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This paper describes two infections with Clostridium tetani (C. tetani). One outbreak occurred after dehorning of calves, the second infection happened after ear tagging of a goat. In the first case 3 young Holstein Friesian calves showed generalized stiffness, severe lock-jaw and bloat two weeks after dehorning. The thermal dehorning wounds were identified as the infection sites of C. tetani by bacterial culture and PCR. The second case was a three-year old male castrated goat, with generalized stiffness. The animal had been ear tagged one week prior to the onset of the symptoms. C. tetani could be cultured from pus on the ear tag. Treatment was attempted in two calves and the goat. Wounds were debrided and disinfected, penicillin and anti-tetanus serum were administered and polyionic perfusions provided. In addition, the goat was vaccinated against tetanus. The goat and one calf fully recovered after 36 and 8 days respectively. To the authors' knowledge a tetanus outbreak in association with thermal dehorning has not been described previously. Also ear tagging as a possible cause for C. tetani infection has not been described in goats.
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Vlaams Diergeneeskundig Tijdschrift, 2011, 80 Case report 351
INTRODUCTION
Tetanus is a life-threatening toxico-infection caused
by the neurotoxin of C. tetani. Typical symptoms are
increased general muscular rigidity evolving to a com-
plete tetanic state, frequently with a fatal outcome
(Linnenbrink et al., 2006). Although tetanus is descri-
bed in all domestic animals, small ruminants and horses
are known to be the most susceptible species (Aslani
et al., 1998; Driemeier et al., 2006; Wernery et al.,
2004). Tetanus usually affects a single animal, but out-
breaks have been sporadically described in farm ani-
mals, especially in association with serial injections
(Barbosa et al., 2009; Driemeier et al., 2007). Infection
occurs as a result of contamination of wounds with spo-
res of C. tetani, which desporulate to the vegetative
form and produce tetanus toxin when anaerobic con-
ditions are present. The most frequently described in-
fection sites in farm animals are castration, shearing
and injection wounds (Aslani et al., 1998). As less
frequent infection sources surgical contamination,
snake bites, umbilical infections and ear tagging have
also been described in animals (Aslani et al., 1998; Lin-
nenbrink et al., 2006; Poudel et al., 2009). This case re-
port describes two tetanus cases with an atypical por-
tal of entry, the first being an outbreak of tetanus in
dairy calves, shortly after thermal dehorning and the se-
cond in a three-year old goat, after ear tagging.
Thermic dehorning and ear tagging as atypical portals of entry of
Clostridium tetani in ruminants
Thermische onthoorning en oormerken als atypische intredeplaatsen van
Clostridium tetani bij herkauwers
1B. Valgaeren, 1P. De Schutter, 1B. Pardon, 2V. Eeckhaut, 2F. Boyen, 2F. Van Immerseel, 1P. Deprez
1Department of Internal Medicine and Clinical Biology of Large Animals
2Department of Pathology, Bacteriology and Avian Diseases,
Faculty of Veterinary Medicine, Ghent University, Salisburylaan 133, B-9820 Merelbeke, Belgium
bonnie.valgaeren@ugent.be
ABSTRACT
This paper describes two infections with Clostridium tetani (C. tetani). One outbreak occurred after de-
horning of calves, the second infection happened after ear tagging of a goat. In the first case 3 young Holstein
Friesian calves showed generalized stiffness, severe lock-jaw and bloat two weeks after dehorning. The ther-
mal dehorning wounds were identified as the infection sites of C. tetani by bacterial culture and PCR. The se-
cond case was a three-year old male castrated goat, with generalized stiffness. The animal had been ear tag-
ged one week prior to the onset of the symptoms. C. tetani could be cultured from pus on the ear tag.
Treatment was attempted in two calves and the goat. Wounds were debrided and disinfected, penicillin and
anti-tetanus serum were administered and polyionic perfusions provided. In addition, the goat was vaccina-
ted against tetanus. The goat and one calf fully recovered after 36 and 8 days respectively. To the authors’ know-
ledge a tetanus outbreak in association with thermal dehorning has not been described previously. Also ear
tagging as a possible cause for C. tetani infection has not been described in goats.
SAMENVATTING
In dit artikel worden twee infecties met Clostridium tetani beschreven. Een eerste uitbraak ontstond na het ont-
hoornen van kalveren, de tweede infectie na het oormerken van een geit. In de eerste casus vertoonden drie jonge
holstein-friesiankalveren veralgemeende stijfheid, een trismus en tympanie twee weken na het onthoornen. De won-
den na de thermische onthoorning werden geïdentificeerd als de infectieplaatsen van Clostridium tetani door mid-
del van bacteriële cultuur en PCR. De tweede casus betrof een mannelijke gecastreerde geit van drie jaar oud met
veralgemeende stijfheid. Een week vóór het begin van de symptomen werden oormerken geplaatst. C. tetani kon
geïsoleerd worden uit de etter verkleefd aan het oormerk. Twee van de drie kalveren en de geit werden behandeld.
De wonden werden schoongemaakt en gedesinfecteerd en penicilline, antitetanus-serum en polyionisch infuus wer-
den toegediend. De geit werd bijkomend gevaccineerd tegen tetanus. De geit en één kalf herstelden volledig na res-
pectievelijk 36 en acht dagen.
Voor zover bekend werd er nog nooit een tetanusuitbraak geassocieerd met thermisch onthoornen, beschreven.
Ook het oormerken werd nog niet beschreven als een mogelijke oorzaak van een C. Tetani-infectie bij geiten.
352 Vlaams Diergeneeskundig Tijdschrift, 2011, 80
CASE 1
Case history
In May 2011 three Holstein Friesian calves, be-
tween 3 and 5 months of age, were referred to the Ve-
terinary Clinic in Merelbeke with complaints of stiff-
ness, recumbency, ruminal bloat and lock-jaw. The
symptoms had started 2 to 7 days before presentation.
At the farm, all animals were housed in the same pen
together with thirteen other calves. Fourteen days be-
fore admission, eight of these calves were thermally de-
horned. Seven days before admission, one of the re-
cently dehorned calves was found dead. No previous
symptoms were noted by the owner, and no necropsy
was performed. The animals were vaccinated against
IBR, but not against clostridial diseases.
Clinical examination and ancillary diagnostics
All calves showed stiffness in all four limbs, mar-
kedly increased muscle tone, pricked ears, lifted tail
and bloat. One calf was still able to lie down and get
up without assistance and to ingest small amounts of
feed and water, whereas the other two calves could not
bend their legs, had severe lock-jaw and were unable
to eat or drink. The dehorning wounds had a thick
crust with pus underneath. No other wounds were de-
tected. Temperature, respiration and heart rate were
normal in all calves.
Standard hematology, biochemistry and blood gas
analysis only showed a mild to severe dehydration in
all calves. The crust was removed from the dehorning
wounds and cultured for Clostridium tetani. The crust
was suspended in sterile phosphate buffer solution
(PBS) and heated at 80°C for 20 minutes. Of this su-
spension, 100µl was cultivated at 37°C for 24 hours on
a blood plate in an anaerobic chamber (Ruskinn Tech-
nology) with 84% N2, 8% CO2and 8% H2. A pure cul-
ture of a hemolytic gram-positive rod with terminal
spores was obtained (Figure 1a). The final identifica-
tion of C. tetani was done by PCR (Akbulut et al.,
2005).
Treatment and further evolution
One calf was euthanized immediately at arrival due
to the graveness of the symptoms and the bad progno-
sis. The dehorning wounds of the remaining calves
were thoroughly cleaned with H2O2.The calves recei-
ved IV 10 ml of anti-tetanus serum®(Intervet), daily in-
jections with procaine benzylpenicillin (10 mg/kg, IM,
Duphapen, Pfizer A.H.) and thiamine (10mg/kg, IV,
tid) for 6 days and polyionic perfusion with 10% glu-
cose. A second calf was euthanized 2 days after arrival
in the clinic due to worsening of the symptoms. In the
third calf, which showed the best clinical condition at
arrival, the symptoms gradually improved and the pa-
tient could leave the clinic 7 days after presentation
with minimal signs of stiffness.
CASE 2
Case history
In June 2011, a castrated male goat of 3 years of age
was presented at the clinic with symptoms of apathy,
generalized stiffness, dysphagia and reduced ruminal
sounds. At home, the veterinarian suspected indigestion
or ruminal acidosis and treated the animal with bu-
tylscopolamine (Buscopan®, Boehringer Ingelheim
BV), flunixine meglumine (Bedozane®, Eurovet), a bi-
carbonate perfusion and supplementation with vita-
mins and minerals. The animal was kept in a hobby set-
ting on pasture together with 5 apparently healthy
other goats. Although all animals were officially re-
gistered since birth, their ear tags had only been placed
a week before presentation at the clinic. The animal had
been vaccinated once against C. tetani before castration
at 6 months of age, but without continuation of the vac-
cination program.
Figure 1b. Spores and bacteria of Clostridium tetani with
a typical drum-stick shape isolated from the ear tags in
case 2 (Malachite Green – 1000x).
Figure 1a. Spores and bacteria of Clostridium tetani with
a typical drum-stick shape isolated from the crust of the
dehorning wounds in case 1 (gram-staining-1000x).
Vlaams Diergeneeskundig Tijdschrift, 2011, 80 353
Clinical examination and ancillary diagnostics
Upon admission, the goat showed obvious stiff-
ness of the limbs and was alert. Rectal temperature,
pulse and respiration rates were normal. Elevated ab-
dominal tension, pricked ears, elevated tail and subtle
ruminal bloat were present. The uptake of food and wa-
ter was impossible due to severe lock-jaw. The animal
could still defecate and urinate in a normal way.
The goat was slightly dehydrated. No other deviati-
ons were found on standard blood examination. The ru-
minal fluid had a normal macroscopic aspect and a pH
of 7.3 (normal values 6-7). Multiple living protozoa
were detected on microscopic examination (10x mag-
nification). Standard parasitological examination resul-
ted in a strongyle count of 8100 eggs per gram feces and
an Eimeria spp. count of 450 oöcysts per gram faeces.
Of the detected oöcysts roughly 10% belonged to the vi-
rulent species Eimeria ninakohlyakimovae. The ear tags
were removed after permission of the official authority
responsible for food animal identification. From pus
sticking to the ear tags, an anaerobic culture was per-
formed as described in case 1 and Clostridium tetani
could be cultured. Further identification was done as
described in case 1. A smear of the purified colonies was
stained with Malachite Green and safranin and the ty-
pical drum-stick shaped rods were visible, as demon-
strated in Figure 1b.
Treatment and further evolution
The crusts were removed and the wounds were dis-
infected with H2O2. The goat received 4 ml of anti-te-
tanus serum® (Intervet), and daily injections with pro-
caine benzylpenicillin (10 mg/kg, IM, Duphapen,
Pfizer A.H.) and thiamine (10mg/kg, IV, tid) for 6 days
and a polyionic perfusion with 10% glucose. Additio-
nally the goat was vaccinated with Covexin 10®(Pfi-
zer AH) containing a minimum of 4.9 IE C. tetani
toxoid. A mixture of beet pulp and moistened concen-
trates was offered by syringe in the animal’s mouth.
Three days after referral to the clinic, the animal was
found in lateral recumbency with severe ruminal bloat,
worsened jaw-lock and stiffness of the limbs. Most pro-
bably the animal had fallen during the night and had
been unable to stand up by itself, resulting in ruminal
bloat. Because of the degree of excitation, the animal
was mildly sedated (midazolam, 0.25 mg/kg, Dormi-
cum, Roche). The bloat was relieved by rumen punc-
ture with a 16G catheter after surgical preparation.
The ear wounds were debrided again and 2 ml of pe-
nicillin was locally administered. The symptoms sta-
bilized over the next days and the animal gradually re-
covered. Eight days after admission, when the animal
was able to eat unaided, it was discharged. The remai-
ning symptoms (stiffness of the limbs) continued to
decrease and 5 weeks after submission in the clinic, the
animal had fully recovered. New ear tags were placed
after recovery.
DISCUSSION
Tetanus is a fatal toxico-infection, caused by toxins
of Clostridium tetani (Poudel et al., 2009). This bac-
terium is able to produce two important toxins, namely
tetanolysin and tetanospasmin. The first has the ability
to lyse cell membranes, causing tissue damage and
stimulating the development of an anaerobic environ-
ment. The latter is responsible for the neurological
symptoms by inhibiting the release of inhibitory neu-
rotransmitters, causing generalized muscle spasm and
alterations of autonomic control. Because the toxin is
slowly transported retrograde from the peripheral ner-
ves to the central nervous system, incubation periods
of 3 to 18 days are described (Driemeier et al., 2006;
Linnenbrink et al., 2006). C. tetani produces very re-
sistant spores that can survive boiling temperatures
for several minutes (Dixit et al., 2005; Linnenbrink et
al., 2006). In order to desporulate to a vegetative form,
the spores need an environment with low oxygen ten-
sion, typically generated under the crust of penetrating
wounds (Linnenbrink et al., 2006). Although the ad-
vanced symptoms might resemble those seen in trau-
matic reticuloperitonitis, white muscle disease, grass
tetany, meningitis, cerebrocortical necrosis, lead in-
toxication, strychnine-intoxication and to a lesser ex-
tent laminitis, poly-arthritis, esophageal obstruction
and other causes of ruminal tympany (Stöber, 2002).
However, in the case of tetanus the symptoms quickly
evolve to the pathognomonic tonic-clonic cramps of
the antigravitational muscles, protrusion of the third
eye lid, stiff ears and a raised tail base. Although teta-
nus typically is an individual problem, outbreaks have
been described in several animal species and humans,
due to very different entry routes. Most famous are hu-
man outbreaks in intravenous drug users due to the use
of contaminated needles (Sun K., 1994; Gormley et al.,
2004). Also in ruminants multiple outbreaks have been
described following injections with contaminated need-
les, for example after injection with anthelmintics in
sheep and cattle or after rabies vaccination in buffalo’s
(Driemeier et al., 2006; Barbosa et al., 2009). Al-
though goats and sheep are more sensitive than cattle,
(Aslani et al., 1998) outbreaks have more frequently
been described in young cattle, possibly due to the
more frequent application of mass injections in calves
(Driemeier et al., 2006).
The present case report describes an outbreak of te-
tanus in three animals of the same herd, following
thermal dehorning. Since the ban on chemical dehor-
ning in 2008, thermal dehorning is the standard de-
horning method for calves of 4 to 8 weeks of age
(Nantier, 2009). The dehorning iron is heated to 600-
700 degrees Celsius and is then placed upon the horn
stumps, burning the epithelium and surrounding tissue
and resulting in permanent removal of the horn stumps.
After 1 to 2 days a thick impermeable crust is formed
which encloses the dehorning wounds (Nantier, 2009).
The temperature reached on the iron is kept for several
minutes and is probably lethal to spores. Therefore, it
is unlikely that the iron itself serves as a vector for C.
354 Vlaams Diergeneeskundig Tijdschrift, 2011, 80
tetani (Dixit et al., 2005). Environmental contamina-
tion of the dehorning wound with faecal material and
dirt from the stable environment seems a more likely
infection route (Driemeier et al., 2006; Linnenbrink et
al., 2006). Additionally, the thermal treatment also
causes the perfect circumstances for the creation of an
anaerobic environment by destroying the blood vessels
and creating a thick impermeable crust. These factors
predispose to the growth and toxin production of C. te-
tani (Nitzschke et al., 2008). Burning wounds are a
well known risk for tetanus in humans whereas no re-
ports in animals were found (Cassel et al., 2002). This
is the first time thermal dehorning is described as a
cause of a tetanus infection. As this method is nowa-
days the standard dehorning procedure in Belgium and
since most calves are not vaccinated against C. tetani
for economical reasons, a higher incidence of tetanus
outbreaks in future years might be possible.
Although the insertion of ear tags is routinely done
in young ruminants, including goats, only one out-
break of tetanus in lambs following ear tag insertion at
7 to 8 days of age has been described (Aslani et al.,
1998). It is not clear whether the older age of the ani-
mal was a risk factor for the occurrence of tetanus.
However, permethrin-impregnated ear tags are relati-
vely frequently administered in cattle and small rumi-
nants at older age and no cases of tetanus have been re-
ported. Therefore, the occurrence of tetanus associated
with ear tagging in this adult goat is likely an unfortu-
nate incident.
A solid vaccination scheme for tetanus is the most
effective preventive measure, both for adults as through
maternal immunity in newborns (Gall et al., 2011).
Vaccination is advisable in highly susceptible species
such as small ruminants and in animals with high eco-
nomical or emotional value. Double primo-vaccination
at minimally 8 and 12 weeks of age followed by yearly
boosters provide a lasting protection later in life. Per-
forming dehorning and ear tagging as clean as possi-
ble and local administration of antimicrobial sprays
might decrease the risk. Inspection of the wounds a few
days later and disinfection when necessary are advisa-
ble. The preventive application of antitetanus serum
might be an option when ear tagging or dehorning va-
luable unvaccinated animals.
These cases illustrate the importance of a continued
alertness when executing routine invasive interventions
as ear tagging and dehorning. Although small rumi-
nants are more sensitive than cattle and although extra
attention should be given to tetanus prophylaxis when
working with goats or sheep, tetanus may also occur in
young cattle.
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... Tetanus bacteria produce tetanolysin and tetanospasmin. Tetanolysin has the ability to lyse cell membranes, causing tissue damage and stimulating the development of an anaerobic environment (Valgaeren et al. 2011;Pugh & Baird 2012). Neurotoxins are then released due to autolysis of the bacterial cell. ...
... Although administration of antitoxin is recommended both parenterally and locally to neutralize the toxin, its effect after appearance of clinical signs is questionable (Upadhyay et al. 2013). Two other reports of tetanus due to ear tagging have been recorded in small ruminants (Valgaeren et al. 2011). ...
... The first outbreak of tetanus in lamb following ear tag insertion at 7-8 days of age was described by Aslani et al. (1998). Valgaeren et al. (2011) reported tetanus in a male goat, a week after ear tagging. Insertion of ear tags is routinely done in young ruminants, therefore unhygienic ear tag placement is possible and if there no vaccination of livestock, higher incidence of tetanus outbreak is likely. ...
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Tetanus is an acute, often fatal, infectious neuromuscular disease in all farmed mammals caused by Clostridium tetani. The disease is sporadic but outbreaks of tetanus have been described, as a result of wound contaminated with spores of C. tetani, which sporulates to the vegetative form and produce toxins. The present study reports an outbreak of tetanus in a sheep flock, shortly after ear tagging. Three sheep from a large flock (with a population of 1000 sheep) were presented with signs of: convulsion, limb stiffness, incoordination and trismus (“lock jaw”). There were wounds and scabs in most livestock where ear tags had been attached 1 week prior. Clinical examination revealed tachycardia, dyspnoea with dilated nostrils, mild fever, erected ear pinnae, teeth grinding, mild bloat, muscles rigidity, prolapse of third eyelid and anxiety. According to the history stated by the owner, the case fatality rate of the disease from the beginning was 50% during the outbreak. Necropsy did not reveal any significant finding. Gram‐positive bacilli with terminal spores representing C. tetani were isolated in anaerobic cultures which were taken from ear wounds. Procaine penicillin G was administrated at 20 000 IU/kg BW for 5 days, but antiglobulin was not available to treat affected animals. Mortality significantly declined one day after onset of treatment. In this report, the organism was probably introduced by contaminated instruments which were used for ear tagging of sheep. Wound exudation and adhesion following rubbing, created a favourable anaerobic condition for the spores to germinate with production of neurotoxin. Vaccination can protect animals against tetanus, but it does not preclude the need to apply standard hygienic principles when performing management procedures causing wounds. In pasture holding system, many pathogens are present in environment, so tetanus should be considered important in farm animals, because of its high fatality rate and the long course of convalescence. An outbreak of tetanus in a big sheep flock, shortly after ear tagging was observed and referred to our clinic. Case fatality rate during outbreak and before referring to clinic was 50%. Treatment with Penicillin G procaine significantly decreased the mortality.
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We sought to determine whether tetanus-diphtheria-pertussis vaccination (Tdap) in pregnancy provides newborns antibodies against pertussis when compared to mothers who did not receive Tdap. Paired maternal and umbilical cord blood samples were collected at the time of delivery and the serum stored at -86°C. For each paired sample of maternal and cord blood, the medical chart and vaccine history was reviewed to determine whether Tdap was received or not. Newborns born from mothers who received Tdap during pregnancy had significantly higher concentrations of diphtheria antitoxin (P < .001), tetanus antitoxin (P = .004), and antibodies to pertussis toxin (P < .001), filamentous hemagglutinin (P = .002), pertactin (P < .001), and fimbriae 2/3 (P < .001) when compared to newborns from mothers who did not receive Tdap. There was a significant increase in the odds that newborns from mothers who received Tdap during pregnancy have antibodies that may provide protection against diphtheria (P = .0141), pertussis toxin (P < .0001), and fimbriae 2/3 (P = .0146). Administering Tdap during pregnancy increases antibody titers against diphtheria and pertussis antigens. Maternal Tdap may prevent neonatal pertussis infection.
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Tetanus is now a rare disease in developed world. However it remains an important cause of death worldwide and is associated with a high case fatality, particularly in the developing world. Tetanus is caused by contamination of wound by spores of Clostridium tetani. Neonatal tetanus results from contamination of the umbilical stump at or following delivery of a child born to a mother who did not possess sufficient circulatory antitoxin to protect the infant passively by transplacental transfer. It produces its clinical effects via a powerful exotoxin, tetanospasmin, which leads to uncontrolled disinhibited efferent discharges from motor neurons in the spinal cord and brainstem, causing intense muscular rigidity and spasm. Shorter incubation and onset times are associated with more severe disease and poorer prognosis. Four clinical forms of tetanus are recognised. They are generalised, localised, cephalic and neonatal tetanus. Tetanus is associated with several complications like respiratory failure, cardiovascular instability, renal failure and autonomic dysfunctions. Recovery from tetanus takes a long time. Diagnosis is established clinically. Symptomatic management, early recognition of complications, careful monitoring for dysautonomia and respiratory assistance are the anchors for successful outcome of patients. Tetanus is preventable through vaccination. Vaccination is highly safe and efficacious. Active immunisation should be instituted in all partially immunised, unimmunised persons and those recovering from tetanus. Passive immunisation is given as treatment of a case as well as prevention following high risk injury. Nepal has achieved neonatal tetanus elimination status on 2005 and is running different programs to sustain the status.
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This study audits the tetanus immunisation management of plastic surgery trauma patients by their referring Accident and Emergency departments, and compares this to nationally published guidelines. We assessed 269 burns and trauma patients, referred from across South Wales, using a questionnaire together with their Accident and Emergency notes or letter. The precise question(s) that had been asked regarding the tetanus immunisation status of the patient, and the immunisation management based on the results of those questions, were recorded. The accurate tetanus immunisation status of the patient was established, the wound was assessed and further management was given as indicated. Only 16 patients had been asked whether they had received a course of tetanus, and 41 patients were not questioned about their tetanus immunisation status by the referring Accident and Emergency department. As a consequence of more accurate questioning, 73 patients (27%) required further action after their arrival in the Plastic Surgery unit. This audit has demonstrated that the management of tetanus immunoprophylaxis in plastic surgery trauma patients cannot be confidently left to the referring Accident and Emergency department but should form an integral part of the treatment at the admitting unit.
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Twenty days after an open castration, a 5-year-old dromedary was presented to the Dubai Camel Hospital with severe central nervous symptoms. The dromedary showed the following signs: off feed, stiff gait with extended neck, external swelling of the preputial sheath and groin region, and foamy saliva drooling from the mouth. The dromedary was unable to swallow. Three days after admission, the camel developed lockjaw, and on the fifth day it was unable to stand owing to paralysis of the hindquarters. Because of the severity of the disease and because it did not respond to treatment, the camel was euthanized 26 days after the operation and submitted to the Central Veterinary Research Laboratory for further investigation. Both castration wounds were closed and spermiducts were filled with necrotic masses from which Clostridium tetani was isolated. Two mice, which were injected with the filtrate of the thioglycolate broth, developed typical signs of tetanic spasm of the hind leg. Faecal samples from camel and horse paddocks that were only 50 metres apart were negative for C. tetani. However, C. tetani was isolated from two soil samples of the horse paddock. It is recommended that camels should be vaccinated against tetanus prior to castration.