The Status of Tetanus in the United States IMPLICATIONS FOR OCCUPATIONAL HEALTH NURSES by Kristine Garetson McIntee, MSN, SM, ARNP I n April 1993, the Occupational Health Nurses in Agricultural Communities (OHNAC)* of Iowa iden- tified a case of localized tetanus through active sur- veillance of emergency room records. A 46 year old horse owner incurred a flap laceration of the left thumb as he added concrete blocks to a drag used to even the ground in the horse arena. The wound was vigorously cleaned with soap and water, and he related having diffi- culty removing debris from the laceration. Stiffness in the thumb persisted for 8 days. During the course of the eighth day, tetany progressed up his arm into his shoulder and neck area. Physical examination showed decreased sensation over the distal two thirds of the left arm, hyper-reflexive deep tendon reflexes, and increased muscle tone of the left arm. Cerebellar function and gait were normal. Intramuscular injections of 3,000 IV of tetanus immune globulin and a tetanus-diphtheria booster were adminis- tered over seven sites. He reported primary childhood tetanus immunizations and a booster in December 1984. His recovery was complete and uneventful. Risk factors in this case include age, sex, warm weath- er, manure/soil environment, inability to completely clean ABOUT THE AUTHOR: Ms. McIntee is Assistant Co-Director, Dual Degree (MS/MPH) Occupational Health Nursing Program, University of South Florida, Tampa, FL, and Occupational Health /Primary Care Adult Nurse Practitioner, Darden Restaurants, Orlando, FL. DECEMBER 1995, VOL. 43, NO.12 the wound, and the rapid progression of localized tetanus. The man was unaware that a lapse in tetanus booster regi- men could reduce immune status and put him at risk for developing the fatal illness. As with many cases of tetanus, it was not possible to document a primary series or boost- er immunizations other than the 1984 booster. Tetanus is not a new disease. Symptoms of tetanus were described by Hippocrates in 360 B.C. Dr. Benjamin Rush postulated a tetanus treatment of "bark and wine and blisters of mercury ointment" in 1787. Another early reference to the "raging disease that baffled the healing art" indicates the lack of diagnostic information and effective treatment available in the 18th century (Leonard, 1800). Today, tetanus is thought to be as innocuous as the "flu." This is an accurate statement con- sidering the epidemic illness and fatality associated with influenza during the early 1900s and the similar potential for tetanus fatality. Tetanus is a serious complication of inadequate immunization and wound care. The focus of this article is the role of occupational health nurses in protecting clients' health through routine assessment of primary immunization; booster administra- tion of tetanus toxoid every 10 years; and educational inter- ventions around fastidious wound care, risk factors, immu- nization schedules, and signs and symptoms of tetanus. THE ORGANISM Tetanus is caused by gram positive, spore forming, anaerobic Clostridium tetani bacilli. Botulinum and tetanus toxins are the most virulent toxins known. Drumstick shaped spores may survive for years in some *OHNAC is a national prevention program conducted by the National Institute for Occupational Safety and Health (NIOSH) that has placed public health nurses in rural communities and hospitals in 10 states (California, Georgia, Iowa, Kentucky. Maine, Minnesota, New York, North Carolina, North Dakota, and Ohio) to conduct surveillance of agriculture related illnesses and injuries among farmers and their fam- ily members. These surveillance data are used to assist in reducing the risk for occupational illness and injury in agricultural populations. 627
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