Intended for healthcare professionals

Rapid response to:

Practice Lesson of the week

Acute dystonic reaction caused by metoclopramide, versus tetanus

BMJ 2007; 334 doi: (Published 26 April 2007) Cite this as: BMJ 2007;334:899

Rapid Response:

A change in the epidemiology of tetanus in the UK in 2003

The authors’ background information on the incidence of tetanus in
the UK states that 8-10 cases of tetanus are reported annually, and that
most cases occur in people aged over 60 years, who have not participated
in the national immunisation programme. Whilst prior to 2003 the
incidence of tetanus was low in the UK, with occasional cases
predominantly in unvaccinated elderly persons, in 2003 a cluster of
tetanus cases in injecting drug users (IDUs) has lead to a change in the
current epidemiological profile of tetanus cases in the UK (1, 2).

Twenty-five cases in IDUs were reported from July 2003 to September
2004 and the median age of male and female patients was 39 and 32 years of
age respectively (range 20-53), much younger than cases reported in non-
IDUs (1,3). The widespread distribution and temporal clustering of cases
suggests a contaminated batch of illicit drugs rather than changes in
injecting practices. Seventeen of 21 patients with information reported
having injected heroin intramuscularly or subcutaneously (skin popping) or
having missed veins. Two patients died. Only one of the cases is known to
have received the recommended five doses of tetanus toxoid-containing
vaccine. Two other patients had tetanus despite their antibody levels
being above the protective threshold, which is well recognised to occur
when the level of toxin production is high (4).

Since this cluster in 2003/4, services for IDUs have been offering
tetanus boosters and the number of cases reported has returned to pre-2003
levels (
Cases of tetanus in IDUs are still being reported to the Health Protection
Agency; four in 2005 and one in 2006 (2). Information was recently
received concerning an IDU who has had tetanus for the second time. This
serves as a reminder that tetanus does not confer immunity, and emphasises
the need to vaccinate patients after recovery from tetanus.

The authors also write that tetanus is unlikely in the absence of
skin injuries. While most cases of tetanus have a history of recent
injury, it is worth being aware that at least 3% of tetanus occurs in
patients without reported injury (3).

The authors refer to an obsolete version of DH guidance, and post
exposure tetanus policy has changed. Clinicians can find the latest (2006)
edition of “The Green Book”, on the Department of Health website:

Information for health professionals and tetanus surveillance forms
for cases of tetanus are available on the HPA’s tetanus webpage:

1. Hahné SJM, White JM, Crowcroft NS, Brett MM, George RC, Beeching
NJ, Roy K, Goldberg D. Tetanus in Injecting Drug Users, United Kingdom.
Emerg Infect Dis 2006;12(4): 709-710.


3. Rushdy AA, White JM, Ramsay ME, Crowcroft NS. Tetanus in England
and Wales, 1984-2000. Epidemiol Infect 2003;130:71-7.

4. Passen EL, Andersen BR. Clinical tetanus despite a protective
level of toxin-neutralizing antibody. JAMA 1986;255(9):1171-3.

Competing interests:
None declared

Competing interests: No competing interests

26 May 2007
Natasha S Crowcroft
Consultant Medical Epidemiologist
Karen Wagner, Joanne M White
Health Protection Agency Centre for Infections, London NW9 5EQ