Tetanus

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Tetanus

• - Prof. N. Shantharam

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Tetanus (contd)

• Tetanus is not common in U.S.A. because of
  mandatory vaccination
• However, a few cases/year in non- vaccinated
  or improper booster individuals
• Tetanus is still very common in Third World
  countriescausing several hundred thousand deaths
  per year
• Many of these deaths involve neonatal tetanus
  due to the umbilical cord being unsterilely cut

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India

• Tetanus is important endemic infection in india
• Factors
• Hand washing
• Delivery practices
• Traditional birth customs
• Interest in immunization
• prior to the national immunization programme an
  estimated
• 3.5 lack children are died annually
• 70,000 cases continue to occur largely in the
  OBIMARU states were TT immunization coverage is
  less than national average (70)

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Tetanus agent

• Clostridium Tetani
• Gram positive
• Spore-forming
• Anaerobic rod

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Clostridium tetani Gram Stain
NOTE Round terminal spores give cells a
drumstick or tennis racket appearance.
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Tetanus (contd)

• Entry of C. tetani into the body usually involves
  implantation of spores into a wound
• After gaining entry, C. tetani spores can
  persist in the body for months, waiting for the
  proper low oxygen growth conditions to develop

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Tetanus (contd)

• When the oxygen levels of the surrounding tissue
  is sufficiently low, the implanted C. tetani
  spore then germinates into a new, active
  vegetative cell that grows and multiplies and
  most importantly produces tetanus toxin

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Tetanus (contd)

• As growing cells of C. tetani produce
  tetanospasmin at the wound site, the toxin starts
  to migrate along nerves and acts mainly on 4
  areas of nervous system
• Motor end plate
• Spinal cord
• Brain
• Sympathetic system
• where it blocks the release of inhibitory
  neurotransmitters
• As a consequence of too much activator
  transmitters, muscles are Over stimulated to
  repeatedly contractcalled spastic paralysis

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Mechanism of Action of Tetanus Toxin
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Reservoir

• Spores of C. tetani are found in soil, dust,
  intestinal tracts of animals and humans
• Throughout the world Spores are very resistant
  to harsh conditions like
• heat
• radiation
• chemicals
• Drying
• Spores can survive for a long time in
  environment---100yrs possibly!
• Communicability
• Tetanus is not contagious from person to person.
• It is the only vaccine-preventable disease that
  is infectious but not contagious.
• Temporal pattern Peak in winter and summer
  season
• Incubation Period 8 DAYS ( 3-21 DAYS)

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• Host Factors
• Age I t is the disease of active age (5-40
  years), New born baby, female during delivery or
  abortion
• Sex Higher incidence in males than females
• Occupation Agricultural workers are at higher
  risk
• Rural Urban difference Incidence of tetanus in
  urban areas is much lower than in rural areas
• Immunity Herd immunity does not protect the
  individual
• Environmental and social factors Unhygienic
  custom habits,Unhygienic delivery practices

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Sequence of events

• Lock Jaw
• Stiff Neck
• Difficulty Swallowing
• Muscle Rigidity
• Spasms

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Risus Sardonicus in Tetanus Patient
A person suffering from tetanus undergoes
convulsive muscle contractions of the jaw--called
LOCKJAW
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Opisthotonos in Tetanus Patient
The contractions by the muscles of the back and
extremities may become so violent and strong that
bone fractures may occur
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CEPHALIC TETANUS A Rare Form of Localized
Tetanus(Courtesy Google image on tetanus)
Unfortunately, the affected individual is
conscious throughout the illness, but cannot stop
these contractions
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Tetanus (contd)

• Death may occur from tetanus, often from cardiac
  (heart) and respiratory (lung) effects or
  secondary complications from the infection

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Types of tetanus

• Traumatic
• Puerperal
• Otogenic
• Idiopathic
• Tetanus neonatorum (8th day disease)

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• Local tetanus is an uncommon form of the
  disease,in which patients have persistent
  contraction of muscles in the same anatomic area
  as the injury. Local tetanus may precede the
  onset of generalized tetanus but is generally
  milder.Only about 1of cases are fatal.
• Cephalic tetanus is a rare form of the
  disease,occasionally occurring with otitis media
  (ear infections)in which C.tetani is present in
  the flora of the middle ear,or following injuries
  to the head.There is involvement of the cranial
  nerves,especially in the facial area.
• The most common type (about 80)of reported
  tetanus is generalized tetanus .The disease
  usually presents with a descending pattern.

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Diagnosis of Tetanus

• Tetanus is suspected upon exposure to a bite or
  puncture wound
• Because C. tetani exhibits such exquisite
  sensitivity to oxygen, it is very difficult to
  recover and/or grow from clinical specimens
• As a result, diagnosis is made on the basis of
  clinical findings and history

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Three Objectives of Management of Tetanus

• To provide supportive care until the
  tetanospasmin that is fixed in tissue has been
  metabolized
• To neutralize circulating toxin
• To remove the source of tetanospasmin.

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Treatment of Tetanus

• Very difficult to treat once symptoms have
  developed
• Antitoxin is administered
• Muscle relaxants
• Supportive therapy (ventilator)
• Cleansing of the wound

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PREVENTION
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Spores are extremely stable,although immersion in
boiling water for 15 minutes kills most spores.
Exposure to saturated steam under 15 lbs.of
pressure for 15-20 minutes at 121c is highly
effective against spores . Sterilization by dry
heat is slower than by moist heat (1 -3 hrs at
160 C),but it is also effective against spores.
Ethylene oxide sterilization is also sporocidal.
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Fumigation

• Sterilization of operation theatre
• 500 ml of formaline, 200gms of Pot.permanganate/30
  cu.meters of space
• All windows and doors are closed except one
• Fissures between the panels of the doors and
  windows are closed with adhesive tape
• After 12 hours the doors and windows are opened
  and the theatre is aired for 24 hours before
  decommissioning it

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• Active Immunization
• Passive Immunization
• Active and passive Immunization
• Antibiotics

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TETANUS TOXOID

• Tetanus toxoid was developed by Descombey in
  1924,
• Tetanus toxoid immunizations were used
  extensively in the armed services during World
  War II.
• Tetanus toxoid consists of a formaldehyde-treated
  toxin.

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TETANUS TOXOID

• There are two types of toxoid available adsorbed
  (aluminum salt precipitated)toxoid and fluid
  toxoid.
• Although the rates of seroconversion are about
  equal,the adsorbed toxoid is preferred because
  the antitoxin response reaches higher titers and
  is longer lasting than that following the fluid
  toxoid.

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ACTIVE IMMUNIZATION

• 1st dose - 6th week (DPT)
• 2nd dose - 10th week (DPT)
• 3rd dose - 14th week (DPT)
• 1st booster - 18th month (DPT)
• 2nd booster - 6th year (DT)
• 3rd booster - 10th year (TT)

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PASSIVE IMMUNIZATION

• 1. ATS(equine) Ig- 1500 IU/s.c after sensitivity
  test
• (or)
• 2. ATS(human) Ig- 250-500 IU, no anaphylactic
  shock, very safe and costly.

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Persons Seven Years of Age or Older Who Have Not
Been Immunized
Immunization requires at least three doses of Td.
1st dose should be administered on the First
visit 2nd dose 4 8 weeks after the first dose
of Td and 3rd dose after 6 months of the
second Td. A booster dose of Td should be
repeated every 10 years throughout life
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Treatment of Tetanus (contd)

• If recovery does occur, there are usually no
  long-term side effects.
• Recovered individuals do not necessarily
  develop natural Immunity against the
  infection--- because the very small amount of
  tetanus toxin produced during the infection
  does not elicit a strong, protective immune
  response which would produce enough antibodies
  against future re-infection

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Photo Courtesy of U.S. Centers for Disease
Control and Prevention
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Newborn showing risus sardonicus and generalized
spasticity
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• Maternal tetanus, defined as tetanus occurring
  during pregnancy or within 6 weeks after any type
  of pregnancy termination, is one of the most
  easily preventable causes of maternal mortality.
• It includes postpartum or puerperal tetanus
• (i) postpartum or puerperal tetanus, usually
  resulting from septic procedures during
  delivery,
• (ii) postabortal tetanus, following septic
  maneuvers during induced abortion
• (iii) Tetanus during pregnancy, generally
  resulting from inoculation through a nongenital
  portal of entry

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• Neonatal tetanus (NNT), a disease preventable by
  immunization, is a major problem and a leading
  cause of neonatal mortality.
• It is easily preventable by 2 tetanus toxoid
  injections and 5 cleans while conducting
  deliveries.
• 2 major programs are in operation for the
  prevention of NNT in the country
• the immunization of pregnant women with tetanus
  toxoid vaccine (TT) under the expanded program on
  immunization (EPI)
• The training of dais under the rural health
  program.

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• NNT will be prevented if the women and the dais
  (who are still associated with almost 70-75 of
  the deliveries in many areas with high NNT
  mortality rates) are convinced of the need for TT
  vaccination during the antenatal period and
  practice the basic principles of cutting cord and
  keeping the umbilical stump free of unclean
  dressings.

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Elimination of Neo natal tetanus

• High risk district
• a) Neo natal death rate gt 1/1000 live births
  
• b) 2 doses of tetanus toxoid coverage lt 70
• c) Deliveries attended by trained dais lt 50
• Medium risk district
• a) Neo natal death rate lt 1 / 1000 live
  births
• b) 2 doses of tetanus toxoid coveragegt 70
• c) Deliveries attended by dais gt 50
• 3. Low risk district
• a) NNT lt0.1/1000 Live Birth
• b) 2 Doses of T.T Coverage gt90
• c) Delivery attended by Trained Dais gt75

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PREVENTION OF NEONATAL TETANUS

• 2 doses of T.T to all pregnant women between 16
  to 36 weeks of pregnancy with an interval of 1 to
  2 months between the two doses.
• The first dose as early as possible the second
  dose a month later preferably 3 weeks before
  delivery.
• If the pregnant woman is previously immunized, a
  booster dose is sufficient.
• If the pregnant woman is not immunized, then the
  new born should be protected against tetanus by
  giving tetanus human immunoglobulin 750 IU with
  in 6 hours of birth.

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thank you