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I. Neonatal tetanus
1.1 Introduction
1.2 Descriptive epidemiology
1.3 Analytical epidemiology
II. Control and prevention of neonatal
tetanus
III. National strategies
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r an acute, non-contagious and often fatal
bacterial disease caused by an exotoxin
of Clostridium tetani

r It is a form of generalized tetanus that

occurs in newborns and is a killer
disease, second only to Measles among
the six target diseases of EPI
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r It is one of the most under reported
"notifiable" diseases and despite being
eminently preventable, continues to be a
leading cause of neonatal mortality in
developing countries
r Evidences show only estimated 2-8% of
all cases are reported worldwide
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r Gasically, it results from contamination
of the umbilical stump at or following
delivery of a child born to a mother who
did not possess sufficient circulatory
antitoxin i.e. immunization to protect the
infant passively by transplacental
transfer.
r 2008 global figure shows that there was
6658 reported cases and 257,000
estimated deaths (2000-2003)
 
 

r w
 
 
 
ÿorldwide but most frequently
encountered in densely populated
regions in hot, damp climates with soil
rich in organic matter. The occurrence is
peak in summer or wet season.
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r m    
è Agent : Clostridium tetani, a gram
positive, anaerobic, spore-bearing
organismis found in soil and lower
intestinal tract of animals and remain
viable for many years. It is resistant to
disinfectants and withstand boiling for
several minutes. It is killed only by
autoclaving at 121 degree celcius for 15
minutes.
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è -ost :
1. Age : Common age of onset is between
five to fifteen days following birth. The
symptoms is usually seen in 7th
days,so, it is also called 8th day
disease in Punjab.
2. Sex : Goth the sexes are equally
affected. Gut higher incidence is found
in males.
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3. Immunity : No age is immune unless
protected by previous immunization.
Immunity lasting for a few weeks (less
than 6 months) can be transferred to the
baby, if the mother is immunized during
pregnancy or if she already has a high
level of immunity at the time she
becomes pregnant.
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è Environment : It tends to occur in areas
with poor access to health care; hence it
often remains hidden within the
community. The environmental factors
are compounded by social factors such
as unhygienic customs and habits;
unhygienic delivery practices (e.g. using
unsterilized instruments for cutting the
umbilical cord, dressing of umbilical cord
with ashes, soil or cow dung)
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r 

 
è 
     Soil, dust, and
animal feces.This is particularly true
with- manure treated soils, as the spores
are widely distributed in the intestines
and feces of many non-human animals
such as horses, sheep, cattle, dogs,
cats, rats, guinea pigs, and chickens.
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è 6   

Non-sterile instrument contaminated
with tetanus spores
è    
   
None. Not transmitted from person to
person.
è ë  



Caused by contamination of wound by
spores of C.tetani, not transmitted from
person to person. It results from
contamination of the umbilical stump
due to unclean delivery or traditional
application of contaminated material at
or following delivery of a child born to a
mother who did not possess sufficient
circulatory antitoxin to protect the infant
passively by transplacental transfer.
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è 6
  
The usual incubation period in NT is five
to ten days, thus most cases of NT have
their onset in the later part of 1st week
or early in the second week of life. The
shorter the incubation period, the more
severe the symptom. In neonatal
tetanus, symptoms usually appear from
4 to 14 days after birth, averaging about
7 days.
·
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è V  


Common presenting features are;
· Muscular rigidity
· Painful paroxysmal spasms of the
voluntary muscles especially the
masseters (trismus), the facial muscles
(risus sardonicus), the muscles of neck
and back(ophisthotonus) and those of
the lower limbs and abdomen.
· -istory of normal suck and cry for the
first two days of life: history of onset of
illness between 3 and 28 days of age;
history of inability to suck.
Other features include;
3 Êever and sweating
3 vomiting
3 cyanosis
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3 flex toes
3 convulsions and seizures
3 stiffness of the body
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è V   

1. Respiratory Êailure
2. Pneumonia
3. Myoglobinuria
4. -ypoxic encephalopathy
5. Pulmonary embolism
6. Laryngospasm
7. Aspiration
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è  

Clinical diagnosis is possible:

Any neonate with normal ability to suck
and cry during the first 2 days of life 
- who, between 3 and 28 days of age,
cannot suck normally 
- becomes stiff or has spasms (i.e.
jerking of the muscles)
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è Y
There¶s no specific treatment, however
the following treatment measures can be
followed:


  



a.Gaby should be kept in quite room with

proper light.
b.Intramuscular injection should be
avoided.
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c.Temperature should be maintained.
d.Oro-pharyngeal secretion should be
sucked periodically.
e.Maintainance of Oxygen is important.
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a. Oral feeding should be stopped and
intravenous line should be established
to provide adequate food,electrolyte and
for proper administration of the drugs.
b. After 3-4 days, milk feeding through
nasogastric tube may be established.
       

    
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Y   

  
 

 
 

  
 ! 


  


 

   

 




  

  


! 


 


Î Deliveries or medical procedures done

outside health-care facilities
Î Girth attendants without medical training
Î Unclean hands and instruments
Î Dirt, straw, or other unclean materials as
delivery surface
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Î Animals kept inside or adjacent to home
(for home deliveries)
Î Animal dung used for fuel
Î Traditional substances used during
labour, delivery, or abortion (ie, cow
ghee and other animal or vegetable oils,
juices or herbs )
Î Traditional substances used for umbilical
cord care (ie, cow dung, rat faeces, cow
ghee other oils or juices, herbs, ash,
surma, soil, sand)
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Î Neonates swaddled in animal dung or
soil
Î Traditional neonatal surgeries (ie,
circumcision, ritual scarification, ear
piercing, uvulectomy)
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 "  

Î Absent or incomplete immunisation with

tetanus toxoid
  


! 


 

   


   
Î Poverty
Î Absent or poor maternal and child health
care education
Î Poor antenatal-care attendance
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Î Young maternal age or first pregnancy
Î Cultural constraints to women¶s
movements and contacts
 w  

Î Death of a previous child in a family from

neonatal tetanus (predictive of
subsequent Cases)
Î Male sex (increased risk of neonatal
tetanus)
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Gasically the control of neonatal tetanus
focuses on training the traditional birth
attendants, providing home delivery kits
and educating pregnant women about
the ³three cleans´ ± clean hands, clean
delivery surface and clean cord care i.e.
clean blade for cutting the cord, clean tie
for the cord and no application on the
cord stump. -owever, the preventive
measures are:
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In the year 1989, in recognition of the

magnitude of neonatal tetanus
incidence, as well as the preventable
nature, the ÿorld -ealth Assembly
resolved to eliminate neonatal tetanus
by 1995. This goal was reaffirmed in
1999 and a new target was set for
elimination of NT by the year 2005.
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The national strategies for the elimination
of neonatal tetanus are:
m

    

"   

a) A clean perineum and a clean delivery

surface; clean hands of birth attendant;
clean cutting and care of the umbilical
cord. Êor purposes of the NNT
elimination programme, a clean delivery
is defined as a delivery attended by
health staff in a medical institution or by
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b) The place of routine antenatal care
services and the quality of care provided
not only monitor the progress of
pregnancy and appropriate interventions
needed but also provide an ideal
opportunity to discuss the place of
delivery and who would assist at the
delivery. Goth these issues are crucial to
the provision of a clean delivery and the
elimination of NNT and therefore need
to be identified, even in situations where
formal antenatal clinic services are not
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  ! YY
Antenatal care services, when available,
offer the ideal opportunity for pregnant
women to be immunized with TT, which
is also a ë
 
in the elimination
of NNT. Countries that have a well-
developed MC- service infrastructure,
which is utilized by pregnant women,
would find the routine provision of TT
immunization at antenatal clinics as the
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· A prerequisite for disease surveillance,
which is the third ë
 
, is the
recognition of NNT from other causes of
neonatal convulsions. The standard
clinical case definition, recommended by
the NNT elimination programme, applies
equally well for use by medical and non-
medical persons alike, namely, normal
suck and cry for the first two days of life;
onset of illness between 3 and 28 days
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· Reporting of NTT cases, separate from
other tetanus cases, is also an important
aspect of disease surveillance. Other
disease surveillance activities include:
· monthly reporting, including zero case
reporting ± in districts where NNT is
known or suspected to persist.
· identification of high-risk areas for
priority attention.
· sentinel reporting ± where accurate
reports are not possible from all