Global, regional, and national burden of tetanus in 204 countries and territories, 1990–2023: a systematic analysis for the Global Burden of Disease Study 2023

Background: Tetanus is a life-threatening, vaccine-preventable disease. Its incidence decreased substantially following global initiatives such as the Expanded Programme on Immunization (EPI) and Maternal and Neonatal Tetanus Elimination (MNTE). Despite these efforts, tetanus elimination has not been achieved, and significant disparities in morbidity and mortality persist across various regions. Therefore, we sought to investigate the global, regional, and national burden of tetanus from 1990 to 2023, using data from the Global Burden of Disease Study (GBD) 2023. Methods: We estimated the global burden of tetanus across 204 countries and territories, seven GBD super-regions, and 21 GBD regions from 1990 to 2023. For investigation, tetanus was defined based on International Classification of Diseases (ICD)-10 codes A33-A35.0 and Z23.5 and ICD-9 codes 037-037.9, 771.3, and V03.7. The tetanus case fatality rate (CFR) was defined as the ratio of fatal tetanus cases to the total number of tetanus cases within a given sample. Incidence and prevalence of tetanus were estimated by linking cause-specific mortality estimates with modeled CFRs and disease-duration assumptions. Disease burden was quantified using age-standardized prevalence, incidence, disability-adjusted life years (DALYs), and mortality rates per 100,000 population, along with corresponding 95% uncertainty intervals (UIs) and total percent change over the study period. Estimates were stratified by age group, sex, and Socio-demographic Index (SDI) across countries and regions. Findings: Global age-standardized incidence rate of tetanus significantly decreased from 11.32 (95% UI, 7.98-16.36) per 100,000 population in 1990 to 0.70 (0.40-1.22) in 2023, representing a 93.8% decrease. The global age-standardized DALY rate also declined by 95.37% between 1990 and 2023. In 2023, the highest age-standardized DALY burden was estimated in sub-Saharan Africa (46.07 [95% UI, 25.71-77.17] per 100,000 population) and South Asia (20.47 [11.99-32.50]), whereas Southeast Asia had the highest age-standardized prevalence and incidence rates. In contrast, high-income regions and Central Europe, Eastern Europe, and Central Asia had the lowest burden of tetanus in 2023, with near-zero incidence and mortality. Tetanus burden showed a strong inverse association with SDI across all epidemiological measures. At the national level, Somalia, the Lao People's Democratic Republic, and Chad had the highest age-standardized DALY rates. Pronounced age- and sex-specific patterns were observed, with the highest rates concentrated among neonates younger than 28 days and generally higher rates in males than in females across most age groups. Although absolute rates declined over time, these demographic inequities persisted. Interpretation: Over the past three decades, global initiatives such as the EPI and MNTE have led to a substantial reduction in the burden of tetanus, bringing it to very low levels in high-income and high SDI countries and territories. Nevertheless, tetanus continues to impose a considerable burden in several regions, particularly in South Asia and sub-Saharan Africa. Because tetanus is a vaccine-preventable infection, the remaining burden and persistent inequities are largely avoidable and should be prioritized in immunization policy. Funding: Gates Foundation.