Eradication of tetanus.

INTRODUCTION: The causative agent of tetanus, Clostridium tetani is widespread in the environment throughout the world and cannot be eradicated. To reduce the number of cases of tetanus efforts are focussed on prevention using vaccination and post-exposure wound care. SOURCES OF DATA: Medline, Pubmed and Cochrane databases; World Health Organization and United Nations Children's Fund publications. AREAS OF AGREEMENT: The maternal and neonatal tetanus elimination initiative has resulted in significant reductions in mortality from neonatal tetanus throughout the world. AREAS OF CONTROVERSY: Although there are few data available it is likely that large numbers of children and adults, particularly men, remain unprotected due to lack of booster immunization. AREAS TIMELY FOR DEVELOPING RESEARCH: It remains unclear how HIV and malaria affect both responses to vaccination and transplacental transfer of antibodies or how this might affect timing of vaccination doses.

[Localised tetanus with no obvious entry site: about a case in Bamako (Mali)]. / Tétanos localisé sans porte d´entrée apparente: à propos d´un cas à Bamako (Mali).

Tetanus is a major public health problem in sub-Saharan Africa. Localised tetanus is rare, unlike generalized tetanus which has been sufficiently described in the literature. We report a case of localised tetanus with no obvious entry site managed in the Department of Infectious Diseases in Bamako. The study involved a retired nurse aged 59 years who had not undergone tetanus booster immunisation within the last 10 years, corresponding to the date of her last delivery. She was referred to our Hospital with dysphagia associated with inability to open the buccal cavity. Patient's history was characterized by long-term therapy associated with many specialized consultations without any improvement. The diagnosis of localised tetanus with no obvious entry site was retained after having excluded any other local disorder. Outcome was favorable ten days after adequate management. Underdiagnosed or unknown to health-care providers, localised tetanus may mimic other diseases delaying diagnosis and management. Targeted campaign to build awareness should be implemented in order to improve adherence with immunization schedules.

Experience with tetanus in a tertiary hospital in south east Nigeria.

BACKGROUND: Tetanus has for long been an avoidable source of morbidity and mortality particularly in developing countries. The aim of this study was to review the experience with managing tetanus in a regional tertiary hospital in Nigeria. METHODS: A retrospective study of patients who were admitted with a clinical diagnosis of tetanus between January 1999 and December 2003 was done. Relevant data were extracted from the patients'case records. RESULTS: A total of 12 patients were identified within the time frame with a diagnosis of tetanus. There were more male than female patients (ratio 1.4:1) with city dwellers constituting a small majority. The mean age of the patients was 29.8 years. Lower limb injuries accounted for the portal of entry in 75% of cases while one case followed a practice of oral sex. All patients were managed in the general ward and no mortality was recorded despite the presence of dysautonomia in some patients. CONCLUSION: Despite the high rate of morbidity and mortality associated with tetanus in developing countries and despite some regional differences in presentation, careful clinical management even in resource poor countries can result in very good outcomes.

[Management of maternal tetanus contracted by an obstetric procedure].

A 34-year-old woman from the Philippines showed difficulty in opening the mouth. She had no wounds in the last one mouth, but was treated with an obstetric procedure after stillbirth 16 days before in the Philippines. She showed trismus, rigidity and muscle pain, but no muscle spasms, dyspnea and autonomic dysfunction. In this case, it is supposed that the obstetric procedure is the origin of the injury. In Japan, this is the first report of maternal tetanus.

Effect of transplacentally acquired tetanus antibodies on the antibody responses to Haemophilus influenzae type b-tetanus toxoid conjugate and tetanus toxoid vaccines in Filipino infants.

BACKGROUND: Pregnant women in developing countries are vaccinated with tetanus toxoid (TT) to prevent neonatal tetanus. In populations in which the maternal TT-vaccination program is efficiently implemented, responses of the infant to TT and TT-conjugated vaccines such as Haemophilus influenzae type b (Hib) capsular polysaccaride (PS) TT-conjugate (Hib-TT) vaccine may be depressed. OBJECTIVES: To study the influence of transplacentally acquired anti-TT antibodies on responses to TT vaccination and to Hib-TT vaccine. METHODS: One hundred ninety-four healthy Filipino infants received three doses of a Hib conjugate (either Hib-TT, PRP-OMP or HbOC) with diphtheria-tetanus-pertussis vaccine (DTP) given simultaneously but in a separate syringe at the age of 6, 10 and 14 weeks (primary series). In addition 54 of the study children received a booster dose of Hib-TT at 9 months simultaneously with the measles vaccine. RESULTS: Transplacentally acquired anti-TT did not interfere with the anti-Hib PS antibody (anti-Hib PS) response to any of the conjugates. The transplacentally acquired anti-TT was not significantly associated with the concentration of anti-Hib PS either before or after the booster dose of Hib-TT. High concentrations (> or =1 IU/ml) of transplacentally acquired anti-TT inhibited the infants' anti-TT responses. CONCLUSIONS: High concentration of transplacentally acquired anti-TT did not depress anti-Hib PS responses to the Hib-TT vaccine. On the other hand the high anti-TT concentrations somewhat depressed the anti-TT responses of the infants. However, the anti-TT concentrations attained were in the protective range in all study children after either the primary series (DTP + Hib-TT) or the booster dose of Hib-TT.

Field test of a rapid assessment technique against a probabilistic community survey: operational implications for neonatal tetanus elimination.

Neonatal tetanus (NNT) is a leading cause of neonatal mortality in developing countries and is frequently called 'the silent epidemic'. It is endemic in over 90 countries throughout the world. Incidence is often not known, obstructing cost-effective resource management for control measures. In many developing countries NNT is responsible for one-half of the neonatal mortality and up to one-quarter of infant mortality. Case-fatality rates (CFR) can, even with treatment, reach 80-90%. Operational tools for the rapid identification of NNT risk areas need to be developed for WHO's programme which calls for the elimination of NNT by 1995. Results of a rapid assessment technique, carried out in 1990, were compared with those found in a household survey, which was independently carried out in Jalisco, Mexico, in 1988. One approach used random sample survey techniques in rural communities, which in previous years had reported NNT. Of 40 neonatal deaths, 8 (20%) were attributable to NNT. The annual incidence rate was 4.6/1000 livebirths. Using this as the 'gold standard', a rapid assessment technique was evaluated. The NNT cases seen at health services were randomly matched with other neonatal illnesses obtained from health records and then mapped. Age-specific catchment areas for hospitals under investigation and risk areas for NNT were obtained. Areas without NNT cases but with other neonatal illnesses have been operationally considered to be at low risk for NNT. The use of health services by neonates with other pathologies supports the hypothesis that an NNT case, if it occurred within the same time period and area under investigation, would most probably have been admitted.(ABSTRACT TRUNCATED AT 250 WORDS)

Human infections derived from dogs.

Infected dogs, including those that appear healthy, have been implicated in the genesis of certain infectious disorders in humans. Failure to appreciate the epidemiologic features of these infections can result in delayed diagnosis and therapy, with occasional fatal results. Efforts directed toward patient education, frequent veterinarian examinations of household pets, and thorough hand washing after animal contact will reduce the incidence of dog-related infections in humans.

Tetanus immunity among pregnant women attending antenatal care in Dar es Salaam, Tanzania.

This study was conducted to investigate immunity to tetanus among pregnant women with verbal histories or documentation of having been vaccinated under the current five-dose tetanus toxoid (TT) schedule. It examined sera from 176 pregnant women attending antenatal care at Muhimbili Medical Centre in Dar es Salaam, Tanzania. Tetanus antitoxin level of 0.1 IU/ml was considered protective. Our findings show that 94.9% of women had tetanus antitoxin > or = 0.1 IU/ml. Multivariate analysis revealed that time after last vaccination, TT doses received and TT vaccination status explained 7.5%, 5.7% and 2.3% of variations in tetanus antitoxin levels respectively. Pregnant women with non-protective levels of tetanus antitoxin (5.1%) pose great risks of neonatal tetanus to their newborns and are also susceptible to maternal tetanus. Proper keeping of TT vaccination records is vitally important to avoid hyper-immunisation.

[Localized tetanus in Abidjan: clinical and prognostic features (1976-1997)]. / Le tétanos localisé à Abidjan: particularités cliniques et évolutives (1976-1997).

UNLABELLED: Localised tetanus, rarely described in Africa, was examined retrospectively in Abidjan, over a period of 22 years (1976-97). Forty-five patients--representing an incidence rate of 2% of tetanus cases--were reported in this time span. The mean age was 23 years, and none of the patients had had prior access to adequate immunoprophylaxis. Three clinical forms were observed: tetanus of the limbs (32 cases, 71%), cephalic tetanus (11 cases, 25%), and abdominal tetanus (2 cases, 4%). Infection had occurred via wounds of the limbs (38%), intramuscular injections (33%), craniofacial wounds (25%), and abdominal wounds (2%). No portal of entry was identified for 2% of the cases. 37 patients were cured (82%) of whom 5 retained sequelae (11%). 7 deaths were observed (16%). In terms of prognosis, the only risk was secondary generalisation of tetanus (27%). CONCLUSION: Localised tetanus is far from being mild and incurs significant rates of sequelae. The only efficient treatment is immunisation-based prophylaxis.

[Morbidity and mortality of tetanus in the infectious and tropical diseases department in Abidjan 1985 - 1998]. / Morbidité et mortalité du tétanos dans le service des maladies infectieuses et tropicales d'Abidjan (1985-1998).

UNLABELLED: In spite of the increase of the antitetanus immunization coverage, tetanus is still one of the main causes of morbidity and mortality in Côte d'Ivoire hospitals. OBJECTIVE: The purpose of this study was to analyse the epidemiological, clinical and prognosis aspects of tetanus in the department of infectious diseases in Abidjan. METHODS: A retrospective analysis was carried out from patients files admitted for tetanus in this department from 1985 to 1998. Tetanus diagnosis was based on clinical arguments. RESULTS: Within a period of fourteen years, 1870 cases of tetanus representing 3% of hospitalised cases were admitted in the infectious diseases department. For 1387 patients answering to the inclusion criteria of the study the ratio MIF was 2.5. The median age was 28 years old (1-85 years). The entrance doors were dominated by cuts (49.3%) and intramuscular injections of drugs (18.7%). Despite the complete vaccination, 7 patients have presented tetanus (0.5%). About 17% have presented progressive complications especially cardio-respiratory complications (41.5%). The total lethality was 31.9% and the after- effects rate 2.3%. The factors of poor prognosis were the age > 60 years old, IM injections, generalised aspect, group III of severity and presence of complications. CONCLUSION: Tetanus frequency certainly drops in infectious and tropical diseases department, but the lethality remains high therefore a reinforcement of the vaccination efforts and a management of patients are recommended.

Neonatal tetanus in Port Harcourt.

In a previous study on neonatal tetanus (NNT), we provided information on clinico-epidemiological data and reported a case-fatality rate of 60.3%. The present report covers a 7-year period, January 1984 to December 1990, and amongst others, focuses on tetanus toxoid vaccine (TT) coverage of pregnant women. The subjects were those with a diagnosis of NNT and other neonatal admissions. Total neonatal admissions, NNT admissions, neonatal deaths, and NNT deaths were: 4,315, 471, 727, and 221 respectively. The overall NNT case-fatality rate was 46.9%. The highest NNT admission rate was in the third quarter of 1984, with a significant decline subsequently except for the increase in 1989. The neonatal tetanus rate began dropping appreciably from 1988 although less than 10% of the mothers in 1990 received two doses of TT. The improper immunization of the mothers during pregnancy with TT is worrying particularly several years into the Expanded Programme on Immunization (EPI), more so as the experience is not unique to Port Harcourt. We suggest intervention at the community level, operational research, and ethnographic studies to determine possible underlying factors to be carried out in all health zones of the country.

Bronchoaspiration as a possible cause in a case of tetanus. A reminder on the importance of adulthood immunizations.

Although preventable by immunization tetanus still takes a large death toll, mostly in developing countries, where adult population is often unprotected and opportune medical care unavailable. We present a case of tetanus in an elderly patient with bronchoaspiration pneumonia after a near-drowning incident, in which no objective entry site could be suspected with as much temporal relation as the bronchoaspiration incident. Bronchoaspiration of organic matter and feces provides both a source of the causative agent and an adequate polymicrobial environment for the development of the disease. It is under such conditions that we propose this unusual entry site as the cause of tetanus in our patient. Special emphasis is made on the importance of adulthood immunization programs and how incidents like this one should be taken into account in the overall care provided to the elderly population.

[The hospital-borne tetanus in the reference service of the Donka National Hospital in Conakry (2001-2011)]. / Le tétanos nosocomial dans le service de référence de l'hôpital National Donka à Conakry (2001-2011).

Become almost non-existent in the developed countries, the hospital-borne tetanus always stays of current events in our country in spite of the forensic problem which it puts. The objectives of this study were to determine prevalence of this affection, to describe its clinical picture and to determine its lethality. It is about a retrospective study of a duration of 11 years realized in the service of the infectious diseases of Conakry. Among 8649 hospitalizations from 2001 till 2012 we brought together 239 cases of tetanus (2.7%) among which 60 hospital-borne tetanus (0.7%). Men represented 73% of these cases, with a sex-ratio M/F of 2.7. The age bracket of 20-40 years was the most affected with 32 cases (53.3%). A single patient had begun his vaccinal calendar which had remained incomplete. Both national hospitals of the CHU of Conakry and private hospitals were the biggest suppliers of this hospital-borne tetanus with respectively 22 and 27 cases (36.6 and 45%). Tetanus related to IM of quinine represented 26 cases (43.3%) whereas the hernial cure was found in 16 cases (26.6%). The average duration of invasion and incubation was respectively 1.5 days and 6 days for the dead (n = 45.7%) and 2 days and 10.5 days for the survivors. Three-quarters of 60 patients died. The fight against this type of tetanus passes inevitably by an improvement of the working conditions, a strict application of the rules of asepsis and the in-service training of the medical and paramedical staff.