TETANUS

TETANUS

1. Dr. Anuj Singh Asst. Professor, Community Medicine Dept.UIMS , Prayagraj

2. Tetanus Tetanus is an infectious disease caused by contamination of wounds by toxigenic strain of bacteria Clostridium tetani These bacilli live in soil (spore), in animal and human intestines, and in manure 3

3. Pathogenesis:

4. Pathogenesis: The bacteria/spores get into a cut or a wound, multiply there, and produce toxins ( tetanoplasmin and tetanolysin ) Toxins affect the nervous system, the brain, nerves, and the spinal cord This toxin interferes with the working of the nerves that control the muscles and makes them stiff As the disease eventually progress to respiratory failure mortality reaches to maximum if there is no ventilator support

5. Tetanus - Burden

6. Tetanus - Burden O ne of the world’s major preventable causes of death E stimated to cause up to one million deaths every year globally 80% cases occur in Africa and Southeast Asia 7 Year Global India Tetanus total Neonatal tetanus Tetanus total Neonatal tetanus 2000 23,711 17,935 8997 3287 2021 9707 4140 1240 81

7. Neonatal & Maternal Tetanus – India

8. Neonatal & Maternal Tetanus – India Neonatal Tetanus (NT) Elimination: “ incidence of less than one case of NT in 1000 live births in every district or similar administrative unit across the nation in a year ” 9

9. Neonatal & Maternal Tetanus – India NT is one of the most underreported diseases in the world India was declared free of maternal tetanus and NT in May, 2015 Next to Rabies and Acute Encephalitis Syndromes, tetanus is the most common infectious disease contributing to high case fatality in India 10

10. Epidemiological Determinants

11. Epidemiological Determinants 12

12. Epidemiological Determinants Host Children (35% cases) Male Maternal (unimmunised) Agriculture occupation Rural Agent anaerobic, gram-positive C. tetani bacillus Reservoir- Cultivated soil

13. Epidemiological Determinants: cont.. Environment (devitalised tissues) Uncleaned wound from unclean deliveries, injuries, burns, surgeries, dental extraction and barefoot in the field poverty, religious prejudices, traditional unhygienic customs lack of mother and child health services

14. Classification of Districts Based on Tetanus Status

15. Classification of Districts Based on Tetanus Status 16 Indicator Tetanus Risk category for the district NT High risk NT Control NT Elimination Neonatal Tetanus (NT) incidence rate >1/1000 live births < 1/1000 live births < 0.1/1000 live births 2 doses of Tetanus Toxoid Coverage < 70% > 70% > 90% % of clean deliveries by trained personnel < 50% > 50% > 75%

16. Transmission Dynamics

17. Transmission Dynamics Tetanus spores gain entrance in tissues through a cut or a puncture, laceration, or other wounds contaminated with spore-bearing soil Incubation period of 7–10 days in neonatal Tetanus The time between the contamination of a wound and the first symptoms is < 2 weeks 2 days to months in case of Non-Neonatal Tetanus 18

18. Diagnosis Classification : Localised (11-12%) Cephalic Generalised (88%) 25

19. Generalized Tetanus

20. Diagnosis: cont.. Clinical Features: most common, early symptom is stiffness of the jaw (lock jaw) This makes it difficult to open the mouth and swallow pain at the wound site, muscle rigidity pain, stiffness of the stomach and back muscles contraction of the facial muscles Opisthotonus Risus Sardonicus

21. Diagnosis: cont.. Clinical Features: Neonates: poor sucking and feeding difficulties appeared after second day of delivery

22. Alblett -Classification-of-Tetanus

23. Operational Case Definition

24. Operational Case Definition Neontal Tetanus: Child who lost the sucking ability between 3-28 days of neonatal period and becomes rigid Adult Tetanus: One of the following sign 1) Trismus 2) Sarodonicus 3) painful contraction of muscles With/without history of injury/wound Spatula test: Touching the posterior wall of the pharynx with soft instrument like spatula will normally lead to gag reflux whereas in case Tetanus this will result in spams of jaw muscles. Helps to rule out other conditions 37

25. Prevention and Treatment

26. Prevention and Treatment Primary Immunization Pentavalent vaccine (6, 10, 14 weeks) DPT Booster – 18 months Tetanus (replaced with Td recently): 5 years, 10 years , 16 years Ante natal women: 2 doses of Td over 4 week interval during pregnancy Previous Pregnancy within 3 years: One booster dose of Td 39

27. For unvaccinated adolescents and adults, the recommended vaccine is Tdap Initial series: First dose of Tdap Second dose : (Td or Tdap ) 4-8 weeks after the first dose Third dose (Td or Tdap ) 6-12 months after the second dose Booster shots : After completing the initial series, a booster dose of Td or Tdap is recommended every 10 years

28. Prevention & Treatment 41

29. Secondary Prevention First Aid Surgical toilet Isolation Dark room isolation Treatment Antibiotics Anti tetanus serum (Prophylactic: 250 IU. Therapeutic: 10000 IU) Sedatives Cortico -steroids Disinfection Surveillance 43

30. Prevention of Neonatal Tetanus

31. Prevention of Neonatal Tetanus Training of traditional birth attendants (TBAs) Clean delivery practices Disposable delivery kits Five cleans—clean surface, clean hands, clean cord care, clean tie, and clean blade Administration of tetanus toxoid to all pregnant mothers (ensuring protective antibodies are passed on to the fetus in utero) 45