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 Tetanus
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 104°F (40°C)
•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 121°c 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 - 6th week
• 2nd dose - 10th week
• 3rd dose - 14th week
• 1st booster - 18th month
• 2nd booster - 6th year
• 3rd booster - 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/tetanusTet
anus 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, 툺 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
. Manson’s Tropical diseases 21 st edition
THANK YOU