Recently occurring adult tetanus in Korea: emphasis on immunization and awareness of tetanus

Tetanus Overlooked Due to the Involvement of Multiple Departments: A Case Report

Tetanus is a fatal disease caused by a neurotoxin produced by the biotrophic anaerobic bacterium Clostridium tetani, which causes muscle hypertonia and autonomic neuropathy. The diagnosis is based on clinical findings and not the result of specific blood and imaging tests; hence, it is very difficult to diagnose at first sight, despite typical initial findings such as lockjaw, muscle spasms, and neck pain and stiffness. This article discusses the case of a 79-year-old woman who first consulted her local doctor because of a lack of jaw opening. Seeing no improvement, she visited our hospital and was suspected of having tetanus after consulting with nine different departments over seven days from the initial visit. In developed countries, tetanus prevalence has declined due to immunization, leading to clinicians' lack of experience in diagnosing it. Furthermore, the increasing specialization in general hospitals poses a risk of missing a tetanus diagnosis when a patient consults multiple departments.

[Tetanus: the clinical features of 11 cases]

Tetanus is an infectious disease induced by wound invasion of Clostridium tetani, which is ubiquitous among soil. Many more cases are reported in Japan than in other developed countries. In this study, we report 11 cases of tetanus experienced at our hospital and discuss the preceding trauma and treatment course. The mean age at onset was 68 years old (35-86 years) and 7 cases required intensive care. Some preceded injuries were clearly contaminated, and others were small and minor. Even minor injuries developed serious tetanus. Trauma was not identified in 2 cases yet both used their family garden every day and had a high risk of exposure to C tetani, suggesting that micro-wounds may have been a gateway to entry. The average length of stay in the intensive care unit was 28 days (4-73 days) and average total hospitalization was 55 days (13-114 days). Only 4 out of 11 cases were diagnosed correctly by the initial physician and others, especially when the trauma was minor or absent, were misdiagnosed even when presenting with characteristic symptoms like lockjaw and posterior neck stiffness. Tetanus should be diagnosed based on medical history and physical examination due to lack of high specific testing. Therefore, a detailed history taking is required, including hobbies in addition to the appropriate neurological examination, thereby facilitating a quick diagnosis and commencement of treatment as soon as possible.

Clinical outcomes and healthcare costs of inpatients with tetanus in Korea, 2011-2019

Background

Tetanus is a rare, vaccine-preventable but extremely serious disease. We investigated the recent trend of the clinical outcomes and medical costs for inpatients with tetanus in South Korea over 10 years.

Methods

We conducted a retrospective review to determine the clinical factors and medical costs associated with tetanus at two national university hospitals in South Korea between January 2011 and October 2019.

Results

Forty-nine patients were admitted for tetanus (mean age, 67.0 years [range, 53.0–80.0 years]; 32 women [57.1%]). All the patients had generalized tetanus, and 5 (10.2%) died during hospitalization. The median duration from symptom onset to hospital admission was 4 days. Trismus (85.7%) was the most common symptom, and the median hospital stay was 39 days. Thirty-two patients (65.3%) required mechanical ventilation, and 20 (40.8%) developed aspiration pneumonia. The median total healthcare cost per patient was US $18,011. After discharge, 35 patients (71.4%) recovered sufficiently to walk without disability.

Conclusions

Tetanus requires long hospital stays and high medical expenditures in South Korea; however, the vaccination completion rate is low. Medical staff should therefore promote medical advice and policies on the management of tetanus to the general South Korean population.

Tetanus presenting primarily as periocular discomfort in a patient who underwent surgery for sleep apnea: A case report and brief literature review

RATIONALE

Tetanus is caused by a neurotoxin (tetanospasmin) secreted by a spore forming gram-positive, anaerobic rod-shaped motile bacillus, Clostridium tetani. The most common symptoms of tetanus are trismus (100%), dysphagia (70.5%), dysarthria (35.2%), and neck stiffness (29.4%). Respiratory failure, laryngeal spasm, seizure, chest pain, nausea/vomiting, opisthotonus, back pain, and rigid abdominal wall can also be observed during progression of the disease. However, there has been no report of periocular discomfort as an initial manifestation after endoscopic sleep surgery in a patient with tetanus. Here, we report a patient who underwent endoscopic sleep surgery with a concurrent diagnosis of tetanus infection presenting with atypical periocular discomfort as the initial symptom.

PATIENT CONCERNS

A 63-year-old man complaining of sleep apnea, snoring, and daytime sleepiness visited our department. He subsequently underwent sleep surgery (anterior pharyngoplasty with tonsillectomy, septoplasty, microdebrider-assisted inferior turbinoplasty, and an endoscopic sinus surgery) for the treatment of his newly diagnosed obstructive sleep apnea. After 3 weeks of surgery, he visited the outpatient clinic of our department with right side periocular discomfort.

DIAGNOSES

Four days after presenting with periocular discomfort, he was diagnosed with tetanus by presenting trismus, jaw pain, dysphagia, and ptosis at an emergency department of a different hospital.

INTERVENTIONS

Tetanus immunoglobulin and antibiotics were administered.

OUTCOMES

His symptoms then resolved after a month without sequelae.

LESSONS

Although periocular discomfort is atypical and is not uncommon after nasal and oral surgeries, care should be taken when patients present with periocular pain because it could be a rare initial symptom of tetanus.

A Phase III Study to Evaluate the Immunogenicity and Safety of GC1107 (Adult Tetanus Diphtheria Vaccine) in Healthy Adults

BACKGROUND

This study was conducted to assess the immunogenicity and safety of GC1107 (adult tetanus diphtheria [Td] vaccine). The primary goal was to evaluate the non-inferiority of the immunogenicity of GC1107 compared to the control vaccine. Additionally, the safety profiles of GC1107 and the control vaccine were compared.

METHODS

The subjects were adults ≥ 18 years old who were not injected with Td or adult tetanus-diphtheria-pertussis (TdaP) vaccine within the recent 5 years. A total of 253 subjects were enrolled and randomized to either the GC1107 group or the control group. For immunogenicity assessment, blood samples were collected at baseline and 28 days after vaccination and antibody titer of diphtheria and tetanus were assessed.

RESULTS

The seroprotection rates of diphtheria and tetanus were 89.76% and 91.34%, respectively, in the GC1107 group, and 87.80% and 86.99% in the control group. The geometric mean titer (GMT) of the anti-diphtheria antibody increased after vaccination in both groups, showing no significant difference between the groups (P = 0.139). The anti-tetanus GMTs after vaccination also showed comparable increases in both groups, and showed no significant difference (P = 0.860). In the safety evaluation, solicited local adverse reactions occurred in 81.2% of the subjects in the GC1107 group and in 86.4% of the subjects in the control group. Solicited systemic adverse events occurred in 33.2% of the subjects in the GC1107 group and in 47.2% of the subjects in the control group, which did not reach statistical significance.

CONCLUSION

This phase III study demonstrated non-inferiority in immunogenicity and comparable safety of GC1107 compared with the control Td vaccine.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02361866.

Immunogenicity and safety of the new reduced-dose tetanus-diphtheria vaccine in healthy Korean adolescents: A comparative active control, double-blind, randomized, multicenter phase III study

BACKGROUND/PURPOSE

A new reduced-dose tetanus-diphtheria (Td) vaccine was developed in Korea, and phase I and II clinical trials were successfully undertaken. We conducted this double-blind, randomized, multicenter phase III clinical trial to assess the immunogenicity and safety of the new Td vaccine.

METHODS

Healthy adolescents 11-12 years of age were enrolled and randomized to receive the new Td vaccine (study group) or a commercially available Td vaccine (control group). Blood samples were collected prior to and 4 weeks after the vaccination. Between the study and control groups, seroprotection rate, booster response, and geometric mean titer of antibodies against diphtheria and tetanus toxoids were compared after the vaccination. All solicited and unsolicited adverse events and serious adverse events during the 6-week study period were monitored.

RESULTS

A total of 164 adolescents received vaccination, and 156 of them were evaluated to assess immunogenicity. The seroprotection rate and geometric mean titer for antibodies against diphtheria were significantly higher in the study group, whereas those against tetanus were significantly higher in the control group. However, all seroprotection rates against diphtheria and tetanus in the study and control groups were high: 100% against diphtheria and tetanus in the study group, and 98.7% against diphtheria and 100% against tetanus in the control group. No significant differences in the frequency of solicited and unsolicited adverse events were observed between the two vaccine groups.

CONCLUSION

The new Td vaccine is highly immunogenic and safe, and this new Td vaccine can be effectively used for preventing diphtheria and tetanus.

Seroepidemiology of tetanus in Korean adults and adolescents in 2012

This seroepidemiologic study was performed to evaluate the immune status against tetanus in Korean adolescents and adults and to provide evidence to develop strategies for tetanus prevention. Between July 2012 and December 2012, serum samples were collected from adults and adolescents 11 years of age and older, and serum anti-tetanus IgG titers were determined using a commercial ELISA kit. Subjects were divided into six age groups: 11-20 years, 21-30 years, 31-40 years, 41-50 years, 51-60 years, and ≥61 years. The mean anti-tetanus IgG titers and tetanus seroprevalence of the age groups were compared. A total of 1193 adults and adolescents were enrolled. Mean anti-tetanus IgG titer and tetanus seroprevalence of all subjects were 1.20 ± 3.58 IU/mL and 56.4%, respectively. The mean anti-tetanus IgG titer decreased with an increase in age (p < 0.001). Tetanus seroprevalence increased from 92.0% in the 11-20 year age group to 95.7% in the 21-30 year age group, and then decreased with a further increase in age (p < 0.001). These results reflected an appropriate Td booster vaccine coverage at 11-12 years of age. However, the tetanus seroprevalence of adults older than 41 years was as low as the levels in previous studies: therefore, adults should be more encouraged to acquire decennial Td booster vaccinations recommended by the National Immunization Program.

Evaluation of immunogenicity and safety of the new tetanus-reduced diphtheria (Td) vaccines (GC1107) in healthy Korean adolescents: a phase II, double-blind, randomized, multicenter clinical trial

This phase II clinical trial was conducted to compare the immunogenicity and safety of a newly developed tetanus-reduced diphtheria (Td) vaccine (GC1107-T5.0 and GC1107-T7.5) and control vaccine. This study was also performed to select the proper dose of tetanus toxoid in the new Td vaccines. Healthy adolescents aged between 11 and 12 yr participated in this study. A total of 130 subjects (44 GC1107-T5.0, 42 GC1107-T7.5 and 44 control vaccine) completed a single dose of vaccination. Blood samples were collected from the subjects before and 4 weeks after the vaccination. In this study, all subjects (100%) in both GC1107-T5.0 and GC1107-T7.5 groups showed seroprotective antibody levels (≥ 0.1 U/mL) against diphtheria or tetanus toxoids. After the vaccination, the geometric mean titer (GMT) against diphtheria was significantly higher in Group GC1107-T5.0 (6.53) and GC1107-T7.5 (6.11) than in the control group (3.96). The GMT against tetanus was 18.6 in Group GC1107-T5.0, 19.94 in GC1107-T7.5 and 19.01 in the control group after the vaccination. In this study, the rates of local adverse reactions were 67.3% and 59.1% in GC1107-T5.0 and GC1107-7.5, respectively. No significant differences in the number of adverse reactions, prevalence and degree of severity of the solicited and unsolicited adverse reactions were observed among the three groups. Thus, both newly developed Td vaccines appear to be safe and show good immunogenicity. GC1107-T5.0, which contains relatively small amounts of tetanus toxoid, has been selected for a phase III clinical trial.

Influences on formation of tetanus antibody after simultaneous injection of tetanus immunoglobulin with tetanus vaccine

The goal of this study was to determine how much the formation of tetanus antibody is influenced after a single injection of tetanus vaccine (Td) and the simultaneous injection of tetanus vaccine with tetanus immunoglobulin (TIG). All of the healthy adult volunteers were divided into two groups: group 1 (Td only) and group 2 (Td plus TIG). Two hundred thirty seven volunteers were enrolled. When the baseline antibody titer, gender and age were adjusted, the geometric mean titers (GMTs) of the tetanus antibody (group 1 vs group 2) was 0.8438 IU/mL vs 0.5684 IU/mL at 4 weeks (P = 0.002), 0.4074 IU/mL vs 0.3217 IU/mL at 6 months (P = 0.072) and 0.3398 IU/mL vs 0.2761 IU/mL at 12 months (P = 0.140) after injection, respectively. The formation of tetanus antibody after tetanus vaccination is not influenced by TIG at the late period and in adults below the age of 50 yr, but there are significant differences between the two groups at the early period of 4 weeks after vaccination and for the patients over 60 yr.

Clinician awareness of tetanus-diphtheria vaccination in trauma patients: a questionnaire study

Background

Most trauma patients visit the hospital via the emergency department. They are at high risk for tetanus infection because many trauma patients are wounded. Tetanus immunity in the Korean population has been revealed to be decreased in age groups over 20 years old. It is important for emergency physicians to vaccinate patients with the tetanus booster in wound management.

Methods

Questionnaires were sent to the directors of the emergency departments of resident training hospitals certified by the Korean Society of Emergency Medicine.

Results

Two thirds of the emergency department directors surveyed reported applying tetanus prophylaxis guidelines to more than 80% of wounded patients. However, about 45% of clinicians in the emergency departments considered giving less than half of the wounded patient tetanus booster vaccinations, and there were no distinct differences in tetanus booster vaccination rates among different age groups. Most emergency physicians are familiar with tetanus prophylaxis guidelines for wound management. However, more than half of the emergency department directors reported that the major reason for not considering tetanus-diphtheria vaccination was due to assumptions that patients already had tetanus immunity.

Conclusion

Attitude changes should be encouraged among emergency physicians regarding tetanus prophylaxis. As emergency physicians are frequently confronted with patients that are at a high risk for tetanus infection in emergency situations, they need to be more informed regarding tetanus immunity epidemiology and encouraged to administer tetanus booster vaccines.

Disease prevalence and mortality among agricultural workers in Korea

The aim of this paper was to provide an overview of mortality and disease prevalence related to occupational diseases among agricultural workers in Korea. We evaluated the age-standardized mortality rates and the prevalence of chronic diseases and compared them with those of other populations using death registration data from 2004 through 2008 and the 2005 Korean National Health and Nutrition Examination Survey. In addition, we conducted a literature review on published articles examining the health status of farmers in Korea. Agricultural workers have a significantly higher mortality of cancer, tuberculosis, chronic respiratory diseases, liver diseases, suicide, motor and non-motor vehicle accidents. Compared to other populations, farmers have higher prevalence rates of arthritis and intervertebral disc disorders. The literature review revealed a number of work-related diseases among farmers, such as musculoskeletal diseases, pesticide poisoning, infections, and respiratory and neurologic diseases. Korean farmers demonstrate a distinct pattern of mortality and disease prevalence compared to other populations. Although lifestyle factors remain important contributors to those deaths and diseases, our study suggests that occupation is a major determinant as well. Intensive programs such as surveillance systems, therefore, should be developed in order to identify and prevent work-related diseases among agricultural workers in Korea.

Immunogenicity and safety of diphtheria-tetanus vaccine in adults

This study was conducted to evaluate the immunogenicity and safety of diphtheria-tetanus (Td) vaccine in adults over 40 yr old who had never received a diphtheria-tetanus-pertussis (DTP) vaccination. A total of 242 subject completed three-doses of Td vaccination and subsequent assays for immunogenicity. Before vaccination, 33.9% and 96.7% participants showed antibody levels of diphtheria and tetanus, respectively, which were below protective level (<0.1 U/mL). After the first dose of Td vaccine, 92.6% and 77.6% of subjects gained protective antibody concentrations (≥ 0.1 U/mL) for diphtheria and tetanus, with an increase to 99.6% and 100% after the third dose. Local and systemic adverse events occurred in 37.9% and 15.5% of the subjects. No serious adverse event requiring an unscheduled hospital visit occurred. In conclusion, three-doses of Td vaccination to unimmunized adults are safe and effective in inducing protective immunity against diphtheria and tetanus.

Immunogenicity and safety of diphtheria-tetanus vaccine in pre-adolescent and adolescent South Koreans

This study was conducted to compare the immunogenicity and safety of diphtheria-tetanus (Td) vaccine between pre-adolescents aged 11-12 years and adolescents aged 13-18 years. A total of 277 subjects (132 pre-adolescents and 145 adolescents) participated. After vaccination, all subjects (100%) in both groups exhibited seroprotective antibody levels (> or =0.1I U/mL) against diphtheria or tetanus toxoids. Although local adverse events following vaccination were more frequently observed in the pre-adolescent group than in the adolescent group (p=0.006), these events resolved within 7 days. Our study shows Td vaccination at age 11-12 years to be immunogenic and tolerable.

Evaluation for tetanus antibodies in Korean-Americans living in the New York area: a pilot study

Public health initiatives to immunize children and adults have effectively reduced the number of tetanus cases in the USA. However, in the third National Health and Nutrition Examination Survey (NHANES III), immigrants from Mexico had a 67% non-protective anti-tetanus antibody (ATA) level. Less work has been conducted among other immigrant populations to determine the extent of this observation. Objective To measure ATA levels among the Korean-American immigrant population. Methods A convenience sample of 50 Korean Americans born outside the USA was recruited to determine the levels of ATA. A non-protective level of ATA was defined as below 0.15 IU/ml. Results The mean age was 59.5 years and 82% were female. There were 43/50 (86% (95% confidence limits 76, 96)) patients with a non-protective ATA level. Those between the ages of 50-59 years (94% were seronegative) and 60 years-highest age (92% were seronegative) were among the least likely to be protected. Neither gender nor a self-reported history of past tetanus immunization or military service predicted protection to tetanus. Discussion In this pilot study we found that 86% of Korean immigrants did not have protective ATA levels, with patients in the 50-59 year age range as unlikely to be protected as the older subjects. Patient reported history was unreliable in determining whether an individual had protective levels. Conclusion The vast majority of sampled Korean American immigrants lack protective ATA levels and are in need of immunization. Additional study is needed to determine the risk of other immigrant groups to tetanus.

Incomplete Immunity and Missed Vaccination Opportunities in East African Immigrants Settling in Australia

BACKGROUND

Immigrants and refugees are at particular risk of incomplete immunisation and may be unaware of their vaccination status. There is a paucity of data on the immunisation status of adult immigrants from African countries.

AIMS

To review the immunisation status of adult immigrants from East Africa, and to identify missed opportunities for vaccination.

METHODS

A community survey was conducted using self-reported vaccination status, Mantoux skin tests, and serological testing for immunity to hepatitis B, tetanus, diphtheria and measles.

RESULTS

Proven inadequate immunity against at least one of tetanus (67%), hepatitis B (41%), diphtheria (34%) or measles (3%) was found among 100/126 (81%) participants despite a median of seven visits to vaccine providers since immigration. A positive Mantoux test occurred in 17% of participants.

CONCLUSIONS

Pre- and post-arrival health assessments are currently failing to address vaccination needs in recently arrived East African adult immigrants. Immigrants should have their immunisation status assessed, with opportunistic vaccination provided wherever possible.