Notes from the Field: Tetanus Cases After Voluntary Medical Male Circumcision for HIV Prevention — Eastern and Southern Africa, 2012–2015

Jonathan M. Grund, MA, MPH1; Carlos Toledo, PhD1; Stephanie M. Davis, MD1; Renee Ridzon, MD2; Edna Moturi, MBChB3; Heather Scobie, PhD3; Boubker Naouri, MD3; Jason B. Reed, MD4; Emmanuel Njeuhmeli, MD5; Anne G. Thomas, PhD6; Francis Ndwiga Benson, MSc, MBA7; Martin W. Sirengo, MBChB7; Leon Ngeruka Muyenzi, MD8; Gissenge J.I. Lija, MD9; John H. Rogers, PhD10; Salli Mwanasalli, DDS10; Elijah Odoyo-June, MBChB, PhD11; Nafuna Wamai, MD12; Geoffrey Kabuye, MD12; James Exnobert Zulu13; Jane Ruth Aceng, MBChB14; Naomi Bock, MD1 (View author affiliations)

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Voluntary medical male circumcision (VMMC) decreases the risk for female-to-male HIV transmission by approximately 60% (1), and the President’s Emergency Plan for AIDS Relief (PEPFAR) is supporting the scale-up of VMMC for adolescent and adult males in countries with high prevalence of human immunodeficiency virus (HIV) and low coverage of male circumcision (2). As of September 2015, PEPFAR has supported approximately 8.9 million VMMCs (3).

During April 2012–November 2015, PEPFAR’s VMMC program reported 12 tetanus cases in five sub-Saharan African countries. Three cases occurred in 2012–2013 (one in Uganda and two in Zambia), six in 2014 (one each in Kenya, Rwanda, and Tanzania and three in Uganda), and three in 2015 (one in Rwanda and two in Uganda). Eight patients received conventional VMMC surgery, and four received PrePex, a nonsurgical male circumcision device. No other VMMC-related tetanus cases had been previously reported. Intensified adverse event and death monitoring and reporting were instituted in July 2014 in all 14 PEPFAR-supported countries providing VMMC for HIV prevention.*

Detailed information was available for eight of the nine cases reported during 2014 and 2015. Based on a case definition established by the World Health Organization (WHO) (4), five of the eight cases were determined by clinical investigation to be causally associated with VMMC. The remaining three were classified as indeterminate because of inconsistent or insufficient data. The age range of patients was 11–47 years. Each patient was deemed eligible for VMMC through preoperative screening and physical examination, and received counseling on postoperative wound care. Among the six causally associated cases in 2014 and 2015, at least three patients (in Kenya, Tanzania, and Uganda) reportedly had applied traditional remedies to aid healing; these remedies might have contained substances contaminated with spores of Clostridium tetani, the causative agent of tetanus.

Six of the nine total cases from 2014 and 2015 were fatal within 12–35 days of circumcision (case fatality ratio = 66.7%). A previous study of tetanus among 154 adolescents and adults at a rural Ugandan hospital reported an in-hospital case fatality ratio of 42.1% among persons aged 14–45 years (5), although this is likely an underestimate because it does not account for deaths following hospital discharge. Several factors, including delays in seeking medical attention, access to tetanus immune globulin, and quality of supportive care, can affect survival.

WHO recommends a 3-dose infant primary series of tetanus vaccination administered as diphtheria-tetanus-pertussis vaccine and, because tetanus immunity wanes over time, 3 booster doses through adolescence and young adulthood (6). However, in most African countries, tetanus vaccination coverage among infants is suboptimal (7), and booster doses required for long-term immunity are predominantly provided for young women as part of maternal and neonatal tetanus elimination programs. As a result, a low proportion of males in the age groups seeking circumcision would be expected to be immune to tetanus.

PEPFAR is working with implementing partners and ministries of health to strengthen national surveillance systems for VMMC-related adverse events, bolster the rapid investigation of reported adverse events, and support the implementation of tetanus mitigation strategies in accordance with WHO tetanus prevention recommendations for VMMC programs, including clean wound care for VMMC clients (4). Despite these 12 reported events, VMMC is safe; <2% of VMMC clients experience moderate or severe adverse events (2). As VMMC scale-up continues, sensitive surveillance systems are needed to monitor all adverse events, including rare events.


Catey Laube, Office of the US Global AIDS Coordinator, Washington, DC; Daimon Simbeye, Division of Global HIV and TB (Tanzania), CDC; Stella T. Alamo, Joseph Lubwama, Steven Wiersma, Division of Global HIV and TB (Uganda), CDC; Omega Chituwo, Division of Global HIV and TB (Zambia), CDC.

Corresponding author: Jonathan M. Grund,, 404-639-8978.

1Division of Global HIV and TB, CDC; 2Independent Consultant, Boston, Massachusetts; 3Global Immunization Division, CDC; 4Office of the U.S. Global AIDS Coordinator, Washington, DC; 5U.S. Agency for International Development, Washington, DC; 6Naval Health Research Center, Department of Defense, San Diego, California; 7National AIDS and STI Control Programme, Ministry of Health, Nairobi, Kenya; 8Rwanda Military Hospital, Ministry of Defence, Kigali, Rwanda; 9National AIDS Control Program, Ministry of Health and Social Welfare, Dar es Salaam, Tanzania; 10Division of Global HIV and TB (Tanzania), CDC; 11Division of Global HIV and TB (Kenya), CDC; 12Division of Global HIV and TB (Uganda), CDC; 13Ministry of Community Development, Mother and Child Health, Lusaka, Zambia; 14Uganda Ministry of Health, Kampala, Uganda.


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* Botswana, Ethiopia, Kenya, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, Swaziland, Tanzania, Uganda, Zambia, and Zimbabwe.

Suggested citation for this article: Grund JM, Toledo C, Davis SM, et al. Notes from the Field: Tetanus Cases After Voluntary Medical Male Circumcision for HIV Prevention — Eastern and Southern Africa, 2012–2015. MMWR Morb Mortal Wkly Rep 2016;65:36–37. DOI:

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