Need a pep talk please - tetanus - Page 2 - Mothering Forums
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#31 of 41 Old 01-20-2008, 09:31 PM - Thread Starter
 
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Originally Posted by Gitti View Post
How is your son doing?
Fine thanks! Sorry, we have been away for 4 days. The wound has remained clean and did not get infected. It was not what I would call a deep wound (maybe one millimetre?), but more like a clean slice, so a little more than a scratch. It had sealed up by the end of the day and was clean and just a light red line remains. I think what concerned me more and made me (and others think of tetanus) was the "rusty and metal" bit of the injury yet it seems this is not adding any more tetanus risk than say a stick protruding from the ground that may cause a deep scratch which I can't imagine many people would think of going off to get a jab for (thinking adults here since most I know do vaccinate their kids yet I don't know of adults getting a booster unless they get a puncture wound that requires medical attention)?). FWIW, the "thing" was not buried in the ground, had been tossed on the surface into long grass (which had been cut short not long ago, so no idea how it got there) - so yes it was old and quite likely containing spores anyway, but was not dirt covered).

Thanks for the discussion all.

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#32 of 41 Old 01-20-2008, 11:39 PM
 
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Originally Posted by dymanic View Post
Here's an interesting tidbit:
Only 4 of 520 persons dying from tetanus (0.7%) had a history of at least 3 TT doses
http://cdc.confex.com/cdc/nic2005/te...paper_7813.htm
Hmm...so, the elderly, who we already know to be at a higher risk, happened to not be vaxed...and were more likely to die. I really don't see anything to that argument.
520 people died in 29 years? I don't see how that's "severe and often fatal." 500 people die every year from listeria and most people have never heard of it!
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#33 of 41 Old 01-21-2008, 02:10 AM
 
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No, I don't. It's pretty clear from the statistics that vax status is the most significant factor as far as incidence is concerned, and coverage among the elderly is poorer than in other groups.
I don't doubt that vax status plays a part.

But why again is it that diabetics are more tetanus prone than other people?

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By itself, poor circulation doesn't lead to wounds, lingering or otherwise.
What causes "diabetic foot"?
BTW..I'm looking for tetanus epidemiology in unvaccinated populations or the prevaccine era.
Surely someone somewhere at some time has done that. If the incidence in kids was/is higher than in the elderly there, then you're (probably) right. If the incidence was/is higher in the elderly, then I'm (probably) right.

Agreed?
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#34 of 41 Old 01-21-2008, 02:12 AM
 
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Originally Posted by mamakay View Post
3 dose DTaP coverage hangs out aroud 95%
http://www.cdc.gov/vaccines/pubs/pin...G/coverage.pdf

2,000 unvaxed kids a year under 1 each year...

Till age 4 will be 8,000...

At age 8, that would be 16,000 if they remain unvaxed...some will vax for school, though, leaving the religious/philo exemptors.

Either way, I wouldn't say unvaxed kids parctically don't exist.
I think I did my math wrong there....

With a 4 million birth cohort...how many kids is 5% of that (for one year)?
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#35 of 41 Old 01-21-2008, 03:29 AM
 
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Originally Posted by nathansmum View Post
The wound has remained clean and did not get infected. It was not what I would call a deep wound (maybe one millimetre?), but more like a clean slice, so a little more than a scratch. It had sealed up by the end of the day and was clean and just a light red line remains.
Sure doesn't sound like the sort of wound that generally raises a lot of concern about tetanus... I mean, a millimeter? Heck, before you know it, that guy's going to be doing jumps off the shed roof with his skateboard. You're gonna need a lot more pep-talking then.

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Originally Posted by Irishcupcake
so, the elderly, who we already know to be at a higher risk, happened to not be vaxed...and were more likely to die. I really don't see anything to that argument.
Not sure that really is an argument. It's a simple observation. The argument (which you seem to have overlooked) is that the elderly are at higher risk because they are less likely to be vaxed.

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520 people died in 29 years? I don't see how that's "severe and often fatal."
In this context, "severe and often fatal" refers to the clinical course of infection, not the likelihood of becoming infected in the first place. The case fatality rate for tetanus in the U.S. these days is about 11%. During 1998-2000, it was 18%. Don't know if you'd call that "severe"; some would. In Turkey, it's closer to 60%, which puts it in the same neighborhood as the CFR for ebola in Sudan.

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500 people die every year from listeria and most people have never heard of it!
Just out of curiosity, how many people have to die each year from something before you'd consider it reasonable to use phraseology like "severe and often fatal"? Do you consider lysteria to meet the requirement?

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Originally Posted by mamakay
But why again is it that diabetics are more tetanus prone than other people?
Because it can fulfill the bacteria's first requirement by providing an opening. Everybody else has to get unlucky enough to get poked with something -- but that can happen to a diabetic, too, so they face the same risk as everybody else PLUS the extra risk produced by their disease. We covered this.

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What causes "diabetic foot"?
Poor circulation. But you can't extrapolate poor circulation in diabetics to poor circulation in non-diabetics. I mean, there's poor circulation and then there's poor circulation. Lots of people with "poor circulation" don't develop open sores as a result. No opening, no tetanus.

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I'm looking for tetanus epidemiology in unvaccinated populations or the prevaccine era.
I haven't found anything that shows age-specific incidence in the pre-vaccination era either; but, yes, I'm willing to predict that if we find it, we'll see that incidence among children was higher then.

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With a 4 million birth cohort...how many kids is 5% of that (for one year)?
I think it ends up being a semantic quibble over the definition of "practically".
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#36 of 41 Old 01-21-2008, 04:20 AM
 
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Originally Posted by dymanic
Poor circulation. But you can't extrapolate poor circulation in diabetics to poor circulation in non-diabetics.
But you can extrapolate this one increased risk of poor circulation in diabetics to poor circulation in the elderly.
Or rather, it seems appropriate to me.

What about poor circulation in the elderly doesn't put them at an increased tetanus risk compared to diabetics?
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Lots of people with "poor circulation" don't develop open sores as a result.
Yes, lots of elderly people and diabetics don't develop tetanus.
I'm not sure what your point is there, though....

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I haven't found anything that shows age-specific incidence in the pre-vaccination era either; but, yes, I'm willing to predict that if we find it, we'll see that incidence among children was higher then
That the incidence in children was higher than it was in the elderly?
I'm not sure we're discussing the same thing, always, dymanic.
When I said:

Quote:
Originally Posted by me
If the incidence in kids was/is higher than in the elderly there, then you're (probably) right. If the incidence was/is higher in the elderly, then I'm (probably) right.
..I was saying that I think that simply being physiologically older puts one at an increased risk of developing tetanus, irrespective of vaccination status. I do think the vaccine is effective, also, and I agree that older folks might have never been vaccinated. But I think poor circulation adds an additional risk (along with declining immune system functioning) to that age group.
Are we arguing about the same thing, or do I need to back up more and explain my position further?

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I think it ends up being a semantic quibble over the definition of "practically".
How many is it that don't (practically or otherwise) exist?
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#37 of 41 Old 01-21-2008, 01:05 PM
 
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Originally Posted by mamakay View Post
But you can extrapolate this one increased risk of poor circulation in diabetics to poor circulation in the elderly.
Sure. You can treat "poor circulation" as a gradient, with the most severe vascular complications of diabetes at the far end. But starting from "normal circulation" and moving toward that far end, you cross a binary threshold: the point at which it begins to result in open sores. Whatever decrease in circulation exists below that threshold can be ignored as far as tetanus incidence is concerned, because it isn't going to impact that directly. If you want to talk about indirectly, then fine, but it's going to get hairy. You're going to be talking about increased risk for accidents, and diabetes (as well as plain old age itself) can impact that in lots of ways: poorer vision, poorer sense of balance...

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Yes, lots of elderly people and diabetics don't develop tetanus.
Right. They don't develop open sores or get poked with anything.

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That the incidence in children was higher than it was in the elderly?
Demography is a science in itself. In considering the risk factors for tetanus, you might begin with vax status, or you might begin by considering the risk factors for certain types of injury -- but you can't ignore either one, no matter where you start. Are children and the elderly equally at risk for puncture wounds or deep lacerations? I don't feel qualified to answer that, but I'd be willing to guess that they're not.

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But I think poor circulation adds an additional risk (along with declining immune system functioning) to that age group.
Immune function as it relates to tetanus infection is a bit of a special case. As with any infectious disease, immune response does not take place until the pathogen has proliferated enough to become visible to the immune system. With tetanus, the problem is that one of the toxins produced by the bacterium is lethal to humans in doses as small as 2.5 nanograms per kilogram of body weight, and is produced (in vitro) in amounts up to 5 to 10% of the bacterial weight. For this reason, previous infection is not associated with immunity to the disease; if the illness progresses far enough to trigger an immune response, it kills you.

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How many is it that don't (practically or otherwise) exist?
Okay, OKAY. Sheesh. I noticed your math error when you first put it up, and roughly calculated that I had used "practically nonexistent" to refer to maybe several million kids. That goes beyond what I'd accept as hyperbole, but rather than retract, I chose to let your math error stand. I might be able to justify a thing like that if it were somebody else, but you deserve better (after all, you have dutifully pointed out every single error you've ever caught me making, as far as I can tell, and I owe it to you to reciprocate). I wish I had a more dignified way out of it, but I don't see any choice but to apologize for my crime of omission and retract my "practically nonexistent". It was a poor choice of words, and I give up on trying to defend it. I don't know precisely how many U.S. children are unvaccinated against tetanus. I think there's about eighty million kids altogether, so if it's five percent, that would be roughly four million. I can't stretch "practically nonexistent" to fit around that.
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#38 of 41 Old 01-21-2008, 04:56 PM
 
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Immune function as it relates to tetanus infection is a bit of a special case. As with any infectious disease, immune response does not take place until the pathogen has proliferated enough to become visible to the immune system
Humoral immune response.

The immune system just clears a lot of stuff out (I think maybe through the lymphatic ststem) as "gunk", too. What all is going on there is getting into the mysterious netherworlds of immunology, though. But we encounter and process all kinds "stuff" that we never develop a humoral memory for. Tetanus spores are certainly among them.
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For this reason, previous infection is not associated with immunity to the disease; if the illness progresses far enough to trigger an immune response, it kills you.
That might or might not be true. Antibodies to tetanus toxin have been found in unvaccinated people, with an increasing incidence of seropositivity with increasing age.
Also, google "subacute tetanus".

Not that I'm personally "banking on" any of that...but it's all probably a bit more compliated than generally thought.
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#39 of 41 Old 01-21-2008, 07:56 PM
 
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Originally Posted by mamakay View Post
Antibodies to tetanus toxin have been found in unvaccinated people, with an increasing incidence of seropositivity with increasing age.
I don't know all of the original sources for that, but at least some appear to have problems with things like the stringency of the assay methods or the accuracy with which immunization histories were determined. As for seropositivity increasing in correlation with age, it looks like some studies reached the opposite conclusion:

"If natural immunity is of epidemiological significance in developing countries, then the percentage of immune persons should increase with age. This is not the case (Misra & Rao 1988, Ray et al. 1978). The data for healthy unimmunized persons do not show a clear dependency between age and the presence of tetanus antibodies (Metzkin & Regev 1985)."
http://pendellmedical.com/pdf/IBMod3e.pdf

"Studies in African schoolchildren (Rey, 1981), Indian military recruits (Menon et al. 1976), persons taking care of horses (Lahiri, 1939), pregnant women in New Guinea (MacLennan et al. 1965), and healthy persons in Upper Volta (Breman et al. 1981), have demonstrated that populations in developing countries with a high level of exposure to tetanus spores usually lack tetanus neutralizing antitoxins. Even if asymptomatic colonization and infection of the intestine with tetanus organisms occurs in some areas of the developing world, natural immunity is not thought to have any practical importance in controlling tetanus."
http://www.who.int/vaccines-documents/DocsPDF07/869.pdf


Another of the weird things about tetanus is that there is no laboratory procedure for confirming infection; diagnosis is strictly clinical. The bacterium is recovered from the wound in only 30% of cases, and can also be isolated from patients who do not have the disease.
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#40 of 41 Old 01-21-2008, 10:18 PM
 
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The data for healthy unimmunized persons do not show a clear dependency between age and the presence of tetanus antibodies (Metzkin & Regev 1985)."
http://pendellmedical.com/pdf/IBMod3e.pdf
I'm not sure what the WHO guys are talking about there...
Here' the study mentioned:

http://www.pubmedcentral.nih.gov/pic...8&blobtype=pdf

Quote:
Naturally Acquired Immunity to Tetanus Toxin in an Isolated
Community
HAIM MATZKINt* AND SHARON REGEV
Quote:
In Ethiopia, health services are
notoriously poor. It has been estimated that there is about
one physician per 100,000 people. The very small ancient
Jewish community in Ethiopia has suffered from prolonged
persecution and cultural isolation. This community has been
deprived of the poor health services in the country, and
according to our information, none of the subjects included
in our study had ever been attended by a physician, let alone
received any injections during their lifetimes
.
[
Quote:
Although only 30% exhibited more than the accepted
protective titer of 0.01 IU/ml (7), the percentage of those
considered protected was age dependent, increasing substantially
from 10% in the first decade to an average of 29% in the
11- to 60-year-old group to 63% in the group over 60 years of
age.
Natural immunity to tetanus is gained, as in many other
diseases, through adequate, repeated, and prolonged antigenic
stimulation that sensitizes the immune system. The
opportunities for achieving immunity increase with age, and
this is well reflected in our data
.
So that's supposed to be a study reaching the opposite conclusion?

Here's another...

http://www.ncbi.nlm.nih.gov/pubmed/6...t=AbstractPlus
Quote:
Among 48 adults without a history of tetanus immunization, we found with the aid of indirect hemagglutination test 20 individuals with protective tetanus antibody titers, 23 with low levels of antitoxin (under 0,1 I.U./ml) and 5 devoid of tetanus antitoxin. In two blood samples of 99 unvaccinated children under 3 years of age (taken at 7 months intervall) 12,1% showed tetanus antitoxin in the first serum sample and 16,2% in the second sample. Protective antibody titers could be found only in 4 children in each of the first and second serum sample. The data suggest a silent oral immunization by tetanus bacilli thus boosting under unhygienic conditions the tetanus immunity with advancing age.
I wonder if anyone's ever looked to see if folks are ever immune to the actual bacteria. Not just the toxin, but the actual bacterial antigens...
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#41 of 41 Old 01-22-2008, 05:14 AM
 
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I'm not sure what the WHO guys are talking about there...
I'm a little fuzzy on that too, but I doubt it was a typo. I can't access the first two studies, so I don't know what the specifics of those were. I might try to sell you the possibility that they didn't show increasing seropositivity with advancing age, and that the Metzkin & Regev study was tacked on for balance, but I don't see myself being able to muster enough enthusiasm to be very convincing. The authors of the WHO article express concerns about some of the assay methodology used, indirect (or "passive") hemagglutination in particular, and they also take a quite reserved approach where the implications on immunity are concerned even when antibodies are detected, especially at very low titers.

They state with some confidence: "A small amount of tetanus toxin, although enough to cause the disease, is insufficient to stimulate antibody production". I'm looking for some further reading on that. It seems like it would be simple enough to test for antibodies following infection, and it's bound to have been done jillions of times, but I browsed through their entire reference list, and if there's a study that used immunocompetent humans, I missed it. Are they extrapolating that from vaccine studies?

Quote:
I wonder if anyone's ever looked to see if folks are ever immune to the actual bacteria. Not just the toxin, but the actual bacterial antigens...
Considering how little bacteria it takes to produce a lethal dose of toxin, it doesn't seem likely, but maybe, I guess.
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