Tetanus is caused by a toxin from Clostridium tetani, bacteria whose spores live in soil, dust and animal faeces and enter the body through wounds. It is not passed from person to person. It is entirely preventable by vaccination, yet it still kills people, especially in places where immunisation coverage and clean birth practices are incomplete. Nursing care is the core of treatment, because there is no quick cure once symptoms start.
Recognising tetanus
- Lockjaw (trismus): difficulty opening the mouth, often the first sign.
- Risus sardonicus: a fixed “grin” from facial muscle spasm.
- Stiff neck, back and abdomen; arching of the back (opisthotonus).
- Painful muscle spasms, triggered by touch, noise or light; spasms of the throat and breathing muscles can stop breathing.
- Autonomic instability in severe cases: swings in heart rate and blood pressure, sweating, fever.
- The person is usually fully conscious throughout.
Neonatal tetanus
Babies infected through the umbilical stump (from unclean cutting or applying substances such as dung or ash to the cord) typically become ill 3–14 days after birth. A baby who fed normally for the first days and then stops sucking, becomes stiff and has spasms, has neonatal tetanus until proven otherwise. Mortality is very high.
Treatment
- Human tetanus immunoglobulin to neutralise unbound toxin, as prescribed.
- Wound care: clean and debride the wound to remove the source.
- Antibiotics (commonly metronidazole), as prescribed.
- Control of spasms with benzodiazepines (e.g. diazepam); magnesium sulfate is also used. Severe cases need sedation, paralysis and ventilation in ICU.
- Vaccinate: having tetanus does not give immunity, so start the vaccine course.
Nursing care
- A quiet, dimly lit room with minimal stimulation. Cluster care to reduce disturbance.
- Airway: suction equipment, oxygen and resuscitation equipment at the bedside. Watch for laryngeal spasm and breathing failure.
- Close monitoring: respiratory rate, SpO₂, heart rate and BP (for autonomic instability), temperature, spasm frequency.
- Nutrition and fluids: patients often can’t swallow; nasogastric feeding once spasms are controlled, as directed.
- Pressure area care, mouth and eye care, bowel and bladder care.
- Explain to the patient, who is often fully aware and frightened, and to the family. Recovery can take weeks.
Wound prophylaxis
For every wound, check tetanus vaccination status. Tetanus-prone wounds include deep puncture wounds, burns, wounds contaminated with soil or manure, animal bites, wounds with dead tissue, and compound fractures. Depending on vaccination history and wound type, give a tetanus-containing vaccine booster and, for high-risk wounds in people not fully vaccinated, tetanus immunoglobulin, following national guidance.
Prevention
- Routine immunisation: WHO recommends 6 doses of tetanus-containing vaccine through childhood and adolescence for lifelong protection.
- Vaccinate pregnant women as per national schedule, protecting both mother and baby.
- Clean birth and cord care: clean hands, clean surface, sterile blade to cut the cord, and nothing applied to the cord except chlorhexidine where recommended.
- Safe circumcision and ear-piercing practices.
WHO’s Maternal and Neonatal Tetanus Elimination initiative has helped most countries eliminate neonatal tetanus, but a small number of countries, including Nigeria, have not yet been validated as having achieved elimination nationally. Every clean birth and every vaccinated mother counts.
Based on WHO tetanus fact sheets and position paper on tetanus vaccines (2017), and WHO Maternal and Neonatal Tetanus Elimination information. Educational content: follow national guidelines.