Tetanus is an uncommon disease in the United States but remains a major health problem worldwide and an important cause of infant mortality in developing countries.1 The institution of effective and widespread immunization programs for children and routine boosters in adults has resulted in a decline in the average annual incidence of tetanus in the United States from 0.39 per 100,000 persons in 1947 to the current annual incidence of 0.02 per 100,000. 2 Although tetanus is probably underreported in the United States,3 the incidence of the disease in this country remains considerably less than the global incidence of 18 per 100,000. 1 In the United States, the majority of tetanus occurs in temperate areas, with the states of Texas, California, and Florida responsible for the greatest number of reported cases (34, 20, and 13, respectively).4 The overall case-fatality rate for tetanus in the United States is about 11 percent where the outcome is known, 2.3 percent among those aged 20 to 39 years; 16 percent among those aged 40 to 59, and 18 percent among those aged 60 years or older.4 From 1995 to 1997, among the 124 cases reported in the United States, only 13 percent of patients had received a primary series of tetanus toxoid, and only half of those who sought medical care were given toxoid.4 Intravenous drug users, especially Hispanics in California, are at disproportionate risk of contracting the disease. 4
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