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Tetanus

1. Tetanus

2. What is tetanus?
•Tetanus is an acute, often fatal, disease caused by an
exotoxin produced by the bacterium Clostridium tetani. 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.

3. •Tetanus
•According to CDC tetanus is an acute illness
with muscle spasms or hypertonia in the
absence of a more likely diagnosis.
•Neonatal tetanus
•according to WHO, it is an illness ocuring in a
child who has the normal ability to suck and
cry in the first 2 days of life but losses this
ability between days 3 and 28 of life and
becomes rigid and has spasms.

4. •Maternal tetanus
•according to WHO, it is tetanus occruing
during pregnancy if within 6 weeks after
conclusion of pregnancy.

5. Etiology
•Clostridium tetani
•an anaerobic, gram-positive, spore forming rod
bacteria
•its spores resist boiling and many disinfectants.
•Spores found in soil, animal feces
•Two exotoxins produced with growth of bacteria
(tetanospasmin and tetanolysin)

6. Epidemiology
• Reservoir
•soil and intestine of animals and humans
•Transmission
•contaminated wounds
•tissue injury
•Communicability
•not contagious

7. Pathogenesis
•Anaerobic conditions allow germination of spores and
production of toxins
• Toxin binds in central nervous system
•Interferes with neurotransmitter release to block inhibitor
impulses
•Leads to unopposed muscle contraction and spasm

8. Clinical manifestations
•Incubation period; 8 days (range, 3-21 days)
•Three clinical forms:
•local (uncommon),
•cephalic (rare),
•generalized (most common)

9. •Local
•persistent contraction of muscles in the same
anatomic area as the injury.
•These contractions may persist for many weeks
before gradually subsiding.
•may precede the onset of generalized tetanus but is
generally milder

10. •Cephalic tetanus
•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.

11. •Generalized tetanus
•trismus (lockjaw)
•stiffness of the neck
•difficulty swallowing
•rigidity of abdominal muscles
•spasms continue for 3-4 weeks
•complete recovery may take months

12. •Neonatal Tetanus
•Generalized tetanus in newborn infant
•Infant born without protective passive immunity
•occurs through infection of the unhealed
umbilical stump, particularly when the stump is
cut with an unsterile instrument

13. Classification
Grade Description
Grade 1
(Mild)
• Mild trismus and spasticity
• no respiratory compromise, spasms,
dysphagia
Grade 2
(Moderate)
•moderate trismus and well marked rigidity
• Short spasms, mild dysphagia
•Moderate respiratory involvement with RR
>30bpm
Grade 3
(Severe)
•Severe trismus and generalized rigidity
• Prolonged spasms, severe dysphagia
• RR >40bpm with apneic spells
• PR >120bpm
Grade 4
(Very severe)
• Grade 3 + Severe hypertension with
tachycardia alternating with hypotension
and bradycardia
Albett classification

14. Treatment
•First is to stop toxin production by the ff:
•cleaning and debridement the wound
•Antibiotic therapy for 7 days (Metronidazole
preferred, 400mg rectally or 500mg IV q6h)
•Second is to neutralize the unbound toxin:
•give tetanus immune globulin or antitoxin.
•HTIG 3000-6000 units IM single dose or
•Equine tetanus antitoxin 10,000-20,000 units
IM single dose

15. Treatment
•Third is to give active immunization:
•tetanus toxoid given at 3 doses at least 2 weeks
apart and booster doses 1 year apart.
•Forth are supportive management:
•benzodiazepines for spasms
•mechanical ventilator for breathing in severe cases
•admit in a calm and quiet environment to prevent
triggering of spasms
•adequate fluid and nutrition

16. DOH programs
•AVAIL OF FREE VACCINATION IN ALL PUBLIC SCHOOLS - DOH
•“School-based immunization is a strategy for reaching older children and adolescents,”
•The DOH’s school-based immunization program aims to reach more children, especially with the yearly
increase in the number of enrollees.
•School-based immunization was piloted in 2013 in selected provinces and cities nationwide. In August
2015, the DOH, in collaboration with Department of Education (DepEd) and the Department of Interior
and Local Government (DILG), successfully conducted vaccination in 38,688 public schools nationwide
providing a second dose for measles and booster doses for diphtheria and tetanus. This became a
yearly activity since 2015 when August was declared  School-Based Immunization month.
•This year’s school-based immunization aims to provide all public school learners enrolled in
Kindergarten to Grade 7 a second opportunity for measles and rubella vaccine. The program will also
provide grade 1 and 7 learners nationwide with booster doses of tetanus-diphtheria.
•For the 2019 school-based immunization, school children from kindergarten to grade 7 (K - 7) are the
target population to be vaccinated.
•School-based immunization pre-implementation started June 2019 while actual vaccination using
selective strategy will be until September 2019.

17. •The Expanded Program on Immunization (EPI)
•established in 1976 to ensure that infants/children and
mothers have access to routinely recommended infant/
childhood vaccines. Six vaccine-preventable diseases
were initially included in the EPI: tuberculosis,
poliomyelitis, diphtheria, tetanus, pertussis and
measles.

19. Immunization in pregnant
women
•If a pregnant woman has not previously been vaccinated,
or if her immunization status is unknown, she should
receive two doses of a tetanus toxoid-containing vaccine
one month apart with the second dose given at least two
weeks before delivery. Two doses protect against tetanus
infection for 1–3 years in most people. A third dose is
recommended six months after the second dose, which
should extend protection to at least five years.

20. Immunization in pregnant
women
–– Two further doses for women who are first vaccinated
against tetanus during pregnancy should be given after the
third dose, in the two subsequent years or during two
subsequent pregnancies.
–– If a woman has had 1–4 doses of a TT in the past, she
should receive one dose of a TT during each subsequent
pregnancy to a total of five doses (five doses protects
throughout the childbearing years).

21. Dose of TT or Td When to give Expected duration of
protection
1 At 1
st contact or as early
as possible in pregnancy
None
2 At least 4 weeks after TT1 1-3 years
3 At least 6 months after
TT2 or during subsequent
pregnancy
At least 5 years
4 At least one year after TT3
or during subsequent
pregnancy
At least 10 years
5 At least one year after TT4
or during subsequent
pregnancy
For all childbearing age
years and possibly longer