Tetanospasmin

Related Terms

Abscesses, arrhythmias, Clostridium tetany, coma, crush wounds, devitalized, diptheria, incubation, lockjaw, pertussis, seizure, spores, tetanospasmin, titanic, tonic, toxoid, trismus, vaccination, vaccine, vegetative cell, whooping cough.

Background

Tetanus, also called lockjaw, is a serious illness caused by tetanospasmin, a powerful nerve toxin produced by Clostridium tetani. The bacterium Clostridium tetani is an organism capable of living many years in the soil as a spore. Tetanus occurs when a wound becomes contaminated with bacterial spores. Infection follows when spores become active, multiply, and produce a very powerful poison that affects the muscles. Tetanus spores are found throughout the environment, usually in soil, dust, and animal waste (such as manure). Clostridium may enter the body through a deep cut, such as cuts acquired when stepping on a nail, from splinters, insect bites, burns, injection-drug sites, or puncturing the skin with a sharp object. Deep wounds or those with devitalized (dead) tissue are particularly prone to tetanus infection.
Tetanus is not transmitted from person to person. An individual usually becomes infected with tetanus when dirt enters a wound or cut.
The infection causes painful tightening of the muscles, usually all over the body. It can lead to "locking" of the jaw, which makes it impossible to open the mouth or swallow. If this occurs, the individual may suffocate. Due to symptoms, tetanus is frequently a fatal infectious disease.
If an individual gets tetanus, there is usually a long course of treatment. Drugs that increase immunity to fight infection, and decrease muscle spasms are used. Tetanus is curable, but depending on the severity and number of symptoms up to 50% of individuals with tetanus may die. The tetanus vaccine is effective, but its protection does not last forever. Adults should get a tetanus shot, or booster, every 10 years.
There are four types of tetanus: generalized, local, cephalic, and neonatal. In generalized tetanus, all skeletal muscles can be affected. Generalized tetanus is the most common, as well as the most severe form of tetanus. Death is usually due to respiratory failure or disturbance of heart rhythm. Local tetanus causes muscle spasms at or near the wound that has been infected with the bacteria. Cephalic tetanus primarily affects one or more muscles in the face. No muscles elsewhere are involved, unless the disease progresses to generalized tetanus. Neonatal tetanus is a common and serious tetanus infection found in newborn babies. Most infants who get the disease die. Neonatal tetanus is particularly common in rural areas where most deliveries are at home without adequate sterile procedures. In 2000, WHO estimates that neonatal tetanus killed about 200,000 infants.
Before World War II, when the vaccine came into widespread use, about 600 cases of tetanus and 180 deaths were reported annually in the United States. Now there are about 70 cases per year and 15 deaths, most of them in elderly adults. Overall, the mortality rate is approximately 45%.
Worldwide, tetanus is predominantly a disease of underdeveloped countries located in warm, damp climates. In developing countries of Africa, Asia, and South America, tetanus is far more common. The annual worldwide incidence is between 300,000-500,000 cases.

Signs and symptoms

The incubation period between contamination of a wound to the bacteria and development of the initial symptoms of tetanus ranges from two days to two months. The incubation period is the amount of time between infection with a virus or bacteria to the start of symptoms. Most commonly initial symptoms emerge within 14 days of injury. The shorter the incubation period of tetanus, the higher the risk of death.
During a one to seven day period, progressive muscle spasms caused by the tetanus toxin in the localized wound area may progress to involve the entire body. Restlessness, headache, sore muscles, weakness, and irritability are common. In children and adults, muscular stiffness in the jaw is a common first sign of tetanus.
In general, the tetanus neurotoxin causes the muscles to tighten up into a continuous ("tetanic" or "tonic") contraction or spasm. The jaw is "locked" by muscle spasms, giving the name "lockjaw" (also called "trismus"). Muscles throughout the body are affected, including the vital muscles necessary for normal breathing. When the breathing muscles lose their power, breathing becomes difficult or impossible and death can occur without life-support measures. Even with breathing support, infections of the airways within the lungs can lead to death.
In cephalic tetanus, in addition to having lockjaw, weakness of at least one other facial muscle occurs. In two-thirds of these cases, generalized tetanus will develop.
In localized tetanus, muscle spasms occur at or near the site of the injury. This condition rarely progresses to generalized tetanus.
Neonatal tetanus is identical to generalized tetanus except that it affects the newborn infant. Newborn babies with tetanus are normal at birth, but stop nursing between three and 28 days after birth.

Diagnosis

The diagnosis of generalized tetanus is made using a combination of the following: a history of incomplete tetanus immunizations; a recent injury resulting in skin breakage (not universal, only 70% of cases have an identified injury); progressive muscle spasms (starting in the facial region, especially lockjaw and progressing outward from the face to include all muscles of the body); fever; changes in blood pressure (especially high blood pressure); and irregular heartbeat. In localized tetanus, pain, cramps, or muscle spasms occur at or near a recent skin injury.

Complications

Fractures of the spine or other bones may occur as a result of muscle spasms and convulsions.
Arrhythmias (abnormal heartbeats) and coma can occur, as can development of pneumonia and other infections. In severe cases of tetanus, life-threatening respiratory and cardiovascular complications can present with troubling rapidity following the initial diagnosis and admission to the hospital. Individuals may have to be placed on a respirator to assist in breathing. Death is particularly likely in the very young and in the elderly.

Treatment

General measures to treat the sources of the bacterial infection with antibiotics, such as penicillin (PenG?), are used. Drainage of the wound site is also carried out in the hospital while the individual is monitored for any signs of compromised breathing muscles. Treatment is directed toward stopping toxin production, neutralizing its effects, and controlling muscle spasms. To treat tetanus, people are often paralyzed (to help stop the muscle spasms) using medications, such as vercuronium (Norcuron?) and then put on a mechanical ventilator to keep them breathing. Muscle relaxants and anti-seizure medicines are important.
Tetanus immune globulins (Hyper-Tet?, Bay-Tet?): Tetanus immune globulin (TIG, Hyper-Tet? or Bay-Tet?) is used as prophylaxis against tetanus and to treat patients with circulating tetanus toxin. TIG provides passive immunity. TIG should be used to treat all individuals with active tetanus, in combination with other supportive and therapeutic treatments such as antibiotics. TIG should also be used to prevent tetanus in individuals with inadequate or unknown immunization status after an acute injury.
Other drugs may be given for the following reasons: to provide sedation and control seizures, such as diazepam (Vaium?); relax the muscles, such as liorisal (Baclofen?); relieve pain, such as morphine (Astromorph?); and control heart arrhythmias and blood pressure, such as labetolol (Normodyne?).
For individuals with moderate to severe infections, a ventilator may be required to assist breathing. Because people with tetanus have trouble swallowing, nourishment is given intravenously or through a tube inserted through the nose and into the stomach.
Passive immunity: In individuals who exhibit the early symptoms of tetanus or in those whose immunization status is unknown or significantly out of date, the tetanus immune globulin (TIG) is injected into the muscle surrounding the wound with the remainder of the dose injected into the buttocks.

Integrative therapies

There are few clinical studies that support the use of integrative therapies specifically for treating tetanus (TB) infections. Studies on potential immune supporting and antibacterial integrative therapies are also included in this monograph.
Strong scientific evidence:
Iodine: Iodine is an element essential to the production of thyroid hormones. The human body needs to make thyroid hormones. Chronic iodine deficiency can cause many health problems, such as thyroid gland dysfunction and many neurologic, gastrointestinal, and skin problems. Iodine is commonly used in products that are applied to the skin to clean wounds, sterilize the skin before surgical/invasive procedures, or to sterilize catheter entry sites. Betadine solution, for example, contains povidone-iodine. Other topical disinfectants include alcohol and antibiotics. Iodine is sometimes used in combination with these. Commercially prepared iodine products are recommended in order to assure appropriate concentrations.
Reactions can be severe and deaths have occurred with exposure to iodine. Avoid iodine-based products if allergic or hypersensitive to iodine. Do no use for more than 14 days. Avoid Lugol solution and saturated solution of potassium iodide (SSKI, PIMA) with hyperkalemia (high amounts of potassium in the blood), pulmonary edema (fluid in the lungs), bronchitis, or tuberculosis. Use cautiously when applying to the skin because it may irritate/burn tissues. Use sodium iodide cautiously with kidney failure. Avoid sodium iodide with gastrointestinal obstruction.
Iodine is safe in recommended doses for pregnant or breastfeeding women. Avoid povidone-iodine for perianal preparation during delivery or postpartum antisepsis.
Probiotics: Probiotics are beneficial bacteria that are sometimes called friendly germs. They help maintain a healthy intestine and aid in digestion. They also help keep harmful bacteria and yeasts in the gut under control. Most probiotics come from food sources, especially cultured milk products. Probiotics can be taken as capsules, tablets, beverages, powders, yogurts, and other foods. An increasing number of studies support the use of probiotics as a supplement to antibiotic therapy. Probiotic supplementation during a course of antibiotics (such as with treating tetanus) may reduce the adverse effects of antibiotics in the intestinal environment. This includes reducing growth of Clostridium difficile bacteria, which can lead to colitis (inflammation of the colon), a common complication of antibiotics. In acutely ill children, synbiotics (nutritional supplements made of probiotics and prebiotics) have been linked to greater weight gain and fewer bacterial illnesses after antibiotics are ended. The evidence consistently supports probiotic supplementation of antibiotics. Probiotics are generally considered safe and well tolerated. Avoid if allergic or hypersensitive to probiotics. Use cautiously if lactose intolerant.
Good scientific evidence:
Probiotics: Limited evidence with day care children suggests supplementation with Lactobacillus GG may reduce the number of sick days, frequency of respiratory tract infections, and frequency of related antibiotic treatments. Fermented milk (with yogurt cultures and L. casei DN-114001) may reduce the duration of winter infections (digestive and respiratory), as well as average body temperature, in elderly people.
Probiotics are generally considered safe and well tolerated. Avoid if allergic or hypersensitive to probiotics. Use cautiously if lactose intolerant.
Unclear or conflicting scientific evidence:
Astragalus: In traditional Chinese medicine (TCM), astragalus is commonly found in mixtures with other herbs. Western herbalists began using astragalus in the 1800s as an ingredient in various tonics. One clinical trial suggests that astragalus may help treat patients with tuberculosis. Further well-designed clinical trials are required before recommendations can be made.
Avoid if allergic to astragalus, peas, or any related plants. Avoid with a history of Quillaja bark-induced asthma. Avoid if taking aspirin, aspirin products, or herbs or supplements with similar blood thinning effects. Avoid with inflammation, fever, stroke, organ transplant, or autoimmune diseases. Stop use two weeks before and immediately after any surgery/dental/diagnostic procedures with a risk of bleeding. Use cautiously with bleeding disorders, diabetes, high blood pressure, lipid disorders, or kidney disorders. Use cautiously with blood-thinners, blood sugar drugs, diuretics, or herbs and supplements with similar effects. Avoid if pregnant or breastfeeding.
Berberine: Berberine is a bitter-tasting, yellow plant alkaloid with a long history of medicinal use in Chinese and Ayurvedic medicine. Berberine has been found to possess antimicrobial properties and there is limited evidence of anti-inflammatory properties as well. Preliminary evidence suggests that berberine eye preparations may be beneficial for trachoma. However, the safety and efficacy of berberine for this indication remains unclear.
Avoid if allergic or hypersensitivity to berberine, plants that contain berberine (goldenseal, coptis or goldenthread, Oregon grape, barberry, and tree turmeric), or to members of the Berberidaceae family. Avoid in newborns due to the potential for developing an increase in free bilirubin, jaundice, and development of kernicterus, a form of brain damage caused by excessive jaundice. Use cautiously with heart disease, gastrointestinal disorders, hematologic disorders, leukopenia (low white blood cell count), kidney disease, liver disease, respiratory disorders, cancer, hypertyrosinemia (abnormally high levels of tyrosine in blood), diabetes, or low blood pressure. Use cautiously in children due to lack of safety information. Use cautiously in individuals with high exposure to sunlight or artificial light. Use cautiously for longer than eight weeks due to theoretical changes in bacterial gut flora. Use cautiously if taking anticoagulants (blood thinners), anti-hypertensives (blood pressure-lowering agents), sedatives, anti-inflammatories, or medications that are broken down by the liver (including cyclosporine or any prescription medications). Avoid if pregnant or breastfeeding.
Beta-sitosterol: Beta-sitosterol is found in plant-based foods, such as fruits, vegetables, soybeans, breads, peanuts, and peanut products. It is also found in bourbon and oils such as olive oil, flaxseed, and tuna. Beta-sitosterol and beta-sitosterol glucoside have been studied as adjunctive treatment of tuberculosis along with anti-tuberculosis medications. The beta-sitosterols in general help improve immune function. One randomized controlled trial, which included a small number of patients, studied beta-sitosterol and beta-sitosterol glucoside for this indication. Larger populations of patients with tuberculosis should be evaluated in randomized controlled trials if conclusions are to be made.
Avoid if allergic or hypersensitive to beta-sitosterol, beta-sitosterol glucoside, or pine. Use cautiously with asthma, breathing disorders, diabetes, primary biliary cirrhosis (destruction of the small bile duct in the liver), ileostomy, neurodegenerative disorders (e.g. Parkinson's disease or Alzheimer's disease), diverticular disease (bulging of the colon), short bowel syndrome, celiac disease, and sitosterolemia. Use cautiously with a history of gallstones. Avoid if pregnant or breastfeeding.
Black tea: Black tea is made from the dried leaves of a perennial evergreen shrub called Camellia sinensis. Black tea has a long history of use, dating back to China about 5,000 years ago. In one small study, inhaled tea catechin, a tannic acid, a component of tea, was reported as temporarily effective in the reduction of Methicillin-resistant Staphylococcus aureus (MRSA) and shortening of hospitalization in elderly patients infected with (MRSA). Additional research is needed to further explore these results.
Avoid if allergic or hypersensitive to caffeine or tannins. Both are components of tea. Skin rash and hives have been reported with caffeine ingestion, such as in tea. Use cautiously with diabetes. Use cautiously if pregnant. Heavy caffeine intake during pregnancy may increase the risk of SIDS (sudden infant death syndrome). Very high doses of caffeine have been linked with birth defects. Caffeine is transferred into breast milk. Caffeine ingestion by infants may lead to sleep disturbances and insomnia. Infants nursing from mothers consuming greater than 500 milligrams of caffeine daily have been reported to experience tremors and heart rhythm abnormalities. Tea consumption by infants has been linked to anemia, decreased iron metabolism, and irritability.
Blessed thistle: Blessed thistle leaves, stems, and flowers have traditionally been used in "bitter" tonic drinks and in other preparations taken by mouth to enhance appetite and digestion. Laboratory studies report that blessed thistle and chemicals in blessed thistle have activity against several types of bacteria and no effects on others. Reliable human study is lacking. Further evidence is necessary before a firm conclusion can be drawn.
Avoid if allergic to blessed thistle, mugwort, bitter weed, blanket flower, chrysanthemum, coltsfoot, daisy, dandelion, dwarf sunflower, goldenrod, marigold, prairie sage, ragweed, Echinacea, or any plants of the Asteraceae or Compositae families. Avoid with a history of bleeding disorders or gastroesophageal reflux disease (GERD). Avoid if taking drugs for anticoagulants or drugs that are used to treat stroke, stomach diseases, or to control stomach acid. Avoid if pregnant or breastfeeding. Stop use two weeks before and immediately after surgery/dental/diagnostic procedures that carry bleeding risks.
Cranberry: Cranberries come from small evergreen shrubs with tart, red, edible berries. The berries are used in sauces, jellies, and drinks. Study results of cranberry as an antibacterial in other conditions show conflicting results. Further study is needed before a conclusion can be drawn.
Avoid if allergic to cranberries, blueberries, or other plants of the Vaccinium species. Sweetened cranberry juice can affect blood sugar levels. Monitor blood sugar regularly in diabetics. Use cautiously with a history of kidney stones. Avoid more than the amount usually found in foods if pregnant or breastfeeding.
Ginseng: For more than 2,000 years, the roots of this slow-growing plant have been used in Chinese medicine. In patients treated with Hochu-ekki-to, which contains ginseng and several other herbs, urinary MRSA has been reported to decrease after a 10-week treatment period. Further study of ginseng alone is necessary in order to draw firm conclusions.
Avoid ginseng with known allergy to plants in the Araliaceae family, such as English ivy. There has been a report of a serious life-threatening skin reaction, possibly caused by contaminants in the ginseng formulation studied.
Goldenseal: Goldenseal is one of the five top-selling herbal products in the United States. Goldenseal can be found in dietary supplements, eardrops, feminine cleansing products, cold/flu remedies, allergy remedies, laxatives, and digestive aids. The goldenseal component berberine has effects against bacteria and inflammation. Several poorly designed human studies report benefits of berberine, used in the eye, to treat trachoma. Better research is needed before a recommendation can be made.
Avoid if allergic or hypersensitive to goldenseal or any of its constituents, such as berberine and hydrastine. Use cautiously with bleeding disorders, diabetes, or low blood sugar. Avoid if pregnant or breastfeeding.
Honey: Honey is a sweet, sticky fluid. Bees make honey from the nectar of flowers. Honey's therapeutic importance as a known antibacterial agent has been recognized since 1892. Currently, there is insufficient available evidence for the use of honey in the treatment of Fournier's gangrene.
Avoid if allergic or hypersensitive to honey, pollen, celery, or bees. Honey is generally considered safe. Avoid honey from the genus Rhododendron because it may cause a toxic reaction. Avoid in infants younger than 12 months of age. Use cautiously with antibiotics. Potentially harmful contaminants (such as C. botulinum or grayanotoxins) can be found in some types of honey and should be used cautiously in pregnant or breastfeeding women.
Hydrotherapy: Hydrotherapy is broadly defined as the external application of water in any form or temperature (hot, cold, steam, liquid, ice) for healing purposes. It may include immersion in a bath or body of water (such as the ocean or a pool), use of water jets, douches, application of wet towels to the skin, or water birth. There is preliminary evidence that some hydrotherapy techniques, used in conjunction with other treatments such as antibiotics, may reduce bacteria on the surface of the skin. It is unknown if there are benefits (or potentially harmful effects) of reducing skin bacteria. There may be benefits in people with skin wounds or ulcers who have a risk of infection, such as immunocompromised patients. There is no evidence that infection of the skin itself (cellulitis) is improved.
Avoid sudden or prolonged exposure to extreme temperatures in baths, wraps, saunas, or other forms of hydrotherapy, particularly with heart disease, lung disease, or if pregnant. Avoid with implanted medical devices, such as pacemakers, defibrillators, or liver infusion pumps. Vigorous use of water jets should be avoided with fractures, known blood clots, bleeding disorders, severe osteoporosis, open wounds, or during pregnancy. Use cautiously with Raynaud's disease, chilblains, acrocyanosis, erythrocyanosis, or impaired temperature sensitivity, such as neuropathy. Use cautiously if pregnant or breastfeeding. Hydrotherapy should not delay the time to diagnosis or treatment with more proven techniques or therapies, and it should not be used as the sole approach to illnesses. Patients with known illnesses should consult their physicians before starting hydrotherapy.
Lavender: Lavender is native to the Mediterranean, Arabian Peninsula, Russia, and Africa. Today, lavender is cultivated around the world. Oils from the flowers are used in aromatherapy, baked goods, candles, cosmetics, detergents, jellies, massage oils, perfumes, powders, shampoo, soaps, and tea. Early laboratory studies suggest that lavender oils may have antibiotic activity. However, this has not been well tested in animal or human studies.
Avoid if allergic or hypersensitive to lavender. Avoid with a history of seizures, bleeding disorders, eating disorders (anorexia, bulimia,) or anemia (low levels of iron). Nausea, vomiting, and anorexia have been reported after large oral doses of lavender. Use cautiously if taking sedatives. Avoid if pregnant or breastfeeding.
L-carnitine: In humans, L-carnitine is produced in the liver, kidneys, and brain and it is transported to other areas of the body. A preliminary study suggests that acetyl-L carnitine may increase antibacterial activity in patients with tuberculosis. Additional study is needed to confirm these findings.
Avoid taking L-carnitine with known allergy or hypersensitivity to carnitine. Use cautiously with peripheral vascular disease, high blood pressure, alcohol-induced liver cirrhosis, or diabetes. Use cautiously in low birth weight infants and individuals on hemodialysis. Use cautiously if taking anticoagulants (blood thinners), beta-blockers, or calcium channel blockers. Avoid if pregnant or breastfeeding.
Lime: The term "lime" refers to many different citrus fruits that are usually round and green or yellow. They are about three to six centimeters wide and contain sour pulp. Lime trees blossom throughout most of the year in tropical and sub-tropical climates, such as California, Florida, and Mexico. One study found that lime juice used in sauces might help prevent cholera. Another preliminary study suggested that using limes in the main meal may also have a protective effect against cholera bacteria. The same primary author conducted both studies. Additional study is needed before a firm recommendation can be made.
Lime is considered safe when used in amounts typically found in foods. Avoid if allergic or hypersensitive to lime or any members in the Rutaceae family. Use cautiously with drugs that are broken down by the liver. Use cautiously with photosensitivity causing drugs, particularly with macrolide, tetracycline, or cephalosporin antibiotics, which can cause sun sensitivity. Avoid if pregnant or breastfeeding. There is no scientific evidence to support using lime juice douche to prevent HIV infection.
Probiotics: Probiotics are beneficial bacteria that are sometimes called friendly germs. Probiotics can be taken as capsules, tablets, beverages, powders, yogurts, and other foods. As a bacterial reservoir, the nose may harbor many varieties of potentially disease-causing bacteria. There is limited evidence that probiotic supplementation may reduce the presence of harmful bacteria in the upper respiratory tract. More studies are needed to establish this relationship and its implications for health.
Results are mixed regarding the ability of probiotics to reduce infective complications of medical treatment. Reduced incidence of infection has been seen in patients treated for brain injury, abdominal surgery, and liver transplantation. Other studies have shown no such reduction in elective abdominal surgery and critical care patients.
Probiotics are generally considered safe and well tolerated. Avoid if allergic or hypersensitive to probiotics. Use cautiously if lactose intolerant.
Propolis: Propolis is a natural resin created by bees to make their hives. Propolis is made from the buds of conifer and poplar tress and combined with beeswax and other bee secretions. Animal and laboratory studies suggest activity of propolis in the treatment of various types of infections. Initial human research reports possible benefits against oral/dental bacteria, genital herpes, urine bacteria, and intestinal bacteria. Additional research is needed before a recommendation can be made.
Avoid if allergic or hypersensitive to propolis, black poplar (Populas nigra), poplar bud, bee stings, bee products, honey, or Balsam of Peru. Severe allergic reactions have been reported. There has been one report of kidney failure with the ingestion of propolis that improved upon discontinuing therapy and deteriorated with re-exposure. Avoid if pregnant or breastfeeding because of the high alcohol content in some tinctures and liquid extracts.
Saccharomyces boulardii: Saccharomyces boulardii is a type of yeast that does not cause disease in humans. Saccharomyces boulardii has been used to treat and prevent diarrhea resulting from multiple etiologies. Evidence from one clinical trial supports improvement of symptoms in patients with amebiasis treated with Saccharomyces boulardii, in addition to standard therapy. Further clinical trials are required before a firm recommendation can be made.
Avoid if allergic or hypersensitive to yeast, Saccharomyces boulardii, Saccharomyces cerevisiae, or other species in the Saccharomycetaceae family. Use cautiously in patients who have weakened immune systems or in critically ill patients. Use cautiously with indwelling central venous catheters, colitis, cancer, or constipation. Use cautiously in the elderly, chemotherapy patients, and infants. Use cautiously if taking medications to treat diarrhea. Avoid with a yeast infection. Avoid if pregnant or breastfeeding.
Seaweed, kelp, bladderwrack: Bladderwrack (Fucus vesiculosus) is a brown seaweed found along the northern coasts of the Atlantic and Pacific oceans and North and Baltic seas. Another seaweed that grows alongside bladderwrack is Ascophyllum nodosum; it is often combined with bladderwrack in kelp preparations. Laboratory studies suggest antifungal and antibacterial activity of bladderwrack. However, there are no reliable human studies to support use as an antibacterial or antifungal agent.
Avoid if allergic or hypersensitive to Fucus vesiculosus or iodine. Avoid with a history of thyroid disease, bleeding, acne, kidney disease, blood clots, nerve disorders, high blood pressure, stroke, or diabetes. Avoid if pregnant or breastfeeding.
Selenium: Selenium is a mineral found in soil, water, and some foods. Preliminary research reports that selenium may be beneficial in the prevention of several types of infection, including recurrence of erysipelas (bacterial skin infection associated with lymphedema) or pneumonia. Further research is needed to confirm these results.
Avoid if allergic or sensitive to products containing selenium. Avoid with a history of non-melanoma skin cancer. Selenium is generally regarded as safe for pregnant or breastfeeding women. However, animal research reports that large doses of selenium may lead to birth defects.
Sorrel: Sorrel has been used as a salad green, spring tonic, diarrhea remedy, weak diuretic (to help eliminate water from the body), and as a soothing agent for sore noses. In Turkey, it is used to treat anemia and to increase appetite. Sorrel is one of the main ingredients in the combination herbal cancer remedy Essiac? and in the European combination herbal sinus remedy Sinupret?. There are no well-conducted published studies that demonstrate sorrel to possess activity against bacteria that cause infections in humans.
Avoid if allergic to sorrel or any member of the Rumex acetosa genus or Polygonaceae plant families. Avoid large doses of sorrel because there have been reports of toxicity and death, possibly caused by oxalate found in sorrel. Fatal oxalic acid poisoning has been reported from sorrel soup. Be aware that many tinctures contain high levels of alcohol and should be avoided when driving or operating heavy machinery. These sorrel formulations may cause nausea or vomiting when taken with the prescription drugs metronidazole (Flagyl?) or disulfiram (Antabuse?). Avoid if pregnant or breastfeeding.
Tea tree oil: The tea tree (Melaleuca alternifolia) is a small tree with narrow, soft, alternate leaves and yellowish flowers the shape of bottlebrushes. It is one of more than 30 species of paperbark trees that are found throughout Australia. Tea tree oil is obtained by steam distillation of the leaves of the tea tree.Laboratory studies report that tea tree oil has activity against methicillin-resistant Staphylococcus aureus (MRSA). It has been proposed that using tea tree oil ointment in the nose plus a tea tree body wash may treat colonization by MRSA. However, there is currently not enough information from studies in humans to make recommendations for or against this use of tea tree oil.
Avoid use if allergic to tea tree oil or plants of the Myrtle (Myrtaceae) family, Balsam of Peru, or banzoin. Use cautiously with a history of eczema. Avoid taking tea tree oil by mouth because reports of toxicity have been reported. Avoid if pregnant or breastfeeding.
Fair negative scientific evidence:
Macrobiotic diet: Macrobiotics is a popular approach to diet that stresses vegetarianism and consumption of whole, healthy foods. Proponents of macrobiotics advocate a flexible approach that allows supplementation with dairy, fish, or other supplements as needed on an individual basis. A macrobiotic diet has been advocated to preserve intestinal health. However, it apparently does not reduce incidence of drug-resistant bacteria in the intestinal flora, nor infections caused by resistant strains in the gastrointestinal tract, compared to a diet with animal products
There is a risk of nutrition deficiencies. However, this can be avoided with appropriate menu planning. Use cautiously with cancer or other medical conditions without expert planning or supplementation. The macrobiotic diet is not recommended in children or adolescents without professional guidance or appropriate supplementation. Not recommended in pregnant or lactating women due to potential deficiencies, unless properly supplemented.
Probiotics: Probiotics are beneficial bacteria that are sometimes called friendly germs. They help maintain a healthy intestine and aid in digestion. They also help keep harmful bacteria and yeasts in the gut under control. Most probiotics come from food sources, especially cultured milk products. Probiotics can be taken as capsules, tablets, beverages, powders, yogurts, and other foods. Passage of bacteria from the gut to other areas of the body where they can cause disease (bacterial translocation) is of special concern in surgery. Limited evidence suggests that supplementation with probiotics may not reduce this problem. Probiotics are generally considered safe and well tolerated. Avoid if allergic or hypersensitive to probiotics. Use cautiously if lactose intolerant.

Prevention

Although many other diseases (for example, chickenpox) leave a person immune to further episodes of the disease, people who survive a tetanus infection are not immune to tetanus. Thus, the full series of vaccinations must be given after the person recovers. A full series of vaccinations includes the initial vaccination and boosters.
Vaccination: Tetanus toxoid (TT) vaccine protects against tetanus, but is rarely used now. TT vaccine protects only against tetanus and neonatal tetanus. Td, or tetanus-diphtheria toxoids adult dose vaccine, is the same vaccine as DT (diptheria/tetanus), but with a lower diphtheria toxoid dose. It is suitable for children older than six years old and adults, including pregnant women. Td has the added advantage of protecting against diphtheria and tetanus.
When given to women of childbearing age, vaccines that contain tetanus toxoid (TT or Td) not only protect women against tetanus, but also prevent neonatal tetanus in their newborn infants. When TT or Td vaccine is given to a woman who is or who becomes pregnant, the antibodies that form in her body are passed to her fetus. These antibodies protect the baby against tetanus during birth and for a few months afterwards. They also protect the woman against tetanus.
A three-dose course of TT or Td provides protection against maternal and neonatal tetanus for at least five years. A maximum of five doses will protect women throughout their childbearing years. Adults should continue to receive a booster dose of Td every 10 years.
Children: The best way to prevent tetanus is with the tetanus toxoid vaccine, which doctors often give in combination with vaccines against two other serious diseases, diphtheria and pertussis (whooping cough). This three-in-one combination is known as the DTaP vaccine. It is a newer and safer version of the DTP vaccine, which is no longer used in the United States. Doctors recommend beginning DTaP vaccination during infancy. The vaccine consists of a series of five shots typically administered in the arm and given to children at these ages: two months; four months; six months; 12-18 months; and four to six years. It takes at least three shots of the pertussis vaccine to fully protect a child against tetanus, but a total of five shots are recommended by age six.
Because immunity from the tetanus vaccine tends to wane by age 11, doctors recommend a booster shot for those in this age group (the tetanus, diphtheria and pertussis vaccine, or Tdap. DTaP is the name of the pediatric vaccine; Tdap is the name of the booster for people 11 years of age and older. The booster is given preferably at ages 11-12. This is in place of the traditional tetanus and diphtheria (Td) vaccine received at this age.
Adults: The U.S. Centers for Disease Control and Prevention's (CDC's) Advisory Committee on Immunization Practices also advises adults to receive a Tdap booster shot every 10 years instead of the Td booster shot. The Tdap vaccine helps protect adults from tetanus. Adults who are or will be in close contact with infants under 12 months of age should also receive the vaccine. Side effects of the vaccine may include fever, crankiness, vomiting, or soreness at the site of the injection. These problems are more likely to occur after the fourth or fifth dose of the DTaP series than after earlier doses. After late doses, some children may develop injection site irritations such as swelling or localized redness of the arm or leg in which the shot was given. In rare cases, severe side effects may occur, including: serious allergic reactions, in which hives or a rash develop within minutes of the injection; high fever, greater than 105 degrees Fahrenheit; and seizures, shock, or coma. Immediate medical attention is necessary.
Some individuals are concerned that the vaccine may cause neurological (nerve) damage. Even though some children have developed brain damage after the immunizations, researchers have not found a definitive link between the vaccine and brain damage. Still, research into this issue is ongoing. Children with known seizure or brain disorders may not be candidates for the DTaP vaccine.
Other vaccines: In 2002, the U.S. Food and Drug Administration (FDA) approved a combination tetanus vaccine called Pediarix?. In addition to helping protect against tetanus, diphtheria and pertussis, Pediarix? immunizes children against polio and hepatitis B (a serious viral liver infection). Because Pediarix? protects against five diseases, children need fewer shots. However, the vaccine also causes a wider range of side effects than does DTaP. In studies, the most common side effects of Pediarix? were pain, redness, and swelling where the shot was given, fever, and fussiness. A pediatrician will help parents choose the best vaccination for their child.

Author information

This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

Bibliography

American Academy of Pediatrics. .
Centers for Disease Control and Prevention. .
Mallick IH, Winslet MC. A review of the epidemiology, pathogenesis and management of tetanus. Int J Surg. 2004;2(2):109-12.
Middleton DB, Zimmerman RK, Mitchell KB. Vaccine schedules and procedures, 2007. J Fam Pract. 2007;56(2 Suppl Vaccines):S47-60, C4-8.
National Institute of Allergy and Infectious Diseases. .
Quinn HE, McIntyre PB. Tetanus in the elderly--An important preventable disease in Australia. Vaccine. 2007;25(7):1304-9.
Thwaites CL, Yen LM, Loan HT, et al. Magnesium sulphate for treatment of severe tetanus: a randomised controlled trial. Lancet. 2006;368(9545):1436-43.
World Health Organization. .
Zimmerman RK, Middleton DB, Burns IT, et al. Routine vaccines across the life span, 2007. J Fam Pract. 2007;56(2 Suppl Vaccines):S18-37, C1-3.

Causes

The cause of tetanus is the bacterium Clostridium tetani. The bacteria are found in two forms: as a spore (dormant) or as a vegetative cell (active). The spores are in soil, dust, and animal waste and can survive there for many years. These spores are resistant to extremes of temperature. Contamination of a wound with bacteria such as C. tetani is rather common. Tetanus, however, can only occur when the spores germinate and turn into the active form. The active cells release three toxins, and one of these toxins, tetanospasmin, is responsible for the disease.
The disease typically follows an acute injury that results in a break in the skin. Most cases result from a puncture wound, laceration (cut), or an abrasion (scrape). Other tetanus-prone injuries include frostbite, surgery, crush wounds (occur when heavy objects fall on a person), abscesses (pocket of puss), childbirth, and intravenous (IV) drug use (at the site of needle injection). Stepping on a nail accounts for 32% of the puncture wounds.
Wounds with devitalized (dead) tissue or foreign bodies (debris) in them are at highest risk for developing tetanus. This occurs mostly in individuals suffering from burns and crush wounds.
Tetanus may develop in people who are not immunized against it or in people who have failed to maintain adequate immunity with active booster doses of the vaccine.
The tetanus toxin affects the site of interaction between the nerve and the muscle that it stimulates. This region is called the neuromuscular junction. The tetanus toxin heightens the chemical signal from the nerve to the muscle causing the muscles to experientially tighten via continuous ("tetanic" or "tonic") contractions or spasms. The result is either localized or generalized muscle spasms.
Tetanus toxin can affect infants causing muscle spasms, seizures, and the inability to nurse. This typically occurs within the first two weeks of birth and is associated with poor sanitation methods in caring for the umbilical cord stump.

Risk factors

Race: Since 1998, the incidence of tetanus in the United States was highest among Latinos (0.38 cases per million population), followed by Caucasians (0.13 cases per million population), and then African Americans (0.12 cases per million population).
Sex: A difference in the levels of tetanus immunity exists between the sexes. In the United States from 1998-2000, the incidence of tetanus in males aged 59 years and younger was 2.8 times higher than in females in the same age range. In developing countries, women have an increased immunity where tetanus toxoid is administered to women of childbearing age to prevent neonatal tetanus.
Age: The incidence of tetanus increases with advancing age. In U.S. patients, 36% are older than 59 years and only 9% are younger than 20 years.