Research and analysis

Tetanus in England: 2023

Updated 26 June 2025

Applies to England

This article updates the report  Tetanus in England: 2022 (which presented surveillance data for England for that year) and reiterates current recommendations on diagnosis and clinical management of tetanus.

The main points arising from this report are that:

• tetanus is a severe, potentially life-threatening but preventable infection and is very rare in the UK due to the success of the immunisation programme
• there were 5 cases recorded between January to December 2023; there were 2 fatalities
• 4 of the cases were associated with domestic injuries
• most cases were partially vaccinated or of unknown vaccination status; 1 case was fully vaccinated
• where an individual presents with a suspected tetanus-prone wound, it is essential to take a full tetanus vaccination history (including primary and boosters) and exposed individuals, depending on their age and vaccination status, should be offered prophylaxis with tetanus immunoglobulin (TIG) along with tetanus vaccine to prevent tetanus, as directed by the Green Book, chapter 30: Tetanus

Surveillance and recent epidemiology

Data sources in England for the enhanced surveillance of tetanus include:

• notifications
• reference and NHS laboratory reports
• death registrations
• source of infection
• severity of disease

This data is obtained from hospital records and general practitioners.

Cases of tetanus are known to be under-reported. A comparison of surveillance data against hospital episode statistics in England between 2001 and 2014 suggested that tetanus was under-reported by 88% during that period. There were 67 additional cases identified in the hospital statistics that were not captured through enhanced surveillance (1).

Five cases of clinical tetanus were identified in England between January and December 2023. This compares to 4 cases in 2022, 11 cases identified in 2021, 7 cases in 2020 and 4 cases in 2019. Tetanus is a notifiable disease in accordance with the amended Public Health (Control of Disease) Act 1984 and the accompanying regulations (SI 2010/659). However, only 3 of the cases were notified as tetanus by healthcare professionals in England.

The cases ranged in age from 27 to 92 years, with 2 cases born before 1961 when routine childhood vaccination was introduced in the UK (1, 2). Only 1 case was female. Cases occurred in February, March, April, September and November. Four of the cases had a history of domestic-related injury; 3 cases were injured or bitten in the garden; 1 case had a pre-existing wound that was believed to be contaminated in the garden; and 1 case had no known injury history.

One case presented with mild symptoms (grade 1) and one case with moderate symptoms (grade 2); 3 cases had severe tetanus (3A). All cases were hospitalised, and there were 2 fatalities. Full details of grading of severity for clinical purposes are contained in the UK Health Security Agency guidelines, Tetanus: guidance for health professionals, which were revised in 2019.

Only the case with mild infection had  vaccination records that could be verified. This individual had received 5 doses of tetanus containing vaccine, the most recent of which however was over 10 years prior to infection. One of the serious cases self-reported a history of tetanus vaccination following a non-UK routine schedule, with their last reported dose received over 30 years ago. One of the fatalities had reportedly received tetanus vaccine, but their most recent dose was more than 40 years ago. The other fatality and the case with moderate severity infection had no tetanus vaccination recorded. Both fatal cases were born before the introduction of tetanus vaccination into the national routine programme.

Only the mild case sought medical advice at the time of injury (the following day) and received a booster dose of tetanus toxoid vaccine. The case did not receive post-exposure prophylaxis with intra-muscular tetanus immunoglobulin (IM-TIG) or human normal immunoglobulin (HNIG)(3).

After the onset of clinical symptoms when tetanus was diagnosed at hospital, all 5 cases received intravenous immunoglobulin (IVIG) during their admission.

Only 1 case was confirmed with polymerase chain reaction (PCR) detection of the neurotoxin gene or by culture of Clostridium tetani. No infected tissue samples were collected from the other cases for PCR testing (3). Serological testing is not a reliable indicator for diagnosis to confirm or to rule out tetanus (3).

Background, diagnosis and immunisation

Tetanus is a life-threatening but preventable disease caused by a neurotoxin (tetanospasmin, TS) produced by C. tetani, an anaerobic spore-forming bacterium. Tetanus spores are widespread in the environment, including in soil, and can survive hostile conditions for long periods of time. Transmission occurs when spores are introduced into the body, often through a puncture wound but also through trivial, unnoticed wounds, chronic ulcers, injecting drug use, and occasionally through abdominal surgery.

Neonatal tetanus is still common in the developing world where the portal of entry is usually the umbilical stump, particularly if there is a cultural practice of applying animal dung to the umbilicus.

The infection is not transmitted from person to person. The incubation period of the disease is usually between 3 and 21 days, although it may range from one day to several months, depending on the character, extent and localisation of the wound.

Tetanus immunisation was introduced in the 1950s and became part of the national routine childhood programme in 1961. Since then, vaccine coverage at 2 years of age has always exceeded 70% in England and Wales, and since 2001 has been around or above 95%, the target coverage set by the World Health Organization (WHO).

The objective of the immunisation programme in the UK is to provide a minimum of 5 doses of tetanus-containing vaccine at appropriate intervals for all individuals. As there is no herd immunity effect, individual protection through vaccination is essential. In most circumstances, a total of 5 doses of vaccine at the appropriate intervals are considered to give satisfactory long-term protection. Routine boosters every 10 years are no longer recommended; however, immunity to tetanus wanes over time and therefore additional boosters may be recommended in specific circumstances. Further details on tetanus immunisation information are available in the Green Book, chapter 30: Tetanus.

Clinical management

Recommendations for the treatment of suspected clinical tetanus and management of tetanus-prone wounds are contained in the revised UKHSA (formerly, PHE) guidelines (3).

Clinical management of tetanus includes administration of IVIG, wound debridement, antimicrobials including agents reliably active against anaerobes such as metronidazole, and vaccination with tetanus toxoid vaccine. The revised guidelines emphasise the clinical diagnosis of suspected tetanus. Laboratory diagnostic tests are ancillary, and the most useful test is detection of C. tetani from the infection site by PCR and culture. 

Debridement of wounds is clinically beneficial and wound samples provide the diagnostic sample for the isolation of C. tetani or detection of toxin by PCR. However, a negative laboratory test does not rule out a case. The revised guidelines provide updated advice on treatment of clinical tetanus using IVIG and on the assessment and management of tetanus-prone wounds based on age and vaccination status, including a tetanus booster if the patient has not received one in the previous 10 years.

The revised guidelines highlight that patients born before 1961 in the UK are unlikely to have completed a primary course and this should be taken into account as part of the risk assessment.

Since the supply of intramuscular IM-TIG is limited, for tetanus-prone wounds requiring prophylactic IM-TIG, HNIG for subcutaneous use may be given intramuscularly as an alternative to TIG. Further details are provided in the revised guidelines (3).

References

1. Collins S, Amirthalingam G, Beeching NJ, and others (2015). ‘Current epidemiology of tetanus in England, 2001 to 2014’ Epidemiology and Infection: volume 144 number 16, pages 3,343 to 3,353

2. Rushdy AA, White JM, Ramsay ME, Crowcroft NS (2003). ‘Tetanus in England and Wales 1984 to 2000’ Epidemiology and Infection: volume 144, number 16, pages 71 to 77

3. UKHSA (2023). ‘Tetanus: guidance for health professionals’