Tetanus Surveillance — United States, 2009–2023

Problem/Condition: Tetanus is a serious but vaccine-preventable disease caused by the toxin produced by germinated spores of Clostridium tetani bacteria. Despite substantial declines in incidence resulting from immunization, cases continue to occur, particularly among unvaccinated and undervaccinated populations. Period Covered: 2009-2023. Description of System: The National Notifiable Diseases Surveillance System uses national surveillance to identify cases of tetanus using the Council of State and Territorial Epidemiologists' tetanus case definition. Tetanus cases identified through clinical diagnosis are reported to CDC by state health departments. Detailed tetanus-specific case information is requested, which includes tetanus toxoid-containing vaccine (TTCV) vaccination history, wound history, medical care before tetanus disease onset, and the clinical course of illness, including death. Results: During 2009-2023, a total of 402 tetanus cases and 37 associated deaths were reported from 47 states and the District of Columbia, with a mean annual tetanus incidence of 0.08 cases and 0.008 deaths per 1 million population. More than half (62.2%) of all reported tetanus cases occurred in males. Incidence was higher among males than females for all persons aged <65 years and higher among women than men for adults aged ≥80 years. Women aged ≥80 years had the highest overall tetanus incidence (0.27 cases per 1 million population). The overall case-fatality rate among persons with tetanus with known vital status was 12.4% (37 of 299), with deaths predominantly affecting older adults. A total of 45.0% of persons with tetanus who had a substantial wound sought medical care before disease onset. Among patients with wounds eligible for tetanus post-exposure prophylaxis, 2.3% received tetanus immune globulin (TIG) and 26% received TTCV per recommendations. Among persons whose vaccination history was known, a substantial proportion (43.9%) had not received any TTCV doses, highlighting substantial gaps in coverage. Interpretation: Despite being preventable through vaccination, tetanus continues to occur among persons of all age groups in the United States. Overall, males have higher incidence compared with females; the highest incidence is among older women. Approximately 1 in 10 persons who develop tetanus will die, with the highest mortality and case-fatality rates among older adults. Public Health Action: Multiple efforts might reduce the incidence of tetanus, including clinicians' assessing for and offering routine tetanus vaccination for children and decennial tetanus boosters for adults. In addition, persons with significant wounds should seek timely medical care, and clinicians should provide recommended wound care, including identifying tetanus-prone wounds and the need for and administration of TTCV and TIG. Because C. tetani is ubiquitous in the environment, continued surveillance and vaccination efforts are crucial to monitor trends, identify opportunities to prevent tetanus cases, and reduce tetanus incidence in the United States.