Geographic Differences Among Tetanus Cases-United States, 2009-2023

Tetanus is a serious but rare noncommunicable disease, with the risk of tetanus exposure dependent on an individual's environment. In addition to pre-exposure vaccination against tetanus, key prevention measures after a wound include seeking prompt medical care and then receiving appropriate wound cleaning and care. Our objective was to identify potential geographic variation in tetanus occurrence based on proxy measures for differences in exposure and ability to access health care.

We evaluated tetanus incidence during 2009-2023 by jurisdiction and across different county-level characteristics using U.S. National Notifiable Diseases Surveillance System tetanus case data combined with population estimates, rural-urban classifications, and social vulnerability indices.

Jurisdiction-specific tetanus incidence ranged from 0 cases to 0.20 cases per 1 million person-years. Rural areas had higher tetanus incidence, even after accounting for social vulnerability indices. In crude analyses, increasing vulnerability with respect to socioeconomic status, per capita income, health insurance, mobile home residency, and medical comorbidities correlated with higher tetanus incidence. Once incidence was stratified by urbanicity, these trends largely disappeared. However, even after stratifying by urbanicity, tetanus incidence was still higher in rural areas as health insurance vulnerability increased.

Rurality and increased health insurance vulnerability were associated with higher tetanus incidence. Geographic differences in access to vaccination, environmental exposures, and timely and quality post-wound care may contribute to these differences. Barriers to tetanus vaccination and timely post-wound care, particularly in rural areas, could be explored in future work.