Tetanus

Definition of Tetanus:

• A non - communicable/infectious disease causing

sustained muscular spasm, contraction
and convulsions.

• Derived from Greek word tetanos - stretch.

• Causes: Contaminated wounds, llacerations,

injection sites, aabrasions, burns, frostbites, fforeign
bodies, surgeries and unhygienic child births
Epidemiology

• Host: Humans, domestic & wild animals

• Causative Organism: Clostridium tetani a gram positive,

spore-forming bacteria.

• Found in two forms:

1. Dormant form (spores)

2. Active form (vegetative).

• Communicability: Not directly transmitted from person-
person.

• Age: Affect any age.

• Distribution: Tetanus occurs worldwide and is endemic in

many developing countries.

• Incidence in developed countries is low due to effective

vaccination programs.
Path physiology

• Spores enter through puncture wounds

• Inside the body spores develop into active form that

multiply and produce a powerful toxin tetanospasmin

• (a poison that attacks nervous system and blocks nerve

signals from the spinal cord to and from the muscles).
Case definitions

• Probable case: In the absence of a more likely diagnosis, an

acute illness with muscle spasms or hypertonia, OR

- diagnosis of tetanus by a health care provider, OR

- Death, with tetanus listed on the death certificate as the

cause of death

• Confirmed case: There is no definition for “confirmed”

tetanus case.
History:

• In 1889 Japanese In 1897, Edmond Nocard showed

bacteriologist Kitasato, tetanus antitoxin produces
isolated tetanus passive immunity (used during
bacterium. World War I).
4 types of Tetanus:

1 Generalized tetanus: Most common & severe form affects all

skeletal muscles
2 Local tetanus: Manifests with muscle spasms at or near
the infected wound

3 Cephalic tetanus: Affects one or more muscles in face in 1

or 2 days after a head injury or ear
infection. Lockjaw occur that can easily
progress to generalized tetanus.

4 Neonatal tetanus: Is similar to generalized tetanus except

that it affects a neonate
1. Generalized tetanus:

1. Lockjaw: spasm of facial muscles.

2. Risussardonicus: A sardonic smile (facial muscle spasms)

Cont,

3. Opistotonus: Progressive and intense muscle spasm

leads to characteristic arching of back and fractures.
2: Cephalic Tetanus:

• Rare, involves 7th cranial nerve

• Lockjaw, weakness of facial muscle occurs

• In 2/3rd of cases, generalized tetanus develops

3: Symptoms of Localized Tetanus

• In localized tetanus, muscle spasms occur at or near the

site of the injury.

• This condition can also progress to generalized tetanus.

 Diagnosis:

• Diagnosis is based on clinical symptoms.

• The bacteria, is recovered from wound in only 30% of cases.

Spatula test:

• Posterior pharyngeal wall is touched with soft-tipped

instrument.
i. Negative test: Elicits a gag reflex, patient tries to expel
spatula.
ii. Positive test: Results in the involuntary contraction of
the jaw (biting down the spatula)
 Treatment:

i. Wound care
ii. Medications
iii. Supportive care
iv. Vaccination

1. Wound care
Clean wound thoroughly by soap & water to remove dirt,
foreign bodies and dead tissue from wound to prevent
growth of tetanus spores.
2. Medications

• Antibiotics. To fight tetanus bacteria.

• Sedatives. Sedatives to control muscle spasms.

• Other drugs. Like magnesium sulfate, beta blockers &

morphine to regulate involuntary muscle activity, regularize
heartbeat and breathing

• IV fluids

3. Supportive therapies: Long period of treatment in an

intensive care settings. E.g. ventilator
Vaccinations

Anti Tetanus vaccine

Tetanus toxoid (TT)
Anti Tetanus vaccine

• Tetanus antitoxin is an immunoglobulin.

• Neutralizes the toxin produced by Clostridium tetani.

• Used to provide temporary passive immunity.

• Contraindicated: not be used for prophylactic use or

when anti tetanus immunoglobulin is available or the
patient is allergic (give test dose)

• The dose is usually from 1500 - 6000 units.

Tetanus Toxoid

• Best tool to prevent tetanus

• Recommended for people of all ages, with booster shots

throughout life.

• After three doses almost everyone is immune.

• Pregnant women should be immunized against tetanus

this can prevent neonatal tetanus.
 EPI for children:

1. A Pentavlent vaccine is 5 vaccines conjugated in 1 to actively

protect infants & children from 5 deadly diseases.

(Homophiles Influenza B, Pertussis, Tetanus, Hepatitis & Diphtheria)

1. PENTAVLENT - 1 at 6 weeks

2. PENTAVLENT - 2 at 10 weeks

3. PENTAVLENT - 3 at 14 weeks

• The booster at 4 - 6 year of age, than every 10 years.

Complications:

• Once tetanus toxin bonds to nerve endings it is

impossible to remove. Complete recovery requires
growth of new nerve endings and takes several months.

• Fractures due to severe muscular spasms.

• Prolonged immobility by high doses sedatives leads to

permanent disability.

• Brain damage in infants.

• Respiratory failure is the most common cause of death.

Prevention

• Tetanus can be prevented through immunization

• Neonatal tetanus can be prevented by immunizing

women of childbearing age with TT, either during

pregnancy or outside of pregnancy.

• This protects the mother and – and through a transfer of

tetanus antibodies to the fetus – also her baby.

Prognosis:

• 25%-50% of people with generalized tetanus will die.

• Very young & old tend to have more severe disease.

• Death is usually due to respiratory or cardiac failure.

• Intensive medical care improves the prognosis.

• Data on worldwide neonatal deaths is not complete due

to poor data collection in many countries, however, it is
about 60%-80%.
Tetanus neonatorum
Neonatal Tetanus:

• Deadly disease of newborn, fatality is 70- 100 %

• About 4 million neonatal deaths occur/year

• Accounts for 2/3rd of infant mortality & 40% under 5 mortality.

• Danger to neonates of non immunized mothers

• Deaths occur before infant is two weeks old

• Common in developing countries and poor communities.

• Causes are unsanitary cord-care and unsterile instruments.

• Not reported among neonates in developed countries.

Symptoms

• Symptoms commonly appear on 3rd day after birth &

include:

1. Difficulty in swallowing

2. Irritability, muscle spasms & rigidity

3. Poor sucking

4. Convulsions
Treatment:

1. Clean wounds thoroughly.

2. Give valium to reduce severity of spasms.

3. Tetanus immunoglobulin and tetanus antitoxin.

4. Antibiotics.

5. Supportive treatments like oxygen and NG tube

6. Tracheotomy may be performed for obstruction of

airway.
Maternal Neonatal tetanus (MNT)

• The MNT Elimination Initiative was launched by UNICEF,

WHO in 1999.

• Aim: achieve < 1 NT /1000 live births in every district.

• In August 2015, MNT remains a major public health

problem in 21 countries.
The strategies

1. Strengthening routine immunization of pregnant

women with tetanus toxoid vaccine

2. TT Supplementary Immunization Activities (SIAs) in

selected high risk areas, targeting women of
reproductive age with 3 properly-spaced doses of the
vaccine

3. Promotion of clean deliveries and clean cord care

practices
Key facts

• Tetanus is acquired when the spores of the bacterium

Clostridium Tetani infect a wound or a new-born's umbilical
stump.

• The spores are universally present in the soil.

• Spores germinate to produce an exotoxin, tetanospasmin, that

causes rigidity & spasms of voluntary skeletal muscles

• People of all ages can get tetanus but the disease is common
and serious in new-born babies.
• Neonatal tetanus is a significant problem in developing
countries due to poor umbilical stump hygiene and lack of
maternal immunization.

• Neonatal tetanus requires treatment in a medical facility, often

in a referral hospital.

• Acute condition requiring intensive care

• Prevention is by immunization