Tetanus
د- هديل فاضل فرهود
Introduction:
An acute disease induced by an exotoxin of the tetanus bacillus , which grows anaerobically at the site of an injury .
The disease is characterized by painful muscular contractions , primarily of the masseter and neck muscles , secondarily of trunk muscle . the case fatality ranges from 10-90% , it is highest in infant and elderly .
The disease is common in agricultural regions and in underdeveloped areas where contact with animal extra is more likely & immunization is adequate, & important cause of death in many countries of Asia, Africa, south America, especially in rural & tropical areas where tetanus neonatorm is common. Paranteral use of the drugs by addicts, particularly IM , SC use , can result in individual cases & occasional circumscribed outbreak. ( in Developing countries , approximately 1,000,000 cases of tetanus are estimated to occur worldwide each year , with 200,000 to 300,000 deaths. While the annual incidence of tetanus in the United States was 0.16 cases/million population (43 cases on average in the United States per year)
Infectious agent: clostriudum tetani, the tetanus bacillius.*
*Reservoir: intestine of horses & other animals, in humans . soil or fomites contaminated with animal & human feces.
*Mode of transmission: tetanus spore are introduce into the body, usually through a puncture wound contaminated in soil, street dust or animal or human feces.
Through lacerations, burns & trivial wound, or by injected contaminated street drugs.
Tetanus occasionally follows surgical procedures which include circumcision. tetanus can develop in unusual clinical settings such as in:
1- Neonates (due to infection of the umbilical stump)
2- Obstetric patients (after septic abortions)
3- Post surgical patients (with necrotic infections involving bowel flora)
4- Patients with dental infections
5- Diabetic patients with infected extremity ulcers
6- Patients who inject illicit and/or contaminated drugs
*Incubation period: average 10 days .
*Period of communicability: not directly transmitted from person to person .
*Susceptibility & resistance:
Susceptibility is general , active immunity is induced by tetnus toxoid & persist for at least 10 years after full immunization. Recovery from tetuns is not result in immunity , 2nd attack can occur.
Methods of control :
A. preventive measures :
1- educate the public on the necessity for complete immunization with tetanus toxoid , the hazards of puncture wounds and closed injuries , and the potential need after injury for active &/or passive prophylaxis .
2- active immunization with tetanus toxoid , which give protection for at least 10 years . the toxoid is generally administered together with diphtheria toxoid and pertussis vaccine as a triple (DTP or DTaP) antigen ( or double DT) antigen for children under 7 years with contraindication to pertussis vaccine , or TD for older people .
In countries with incomplete immunization programs for children , all pregnant women should received 2 doses of tetanus toxoid .
a- the schedules recommended of tetanus toxoid is the same as diphtheria ( 2,4,6 months & 1st booster
dose at 18 months ,2nd at 4-6 years of age prior to school entry ).
b- tetanus toxoid of the militaries recommended to workers in contact with soil , sewage and domestic animals , members of the military forces , policemen and other with greater than usual risk of traumatic injury , older adult , immunocompromised children and adults .
c- active protection should be maintained by administering booster doses of Td every 10 years .
3- prophylaxis in wound management :
Tetanus prophylaxis in patients with wound is based on careful assessment of whether the wound is clean or contaminated , the immunization status of the patient , Tetanus toxoid & / or TIG, wound cleaning wher required .
TETANUS NEONATORUM
Is a serious health problem in many developing countries where maternity care services are limited and immunization against tetanus is inadequate .
WHO estimate more than 500,000 deaths due to tetanus neonatorum still occur annually in the developing countries. Case fatality rates are very high exceed 80% . Most newborn infants with tetanus born to nonimmunized mothers delivered by a traditional birth attendant outside a hospital .
Prevention of tetanus neonatorum can be achieved by a combination of two approaches :
By improving maternity care on increasing the tetanus toxoid immunization coverage of women of childbearing age (especially pregnant women ), and by increasing the proportion of deliveries attended by trained attendants.
Important control measures including licensing of midwife, providing professional supervision and education as to mothers , equioment & techniques of sepsis in childbirth &educate mothers , relative , attendance in the practice of strict asepsis of the umbilical stump of newborn infants.
Nonimmunized women should received at least 2 doses of tetanus toxoid according to following schedule: the first at initial contact or as early as possible during pregnancy ( 4 months of pregnancy ) , the second dose at 5 months of pregnancy or preferably at least 2 weeks before delivery , the third dose could be given 6-12 months after the second, or during her next pregnancy . an additional 2 doses should be given at annual intervals .
Atotal 5 doses should protect the previously unimmunized women through her entire childbearing period .