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Tetanus

GMJ News knowledge hub · last reviewed August 2026 · Georgian Medical Journal

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Tetanus — caused by tetanospasmin, the neurotoxin of Clostridium tetani spores ubiquitous in soil and animal intestines — remains a significant global killer despite the existence of a highly effective, cheap vaccine: approximately 60,000-100,000 people die from tetanus each year, predominantly from neonatal tetanus (from contaminated cord cutting in unvaccinated mothers — responsible for approximately 34,000 neonatal deaths/year, WHO 2019) and wound tetanus in unvaccinated adults in LMICs (WHO). Tetanospasmin causes spastic paralysis (the opposite of botulinum toxin) — producing the pathognomonic trismus (lockjaw), risus sardonicus (sardonic grin) and opisthotonus (arched back) — with no antidote to toxin already bound to nerve tissue, making vaccination and timely tetanus immunoglobulin (TIG) administration the critical interventions.

Key messages

60-100K deaths/year — entirely preventable by vaccination
60,000-100,000 people die from tetanus each year globally — with neonatal tetanus alone killing approximately 34,000 newborns/year (WHO 2019). Every single death is preventable with a cheap, highly effective vaccine (tetanus toxoid). This is one of the most striking examples of vaccine-preventable mortality in modern medicine.
Spastic paralysis — opposite of botulism
Tetanospasmin causes spastic (rigid) paralysis by blocking inhibitory neurotransmitter (glycine and GABA) release in the spinal cord — the opposite of botulinum toxin which blocks excitatory acetylcholine release. Result: uncontrolled muscle contractions, trismus, opisthotonus, autonomic instability.
Trismus + risus sardonicus + opisthotonus — the clinical triad
The pathognomonic tetanus triad: trismus (lockjaw — masseter spasm preventing mouth opening); risus sardonicus (sardonic grin from facial muscle spasm); opisthotonus (arching of the back from paravertebral muscle spasm). Generalised spasms triggered by any stimulus — noise, touch, light.
TIG immediately — antitoxin does not reverse existing paralysis
Tetanus immunoglobulin (TIG) — human hyperimmune globulin — neutralises circulating tetanospasmin before it binds permanently to nerve endings. TIG must be given IMMEDIATELY in any suspected or confirmed tetanus case. Toxin already bound to nerve endings cannot be reversed.
Neonatal tetanus — from unclean cord cutting in unvaccinated mothers
Neonatal tetanus (from C. tetani spores infecting the umbilical cord stump after unclean cutting practices) occurs exclusively in babies born to non-vaccinated mothers. Two doses of tetanus toxoid (TT) in pregnancy provide >95% protection to the neonate through transplacental antibody transfer.
Decennial boosters — adults often unprotected
Tetanus immunity from vaccination wanes over time. Adult boosters (Td — tetanus-diphtheria) are recommended every 10 years. Many adults in both LMICs and HICs are unprotected due to missed boosters — particularly elderly individuals, immigrants and people without documented vaccination records.

Key statistics

60-100K
tetanus deaths/year globally (WHO estimate)
WHO
~34K
neonatal tetanus deaths/year (WHO 2019)
WHO 2019
2 doses TT
in pregnancy protects >95% of neonates from tetanus
WHO
10yr
recommended Td adult booster interval
WHO/ACIP
100%
preventable with vaccination — tetanus is never natural immunity
WHO
WHO 2030
target: elimination of maternal and neonatal tetanus globally (47/59 countries achieved by 2023)
WHO 2023

Tetanus forms — clinical types and typical contexts

Source: WHO. Generalised tetanus most common. Neonatal tetanus predominantly LMIC; wound tetanus in unvaccinated adults.

Glossary of key terms

Tetanospasmin
WHOA zinc-endopeptidase neurotoxin — the second most toxic substance known (after botulinum toxin, LD50 approximately 1-2 ng/kg). Produced by Clostridium tetani vegetative cells in anaerobic wound conditions. Transported retrogradely along motor neurons to the spinal cord, where it cleaves synaptobrevin (VAMP) on inhibitory interneurons — preventing glycine and GABA release. The result: loss of inhibitory control → unopposed motor neuron firing → spastic paralysis.
Trismus (lockjaw)
WHO/ClinicalSpasm of the masseter and other jaw muscles — preventing mouth opening. Often the earliest sign of generalised tetanus (typically appears 1-7 days after spasms begin). Once trismus is fully established, patients cannot open their mouths, eat, drink or communicate normally. Historically resulted in death by starvation before ICU support was available.
Opisthotonus
WHO/ClinicalSevere hyperextension of the spine from sustained contraction of the paravertebral and neck extensor muscles — arching the entire body backwards so that only the back of the head and heels touch the bed. A classic (but not always present) sign of severe generalised tetanus.
Wound management in tetanus prevention
WHO/ATLSAll wounds must be cleaned and debrided. Post-wound tetanus prophylaxis: (1) Fully vaccinated (≥3 doses, last dose <5 years): wound care only. (2) Fully vaccinated, last dose 5-10 years: Td booster. (3) Fully vaccinated, last dose >10 years: Td + TIG if dirty wound. (4) Unknown/incomplete vaccination (<3 doses): Td + TIG regardless. High-tetanus-risk wounds: contaminated with soil, manure, saliva; crush injuries; burns; puncture wounds; wounds >6 hours old.
Tetanus treatment: diazepam and magnesium
WHOTreatment targets: neutralise toxin (TIG); control spasms; manage airway. Muscle relaxants: benzodiazepines (diazepam IV/rectal — dose-titrated for spasm control; very high doses often needed); baclofen (intrathecal — for severe cases). Autonomic control: IV magnesium sulfate (reduces spasm frequency and severity, blocks neuromuscular junction, controls autonomic dysfunction — now first-line in many ICUs alongside diazepam). Severe disease: mechanical ventilation + neuromuscular blockade + tracheostomy.
Neonatal tetanus elimination
WHOWHO's maternal and neonatal tetanus elimination (MNTE) initiative targets elimination defined as <1 neonatal tetanus case per 1,000 live births per district. Two doses of TT (tetanus toxoid) or Td in pregnancy provide >95% neonatal protection through transplacental IgG transfer. Clean cord cutting (sterile blade, antiseptic) also essential. By 2023, 47 of the original 59 high-priority countries achieved elimination — approximately 12 countries remain.

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Related health topics

DTP/Td vaccinationBotulism (opposite paralysis)Diphtheria (DTP triplet)Pertussis (DTP triplet)Neonatal tetanusWound infection

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