TETANUS

DR.I.SELVARAJ I.R.M.S
B.SC.,M.B.B.S.,(M.D)., D.P.H.,D.I.H.,PGCH&FW/NIHFW,New Delhi

Sr.D.M.O/S.RAILWAY (On study leave)

Indian Railway Medical service

Photo Courtesy of U.S. Centers for Disease

Control and Prevention

Courtesy: Google image on tetanus

CEPHALIC TETANUS : A Rare Form of Localized Teta

Courtesy : Google image on tetanus)

Courtesy: Google image on tetanus

Newborn
showing risus
sardonicus and
generalized
spasticity

Tetanus is an acute,often fatal,disease caused by

an exotoxin produced by the bacterium
Clostridiumtetani. But prevented by immunization
with tetanus toxoid. It is characterized by
generalized rigidity and convulsive spasms of
skeletal muscles.The muscle stiffness usually
involves the jaw (lockjaw)and neck and then
becomes generalized.

Epidemiology

 Tetanus was first described in Egypt over 3000 years ago(Edwin

smith papyrus). It was again described by Hippocrates
Carle and Rattone in 1884 who first noticed tetanus in animals by
injecting them with pus from a fatal human tetanus case.
During the same year,Nicolaier produced tetanus in animals by
injecting them with samples of soil.
In 1889,Kitasato isolated the organism from a human
victim,showed that it produced disease when injected into
animals,and reported that the toxin could be neutralized by
specific antibodies.
Nocard demonstrated the protective effect of passively transferred
antitoxin,and passive immunization in humans
Passive immunization and prophylaxis for tetanus during World
War I
Tetanus Toxoid was first widely used during world war II

 Tetanus - Greek Word -- Tetanos-to

Contract
Tetanus Remains a Major Public Health
Problem in the Developing World and Is Still
Encountered in the Developed World.
There Are Between 800 000 and 1 Million
Deaths Due to Tetanus Each Year. Eighty Per
Cent of These Deaths Occur in Africa and
South East Asia and It Remains Endemic in
90 Countries World Wide.

1998 - U.K,USA 7 Cases, 41 Cases Including One Neonate

Acridine orange stain of characteristic C tetani with

endospores wider than the characteristic drumstick shape.

Courtesy : Google Image on tetanus

 C.tetani is a slender,gram-positive,anaerobic rod that may

develop a terminal spore,giving it a drumstick appearance.
The organism is sensitive to heat and cannot survive in the
presence of oxygen.The spores,in contrast,are very resistant to
heat and the usual antiseptics.
They can not survive autoclaving at 249.8 F (121 C)for 20
minutes.
The spores are also relatively resistant to phenol and other
chemical agents.
The spores are widely distributed in soil and in the intestines
and faeces of horses,sheep,cattle,dogs,cats,rats, guinea
pigs,and chickens.Manure-treated soil may contain large
numbers of spores.Spores may persist for months to years.
C. tetani produces two exotoxins, tetanolysin and
tetanospasmin. The function of tetanolysin is not known with
certainty. Tetanospasmin is a neurotoxin and causes the
clinical manifestations of tetanus.
Tetanospasmin estimated Human lethal dose 2.5 ng/kg

Occurrence: Tetanus occurs worldwide but is most frequently

encountered in densely populated regions in hot,damp climates
with soil rich in organic matter.
Reservoir:Organisms are found primarily in the soil and
intestinal tracts of animals and humans.
Mode of Transmission:Transmission is primarily by
contaminated wounds,Tissue injury( surgery,burns,deep
puncture wounds,crush wounds,Otitis media ,dental
infection,animal bites, abortion,and pregnancy).
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)

 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 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

Diagnosis Of Tetanus
Clinically it is confirmed by noticing the
following features:
1. Risus sardonicus or fixed sneer.
2. Lock jaw.
3. Opisthotonos (extension of lower
extremities, flexion of upper extremities and
arching of the back. The examiners hand
can be passed under the back of the patient
when he lies on the bed in supine position.)
4. Neck rigidity

Type of Tetanus

Traumatic tetanus
Puerperal tetanus
Otogenic tetanus
Idiopathic tetanus
Tetanus Neonatorum

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 1%of 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.

Three Objectives of
Management of Tetanus
(1)To provide supportive care until
the
tetanospasmin that is fixed in
tissue has been metabolized
(2)To neutralize circulating toxin
(3)To remove the source of
tetanospasmin.

The rating scale for the severity and the prognosis of tetanus is described below.
Score 1 point for each of the following:
Incubation period less than 7 days
Period of onset less than 48 hours
Acquired from burns, surgical wounds, compound fractures, or septic
abortion
Narcotic addiction
Generalized tetanus
Temperature greater than 104F (40C)
Tachycardia greater than 120 beats per minute (>150 beats per min in
neonates)
Total score indicates the severity and the prognosis as follows:
Score of 0-1 indicates mild severity with less than a 10% mortality
rate.
Score of 2-3 indicates moderate severity with a 10-20% mortality rate.
Score of 4 indicates severe tetanus with a 20-40% mortality rate.
Score of 5-6 indicates very severe tetanus with greater than a 50%
mortality rate. (http://www.emedicine.com/ped/topic3038.htm)
Phillips, Dakar,. Udwadia Score

PREVENTION

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 .

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

Active Immunization
Passive Immunization
Active and passive Immunization
Antibiotics

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.
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.

Tetanus Toxoid Adsorbed USP,for intramuscular use,is a sterile

suspension of alum-precipitated (aluminum potassium sulfate)toxoid
in an isotonic sodium chloride solution containing sodium phosphate
buffer to control pH.The vaccine,after shaking,is a turbid
liquid,whitish-gray in color.
Clostridium tetani culture is grown in a peptone-based medium and
detoxified with formaldehyde.The detoxified material is then purified
by serial ammonium sulfate fractionation,followed by sterile
filtration,and the toxoid is adsorbed to aluminum potassium sulfate
(alum).The adsorbed toxoid is diluted with physiological saline
solution (0.85%)and thimerosal (a mercury derivative)is added to a
final concentration of 1:10,000.
Each 0.5 mL dose is formulated to contain 5 Lf (flocculation units)of
tetanus toxoid and not more than 0.25 mg of aluminum.
The residual formaldehyde content,by assay,is less than 0.02%.The
tetanus toxoid induces at least 2 units of antitoxin per mL in the
guinea pig potency test.

Active Immunization

1st dose
2nd dose
3rd dose
1st booster
2nd booster
3rd booster

- 6th week
- 10th week
14th week
18th month
6th year
10th year

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.

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

The Maternal and Neonatal Tetanus

elimination initiative was launched by
UNICEF, WHO and UNFPA in 1999,
revitalizing the goal of MNT elimination
as a public health problem - defined as
less than one case of neonatal tetanus
per 1000 live births in every district of
every country

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
and (iii) tetanus during pregnancy, generally resulting
from inoculation through a nongenital portal of entry

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)
and the training of dais under the rural health program.
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.

Elimination of Neo natal tetanus

1. High risk district:
a) Neo natal death rate > 1/1000 live births
b) 2 doses of tetanus toxoid coverage < 70%
c) Deliveries attended by trained dais < 50%

2. Medium risk district:

a) Neo natal death rate < 1 / 1000 live births
b) 2 doses of tetanus toxoid coverage> 70%
c) Deliveries attended by dais > 50%

3. Low risk district:

a) NNT <0.1/1000 Live Birth
b) 2 Doses of T.T Coverage >90%
c) Delivery attended by Trained Dais >75%

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.

REFERENCE
http://www.medindia.net/health_statistics/diseases/tetanusTeta
nus J J Farrara b, L M Yenc, T Cookd, N Fairweathere, N Binhc,
J Parrya b, C M Parrya b
http://www.who.int/immunization_monitoring/diseases/Tetan
us_map_cases.jpg
Txt book of preventive and social medicine 18 th edition by
K.PARK
Text book of community medicine by T. Bhaskar Rao
Management and Prevention of Tetanus
Richard F.Edlich,MD PhD,?Lisa G..Hill,?Chandra A..Mahler,
ary Jude Cox,MD,?Daniel G..Becker MD,?Jed
H..Horowitz,MD 4 Larry S.Nichter MD MS,4 Marcus
L.Martin,MD 5 &William C.Lineweaver MD6
. www.rxlist.com/cgi/generic/tettoxpi.htm - 22k
. Mansons Tropical diseases 21 st edition

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