Intended for healthcare professionals


Parents of US boy who survived tetanus after nearly $1m of care refuse vaccine

BMJ 2019; 364 doi: (Published 13 March 2019) Cite this as: BMJ 2019;364:l1172
  1. Janice Hopkins Tanne
  1. New York

The parents of a 6 year old boy who survived tetanus after 57 days in an Oregon paediatric acute care unit in 2017 have refused the recommended second dose of tetanus vaccine.

They boy’s hospital care in 2017 cost $811 929 (£620 000; €720 000)—plus the unreported cost of emergency air transport, rehabilitation, and follow-up care, an account in Morbidity and Mortality Weekly Report said.1

This was the first case of tetanus in the state of Oregon in 30 years. A reported 7.5% of Oregon’s school age children do not receive any vaccinations because parents choose “non-medical exemptions”—that is, for personal reasons.2 The case fatality rate for tetanus is 13.2%, the Centers for Disease Control and Prevention has reported.3

Recommended protection against tetanus is five doses of the DTaP (diphtheria, tetanus, and acellular pertussis) vaccine given to children at 2, 4, 6, and 15-18 months and at 4-6 years. A booster shot is recommended every 10 years throughout life.

Carl Eriksson, a paediatric critical care specialist at Doernbecher Children’s Hospital in Portland and coauthor of the report, told The BMJ that he had never seen a case of tetanus. “Most physicians in the United States have never seen a case. It was recognized in the emergency department. He presented with classic symptoms and a history that was classic,” he said.

The boy cut his forehead while playing outdoors on a farm. The cut was cleaned and sutured at home. “Six days later, he had episodes of crying, jaw clenching, and involuntary upper extremity muscle spasms, followed by arching of the neck and back (opisthotonos) and generalized spasticity. Later that day, at the onset of breathing difficulty, the parents contacted emergency medical services, who air transported him directly to a tertiary pediatric medical center,” the report says.

The boy had not received the tetanus vaccine. When the boy arrived at the hospital he asked for water but could not open his mouth because of jaw muscle spasms. He had trouble breathing because of diaphragmatic and laryngeal spasms. He was sedated, intubated, and put on a respirator. He received 3000 units of tetanus immune globulin, DTaP vaccine, and intravenous metronidazole. The cut on his forehead was irrigated and cleaned, and he was admitted to the paediatric intensive care unit. Because stimulation increased his spasms, he had ear plugs and was cared for in a darkened room.

But the boy’s muscle spasms worsened. He developed hypertension and tachycardia, and his body temperature ranged from 36.1°C to 40.5°C. He was given multiple continuous medication infusions to control his pain and blood pressure and underwent neuromuscular blockade to manage his muscle spasms. He had a tracheostomy for prolonged ventilator support.

“It’s hard to see a child suffer from a disease that’s preventable. I’ve seen close to 100 patients who needed intensive care because of a disease that is preventable by vaccine. I’ve never had to give intensive care because of complications from a vaccine,” Eriksson told The BMJ.

After 44 days, the boy was able to come off the ventilator and could take sips of clear liquids. He was transferred to an intermediate care unit, and a few days later he was able to walk 20 feet with assistance. His tracheostomy was removed, and three days later he was moved to a rehabilitation centre where he spent 17 days. A month after inpatient rehabilitation the boy was able to return to his normal activities, including running and cycling.

“We are really excited that this patient made a complete recovery after time in the ICU, multiple medications, and swings in heart rate and temperature,” Eriksson said.

Despite the medical team’s efforts at education and persuasion the boy’s parents refused the recommended further DTaP vaccination. Eriksson could not say why because of privacy concerns. Surviving one episode of tetanus does not protect against a second infection.


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