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Outbreak of tetanus among elderly women treated with sheep cell therapy.

Tetanus is a worldwide disease whose incidence is highest in developing countries. In most Western nations, however, the incidence is less than one case per million population per year [1]. About 60% of the cases occur in persons years [2]. In Argentina, a country with 34 million inhabitants, 10 to 67 cases have been reported yearly in the past decade [1]. We describe an outbreak of tetanus in a population of elderly patients who received sheep cell therapy in Buenos Aires, Argentina, between March and April 1996. On 14 March 1996, a 63-year-old Argentine woman complained to her relatives of muscle rigidity in her face and legs. She was treated at a medical center for symptoms of high blood pressure and contractures. The patient's condition gradually worsened, and on 18 March, when she became unable to walk, a diagnosis of tetanus was reached. She died 3 days later. On 22 March, a 54year-old woman with a clinical diagnosis of tetanus died, and six other women with tetanus were admitted to infectious disease services in two hospitals in the province of Buenos Aires. The following week, four more patients with clinical diagnoses of tetanus were admitted to these hospitals. Of these 12 women, seven subsequently died. All patients developed the severe generalized type of tetanus; no mild cases or the local or cephalic types of the disease were seen in this patient population. Interviews of the patients and their relatives revealed that all had received intramuscular injections of fetal sheep cells as part of an alternative treatment for rheumatism and arthrosis between 8 and 14 days before the onset of symptoms (mean interval, 11 days). All patients had received cell therapy for several years at a single clinic in the province of Buenos Aires. A single pharmaceutical company was the source of the sheep cell preparations. Family members reported that the patients had not previously been vaccinated with tetanus toxoid. While most patients received the doses of cell therapy at the clinic, the possibility that needles or syringes were shared in the clinic or outside the facility was ruled out. The fetal sheep cells used by the patients were analyzed at three independent infectious disease centers. At the first center, gram staining for Clostridium tetani was not performed. At the second center, the samples were reanalyzed, and positive evidence of anaerobic organisms was found in one of the samples, although the presence of clostridia was not demonstrated. At the third center, rodents and rabbits were inoculated with this sample. These animals subsequently developed the clinical symptoms of tetanus. About one century has elapsed since the protein neurotoxins produced by clostridia were identified as the cause of the paralytic syndromes of tetanus and botulism [3]. Despite the availability of effective and inexpensive tetanus toxoid vaccines, cases of tetanus continue to occur in most countries. The cases described in this report are