
4% (4)
Tetanus Cases and Deaths, by Age
Group, 1972-2001
700
600
400
Deaths
Non-fatal Cases
300
200
100
1-19 y
20-39 y
40-59 y
9201
7281
9201
7281
9201
7281
9201
0
7281
Cases
500
60+ y
Tetanus Annual Incidence
by Age Group
1.2
1-19 y
20-39 y
1.0
per million
40-59 y
60+ y
0.8
0.6
0.4
0.2
0.0
72-81
82-91
92-01
Tetanus Cases and IDUs, by Age
Group,
1972-2001
450
400
350
250
IDUs
Non-IDU Cases
200
150
100
50
1-19 y
20-39 y
40-59 y
01
92
-
81
72
-
01
92
-
81
72
-
01
92
-
81
72
-
01
92
-
81
0
72
-
Cases
300
60+ y
Racial & Ethnic Distribution of Tetanus
Cases: IDUs vs. Non-IDUs, 1972-2001
Injection Drug Users
22%
28%
48%
Non-Injection Drug Users
Native American/AN
Asian/PI
Black
Hispanic
White
Unknown
17%
8%
67%
Hispanics make up 48% of tetanus cases in IDUs,
compared to only 8.4% of cases in non-IDUs
Tetanus Incidence, by
Race/Ethnicity, 1972-2001
Black
Nat Amer/Alas Nat
Hispanic
White
Asian/Pacific Islander
0.7
0.6
per million.
0.5
0.4
38% IDUs
0.3
0.2
0.1
0
1972-1981
1982-1991
1992-2001
Tetanus in 20 to 39 year olds
• Incidence rates have not decreased in
the 20-39 yr age group
• The outbreak of tetanus among IDUs on
the West Coast does not account for
this lack of decrease
• When the IDUs are excluded, the
proportion of Hispanics is the same as
in other age groups
Tetanus among Diabetics
1987-2001
•
13% (85/675) of all cases
•
29% (37/128) of all deaths
•
CFR: 44% mortality (37/85) among
diabetics
Diabetes Tetanus Risk*, 1987-2001
• Overall incidence: diabetics 0.7 /million
non-diabetics 0.2 /million
• Age-adjusted relative risk for tetanus
diabetics vs. non-diabetics
3.16 (2.51-3.99)
• Age-adjusted relative risk for tetanus death
diabetics vs. non-diabetics
4.41 (2.99-6.76)
*Based on population estimates from the US Census and the NCHS Division of Diabetes
Translation
Acute Wounds, 1972-2001
•
76% (1366/1805) acute wounds
– 38% punctures (nails & other sharp tools,
splinters, body piercing & tattoos)
– 42% lacerations or abrasions
– 20% other (blunt trauma, crush injuries,
burns, frostbite, surgeries, gunshots, animal
bites/scratches)
Non-Acute Wounds, 1972-2001
•
16% (285/1805) non-acute wounds
– 34% chronic ulcers
– 21% gangrene
– 21% abscesses / cellulitis
– 4% dental infections
– 5% other infections
– 15% injection drug use (IDU) only
•
8% (154/1805) of all cases had no
identifiable injury/lesion
Impact of Tetanus
• Severe
- CFR 28%
- 78% (518/668) hospitalized
• Expensive*
- Average cost per hospitalization:
$84,277 (range $1718 - $925,315)
- Total annual cost = $12,641,550
*Estimates based on HCUP data, 1988-2001
Summary
• Tetanus morbidity and mortality have
decreased over the past 30 years
• The elderly and diabetics are at increased
risk for disease and death
• Many cases did not have classic “tetanus
prone” wounds
Summary
• Tetanus disease/mortality associated
with inadequate vaccination
• Racial/regional differences have
disappeared
• Neonatal tetanus virtually nonexistent
Recommendations
• Public Health:
– Collect more complete case data
(especially vaccination history)
• Clinicians:
– Ensure all patients, especially
diabetics, are up-to-date
(pay attention to primary series)
– Recognize that tetanus can occur
even in absence of “tetanus-prone”
wounds
– Report cases
Acknowledgments
• State and Local Health Departments
• Tetanus Team, National Immunization
Program, CDC
Kristin Brown
Jufu Chen
Katrina Kretsinger
Martha Roper
• National Immunization Program, CDC
Rongping Zhang
Tetanus is Preventable
Regions
Midwest
Northeast
South
West
Regions
Age-Specific Prevalence of Immunity by Sex
NHANES III 1988-1994
100
Males
Females
80
60
40
20
0
6-11
12-19 20-29 30-39 40-49 50-59 60-69
Years
McQuillan et al. Ann Intern Med, May 2002; 136:660-666.
70+
Age-Specific Prevalence of Immunity
NHANES III 1988-1994
100
80
60
40
20
0
6-11
12-19
20-29
30-39
40-49
50-59
60-69
Age Group (years)
McQuillan et al. Ann Intern Med, May 2002; 136:660-666.
70+
Age-Specific Prevalence of Immunity by Sex 1988-94*
& Reported Tetanus Cases 1988-94
90
100
80
90
80
70
No. Cases
Cases-male
60
Cases-female
50
50
Serology-male
40
40
Serology-female
30
30
20
20
10
10
0
0
6-11
12-19
20-29
30-39 40-49 50-59
Age Group (years)
*McQuillan et al. Ann Intern Med, May 2002; 136:660-666.
60-69
>70
% Seropositive
70
60
Tetanus in the Elderly (>60 years),
1972-2001
•
940/1805 (52%) of cases were >60 y
•
379/512 (74%) of total deaths ;
•
CFR: 379/940 (40%) of cases ≥60 y
died
•
379/940 (40%) with no dose, 10/940
(1%) with >3 doses, 405/940 (43%)
with missing dose
Tetanus Incidence by Age Group, 1972-2001
14.00
12.00
Rate per Million Pop.
10.00
8.00
6.00
4.00
2.00
0.00
72-81
82-91
92-01
Decades
1-19
20-39
40-59
60+
Tetanus Cases in Injection Drug Users,
1972-2001
60
50
Age Groups:
Cases
40
50+
40-49
30-39
20-29
10-19
30
20
10
0
72-81
82-91
Decade
92-01
Racial & Ethnic Distribution of Tetanus
Cases: Diabetics vs. Non-Diabetics,
1987-2001
Non-Diabetics
Diabetics
Native
American/AN
Asain/PI
22%
50%
21%
11%
African
American
Hispanic
White
16%
67%
Unknown
• Among the diabetic cases: 22% were African American and
21% were Hispanic compared to 12% and 16% respectively,
among the non-diabetics
Tetanus - Seasonal Trends, 1972-2001
300
Cases
250
200
72-81
82-91
92-01
150
100
50
0
Winter
Spring
Summer
Seasons
Fall
Tetanus in Diabetics, 1987-2001
• 72% of diabetics had acute wounds,
compared to 76% of non-diabetics
• Of the 18 diabetics with non-acute
wounds, 44% (8) had ulcers and 39%
(7) had gangrene—of the non-diabetics
with non-acute wounds, 33% had ulcers
and 20% had gangrene
• 68% (44/65) diabetics insulin dependent