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  1. J J Farrara,b,
  2. L M Yenc,
  3. T Cookd,
  4. N Fairweathere,
  5. N Binhc,
  6. J Parrya,b,
  7. C M Parrya,b
  1. aWellcome Trust Clinical Research Unit, Centre for Tropical Diseases, Cho Quan Hospital, 190 Ben Ham Tu, District 5, Ho Chi Minh City, Vietnam, bCentre for Tropical Medicine, Nuffield Department of Clinical Medicine, John Radcliffe Hospital, Oxford, UK, cCentre for Tropical Diseases, Cho Quan Hospital, 190 Ben Ham Tu, District 5, Ho Chi Minh City, Vietnam, dDepartment of Anaesthetics, Royal United Hospital, Bath, United Kingdom, eThe Department of Biochemistry, Imperial College of Science, Technology and Medicine, London SW7 2AZ, United Kingdom
  1. Dr Jeremy Farrarjeremyjf{at}

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General description

Tetanus was first described in Egypt over 3000 years ago and was prevalent throughout the ancient world. Despite the availability of passive immunisation since 1893 and an effective active vaccination since 1923, tetanus remains a major health problem in the developing world and is still encountered in the developed world. There are between 800 000 and 1 million deaths due to tetanus each year, of which about 400 000 are due to neonatal tetanus.1 Eighty per cent of these deaths occur in Africa and south east Asia and it remains endemic in 90 countries world wide.2 Incomplete vaccine deployment among the population at risk is the major factor, but the quality of the tetanus toxoid and how it is stored is also important. Fifteen lots, in use from eight manufacturers in seven countries, had potency values below World Health Organisation (WHO) requirements.1

In this decade 12–15 cases have been reported per year in Britain3 and between 40–60 in the United States.4 5 Mortality varies with patients' age. In the United States mortality in adults younger than 30 may be as low as zero. However, in those aged over 60, who account for 75% of tetanus deaths, mortality is above 50%.4-6 In Portugal between 1986 and 1990 all age mortality varied between 32% and 59%.7 In neonatal cases mortality without ventilation was reported as 82% in 1960 and 63%-79% in 1991.8 9 With ventilation this may be reduced to as low as 11%.10

The facilities available to manage severe tetanus have a major impact on the therapeutic options and mortality. In the United Kingdom intensive care costs $1500–2500/patient/day; such costs are clearly unrealistic in most of the world where tetanus is a major problem.11 Without the facility to artificially ventilate patients, …

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