Tetanus

E.S. Herini
Pediatrics Department
FK UGM / RSUP Dr. Sardjito
Yogyakarta

 Tetanus Neonatorum
Tetanus

Introduction
Tetanus Neonatorum
In developing countries:
very common
A major cause of neonatal death

In Sudan: 1 in every 110 infants died

In Bangladesh, Pakistan, and India: > 20 per 1000 live births

In The US:
a rare disorder, because of widespread immunization
programs and effective obstetrical care
Volpe, 2008
3

ETIOLOGY
Clostridium tetani
Gram positive anaerobic rod.
The bacilli are widely distributed in soil; street
dust; and the feces of some horses, sheep,
cattle, dogs, cats, rats, guinea pigs, and
chickens

EPIDEMIOLOGY

Incubation Period
The median incubation : 6.2 and 7.6 days
If this period is shorter than 48 hours
severe
If the interval is longer
milder
Mortality in tetanus neonatorum is higher if the
incubation period is less than 4 days

Krugmans, 2004
6

Pathogenesis
Exotoxin of the anaerobe Clostridium tetani
the umbilical stump
The umbilical cord
cut at the time of birth
with an unsterile instrument
Any degree of passive transfer of immunity to the infant
during gestation is rare
Study in Bangladesh: risk of tetanus neonatorum initially
appeared to be no less in infants of mothers who had
received tetanus toxoid previously
Volpe, 2008

Neonatal tetanus in Turkey; what has changed in the last

decade?
Bunyamin Dikici1, Hakan Uzun*1, Ebru Yilmaz-Keskin2, Taskin Tas3,
Ali Gunes4, Halil Kocamaz4, Capan Konca4 and Mehmet A Tas4
Abstract
Background: Neonatal tetanus (NT) is still considered as one of the major causes of neonatal
death in many developing countries. The aim of the present study was to assess the characteristics
of sixty-seven infants with the diagnosis of neonatal tetanus followed-up in the Pediatric Infectious
Diseases Ward of Dicle University Hospital, Diyarbakir, between 1991 and 2006, and to draw
attention to factors that may contribute (or may have contributed) to the elimination of the disease
in Diyarbakir.
Methods: The data of sixty-seven infants whose epidemiological and clinical findings were
compatible with neonatal tetanus were reviewed. Patients were stratified into two groups
according to whether they survived or not to assess the effect of certain factors in the prognosis.
Factors having a contribution to the higher rate of tetanus among newborn infants were discussed.
Results: A total of 55 cases of NT had been hospitalized between 1991 and 1996 whereas only 12
patients admitted in the last decade. All of the infants had been delivered at home by untrained
traditional birth attendants (TBA), and none of the mothers had been immunized with tetanus
toxoid during her pregnancy. Twenty-eight (41.8%) of the infants died during their follow-up.
Lower birth weight, younger age at onset of symptoms and at the time admission, the presence of
opisthotonus, risus sardonicus and were associated with a higher mortality rate.
Conclusion: Although the number of neonatal tetanus cases admitted to our clinic in recent years
is lower than in the last decade efforts including appropriate health education of the masses,
ensurement of access to antenatal sevices and increasing the rate of tetanus immunization among
mothers still should be made in our region to achieve the goal of neonatal tetanus elimination.
BMC Infectious
Diseases, 2008
8

Clinical Manifestations
Home delivery of infant
Deficient or absent
maternal immunization
Fever
Diminish suck or refusal
to such
Impaired feeding
Abnormal crying

Rigid abdomen
Trismus
Cyanosis
Facial rigidity (risus
sardonicus)
Opisthotonus
Generalized rigidity
Flexed toes; muscular
spasm
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Volpe, 2008

10

Generalized tetanus in a 4-year old boy presenting with

dysphagia and trismus: a case report
Petrus Rudolf de Jong1, Thea de Heer-Groen2, Cornelis Hendrik Schrder2
and Nicolaas Johannes Georgius Jansen1*
Abstract
Introduction: The low incidence of tetanus in developed countries has resulted in a decreased
vigilance of this disease. This raises concern, as the prodromal stadium of a generalized tetanus
infection may lack the characteristic paroxysmal muscle spasms. Tetanus can rapidly progress into
life-threatening muscle spasms accompanied by respiratory insufficiency and/or autonomic
dysfunction. This emphasizes the need for early diagnosis and treatment.
Case presentation: A 4-year-old Caucasian boy presented with a one-week history of general
malaise, mild fever, indolence and anorexia. He subsequently developed dysphagia, sialorrhoea,
difficulties opening the mouth and eventually dehydration. Due to parental concerns about the boys
refusal of fluids, a pediatrician was consulted. At that time of presentation he showed signs of trismus
and muscle rigidity. Together with the lack of immunization and a toe nail infection, this lead to the
suspicion of a generalized tetanus infection. After sedation, endotracheal intubation and ventilation,
passive immunization and initiation of antimicrobial treatment, he was immediately transferred to a
pediatric intensive care unit (PICU) for further treatment. The frequency and severity of paroxysmal
muscle spasms increased progressively during his PICU stay, despite high doses of sedatives. Not
before two weeks after admittance, extubation and careful weaning off sedatives was achieved.
Conclusion: Tetanus infection remains a rare but potentially lethal disease in developed countries.
As the full scope of classical symptoms may be absent at first presentation, tetanus should always be
considered in non-immunized patients with an acute onset of dysphagia and trismus.

Cases
Journal, 2009
11

Figure 1.
(A) A 4-year-old caucasian boy with
generalized tetanus at the
time of admittance to the pediatric
intensive care unit where
mechanical ventilation, deep sedation
and extensive
cardiorespiratory monitoring were
performed. (B) More
detailed photograph of the left hallux
toenail, in this case the
most likely portal of entry, after
surgical debridement.
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Characteristic tetanus infection in disaster-affected areas: case

study of the Yogyakarta earthquakes in Indonesia
Agung Budi Sutiono*1,2, Andri Qiantori1, Hirohiko Suwa1 and
Toshizumi Ohta1
Abstract
Background: Tetanus is an infectious disease caused by the contamination of wounds from
bacteria that live in soil. The tetanus mortality rate remains high in developing countries affected
by natural disasters. Whether the socio-demography and geographical conditions may influence the
tetanus treatment outcome on the earthquake situation in Yogyakarta, Indonesia has not been
investigated.
Findings: We present 26 tetanus patients who were admitted to eight hospitals following the
earthquakes that occurred on May, 27, 2006, in Yogyakarta, Indonesia. The independent variables
were age, gender, distance, admission, hospitalization, and type of hospital with the dependent
variable surviving or perishing. Data were analyzed by logistic regression methods on SPSS 17.0.
The distance from the patient's place of residence to the hospital were obtained and analyzed by
using geospatial tools MapInfo 7.8 SCP and Global Mapper 7. Eight of the 26 patients were dead
(30.8%) and statistical results showed that the distance (OR = 1.740, 95% CI = 1.0682.835) and
type of hospital (OR = 0.067, 95% CI = 0.0013.520) were significant predictors of death.
Conclusion: Our findings show that in order to reduce the mortality rates, performing triage
systems based on the distance and type of hospital priority for internally displaced persons could
be proposed as well as making provisions for the generally old population in order to prevent an
outbreak of tetanus following earthquakes in Yogyakarta, Indonesia.

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Figure 1 r Clostridium tetani

Open wound on disaster is susceptible for Clostridium
tetani.

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Diagnosis
The diagnosis of neonatal tetanus is based primarily
on clinical findings:
The setting of birth at home
Inadequate management of the umbilical stump
Nonimmunized mother
Characteristic neurological features should raise the suspicion
of the diagnosis of tetanus.

Laboratory:
No convenient laboratory test identifies neonatal tetanus
Cultures of the umbilical stump, even when handled carefully
for anaerobic organism, are usually negative

Volpe,15
2008

Differential Diagnosis

Nuchal rigidity :
Meningitis
Intracranial hemorrhage
The spasm are readily mistaken for
convulsions and therefore a variety of cerebral
conditions

Volpe, 16
2008

Management
The aspects should be considered :
1. Early diagnosis
2. Specific treatment: wound management, antibiotic,
neutralization toxin, control of muscle spasms
3. Prevention of early complications
4. Supportive treatment

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Management of Neonatal Tetanus

Intravenous fluids
Enteric feeding
Temperature control
Respiratory support, including mechanical ventilation
and neuromuscular blockade
Sedation and muscle relaxation, especially with highdose diazepam (20 to 40 mg/kg/day)
Tetanus immune globulin 500 units, i.m, in divided
doses
Penicillin G 10,000 units/kg/day for 10 days
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Volpe,

Prognosis

The mortality of tetanus neonatorum: 60-85%

In India (1950s): approximately 85%
More recent studies: approximately 10%
In underdeveloped areas : 30-80%
For person >50 years :70%
For patients 10 to 19 years: 10-20%

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Prevention
The most essensial feature of management of
tetanus neonatorum is prevention
Immunization of women during pregnancy has
proved highly effective
Delivery of infants and management of the
newborn and the umbilical cord under aseptic
conditions

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Schedule of Immunization in children

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IMMUNIZATION SCHEDULE FOR WOMEN OF

CHILDBEARING AGE FOR PREVENTING NEONATAL
TETANUS
The first dose of TT at first contact or as early as possible
during pregnancy.
The second TT dose four weeks after the first dose.
The third and most important dose 6 to 12 months after the
second dose or during the subsequent pregnancy. This
immunization schedule protects mothers and their newborns
for at least 5 years. If it has not yet been given as a part of
postnatal care, it can be given at the subsequent pregnancy,
when the mother brings her child for immunization or when
she is seeking medical care.

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IMMUNIZATION SCHEDULE FOR WOMEN OF

CHILDBEARING AGE FOR PREVENTING
NEONATAL TETANUS
A fourth TT dose should be given at least one year after the
third or during the subsequent pregnancy. This dose will
protect mother and future newborns for at least 10 years.
A fifth TT dose should be given at least ,one year after the
fourth or during the subsequent pregnancy. This dose will
provide life-long protection.
If only a first TT dose has been administered during
pregnancy, the second dose should be given at the time of
delivery or when the mother brings her child for the first
immunization.

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REFERENCES
1. Behrman, Kliegman, Jenson. Nelson
Textbook of Pediatrics. 17th edition, 2004
2. Krugmans. Infectious Diseases of Childrens.
11th edition, 2004
3. Volpe JJ. Neurology of the Newborn. 5th
edition, 2008

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