Tetanus in Serbia, 2015-2025: Epidemiological Overview and Lessons from Two Pediatric Cases

Tetanus is a vaccine-preventable disease that has become rare in countries with sustained immunization programs. However, unvaccinated children remain at risk of severe disease. We provide an epidemiological overview of tetanus in Serbia and describe two cases of generalized tetanus in children.

We retrospectively reviewed tetanus surveillance data and immunization coverage reports in Serbia for 2015-2025. Tetanus cases were recorded under ICD-10 code A35. We analyzed demographics, incidence, outcomes, case-fatality, and tetanus-containing vaccine coverage. Two pediatric cases were reviewed for clinical presentation, diagnostic challenges, management, and outcomes.

Fourteen tetanus cases were reported during 2015-2025 (annual incidence, 0-0.06 per 100,000 population), including two children. Most cases occurred among women aged >60 years; the overall case-fatality proportion was 42.9%. Primary vaccination coverage ranged from 90.8% to 95.1%, while recommended revaccination coverage remained below the 95% target. Both pediatric patients had received only BCG and hepatitis B vaccination at birth with no subsequent routine immunization due to parental neglect or refusal. The 18-month-old boy presented with fever, otorrhea, and recurrent episodes of generalized stiffening and was initially evaluated for meningoencephalitis. The emergence of trismus, opisthotonus, and neck muscle rigidity led to the diagnosis of tetanus. The 6-year-old boy presented with odynophagia and involuntary tongue biting, followed by progressive trismus and limb spasms. Tetanus was suspected based on the clinical findings and absent immunization. He developed respiratory failure and autonomic instability. Both patients recovered following tetanus immunoglobulin, antimicrobial therapy, and supportive care.

Although tetanus remains rare in Serbia and predominantly affects older adults, unvaccinated children remain at risk of severe disease. Atypical presentations may delay diagnosis, emphasizing the importance of early recognition and timely treatment. Maintaining high vaccination coverage and ensuring catch-up immunization remain essential for prevention.