Research and analysis

Tetanus in England: 2024

Updated 18 December 2025

Applies to England

This article updates the report Tetanus in England: 2023 (which presented surveillance data for England for that year) and reiterates current recommendations on the 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 6 cases recorded between January to December 2024; there were 2 fatalities
• 4 of the cases were associated with domestic injuries
• most cases were of unknown vaccination status; 1 case was partially 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).

There were 6 cases of clinical tetanus identified in England between January and December 2024. This compares to 5 cases in 2023, 4 cases identified in 2022, 11 cases 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). Five of the cases were notified as tetanus by healthcare professionals in England.

The cases ranged in age from 22 to 94 years, with 4 cases born before 1961 when routine childhood vaccination was introduced in the UK (1, 2). Only 2 cases were male. Cases occurred between April and September. Four of the cases were injured in the garden; 1 case was bitten by a dog; and 1 case sustained an abrasion after tripping and falling onto gravel.

Two cases presented with mild symptoms (grade 1); 1 case had severe tetanus (3A) and 3 cases had very severe tetanus (3B). 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 (UKHSA) guidelines, Tetanus: guidance for health professionals.

One of the cases with mild infection had vaccination records that could be verified. This individual had received 4 doses of tetanus-containing vaccine; however, the most recent dose was over 10 years prior to infection.

Immunisation history was not known/reported for the other 5 cases; this includes the 2 fatal cases, who were both born before the introduction of tetanus vaccination into the national programme.

Both of the mild cases sought medical advice at the time of injury, with one receiving antibiotic treatment. On subsequently presenting with clinical symptoms of tetanus, both cases were treated with IVIG and antibiotics.

Among the 4 serious cases, 2 sought medical advice at the time of injury and received post exposure prophylaxis with a tetanus containing vaccine. Information is not available on post exposure prophylaxis for the other 2 cases. All four cases were hospitalised with symptoms of tetanus and 1 case is known to have received treatment with intravenous immunoglobulin (IVIG) but this information is not available for the other 3 severe cases.

One case was tested by polymerase chain reaction (PCR) detection of the neurotoxin gene and this was negative. Negative results for any laboratory test do not exclude tetanus as it is a clinical diagnosis. 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 low-income countries 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 from 2001 was around or above 95%, the target coverage set by the World Health Organization (WHO). There has however been a gradual decline in uptake across the routine childhood immunisation programmes over the last decade and the annual coverage April 2024 to March 2025 was 92.8% for the 6-in-1 vaccine in children aged 2 years (4)

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 UKHSA national 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 culture and PCR. 

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 national guidelines provide advice on treatment of clinical tetanus using IVIG.

The guidelines also advise on the assessment and management of tetanus-prone wounds based on age and vaccination status including a tetanus booster if one has not been received in the previous 10 years. It is highlighted 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 any risk assessment.

The supply of intramuscular IM-TIG is no longer limited, and this should be used for tetanus-prone wounds requiring prophylactic immunoglobulin in addition to a tetanus containing vaccine. Every effort should be made to source IM-TIG directly from the manufacturers but HNIG for subcutaneous use may be given intramuscularly, as an alternative to TIG, if significant delay in receipt is likely. 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’

4. ‘Vaccination coverage statistics for children aged up to 5 years, England (COVER programme) report: April 2024 to March 2025’