It takes about 7 to 8 days for the tetanus bacteria to show effect. The following are some of the most common signs and symptoms of tetanus:

• Spasms accompanied by stiffness in muscle of jaw; hence known as “lockjaw”.
• Difficulty in swallowing due to muscle contractions and spasms.
• Stiffness in the muscles of the neck region.
• Severe painful body spasms.
• Individuals with tetanus may also experience, fever, rapid heart rate, high blood pressure and sweating.

• Fever

  Symptoms usually begin eight days after the infection, and include headache and muscular stiffness in the jaw, followed by stiffness of the neck, difficulty in swallowing, rigidity of abdominal muscles, spasms, sweating and fever. [wpro.who.int]

  Tetanus symptoms include: Headache Jaw cramping Sudden, involuntary muscle tightening – often in the stomach (muscle spasms) Painful muscle stiffness all over the body Trouble swallowing Jerking or staring (seizures) Fever and sweating High blood pressure [web.archive.org]

  Blood infection: These symptoms include fever, confusion, headaches, body aches and a general feeling of being unwell. Brain infection: These symptoms include fever, severe headaches, changes in behaviour, and a stiff neck and back. [immunize.ca]

  It causes sore throat, fever and chills. It can be complicated by breathing problems, heart failure and nerve damage. Diphtheria kills about one out of every 10 people who get the disease. [health.gov.on.ca]

  In the case of a more severe illness with a fever or any type of infection, wait until you get better before receiving this vaccine. It is not known whether Td vaccine will harm an unborn baby. [drugs.com]

• Chills

  […] infection, from time of exposure to appearance of the first symptoms, ranges from three days to three weeks. 4 Initial symptoms include muscular stiffness of the jaw and neck, headache, seizures, changes in heart rate and blood pressure, fever, and chills [nvic.org]

  Less common side effects include swollen lymph nodes, chills and sore joints. In some cases, the tetanus shot can cause a deep aching pain that begins between two days and four weeks after the tetanus shot, Drugs.com states. [livestrong.com]

  Photo Credit Dolly Faibyshev for The New York Times Work Out and Chill? Cool temperature workouts may be the answer for those who want to exercise without becoming a hot mess. [nytimes.com]

  Symptoms and course: Sore throat, slight fever and chills are early symptoms, appearing 2 to 4 days after exposure to diphtheria. Sometimes a thick coating occurs in the nose and back of the throat, making it hard to swallow or even breathe. [my.clevelandclinic.org]

• Low Fever

  They may include: Pain, swelling, or redness where the shot was given Low fever and chills Headache and body aches Feeling tired Upset stomach, throwing up, and diarrhea (watery poop) Not feeling hungry Fussing (in children) It’s very rare, but the DTaP [vaccines.gov]

  Those who do can have a low fever, cold-like symptoms, a pink or red rash, achy joints, and slightly swollen glands. How is it spread? Rubella is spread through coughing and sneezing. [immunize.ca]

• Pathologist

  The etiology of the disease was further elucidated in 1884 by Antonio Carle and Giorgio Rattone, two pathologists of the University of Turin, who demonstrated the transmissibility of tetanus for the first time. [en.wikipedia.org]

• Malaise

  […] studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks.” ( source ) “The known and documented side effects listed by the manufacturers and pharmaceutical guidelines include local inflammation, malaise [mommypotamus.com]

• Dyspnea

  The following day, there was progression of symptoms to generalized tetanus, such as dyspnea and generalized rigidity. Videofluoroscopic swallow study showed penetration and aspiration. [ncbi.nlm.nih.gov]

  A tracheotomy was performed in the latter patient because of dyspnea. He discharged on the 26th hospital day. Both patients had no functional sequelae. [doi.org]

• Pharyngeal Spasm

  Hypoxemia can also induce cardiac arrest, and pharyngeal spasm leads to aspiration of oral secretions with subsequent pneumonia, contributing to a hypoxemic death. Pulmonary embolism is also possible. [merckmanuals.com]

• Tachypnea

  The patient showed recurrent tachypnea and bradypnea, which seemed typical of Cheyne-Stokes respiration. A neurally adjusted ventilatory assist (NAVA) catheter was inserted transnasally, and electrical activity of the diaphragm (Edi) was monitored. [ncbi.nlm.nih.gov]

• Stridor

  […] may be associated with such conditions as parathyroid hypofunction, vitamin D deficiency, and alkalosis or result from ingestion of alkaline salts; it is characterized by carpopedal spasm, muscular twitching and cramps, laryngospasm with inspiratory stridor [dic.impact.pe.kr]

• Dysphagia

  The patient reported trismus and dysphagia as his main complaints. The suspicion of tetanus emerged from the patient's manifestations in conjunction with his history of trauma and his agricultural occupation. [ncbi.nlm.nih.gov]

  We report a case of cephalic tetanus with ptosis, facial palsy, and dysphagia, which progressed to generalized tetanus. [doi.org]

• Constipation

  If constipation, which is common, develops, stool softeners are given, and a tube may be inserted into the rectum to help manage gas production. [merckmanuals.com]

• Abdominal Rigidity

  Furthermore, the differential diagnosis of non-immunized children with abdominal rigidity should include generalized tetanus. [ncbi.nlm.nih.gov]

  A common first sign suggestive of tetanus in older children and adults is abdominal rigidity, although rigidity is sometimes confined to the region of injury. Generalized spasms occur, frequently induced by sensory stimuli. [web.archive.org]

  Older children and adults may present with abdominal rigidity due to involvement of the muscles of the trunk. Transmission Tetanus is not directly transmitted from person to person. [conditions.health.qld.gov.au]

• Trismus

  Tetanus can be easily diagnosed as it presents trismus first. [doi.org]

  This case focuses on the importance of considering tetanus in the differential diagnosis of trismus associated with systemic symptoms, and discusses the clinical implications of an initial wrong diagnostic pathway. [ncbi.nlm.nih.gov]

• Jaw Stiffness

  Diagnosis Your doctor can diagnose tetanus by: examining recent cuts or wounds that could have been in contact with soil checking for other symptoms such as neck or jaw stiffness, trouble swallowing and irritable behaviour asking when you had your last [health.gov.au]

  Early symptoms of tetanus include: Painful muscle spasms that begin in the jaw (lock jaw) Stiff neck, shoulder and back muscles Difficulty swallowing Violent generalized muscle spasms Convulsions Breathing difficulties A person may have a fever and sometimes [health.nsw.gov.au]

  Symptoms of tetanus include Jaw stiffness (most frequent) Difficulty swallowing Restlessness Irritability Stiff neck, arms, or legs Headache Sore throat Tonic spasms Later, patients have difficulty opening their jaw (trismus). [merckmanuals.com]

  Symptoms of tetanus include Jaw stiffness (most frequent) Difficulty swallowing Restlessness Irritability Stiff neck, arms, or legs Arching of the back (opisthotonos) Headache Sore throat Tonic spasms Later, patients have difficulty opening their jaw [msdmanuals.com]

• Difficulty Opening the Mouth

  The first signs of this disease include difficulty opening the mouth -- often called lockjaw -- and difficulty swallowing. Lockjaw is able to escape and becomes separated from his city. [fi.bab.la]

• Masseter Spasm

  It also had a full blown clinical picture of neonatal tetanus including: masseter spasm; generalized rigidity; a high pitched cry: and intermittent opisthotonos posturing. [ncbi.nlm.nih.gov]

• Hypertension

  The patient's initial symptoms were rotatory vertigo and hypertension. He then developed trismus and cranial nerve palsies of the fifth and seventh nerves. [ncbi.nlm.nih.gov]

  […] physical or emotional stimuli, laryngospasm, risus sardonicus, opisthotonos (severe spasm in which the back arches and the head bends back and heels flex toward the back) autonomic disturbance (onset after spasms, lasts 1-2 weeks) — tachycardia and hypertension [lifeinthefastlane.com]

  Complications of Tetanus Laryngospasms Fractures Hypertension Nosocomial infections Pulmonary embolism Aspiration pneumonia Death Top of Page [web.archive.org]

  She had multiple vascular risk factors: hypertension, hypercholesterolaemia, impaired glucose tolerance and a 50 pack-year smoking history. Twelve days before presentation she had developed right-sided facial weakness. [doi.org]

• Tachycardia

  […] spontaneous or provoked by physical or emotional stimuli, laryngospasm, risus sardonicus, opisthotonos (severe spasm in which the back arches and the head bends back and heels flex toward the back) autonomic disturbance (onset after spasms, lasts 1-2 weeks) — tachycardia [lifeinthefastlane.com]

  Signs of tetanus may include: Stiffness of muscles in the jaw Neck stiffness Difficulty swallowing Stomach muscle stiffness Spasms of muscles Sweating Fever Bloody stools and/or diarrhea Tachycardia It is also possible for bone fractures, particularly [news-medical.net]

  Beta-blockade is used to control episodes of hypertension and tachycardia, but use of long-acting drugs such as propranolol is not recommended. [merckmanuals.com]

  Increased sympathetic tone causes vasoconstriction, tachycardia and hypertension. ‘Autonomic storms’ are associated with raised catecholamine levels. These alternate with episodes of sudden hypotension, bradycardia and asystole. [ceaccp.oxfordjournals.org]

• Hypotension

  […] risus sardonicus, opisthotonos (severe spasm in which the back arches and the head bends back and heels flex toward the back) autonomic disturbance (onset after spasms, lasts 1-2 weeks) — tachycardia and hypertension may alternate with bradycardia and hypotension [lifeinthefastlane.com]

  Mortality was directly associated with symptomatic period, acute renal failure cardiac arrest and hypotension, and inversely associated with onset period in the multivariate analyses. [ncbi.nlm.nih.gov]

  Mortality was directly associated with symptomatic period, acute renal failure cardiac arrest and hypotension, and inversely associated with onset period in the multivariate analyses. Conclusions. [doi.org]

  Prolonged sympathetic activity may end with profound hypotension and bradycardia. Parasympathetic over activity may lead to sinus arrest. Direct damage to the vagal nucleus by the tetanus toxin has been implicated. [ceaccp.oxfordjournals.org]

• Cyanosis

  Spasms also interfere with respiration, causing cyanosis or fatal asphyxia. Temperature is only moderately elevated unless a complicating infection, such as pneumonia, is present. Respiratory and pulse rates are increased. [merckmanuals.com]

• Muscle Spasm

  As the toxin produced by the bacteria circulates more widely, it interferes with the normal activity of nerves throughout the body, leading to generalized muscle spasms. Without treatment, tetanus can be fatal. [wpro.who.int]

  Tetanus is diagnosed clinically, through recognition of the characteristically inducible muscle spasms. Three clinical forms described in adults are generalised, localised and cephalic tetanus. [ncbi.nlm.nih.gov]

  The bacteria produce a neurotoxin called tetanospasmin, which causes muscle spasm in the jaw and other anatomic sites. [wikidata.org]

• Muscle Cramp

  Most commonly, it is a muscle cramp which is accompanied by a sudden burst of pain. A muscle cramp is usually harmless and ceases after a few minutes. It is typically caused by ion imbalance or muscle overload. [en.wikipedia.org]

  • Tetanus can cause extremely painful muscle cramps all over the body. This disease can be deadly. [vaccineinformation.org]

  A muscle that involuntarily contracts without our consciously willing it is called a "spasm." If the spasm is forceful and sustained, it becomes a cramp. A muscle cramp is an involuntarily and forcibly contracted muscle that does not relax. [emedicinehealth.com]

• Muscle Spasticity

  In localized tetanus, there is spasticity of muscles near the entry wound but no trismus; spasticity may persist for weeks. Cephalic tetanus is a form of localized tetanus that affects the cranial nerves. [merckmanuals.com]

• Neonatal Tetany

  없는 신생아 파상풍(Neonatal tetany without calcium or magnesium deficiency) 신생아 파상풍(Neonatal tetany) NOS P71.4 일과성 신생아 부갑상선 기능저하증(Transitory neonatal hypoparathyroidism) P71.8 기타 일과성 신생아 칼슘 및 마그네슘 대사장애(Other transitory neonatal disorders of calcium and magnesium [dic.impact.pe.kr]

• Carpopedal Spasm

  spasm, muscular twitching and cramps, laryngospasm with inspiratory stridor, hyperreflexia and choreiform movements. 2. tetanus. trismus (개구장애, 아관긴급) 동의어=mandibular trismus. [dic.impact.pe.kr]

• Risus Sardonicus

  In orally intubated patients, trismus and risus sardonicus may be overlooked, and although rare, cephalic tetanus should be considered to be a differential diagnosis of facial nerve palsy. [ncbi.nlm.nih.gov]

• Facial Spasm

  We found this case to be associated with dysphagia and facial spasm, and we learned that the child had dropped a brick on his foot 2 weeks previously. The patient was subsequently diagnosed with tetanus and treated accordingly. [ncbi.nlm.nih.gov]

  Tetanus is classified into generalized, localized, cephalic, and neonatal tetanus. 3 In particular, cephalic tetanus may present symptoms such as dysphagia, facial pain, nystagmus, dysarthria, and facial spasm in addition to trismus. 1, 4 Latent period [doi.org]

  The spasms can also affect the facial muscles resulting in an appearance called risus sardonicus. Chest, neck, back, abdominal muscles, and buttocks may be affected. Back muscle spasms often cause arching, called opisthotonos. [en.wikipedia.org]

• Seizure

  The infant recovered, with no seizures by the 16th day from admission, and was off the ventilator by the 18th day. This was shorter than the usual 3 - 4 weeks for neonates with tetanus at the hospital. [ncbi.nlm.nih.gov]

  Seizures may occur, and the autonomic nervous system may also be affected. Symptoms and Diagnosis Tetanus is a clinical syndrome without confirmatory laboratory tests. [web.archive.org]

  […] disorder hypocalcemic tetany psychogenic meningism Neonatal tetanus may resemble: Seizures meningitis sepsis INVESTIGATIONS urinary strychnine to exclude this as a cause CK, UEC, CMP for rhabdomyolysis and to rule out low Ca ABG (respiratory failure) [lifeinthefastlane.com]

• Headache

  Symptoms usually begin eight days after the infection, and include headache and muscular stiffness in the jaw, followed by stiffness of the neck, difficulty in swallowing, rigidity of abdominal muscles, spasms, sweating and fever. [wpro.who.int]

  Tetanus symptoms include: Headache Jaw cramping Sudden, involuntary muscle tightening – often in the stomach (muscle spasms) Painful muscle stiffness all over the body Trouble swallowing Jerking or staring (seizures) Fever and sweating High blood pressure [web.archive.org]

  Symptoms Common initial symptoms of tetanus are a headache and muscular stiffness in the jaw (lockjaw) followed by stiffness of the neck, difficulty swallowing, hardening of abdominal muscles, spasms, sweating, and fever. [nfid.org]

  Tetanus symptoms include: Jaw cramping Sudden, involuntary muscle tightening (muscle spasms) – often in the stomach Painful muscle stiffness all over the body Trouble swallowing Jerking or staring (seizures) Headache Fever and sweating Changes in blood [cdc.gov]

  Other symptoms include: headache, seizures (violent jerking or shaking of the body), fever and sweating, high blood pressure, and fast heart rate. Without proper hospital treatment, tetanus can be fatal. [phac-aspc.gc.ca]

• Irritability

  This toxin causes: the muscles to stiffen around the jaw, neck, back, chest, abdomen and limbs sometimes, a high temperature and sweating nerve irritation, which leads to severe muscle spasms and difficulty in breathing. [health.govt.nz]

  Further symptoms include: Breathing problems Drooling Excessive sweating Fever Hand/foot spasms Irritability Swallowing difficulty Uncontrolled urination, defecation What to do: Once infected, a person with tetanus should undergo antibiotics and get plenty [ccchd.com]

  Diagnosis Your doctor can diagnose tetanus by: examining recent cuts or wounds that could have been in contact with soil checking for other symptoms such as neck or jaw stiffness, trouble swallowing and irritable behaviour asking when you had your last [health.gov.au]

  On irritating the heart with the point of the scalpel, the ventricles... ‎ [books.google.ro]

  The affected child experiences spasms of the jaw muscles, a headache, and irritability. Next, she experiences muscle tightening, pain, and spasms spread to other parts of the body including the neck, shoulders, and back with increasing intensity. [healthychildren.org]

• Opisthotonus

  During hospitalization, the patient's clinical conditions worsened rapidly, and, although in absence of the classic clinical presentation (trisma, nuchal rigidity, and opisthotonus), a diagnosis of tetanus was suspected. [ncbi.nlm.nih.gov]

  Opisthotonus, airway obstruction, and circulatory disturbance did not occur. The patient recovered without tracheotomy or tracheal intubation. Tetanus is a fatal infectious disease, if early treatment is not appropriately performed. [doi.org]

  Clostridium tetani D DPT vaccine DPT-Hib vaccine DTaP-Hib vaccine DTaP-IPV/Hib vaccine DTaP-IPV vaccine DTaP-IPV-HepB vaccine DTP vaccine DTP-HepB vaccine H Hexavalent vaccine J Jim (horse) K Kitasato Shibasaburō N Neonatal tetanus Arthur Nicolaier O Opisthotonus [en.wikipedia.org]

• Meningism

  Neonatal tetanus may resemble: Seizures meningitis sepsis INVESTIGATIONS urinary strychnine to exclude this as a cause CK, UEC, CMP for rhabdomyolysis and to rule out low Ca ABG (respiratory failure) MANAGEMENT Resuscitation A – intubate as requires [lifeinthefastlane.com]

  His symptoms progressed despite a course of antibiotics for presumed meningitis. [ncbi.nlm.nih.gov]

  Differential diagnosis Differential diagnosis includes local causes of trismus, muscular dystonia induced by certain drugs, and much more rarely, meningitis or certain forms of hysteria. [orpha.net]

  Table 2 Differential diagnosis of tetanus Hypocalcaemic tetany Epilepsy Chorea Meningitis Encephalitis Subarachnoid haemorrhage Strychnine poisoning Rabies Sepsis Drug withdrawal Hypocalcaemic tetany Epilepsy Chorea Meningitis Encephalitis Subarachnoid [ceaccp.oxfordjournals.org]

  Tests may be used to rule out meningitis, rabies, strychnine poisoning, and other diseases with similar symptoms. [medlineplus.gov]

Laboratory tests usually are not required for diagnosis of tetanus. A thorough physical examination of the signs and symptoms of muscle spasms and stiffness are enough to draw an appropriate conclusion. For cases when confirmed diagnosis cannot be made based on physical examination, the spatula test can be used. In this test, a spatula is inserted into back of the throat. If the individual is suffering from tetanus, then the spatula would cause spasms inside the throat compelling the individual to bite on the object. Such an activity would confirm the diagnosis of tetanus [8].

• Atelectasis

  […] environment cardiac monitoring nutrition e.g. enteral feeding often require tracheostomy prevention of pressure sores and GI stress ulcers COMPLICATIONS Respiratory Aspiration Laryngospasm/obstruction Sedative-associated obstruction Respiratory apnoea Type I (atelectasis [lifeinthefastlane.com]

  Meticulous mouth care, chest physiotherapy, and regular tracheal suction are essential to prevent atelectasis, lobar collapse, and pneumonia particularly as salivation and bronchial secretions are greatly increased in severe tetanus. [doi.org]

Tetanus infection cannot be cured. The symptoms can be managed by following appropriate treatment course. Initially the wound should be promptly treated to avoid further complications. The wound is cleansed using an antibiotic solution to remove the dirt, dead tissue and foreign bodies. Following this, medications form the secondary line of treatment for tetanus. Medicines such as antitoxin, antibiotics, sedatives and vaccine are given to treat the infection and control the spasms and muscle stiffness. An antitoxin such as tetanus immune globulin is effective for neutralizing only those toxins that have not attached the nerve endings. Antibiotics are administered to ward off the infections from the body. Strong sedatives are used for controlling muscle spasms and stiffness [9].

The prognosis of the disease is poor owing to the fact that once the toxins have attached to the nerve endings, it gets practically impossible to remove them. Absolute recovery from the tetanus infection can only be achieved when a new nerve ending develops. This may take several months. Recovery is very slow in such cases and can take 2 to 4 months for the individual to get back to normal. There are higher chances of the tetanus to recur and therefore it is advised that affected individuals be actively immunized against it [7].

Tetanus is caused by the anaerobic bacteria Clostridium tetani which resides in soil, manure and dust. The bacteria gains entry into the body either through a deep wound, caused due to nail or from a burn [3]. Once bacteria enter the body they produce a toxin known as tetanospasmin. This toxin is adversely affecting the nervous system of the individuals giving rise to painful muscle contractions characterized by stiffness of the neck muscles and spasms. Certain group of individuals such as travelers and those who inject recreational drugs are at an increased risk of developing tetanus.

The incidence of tetanus has undergone a steep decline since the year 1940 in the United States owing to tetanus immunization [4]. In England and Wales, there were only 3 cases of tetanus recorded in the year 2011 [5]. This is however the scenario in the developed countries, while the developing countries continue to face high numbers of cases of tetanus. It has been estimated that about 1 million cases of tetanus occurs every year across the globe. Amongst all age groups, elderly population is the most affected. Statistics reveal that in the period 1998 – 2000, about 70% of cases of tetanus were recorded for the elderly individuals in the United States.

The bacteria Clostridium tetani is an anaerobic, motile and gram-positive bacillus that is commonly found in dust, soil and feces of humans and animals. For the bacteria to cause an infection, it must gain entry into the human system. Individuals who have suffered deep cut wounds are potential candidates for developing tetanus. Once the bacteria gain entry into the system, they release a potent toxin known as the tetanospasmin. The toxin then gradually impairs the nervous system giving rise to various incapacitating symptoms [6].

Tetanus can easily be prevented by receiving vaccination against it. It is better to receive vaccination when one has suffered a deep wound either from nails or burns. Failure to do so can lead to development of tetanus infection. The condition can be very well treated if the toxin has not attached to the nerve endings. Children usually receive this vaccine as part of their diphtheria, acellularpertusis and tetanus toxoids vaccines [10].

Tetanus is characterized by painful muscular contractions more specifically of the jaw and muscles of the neck. Due to its characteristic features, the disease is also commonly referred to as “lockjaw”. If the disease is not treated on time it can lead to life threatening conditions. However, with the advent of tetanus vaccine, the incidence of the disease has significantly declined, especially in the developed countries. But, there are still considerable numbers of cases of tetanus occurring in the developing countries. Tetanus cannot be cured, but the symptoms can be well managed with a proper treatment regime [2].

Definition

Tetanus is a kind of severe bacterial disease adversely affecting the nervous system. Such a kind of disease causes muscle contractions of the jaws and the neck. It can also lead to breathing difficulty which can eventually lead to life threatening conditions. Tetanus is also referred to as “lockjaw”.
Cause

The bacteria known as Clostridium tetani cause tetanus. Individuals with deep cuts wounds fall easy prey to this disease condition as the bacteria can gain easy access through the wounds in the body. Once the bacteria enter the human system, it produces toxin known as the tetanospasmin which weakens the nervous system giving rise to an array of problems.

Symptoms 

Symptoms of tetanus begins to show effect within 7 to 8 days after the bacteria enters the body. Affected individuals experience painful muscle contractions, specifically of the jaws and the neck, difficulty in breathing, stiffness of abdominal and neck muscle and painful body spasms. In addition, individuals can also experience rapid heart rate, high blood pressure, sweating and fever.

Diagnosis

Physical examination of the symptoms is enough to diagnose tetanus. No laboratory studies are required for diagnosing this condition. However, if appropriate conclusion cannot be drawn then the spatula test can be carried out.

Treatment

Tetanus cannot be cured; however the symptoms can be well managed with appropriate treatment regime. Medications are given to manage the muscular contractions and spasms. In addition to this, antibiotics are also administered to ward off the infection from the body.

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2. Bleck TP. Clostridium tetani. In: Mandell GL, Bennett JE, Dolin R, eds. Bennett's Principles and Practice of Infectious Diseases. Philadelphia, Pa: Churchill Livingstone; 1995:2373-8.
3. Fitzgerald RH Jr, Cowan JD. Puncture wounds of the foot. OrthopClin North Am 1975; 6:965.
4. Pascual FB, McGinley EL, Zanardi LR, Cortese MM, Murphy TV. Tetanus surveillance--United States, 1998--2000. MMWR SurveillSumm. Jun 20 2003;52(3):1-8.
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8. Apte NM, Karnad DR. Short report: the spatula test: a simple bedside test to diagnose tetanus. Am J Trop Med Hyg. Oct 1995;53(4):386-7.
9. Engrand N, Guerot E, Rouamba A, Vilain G. The efficacy of intrathecal baclofen in severe tetanus.Anesthesiology. Jun 1999;90(6):1773-6.
10. Centers for Disease Control and Prevention.Diphtheria. In: Epidemiology and Prevention of Vaccine-Preventable Diseases. The Pink book, 12th ed. Atkinson W, Wolfe S, Hamborsky J (Eds).Public Health Foundation, Washington, DC 2011.