Tetanus is making a comeback. There’s an easy way to fight back.

In the classic tale of tetanus, a farmworker steps on an old barn nail and develops the bacterial disease. Most Americans don’t work on farms these days, so it’s easy for people to dismiss the illness as something they’re unlikely to encounter. In reality, this serious microbial infection can impact anyone anywhere, and more Americans are succumbing.

Some 38 people came down with tetanus in 2025, the highest number in nearly 20 years. Experts blame declining vaccination rates and worry that case numbers will keep rising in the coming years if fewer people get the recommended shots.

“These cases, while rare, are very troubling, because tetanus is totally preventable,” says Larry Madoff, an infectious disease physician at the Center on Emerging Infectious Diseases at Boston University. Madoff’s center first pointed to the concerning trend in a report published online late last year.

A serious neurological disease

Tetanus is caused by the Clostridium tetani bacteria, which are abundant in soil and typically enters the body through wounds that break skin. The bacteria flourish in areas without oxygen, which is why deep cuts are especially prime.

Once inside this environment, spores multiply rapidly. Within weeks, they emit a potent toxin, tetanosmasmin, that prevents the body’s nervous system from functioning normally. Painful muscle contractions and stiffness, including the disease’s signature lockjaw, soon appear. Other serious complications include pneumonia, kidney damage, and blood clots in the lungs.

The disease was once widespread in the U.S.—and not because more people had barns. It was the development and deployment of a highly effective vaccine in the 1930s that plunged annual cases, which fell from roughly 600 Americans in the 1940s to 17 in 2020. Mortality also dropped, by a whopping 99 percent, following the vaccine’s introduction.

“Americans forget how serious these infections are,” because we no longer see so many people around us developing them, says Kristin Moffitt, a pediatric infectious disease doctor at Boston’s Children Hospital. But globally, the disease still kills 50,000 people a year.

In the U.S., tetanus kills roughly 12 percent of people who come down with it, according to an analysis in April of a recent 15-year period by the U.S. Centers for Disease Control and Prevention (CDC). Most deaths happen in people over 70, as well as in infants. Another analysis published last year in the International Journal of Infectious Diseases found people with diabetes and heart disease also face a high risk of serious complications.

Once the toxin takes hold, there is no cure. Doctors administer antibiotics and other drugs to help neutralize the poison, surgically clear the wound that harbors the bacteria, and control muscle spasms with medication. Because nerve damage in the throat is common, about half of hospitalized patients need breathing tubes.

These treatments aim to keep the person alive until the immune system clears the toxins from the body, a process that takes weeks, Madoff says.

Any deep wound can be a conduit

Because C. tetani bacteria are widespread across the U.S., it’s surprisingly easy to come in contact with spores. A few years ago, scientists tested the soil, dog feces, and rusted metal and concrete in the county around Miami, Florida. They found the bacteria in 18 percent of samples, with aging signs, railings, and walkways at a large university containing the highest amounts. While we often associate rusty objects with tetanus, the risk comes from how long an object has been exposed to the environment rather than the rust itself.

On the surface of the skin, the bacteria are not dangerous. But anyone who gets a penetrating wound, such as from dog bites, cuts from sharp objects, car accidents, and even deep splinters can contract the disease. Items that have been outside for a while, such as the stereotypical rusty nail, are especially likely to contain the germs.

“If you step on any object that’s been in the environment that pierces the skin, or if you have an open puncture and are walking outside barefoot where the bacteria can get deep inside, you are at risk,” Moffitt says.

Fortunately, unlike with highly contagious diseases like measles, tetanus does not spread from one infected person to another.

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The Boston University report details some cautionary cases. One teenager in Kansas spent 40 days in intensive care after the bacteria infected his injured foot, and a Nevada woman who had only a minor cut in her leg battled the disease in the hospital for a week.

The long hospital stays that often come with a tetanus infection can be pricey, the report notes. The parents of a young Oregon boy with the disease faced medical bills totaling almost a million dollars.

Prevent tetanus by staying up on vaccines

What all of the patients described in the Boston University report have in common is they were not up to date on the recommended tetanus vaccinations.

That was also the case for several infections in children reported in April by the CDC. Two of the children had sought medical care for their wounds, but their parents declined the offered vaccinations, which would have protected them. Both later developed tetanus, as did two other unvaccinated youth whose wounds were so minor they did not even see a healthcare provider. All of the children were hospitalized with tetanus; fortunately, none died.

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In the U.S., tetanus shots are given in one of three combinations—DTap, Tdap, or Td. Infants and children younger than seven receive a five-dose series of the DTaP vaccine, which also protects against diphtheria and pertussis (better known as whooping cough), according to the CDC. The T in the vaccine provides the tetanus protection.

Around age 11, children need a single booster with a similar shot called Tdap, containing slightly lower doses of the diphtheria and pertussis components.

Every subsequent 10 years thereafter, adults need a booster dose of tetanus to maintain protection. This can be provided with a Td vaccine or via a Tdap booster (which adds pertussis protection). The latter shot is sometimes called the “grandparent’s vaccine” because people who spend time around infants often get it to better protect newborns who aren’t yet eligible.  Pregnant women are also urged to get Tdap early in the third trimester.

Vaccine hesitancy may continue eroding protection

Around the country, rates of these immunizations are dropping, especially for younger children. The number of kindergarteners who have received the full DTap series is now 92 percent, down from 95 percent a decade earlier, according to the CDC. Throughout the U.S., some 70 percent of counties have students who are not up to date on their shots, according to an analysis by Stanford University and NBC News published last year.

One state, Florida, has only 89 percent coverage, according to the Boston University report. Should the downward trend continue, coverage in the state will dip to 85 percent in a few years, leaving 15 percent of children unprotected against tetanus and other severe diseases.

Tetanus vaccines have a long, well-documented safety records. Numerous studies show the Tdap vaccine is safe for all ages. A report published last month by the University of Minnesota’s Vaccine Integrity Project reaffirmed its safety for pregnant women and their babies.

After carefully evaluating 91 observational studies and randomized trials, “we don’t see a meaningful increase in any important adverse events” to either the mother or the baby, says Emily Senerth, a public health expert who led the research.

In all its iterations, tetanus vaccines have “one of the longest safety and efficacy track records in all of U.S. vaccination history,” Moffitt says.

Madoff laments the rising skepticism of such a valuable vaccine. He recalls how early in his medical education he worked in a hospital in India. There were so many tetanus patients there, they had their own dedicated ward.

“The memory of that gives me fuel to advise people to get the vaccine,” Madoff says. “That’s a whole lot better than getting tetanus.”