Perspective

Oregon boy’s case shows how ‘horrific’ tetanus can be

Judith Guzman-Cottrill, MD
Judith A. Guzman-Cottrill

A recent MMWR highlighted the care needed for a young, unvaccinated boy in Oregon infected with tetanus in 20107. His inpatient care spanned 57 days, 47 of which were spent in an ICU, and total inpatient costs exceeded $800,000.

Following the boy’s recovery, his family declined a second dose of DTaP vaccine, along with any other recommended immunizations.

“There are currently several outbreaks of vaccine-preventable diseases across our country, including measles and mumps,” Judith A. Guzman-Cottrill, DO, professor of pediatrics at Oregon Health and Science University and an author of the report, told Infectious Diseases in Children. “Our case raised the point that the medical management of vaccine-preventable diseases is very costly.”

According to the MMWR, the 6-year-old boy cut his forehead, which was cleaned and sutured at home. Six days later, he had episodes of crying, jaw clenching and involuntary upper extremity spasms, followed by arching of the neck and back, as well as generalized spasticity. His parents contacted emergency medical services after he began having difficulty breathing, and he was air-transported to a tertiary pediatric medical center. He was treated at the center for 8 weeks in inpatient care, followed by rehabilitation.

Physicians sedated the boy on arrival due to respiratory distress and administered tetanus immunoglobulin (3,000 units) and a dose of DTaP vaccine. The child also received IV metronidazole.

While receiving care, the boy required a darkened room and ear plugs because stimulation exacerbated his painful spasms.

The boy’s opisthotonos worsened, the authors said, and he developed autonomic instability, including hypertension, tachycardia and body temperatures of up to 104.9°F (40.5°C). He was treated with several continuous IV medication infusions to control his pain and blood pressure, and a neuromuscular blockade was required to control his spasms. After 5 days of treatment, a tracheostomy was placed for ventilator support.

After 35 days of treatment, he was weaned from neuromuscular blockade, and after 44 days, he was taken off ventilator support and could tolerate sips of clear liquid. He began walking a few steps after 50 days.

“Tetanus is a horrific, life-threatening disease,” Guzman-Cottrill said. “This patient suffered in a way that most U.S. clinicians will never witness. I hope to never see a child suffer from tetanus again. There is no confirmatory test for tetanus, like a wound culture. But, when you see a child with severe tetanus, there is no mistake what disease the child has.” – by Katherine Bortz

Disclosures: The authors report no relevant financial disclosures.

Judith Guzman-Cottrill, MD
Judith A. Guzman-Cottrill

A recent MMWR highlighted the care needed for a young, unvaccinated boy in Oregon infected with tetanus in 20107. His inpatient care spanned 57 days, 47 of which were spent in an ICU, and total inpatient costs exceeded $800,000.

Following the boy’s recovery, his family declined a second dose of DTaP vaccine, along with any other recommended immunizations.

“There are currently several outbreaks of vaccine-preventable diseases across our country, including measles and mumps,” Judith A. Guzman-Cottrill, DO, professor of pediatrics at Oregon Health and Science University and an author of the report, told Infectious Diseases in Children. “Our case raised the point that the medical management of vaccine-preventable diseases is very costly.”

According to the MMWR, the 6-year-old boy cut his forehead, which was cleaned and sutured at home. Six days later, he had episodes of crying, jaw clenching and involuntary upper extremity spasms, followed by arching of the neck and back, as well as generalized spasticity. His parents contacted emergency medical services after he began having difficulty breathing, and he was air-transported to a tertiary pediatric medical center. He was treated at the center for 8 weeks in inpatient care, followed by rehabilitation.

Physicians sedated the boy on arrival due to respiratory distress and administered tetanus immunoglobulin (3,000 units) and a dose of DTaP vaccine. The child also received IV metronidazole.

While receiving care, the boy required a darkened room and ear plugs because stimulation exacerbated his painful spasms.

The boy’s opisthotonos worsened, the authors said, and he developed autonomic instability, including hypertension, tachycardia and body temperatures of up to 104.9°F (40.5°C). He was treated with several continuous IV medication infusions to control his pain and blood pressure, and a neuromuscular blockade was required to control his spasms. After 5 days of treatment, a tracheostomy was placed for ventilator support.

After 35 days of treatment, he was weaned from neuromuscular blockade, and after 44 days, he was taken off ventilator support and could tolerate sips of clear liquid. He began walking a few steps after 50 days.

“Tetanus is a horrific, life-threatening disease,” Guzman-Cottrill said. “This patient suffered in a way that most U.S. clinicians will never witness. I hope to never see a child suffer from tetanus again. There is no confirmatory test for tetanus, like a wound culture. But, when you see a child with severe tetanus, there is no mistake what disease the child has.” – by Katherine Bortz

Disclosures: The authors report no relevant financial disclosures.

    Perspective
    Parvathi S. Kumar

    Parvathi S. Kumar

    The United States has low rates of vaccine-preventable diseases (VPDs), but this is not true for other parts of the world. The cases of measles seen in the U.S. are mostly imported from countries with known and active outbreaks, causing disease in individuals who were intentionally unvaccinated. We are able to contain these clusters of VPDs because most Americans are vaccinated, although these diseases are becoming more prevalent in the U.S., in part due to altered knowledge and attitudes toward vaccination.

    In 2015, a total of 29 tetanus cases and two deaths were reported through the National Notifiable Diseases Surveillance System. From 2009 through 2015, 24 cases of tetanus were reported in persons aged younger than 20 years, including two cases of neonatal tetanus. Parents who are hesitant to vaccinate their children may delay routine immunizations or seek exemptions from state vaccine mandates. Herd immunity can be protective against vaccine preventable illnesses like measles and pertussis, but it does not play a role in protecting people against tetanus, a painful but preventable disease.

    The average cost of treating tetanus in the U.S. is about $90,635 per hospitalization, contrasted against a cost of $8.55 (primary vaccine series) and $3.13 (booster doses) to prevent tetanus. All cases of tetanus need hospitalization due to the associated morbidity, usually with good recovery of full function, but this requires an exorbitant interim support during recovery.

    References:

    Ahmed BS, et al. J Pediatr Infect Dis Soc. 2018;doi:10.1093/jpids/piy086.

    Faulkner AE, Tiwari SPT. Chapter 16: Tetanus. In: CDC. Manual for the Surveillance of Vaccine-Preventable Diseases. Washington, D.C.: CDC: 2019. https://www.cdc.gov/vaccines/pubs/surv-manual/chpt16-tetanus.html. Accessed March 21, 2019.

    Zhou F, et al. Pediatrics. 2009;doi:10.1542/peds.2013-0698.

    • Parvathi S. Kumar, MD
    • Assistant professor of pediatrics
      Penn State College of Medicine

    Disclosures: Kumar reports no relevant financial disclosures.