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Internal Medicine›Condition·Updated Apr 17, 2026·v1

Tetanus

Tetanus is a severe neurological syndrome caused by *C. tetani* toxin, characterized by muscle rigidity and spasms. Management centers on toxin neutralization, antibiotic eradication, and intensive supportive care for respiratory and autonomic complications.

High Evidence105 references·673 words·3 min read·v1
Infectious DiseaseCritical CareNeurologyVaccine Preventable

Quick Reference

RxDrug of choiceMetronidazole (500 mg IV q6-8h) + HTIG (3,000-6,000 units IM)
AltAlternativesPenicillin G (though GABA-antagonism is a concern), Doxycycline
⊘AvoidNon-selective beta-blockers (e.g., Propranolol) in autonomic instability
DxTest of choiceClinical diagnosis (supported by a positive Spatula Test)
ScKey scoreAblett Classification (Grades 1-4 for severity)
→When to referRefer all suspected cases to a tertiary center with ICU and mechanical ventilation capabilities
Tetanus is a clinical diagnosis requiring immediate toxin neutralization, antibiotic therapy, and aggressive ICU-based spasm control.
Tetanus is a life-threatening, vaccine-preventable neuroparalytic disease caused by the potent neurotoxin tetanospasmin, produced by the anaerobic bacterium *Clostridium tetani*. The disease is characterized by progressive muscle rigidity and paroxysmal spasms, often beginning with the masseter muscles (trismus or lockjaw). While global incidence has declined due to widespread immunization, it remains a critical public health concern in resource-limited settings and among undervaccinated populations in developed nations, particularly the elderly with waning immunity.

Overview and Recommendations

Background

  • •Recognize tetanus as a non-communicable, toxin-mediated disease caused by Clostridium tetani, an anaerobic gram-positive, spore-forming rod found ubiquitously in soil, dust, and animal feces. The disease occurs when spores enter the body through contaminated wounds, germinate in anaerobic conditions, and release , a neurotoxin that irreversibly blocks the release of inhibitory neurotransmitters (GABA and glycine) at the presynaptic terminals.
  • •Identify the four clinical variants: generalized tetanus (the most common form, characterized by descending muscle rigidity and spasms), neonatal tetanus (occurring in infants due to umbilical contamination), cephalic tetanus (localized to the head following ear or head injuries, often involving cranial nerve palsies), and local tetanus (rigidity confined to the muscles near the site of injury).
  • •Understand the shifting epidemiology in developed nations, where the disease primarily affects adults over age 65 due to waning vaccine-induced immunity and suboptimal booster compliance. In contrast, resource-limited settings still face a significant burden of neonatal and maternal tetanus due to inadequate antenatal care and unsterile delivery practices.
  • •Note that the incubation period typically ranges from 3 to 21 days, with a shorter incubation period (less than 7 days) and a shorter period of onset (time from first symptom to first generalized spasm, less than 48 hours) serving as strong predictors of severe disease and higher mortality.
  • •Acknowledge that clinical infection does not confer natural immunity because the lethal dose of tetanospasmin is lower than the dose required to stimulate an effective immune response; therefore, all survivors must receive a full primary vaccination series or booster.

Evaluation

  • •Suspect tetanus in any patient presenting with unexplained muscle stiffness, difficulty swallowing, or painful spasms, especially if there is a history of a recent wound and an uncertain or incomplete vaccination history. Do not wait for laboratory confirmation, as the diagnosis is entirely clinical.
  • •Perform the spatula test at the bedside by touching the posterior pharyngeal wall with a sterile spatula; a positive result occurs when the patient involuntarily bites down on the spatula due to masseter spasm, rather than the normal gag reflex (high specificity for tetanus).
  • •Assess for trismus (lockjaw), which is the most common presenting symptom (occurring in over 85% of cases), and , a characteristic grimace caused by sustained contraction of the facial muscles.
  • •Examine the patient for , a state of severe hyperextension where the head, neck, and spinal column enter a complete arching position due to dominant extensor muscle spasms.
  • •Monitor for signs of autonomic nervous system dysfunction (ANSD), which typically appear in the second week of illness and include labile blood pressure, tachycardia, profuse diaphoresis, and intermittent hyperthermia.
  • •Evaluate the portal of entry, which may include obvious traumatic wounds (e.g., rusty nail punctures), but also minor abrasions, chronic ulcers, dental infections, or surgical sites. In some cases, no clear entry point is identified.
  • •Order baseline laboratory tests, including creatine kinase (CK), which is often elevated due to intense muscle activity, and a wound culture, though C. tetani is isolated in only about 30% of cases and a negative culture never rules out the disease.
  • •Rule out differential diagnoses such as strychnine poisoning (which mimics generalized spasms), hypocalcemic tetany (look for Chvostek or Trousseau signs), dystonic reactions to neuroleptics, and meningoencephalitis (perform CSF analysis if meningism is present).
  • •Grade the severity of the disease using the Ablett Classification: Grade 1 (mild trismus, no spasms), Grade 2 (moderate trismus, brief spasms), Grade 3 (severe trismus, frequent spasms, respiratory distress), and Grade 4 (Grade 3 plus severe autonomic instability).
  • •Obtain a chest X-ray to screen for or fractures of the ribs or vertebrae, which are common complications of severe paroxysmal spasms.

Management

  • •Admit all patients with suspected tetanus to a quiet, darkened room in an Intensive Care Unit (ICU) to minimize external stimuli (light, noise, touch) that can trigger life-threatening spasms.
  • •Administer Human Tetanus Immunoglobulin (HTIG) immediately to neutralize unbound toxin; for treatment of active disease, doses of 3,000 to 6,000 units IM are often used, though some protocols suggest 500 units may be sufficient. If HTIG is unavailable, use equine antitoxin after performing a sensitivity test.
  • •Initiate antibiotic therapy with Metronidazole 500 mg IV every 6 to 8 hours for 7 to 10 days as the first-line agent; avoid penicillin G if possible, as it is a GABA antagonist and may theoretically worsen spasms.
  • •Perform surgical debridement of the wound only after the patient has been stabilized and antitoxin has been administered, to prevent the further release of toxin into the circulation.
  • •Control muscle spasms using Magnesium Sulfate as a first-line adjunct; administer a 70 mg/kg IV bolus over 30 minutes, followed by a continuous infusion of 2 g/hour, titrating to maintain the patellar tendon reflex.
  • •Utilize high-dose benzodiazepines for sedation and spasm control; Diazepam can be administered via IV infusion at 5 to 20 mg/kg/day, though clinicians must be prepared for the resulting respiratory depression.
  • •Secure the airway early in patients with Grade 3 or 4 disease; perform a tracheostomy for those requiring prolonged mechanical ventilation (often 3-4 weeks) to avoid triggering spasms during endotracheal suctioning.
  • •Manage autonomic storms with alpha-2 agonists like Dexmedetomidine or short-acting beta-blockers like Labetalol (0.25-0.5 mg/min IV infusion); avoid non-selective beta-blockers (e.g., propranolol) which may cause sudden cardiac arrest.
  • •Provide aggressive supportive care, including enteral nutrition to meet high metabolic demands, VTE prophylaxis with Enoxaparin 40 mg SC daily, and physical therapy to prevent joint contractures.
  • •Administer a tetanus-containing vaccine (Tdap or Td) at a site distant from the HTIG injection to initiate active immunization, as the disease itself does not provide immunity.
  • •Follow post-exposure prophylaxis (PEP) protocols for future wounds: for clean wounds, give a booster if the last dose was >10 years ago; for tetanus-prone wounds, give a booster if >5 years ago and add HTIG 250 IU if the primary series is incomplete.

Board Review — High Yield

  • •Risus sardonicus — Characteristic 'sneering' grimace due to facial muscle spasms.
  • •Spatula test — Biting down on a tongue blade (positive) instead of gagging (negative); highly specific for tetanus.
  • •Tetanospasmin mechanism — Cleaves SNARE proteins (synaptobrevin), blocking GABA and glycine release from Renshaw cells in the spinal cord.
  • •Opisthotonus — Severe arching of the back due to spasms of the axial musculature.
  • •Autonomic Storms — Labile hypertension and tachycardia occurring in the second week; managed with magnesium or dexmedetomidine.
  • •Vaccination — Natural infection does NOT confer immunity; patients must be vaccinated during recovery.
  • •Neonatal Tetanus — Usually presents with 'failure to suck' and grimacing in an infant 3-14 days after birth, often due to unsterile cord care.

Deep Dive — Evidence Details

References

  1. [1]

    Chen Z, Lin Z, Zhang W et al.. “Mortality and risk factors in hospitalised adult patients with tetanus: a systematic review and meta-analysis.” BMJ open (2025). PMID: 40721266 ↗

    L2aSR_OBSCited in: Epidemiology and Risk Factors, Supportive Care and Complication Management, Prognosis and Long-term Outcomes, Guidelines and Resources
  2. [2]

    Kolsuz S, Güllü D, Karahan KD et al.. “Risk factors and preventive role of vaccination in adult tetanus fatality: a systematic review of reported cases (1990-2024) and meta-analysis.” International journal of infectious diseases : IJID : official publication of the International Society for Infectious Diseases (2025). PMID: 39814168 ↗

    L2aSR_OBSCited in: Epidemiology and Risk Factors, Supportive Care and Complication Management, Prevention and Screening, Guidelines and Resources
  3. [3]

    Nicholson L, Adkins E, Karyanti MR et al.. “What is the true burden of diphtheria, tetanus, pertussis and poliovirus in children aged 3-18 years in Asia? A systematic literature review.” International journal of infectious diseases : IJID : official publication of the International Society for Infectious Diseases (2022). PMID: 35077880 ↗

    L2aSR_OBSCited in: Epidemiology and Risk Factors
  4. [4]

    Nepal G, Coghlan MA, Yadav JK et al.. “Safety and efficacy of Magnesium Sulfate in the management of Tetanus: A systematic review.” Tropical medicine & international health : TM & IH (2021). PMID: 34403179 ↗

    L2aSR_OBSCited in: Epidemiology and Risk Factors, Supportive Care and Complication Management
  5. [5]

    Liu X, Wei C, Huang H et al.. “Preliminarily evaluation the safety and immunogenicity of tetanus, reduced diphtheria and acellular pertussis (five components) combined vaccine, adsorbed (Tdcp) in participants aged 6 years and above: a blinded and randomised, and controlled phase I clinical trial.” Frontiers in immunology (2025). PMID: 40977696 ↗

    L1bRCTCited in: Epidemiology and Risk Factors, Special Populations, Prevention and Screening
  6. [6]

    Liang Z, Liu S, Guo W et al.. “Recombinant monoclonal antibody siltartoxatug versus plasma-derived human tetanus immunoglobulin for tetanus: a randomized, double-blind, active-controlled, phase 3 trial.” Nature medicine (2025). PMID: 40628965 ↗

    L1bRCTCited in: Epidemiology and Risk Factors, Special Populations, Guidelines and Resources
  7. [7]

    Nakano T, Hasegawa M, Endo M et al.. “Immunogenicity and safety of adsorbed diphtheria-purified pertussis-tetanus-inactivated polio (Sabin strain)-Haemophilus type b conjugate combined vaccine (DPT-IPV-Hib) in healthy Japanese Infants ≥ 2 and < 43 months of Age: A phase III, multicenter, active controlled, assessor-blinded, randomized, parallel-group study.” Vaccine (2024). PMID: 38582691 ↗

    L1bRCTCited in: Epidemiology and Risk Factors, Prevention and Screening
  8. [8]

    Choi UY, Kim KH, Lee J et al.. “Immunogenicity and Safety of a Newly Developed Tetanus-Diphtheria Toxoid (Td) in Healthy Korean Adolescents: a Multi-center, Randomized, Double-blind, Active-Controlled Phase 3 Trial.” Journal of Korean medical science (2021). PMID: 34931494 ↗

    L1bRCTCited in: Epidemiology and Risk Factors
  9. [9]

    Lanuza PDT, Garcia JJB, Turalde CWR et al.. “Clinical profile and outcomes of tetanus patients in a tertiary hospital in the Philippines: a ten-year retrospective study.” BMC infectious diseases (2024). PMID: 38287272 ↗

    L2bCOHORTCited in: Epidemiology and Risk Factors, History and Physical Examination
  10. [10]

    Grasselli Kmet N, Muzlovič I, Martinčič Ž et al.. “Adult patients with tetanus in Slovenia 2006-2021 : Results of a national cohort study.” Wiener klinische Wochenschrift (2023). PMID: 37278856 ↗

    L2bCOHORTCited in: Epidemiology and Risk Factors, Supportive Care and Complication Management
  11. [11]

    Rao Y, Xu X, Chen L et al.. “Delirium in tetanus patients: a review of clinical features, pathophysiology, and integrated management strategies.” Annals of medicine (2025). PMID: 40770926 ↗

    L2aSR_OBSCited in: Epidemiology and Risk Factors
  12. [12]

    Sharma HJ, Parekh S, Pujari P et al.. “Safety and immunogenicity of an indigenously developed tetanus toxoid, diphtheria toxoid, and acellular pertussis vaccine (Tdap) in adults, adolescents, and children in India.” Expert review of vaccines (2023). PMID: 36883291 ↗

    L1bRCTCited in: Epidemiology and Risk Factors
  13. [13]

    Hughes MM, Amin AB, Rubis AB. “Tetanus Surveillance - United States, 2009-2023.” Morbidity and mortality weekly report. Surveillance summaries (Washington, D.C. : 2002) (2026). PMID: 41980046 ↗

    L5OTHERCited in: Epidemiology and Risk Factors, Prevention and Screening
  14. [14]

    Donaghy F, Karunakaran S. “Clinical progress note: Tetanus.” Journal of hospital medicine (2026). PMID: 40818092 ↗

    L5OTHERCited in: Epidemiology and Risk Factors
  15. [15]

    Slifka MK, Thomas A, Gao L et al.. “Lessons learned from successful implementation of tetanus and diphtheria vaccination programs.” Clinical microbiology reviews (2025). PMID: 40662744 ↗

    L5REVIEW_NARRATIVECited in: Epidemiology and Risk Factors, Prevention and Screening
  16. [16]

    He L, Liu C, Nie X et al.. “Global analysis of tetanus incidence and mortality in children under 5 years: findings from the Global Burden of Disease Study 2021.” BMJ paediatrics open (2025). PMID: 40374285 ↗

    L5OTHERCited in: Epidemiology and Risk Factors
  17. [17]

    Shalaby M, Catenazzi A, Smith MF et al.. “An Assessment of the Presence of Clostridium tetani in the Soil and on Other Surfaces.” The western journal of emergency medicine (2024). PMID: 39625759 ↗

    L5OTHERCited in: Epidemiology and Risk Factors
  18. [18]

    Baroncelli S, Galluzzo CM, Orlando S et al.. “Seroprotection against tetanus in HIV-exposed and HIV-unexposed infants in Malawi in 2019-2020.” BMJ paediatrics open (2024). PMID: 39317654 ↗

    L5OTHERCited in: Epidemiology and Risk Factors
  19. [19]

    Lima CP, Barreiros GM, Oliveira ASA et al.. “A Dual Strategy-In Vitro and In Silico-To Evaluate Human Antitetanus mAbs Addressing Their Potential Protective Action on TeNT Endocytosis in Primary Rat Neuronal Cells.” International journal of molecular sciences (2024). PMID: 38891974 ↗

    L5OTHERCited in: Epidemiology and Risk Factors
  20. [20]

    Bagordo F, Grassi T, Rota MC et al.. “Seroprotection against tetanus in the Italian general population.” Vaccine (2024). PMID: 38762356 ↗

    L5OTHERCited in: Epidemiology and Risk Factors
  21. [21]

    Gaumer G, Crown WH, Kates J et al.. “Analysis of maternal and child health spillover effects in PEPFAR countries.” BMJ open (2023). PMID: 38135335 ↗

    L5OTHERCited in: Epidemiology and Risk Factors
  22. [22]

    Tamir TT, Kassie AT, Zegeye AF. “Prevalence and determinants of two or more doses of tetanus toxoid-containing vaccine immunization among pregnant women in sub-Saharan Africa: Evidence from recent demographic and health survey data.” Vaccine (2023). PMID: 37949753 ↗

    L5OTHERCited in: Epidemiology and Risk Factors
  23. [23]

    Bampoe VD, Brown N, Deng L et al.. “Serologic Immunity to Tetanus in the United States, National Health and Nutrition Examination Survey, 2015-2016.” Clinical infectious diseases : an official publication of the Infectious Diseases Society of America (2024). PMID: 37787062 ↗

    L5OTHERCited in: Epidemiology and Risk Factors
  24. [24]

    Khan MAS, Hasan MJ, Hawlader MDH. “The road towards protection of all against tetanus.” PLoS neglected tropical diseases (2023). PMID: 37733677 ↗

    L5OTHERCited in: Epidemiology and Risk Factors
  25. [25]

    Zhang T, He Q, Richardson S et al.. “Does armed conflict lead to lower prevalence of maternal health-seeking behaviours: theoretical and empirical research based on 55 683 women in armed conflict settings.” BMJ global health (2023). PMID: 37612034 ↗

    L5OTHERCited in: Epidemiology and Risk Factors
  26. [26]

    Perrin L, Bisdorff M, Saxena S et al.. “Predicting personalised remifentanil effect site concentration for surgical incision using the nociception level index: A prospective calibration and validation study.” European journal of anaesthesiology (2022). PMID: 36125017 ↗

    L2bTRIAL_NONRANDOMCited in: History and Physical Examination, Diagnosis and Workup
  27. [27]

    Nomura K, Sakawaki E, Sakawaki S et al.. “Non-surgical treatment of tetanus infection associated with breast cancer skin ulcer: a case report and literature review.” BMC infectious diseases (2021). PMID: 33413196 ↗

    L4CASE_REPORTCited in: History and Physical Examination
  28. [28]

    A R, Chandran S, Ghatak AR et al.. “Novel Mutations in CRLF1: Case Reports with Crisponi Syndrome.” Indian journal of pediatrics (2022). PMID: 35984556 ↗

    L4CASE_REPORTCited in: History and Physical Examination, Diagnosis and Workup
  29. [29]

    Adeleye AO, Azeez AL. “Fatal tetanus complicating an untreated mild open head injury: a case-illustrated review of cephalic tetanus.” Surgical infections (2012). PMID: 23039234 ↗

    L4CASE_REPORTCited in: History and Physical Examination
  30. [30]

    Skuby SO, Rhee E, Thilo EH et al.. “Tetanus and Occam's Razor: Almost Forgotten but Not Gone: A Case Report.” Pediatrics (2016). PMID: 27940761 ↗

    L4CASE_REPORTCited in: History and Physical Examination
  31. [31]

    Ganesh M, Sheikh NK, Shah P et al.. “Detection of Clostridium tetani in human clinical samples using tetX specific primers targeting the neurotoxin.” Journal of infection and public health (2016). PMID: 26220795 ↗

    L4CASE_REPORTCited in: History and Physical Examination
  32. [32]

    Giordano M, Ciarambino T, Di Bella O et al.. “Acute dysphagia in an octogenarian: an unusual case of tetanus.” The American journal of emergency medicine (2014). PMID: 24468126 ↗

    L4CASE_REPORTCited in: History and Physical Examination
  33. [33]

    Vollman KE, Acquisto NM, Bodkin RP. “A case of tetanus infection in an adult with a protective tetanus antibody level.” The American journal of emergency medicine (2014). PMID: 24211286 ↗

    L4CASE_REPORTCited in: History and Physical Examination
  34. [34]

    Gadoth A, Mukadi Nkamba D, Arena PJ et al.. “Assessing the feasibility of passive surveillance for maternal immunization safety utilizing archival medical records in Kinshasa, Democratic Republic of the Congo.” Vaccine (2022). PMID: 35570074 ↗

    L5OTHERCited in: History and Physical Examination
  35. [35]

    Merrick M, Scarrott I. “Tetanus presenting as painful muscle spasms, dysphagia and delirium in an older adult.” Age and ageing (2021). PMID: 34115833 ↗

    L5OTHERCited in: History and Physical Examination
  36. [36]

    Bae S, Go M, Kim Y et al.. “Clinical outcomes and healthcare costs of inpatients with tetanus in Korea, 2011-2019.” BMC infectious diseases (2021). PMID: 33750329 ↗

    L5OTHERCited in: History and Physical Examination
  37. [37]

    Tadesse GA, Javed H, Thanh NLN et al.. “Multi-Modal Diagnosis of Infectious Diseases in the Developing World.” IEEE journal of biomedical and health informatics (2020). PMID: 31944967 ↗

    L5OTHERCited in: History and Physical Examination
  38. [38]

    Trieu HT, Lubis IN, Qui PT et al.. “Neonatal Tetanus in Vietnam: Comprehensive Intensive Care Support Improves Mortality.” Journal of the Pediatric Infectious Diseases Society (2016). PMID: 26407289 ↗

    L5OTHERCited in: History and Physical Examination
  39. [39]

    Narang M, Khurana A, Gomber S et al.. “Epidemiological trends of tetanus from East Delhi, India: a hospital-based study.” Journal of infection and public health (2014). PMID: 24284024 ↗

    L5OTHERCited in: History and Physical Examination
  40. [40]

    De Vito M, Capannolo G, Alameddine S et al.. “Trauma in pregnancy clinical practice guidelines: systematic review.” The journal of maternal-fetal & neonatal medicine : the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians (2022). PMID: 35703623 ↗

    L1cGUIDELINECited in: Diagnosis and Workup
  41. [41]

    Van Hao N, Loan HT, Yen LM et al.. “Human versus equine intramuscular antitoxin, with or without human intrathecal antitoxin, for the treatment of adults with tetanus: a 2 × 2 factorial randomised controlled trial.” The Lancet. Global health (2022). PMID: 35561721 ↗

    L1bRCTCited in: Diagnosis and Workup, Supportive Care and Complication Management, Prognosis and Long-term Outcomes
  42. [42]

    Yamamoto T, Sada RM, Yamamoto S et al.. “Functional prognosis of older adults with tetanus in Japan: a single-center retrospective study.” BMC infectious diseases (2025). PMID: 41152751 ↗

    L2bCOHORTCited in: Diagnosis and Workup, Supportive Care and Complication Management, Prognosis and Long-term Outcomes, Special Populations
  43. [43]

    Shi C, Jing ZC, Yang DG et al.. “A rare case of type 1 leprosy reactions following tetanus infection in a borderline tuberculoid leprosy patient and a literature review.” Infectious diseases of poverty (2018). PMID: 29908564 ↗

    L4CASE_REPORTCited in: Diagnosis and Workup, Prognosis and Long-term Outcomes
  44. [44]

    Sun C, Zhao H, Lu Y et al.. “Prognostic factors for generalized tetanus in adults: A retrospective study in a Chinese hospital.” The American journal of emergency medicine (2019). PMID: 29891121 ↗

    L2bCOHORTCited in: Diagnosis and Workup, Prognosis and Long-term Outcomes
  45. [45]

    Deniz M, Erat T. “Generalized tetanus: a pediatric case report and literature review.” Revista do Instituto de Medicina Tropical de Sao Paulo (2023). PMID: 37377323 ↗

    L4CASE_REPORTCited in: Diagnosis and Workup, Prognosis and Long-term Outcomes
  46. [46]

    Aiello M, Roy S, Chitty L et al.. “Prolonged administration of intrathecal baclofen in a patient with generalized grade 4 tetanus.” Regional anesthesia and pain medicine (2024). PMID: 38724273 ↗

    L4CASE_REPORTCited in: Diagnosis and Workup, Supportive Care and Complication Management
  47. [47]

    Knipe M, Embersics C, Dickinson P. “Electroencephalography of rapid eye movement sleep behavior disorder in a dog with generalized tetanus.” Journal of veterinary internal medicine (2023). PMID: 36457276 ↗

    L4CASE_REPORTCited in: Diagnosis and Workup
  48. [48]

    Niederschweiberer J, Lauerer M, Schweyer K et al.. “Acute disseminated encephalomyelitis following Tdap vaccination and bacterial meningoencephalitis.” Multiple sclerosis and related disorders (2020). PMID: 32877821 ↗

    L4CASE_REPORTCited in: Diagnosis and Workup
  49. [49]

    Gordon AA, Tran LT, Phelps PO. “Eyelid and orbital trauma for the primary care physician.” Disease-a-month : DM (2020). PMID: 32622682 ↗

    L5REVIEW_NARRATIVECited in: Diagnosis and Workup
  50. [50]

    Okike CO, Muoneke UV, Uwaezuoke SN et al.. “The Prevalence and Case-Fatality Rates of Post-Neonatal Tetanus in a Population of Hospitalized Nigerian Children: An 8-Year Retrospective Review.” Journal of tropical pediatrics (2020). PMID: 31397484 ↗

    L5REVIEW_NARRATIVECited in: Diagnosis and Workup
  51. [51]

    Cheng D, Liang L, Miaomiao H et al.. “Adult patients with tetanus in Anhui Province of China from 2013 to 2022: A retrospective study.” Medicine (2023). PMID: 37800818 ↗

    L2bCOHORTCited in: Diagnosis and Workup, Prognosis and Long-term Outcomes, Special Populations
  52. [52]

    Guedra M, Cortellini S, Humm K. “Respiratory complications in dogs with tetanus: A retrospective study of 53 cases.” The Canadian veterinary journal = La revue veterinaire canadienne (2021). PMID: 34728847 ↗

    L2bCOHORTCited in: Diagnosis and Workup, Prognosis and Long-term Outcomes
  53. [53]

    Woldeamanuel YW, Andemeskel AT, Kyei K et al.. “Case fatality of adult tetanus in Africa: Systematic review and meta-analysis.” Journal of the neurological sciences (2016). PMID: 27538652 ↗

    L2aSR_OBSCited in: Supportive Care and Complication Management, Prognosis and Long-term Outcomes
  54. [54]

    Rodrigo C, Samarakoon L, Fernando SD et al.. “A meta-analysis of magnesium for tetanus.” Anaesthesia (2012). PMID: 23033859 ↗

    L2aSR_OBSCited in: Supportive Care and Complication Management
  55. [55]

    Thwaites CL, Yen LM, Cordon SM et al.. “Effect of magnesium sulphate on urinary catecholamine excretion in severe tetanus.” Anaesthesia (2008). PMID: 18582257 ↗

    L1bRCTCited in: Supportive Care and Complication Management
  56. [56]

    Thwaites CL, Yen LM, Loan HT et al.. “Magnesium sulphate for treatment of severe tetanus: a randomised controlled trial.” Lancet (London, England) (2006). PMID: 17055945 ↗

    L1bRCTCited in: Supportive Care and Complication Management
  57. [57]

    Gibson K, Bonaventure Uwineza J, Kiviri W et al.. “Tetanus in developing countries: a case series and review.” Canadian journal of anaesthesia = Journal canadien d'anesthesie (2009). PMID: 19296192 ↗

    L4CASE_REPORTCited in: Supportive Care and Complication Management
  58. [58]

    Mathew PJ, Samra T, Wig J. “Magnesium sulphate for treatment of tetanus in adults.” Anaesthesia and intensive care (2010). PMID: 20191795 ↗

    L2bTRIAL_NONRANDOMCited in: Supportive Care and Complication Management
  59. [59]

    Ogundare EO, Ajite AB, Adeniyi AT et al.. “A ten-year review of neonatal tetanus cases managed at a tertiary health facility in a resource poor setting: The trend, management challenges and outcome.” PLoS neglected tropical diseases (2021). PMID: 34874950 ↗

    L5REVIEW_NARRATIVECited in: Supportive Care and Complication Management
  60. [60]

    Yen LM, Thwaites CL. “Tetanus.” Lancet (London, England) (2019). PMID: 30935736 ↗

    L5REVIEW_NARRATIVECited in: Supportive Care and Complication Management
  61. [61]

    Afshar M, Raju M, Ansell D et al.. “Narrative review: tetanus-a health threat after natural disasters in developing countries.” Annals of internal medicine (2011). PMID: 21357910 ↗

    L5REVIEW_NARRATIVECited in: Supportive Care and Complication Management
  62. [62]

    Bandt C, Rozanski EA, Steinberg T et al.. “Retrospective study of tetanus in 20 dogs: 1988-2004.” Journal of the American Animal Hospital Association (2007). PMID: 17473020 ↗

    L2bCOHORTCited in: Supportive Care and Complication Management
  63. [63]

    Firth PG, Solomon JB, Roberts LL et al.. “Airway management of tetanus after the Haitian earthquake: new aspects of old observations.” Anesthesia and analgesia (2011). PMID: 21778337 ↗

    L4CASE_REPORTCited in: Supportive Care and Complication Management
  64. [64]

    Sykora M, Diedler J, Veltkamp R et al.. “Autonomic impairment in tetanus: delayed baroreflex involvement.” Journal of the neurological sciences (2008). PMID: 18358492 ↗

    L4CASE_REPORTCited in: Supportive Care and Complication Management
  65. [65]

    Freshwater-Turner D, Udy A, Lipman J et al.. “Autonomic dysfunction in tetanus - what lessons can be learnt with specific reference to alpha-2 agonists?” Anaesthesia (2007). PMID: 17845661 ↗

    L4CASE_REPORTCited in: Supportive Care and Complication Management
  66. [66]

    Yoshino Y, Ohtsuka M, Kawaguchi M et al.. “The wound/burn guidelines - 6: Guidelines for the management of burns.” The Journal of dermatology (2016). PMID: 26971391 ↗

    L1cGUIDELINECited in: Prognosis and Long-term Outcomes
  67. [67]

    Higgins JP, Soares-Weiser K, López-López JA et al.. “Association of BCG, DTP, and measles containing vaccines with childhood mortality: systematic review.” BMJ (Clinical research ed.) (2016). PMID: 27737834 ↗

    L2aSR_OBSCited in: Prognosis and Long-term Outcomes
  68. [68]

    Han SB, Rhim JW, Shin HJ et al.. “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.” Journal of microbiology, immunology, and infection = Wei mian yu gan ran za zhi (2017). PMID: 26055693 ↗

    L1bRCTCited in: Prognosis and Long-term Outcomes
  69. [69]

    Roos N, Lambach P, Mantel C et al.. “Maternal Immunization and Antenatal Care Situation Analysis (MIACSA) study protocol: a multiregional, cross-sectional analysis of maternal immunization delivery strategies to reduce maternal and neonatal morbidity and mortality.” BMJ open (2019). PMID: 31167857 ↗

    L2bTRIAL_NONRANDOMCited in: Prognosis and Long-term Outcomes
  70. [70]

    Kovac M, Kostanyan L, Mesaros N et al.. “Immunogenicity and safety of a second booster dose of an acellular pertussis vaccine combined with reduced antigen content diphtheria-tetanus toxoids 10 years after a first booster in adolescence: An open, phase III, non-randomized, multi-center study.” Human vaccines & immunotherapeutics (2018). PMID: 29630439 ↗

    L2bTRIAL_NONRANDOMCited in: Prognosis and Long-term Outcomes
  71. [71]

    Salim AM, Liang Y, Kilgore PE. “Protecting Newborns Against Pertussis: Treatment and Prevention Strategies.” Paediatric drugs (2015). PMID: 26542059 ↗

    L5REVIEW_NARRATIVECited in: Prognosis and Long-term Outcomes
  72. [72]

    Taye BA, Weldearegay BY, Yirsaw BG et al.. “Tetanus toxoid vaccination coverage and associated factors among pregnant women in East Africa: systematic review and meta-analysis.” BMC public health (2025). PMID: 41044529 ↗

    L2aSR_OBSCited in: Special Populations, Prevention and Screening
  73. [73]

    Deese J, Schaible K, Massierer D et al.. “Systematic Literature Review of Maternal Antibodies in Human Milk Following Vaccination During Pregnancy or Lactation: Tetanus, Pertussis, Influenza and COVID-19.” The Pediatric infectious disease journal (2025). PMID: 39951072 ↗

    L2aSR_OBSCited in: Special Populations, Prevention and Screening
  74. [74]

    Fatly ZA, Betjes MGH, Dik WA et al.. “Mycophenolate mofetil hampers antibody responses to a broad range of vaccinations in kidney transplant recipients: Results from a randomized controlled study.” The Journal of infection (2024). PMID: 38432583 ↗

    L1bRCTCited in: Special Populations
  75. [75]

    Aydin I, May M, Pisano F et al.. “Safety and immunogenicity of SIIPL Tdap, a new tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine, in healthy subjects 4-65 years of age: A Phase II/III randomized, observer-blinded, active controlled, multicenter clinical study in Germany.” Vaccine (2023). PMID: 37827966 ↗

    L1bRCTCited in: Special Populations
  76. [76]

    Puthanakit T, Chokephaibulkit K, Chaithongwongwatthana S et al.. “A phase 2 randomized controlled dose-ranging trial of recombinant pertussis booster vaccines containing genetically inactivated pertussis toxin in pregnant women.” Vaccine (2023). PMID: 37330371 ↗

    L1bRCTCited in: Special Populations
  77. [77]

    Embacher S, Maertens K, Herzog SA. “Half-life Estimation of Pertussis-Specific Maternal Antibodies in (Pre)Term Infants After In-Pregnancy Tetanus, Diphtheria, Acellular Pertussis Vaccination.” The Journal of infectious diseases (2023). PMID: 37285482 ↗

    L2bTRIAL_NONRANDOMCited in: Special Populations
  78. [78]

    Guan Q, Liu J, Tang M et al.. “A single-center, randomized, double-blind, positive-controlled, phase IV clinical trial to assess the immunogenicity and safety of adsorbed tetanus toxoid vaccine in individuals aged ≥16 years.” Human immunology (2025). PMID: 41240607 ↗

    L1bRCTCited in: Special Populations, Prevention and Screening
  79. [79]

    Ayouni I, Mbangiwa T, Amponsah-Dacosta E et al.. “Acceptance and uptake of vaccines against tetanus, influenza, pertussis, and COVID-19 among pregnant and postpartum women in low- and middle-income countries: a systematic review and meta-analysis protocol.” Systematic reviews (2024). PMID: 39237969 ↗

    L2aSR_OBSCited in: Special Populations, Prevention and Screening
  80. [80]

    Ono S, Nakajima M, Yamana H et al.. “Tetanus toxoid vaccination uptake by trauma patients in Japan: A retrospective cohort study using large administrative claims data.” Vaccine (2025). PMID: 39892109 ↗

    L2bCOHORTCited in: Special Populations, Prevention and Screening, Guidelines and Resources
  81. [81]

    Thibault M, Deceuninck G, Quach C et al.. “Antenatal tetanus, diphtheria, and acellular pertussis (Tdap) immunization and risk of serogroup 19 IPD in children: An indirect cohort study.” Human vaccines & immunotherapeutics (2024). PMID: 38330991 ↗

    L2bCOHORTCited in: Special Populations, Prevention and Screening
  82. [82]

    Zegeye AF, Tamir TT, Mekonen EG et al.. “Number of tetanus toxoid injections before birth and associated factors among pregnant women in low and middle income countries: Negative binomial poisson regression.” Human vaccines & immunotherapeutics (2024). PMID: 38772729 ↗

    L5REVIEW_NARRATIVECited in: Special Populations, Prevention and Screening
  83. [83]

    Zhou C, Zuo Y, Ma J et al.. “Two decades of global research on tetanus vaccines and tetanus immunoglobulins: a comprehensive bibliometric analysis and integrative review (2000-2025).” Frontiers in cellular and infection microbiology (2026). PMID: 41909843 ↗

    L2aSR_OBSCited in: Prevention and Screening, Guidelines and Resources
  84. [84]

    Richmond P, Nolan T, McGirr A et al.. “Phase 1 trial of an investigational Tdap booster vaccine with CpG 1018 adjuvant compared with Boostrix in healthy adults and adolescents.” Vaccine (2024). PMID: 39226786 ↗

    L1bRCTCited in: Prevention and Screening
  85. [85]

    Eskenazi B, Rauch S, Elsiwi B et al.. “Undernutrition and antibody response to measles, tetanus and Haemophilus Influenzae type b (Hib) vaccination in pre-school south African children: The VHEMBE birth cohort study.” Vaccine (2025). PMID: 39665976 ↗

    L2bCOHORTCited in: Prevention and Screening
  86. [86]

    Guerra A, Costantino C, Martinon-Torres F et al.. “A phase 4, open-label study to evaluate the safety and immunogenicity of DTaP5-HBV-IPV-Hib in children previously vaccinated with DTaP2-HBV-IPV-Hib or DTaP5-HBV-IPV-Hib (V419-016).” Human vaccines & immunotherapeutics (2024). PMID: 38327239 ↗

    L2bTRIAL_NONRANDOMCited in: Prevention and Screening
  87. [87]

    Ergönül Ö, Kolsuz S, Figueroa JP. “Tetanus.” Lancet (London, England) (2026). PMID: 41544646 ↗

    L5REVIEW_NARRATIVECited in: Prevention and Screening
  88. [88]

    Tang X, Xiao Y, Chen J et al.. “Immunogenicity and safety of co-purified diphtheria, tetanus and acellular pertussis vaccine in 6-year-old Chinese children.” Nature communications (2025). PMID: 41318685 ↗

    L1bRCTCited in: Prevention and Screening
  89. [89]

    Epaulard O, Carré M, Hermet E et al.. “Antibody response to tetanus, diphtheria, poliomyelitis, hepatitis B, and H. influenzae b vaccines in allogeneic hematopoietic stem cell transplant adult recipients: A multicenter trial.” PloS one (2025). PMID: 41144397 ↗

    L1bRCTCited in: Prevention and Screening
  90. [90]

    Stala O, Patel S, Donlon C et al.. “Tetanus Control in the United States and Global Disaster Settings: Public Health Disparities and Prevention Strategies.” Medicina (Kaunas, Lithuania) (2026). PMID: 41752737 ↗

    L5REVIEW_NARRATIVECited in: Prevention and Screening
  91. [91]

    Haghnejad V, Lucas M, Chevrier L et al.. “Hepatitis B Virus, Pneumococcal, Diphtheria, and Tetanus Vaccination Responses in Compensated Cirrhosis.” Liver international : official journal of the International Association for the Study of the Liver (2026). PMID: 41968440 ↗

    L5OTHERCited in: Prevention and Screening
  92. [92]

    Mühlstein-Barasche J, Gualtieri R, Wagner N et al.. “Evaluation of vaccine immunity against tetanus, hepatitis B, measles, mumps, rubella and varicella, in migrant adolescents aged 13 to 18 years arriving in Geneva in 2023.” European journal of pediatrics (2026). PMID: 41817808 ↗

    L5OTHERCited in: Prevention and Screening
  93. [93]

    Paternina-De La Ossa R, Oliveira MC, Achcar JA et al.. “Immunological responses to tetanus, diphtheria, pertussis (Tdap) vaccine in Brazilian hematopoietic stem cell transplant recipients.” Vaccine (2026). PMID: 41544367 ↗

    L5OTHERCited in: Prevention and Screening
  94. [94]

    Salloum M, Vandermosten L, Maseko T et al.. “Assessing vaccination coverage and antibody levels for measles, pertussis, and tetanus in Boende, DR Congo: Implications for maternal and child health.” Vaccine (2026). PMID: 41455185 ↗

    L5OTHERCited in: Prevention and Screening
  95. [95]

    Özsoy M, Öztürk H, Tuna A et al.. “Evaluation of anti-tetanus IgG antibody levels and influencing factors in patients undergoing hemodialysis.” Frontiers in immunology (2025). PMID: 41415284 ↗

    L5OTHERCited in: Prevention and Screening
  96. [96]

    Saso A, Fröberg J, Jobe H et al.. “Mucosal immune responses to Bordetella pertussis in Gambian infants after maternal and primary vaccination: an immunological substudy of a single-centre, randomised, controlled, double-blind, phase 4 trial.” The Lancet. Microbe (2026). PMID: 41519134 ↗

    L1bRCTCited in: Guidelines and Resources
  97. [97]

    Saso A, Kanteh E, Jeffries D et al.. “The effect of pertussis vaccination in pregnancy on the immunogenicity of acellular or whole-cell pertussis vaccination in Gambian infants (GaPS): a single-centre, randomised, controlled, double-blind, phase 4 trial.” The Lancet. Infectious diseases (2025). PMID: 40154521 ↗

    L1bRCTCited in: Guidelines and Resources
  98. [98]

    McAlister SM, van den Biggelaar AHJ, Cooper MN et al.. “Acellular Pertussis Vaccine Given in the Week After Birth Does Not Impair Antibody Responses to Later Childhood Doses.” The Pediatric infectious disease journal (2025). PMID: 40063739 ↗

    L1bRCTCited in: Guidelines and Resources
  99. [99]

    Nakabembe E, Greenland M, Amaral K et al.. “Safety and immunogenicity of an acellular pertussis vaccine containing genetically detoxified pertussis toxin administered to pregnant women living with and without HIV and their newborns (WoMANPOWER): a randomised controlled trial in Uganda.” The Lancet. Global health (2025). PMID: 39706666 ↗

    L1bRCTCited in: Guidelines and Resources
  100. [100]

    Qadri F, Khanam F, Zhang Y et al.. “5-year vaccine protection following a single dose of Vi-tetanus toxoid conjugate vaccine in Bangladeshi children (TyVOID): a cluster randomised trial.” Lancet (London, England) (2024). PMID: 39396349 ↗

    L1bRCTCited in: Guidelines and Resources
  101. [101]

    Pérez Chacón G, Estcourt MJ, Totterdell J et al.. “Immunogenicity, reactogenicity, and IgE-mediated immune responses of a mixed whole-cell and acellular pertussis vaccine schedule in Australian infants: A randomised, double-blind, noninferiority trial.” PLoS medicine (2024). PMID: 38857311 ↗

    L1bRCTCited in: Guidelines and Resources
  102. [102]

    O'Neill S, Grieve R, Singh K et al.. “Persistence and heterogeneity of the effects of educating mothers to improve child immunisation uptake: Experimental evidence from Uttar Pradesh in India.” Journal of health economics (2024). PMID: 38805881 ↗

    L1bRCTCited in: Guidelines and Resources
  103. [103]

    Radia K, Sapuan S, Grassly N et al.. “An observational, cohort, multi-centre, open label phase IV extension study comparing IPV immune responses to preschool dTaP-IPV booster vaccines in children whose mothers received or did not receive an IPV-containing pertussis vaccine during pregnancy in England.” Vaccine (2026). PMID: 41690287 ↗

    L2bTRIAL_NONRANDOMCited in: Guidelines and Resources
  104. [104]

    Susarla SK, Narang M, Khandgave PN et al.. “A Phase II/III multicenter randomized single blind non-inferiority immunogenicity and safety study of TeddyVac™ vaccine of Human Biologicals Institute in healthy subjects of 10 years to 60 years of age.” Infectious diseases (London, England) (2025). PMID: 39378070 ↗

    L2bTRIAL_NONRANDOMCited in: Guidelines and Resources
  105. [105]

    Robertson CA, Jacqmein J, Selmani A et al.. “Immune persistence and booster response of a quadrivalent meningococcal conjugate vaccine (MenACYW-TT) 5 years after primary vaccination of adults at ≥56 years of age.” Human vaccines & immunotherapeutics (2024). PMID: 39555800 ↗

    L1bRCTCited in: Guidelines and Resources

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