Tetanus
Tetanus has been familiar to man for millennia. The disease is widespread, but it especially kills numerous individuals in tropical nations, where the disease goes by many local names. With the invention of tetanus toxoid and the establishment of modern immunization services, tetanus is an entirely preventable disease. Despite the existence of an inexpensive, safe, and effective vaccine, tetanus is a persistent medical problem in numerous nations.
In industrialized nations where immunization schemes for infants, children, and adolescents have been in place for many decades and where nearly all infants are delivered in hospitals, tetanus is a rare condition that occurs primarily in older patients. In developing nations, tetanus remains a significant health burden, and the disease occurs across all age groups, with a particular fondness for newborns and young individuals. Tetanus has been identified as a priority issue and has been among the six target diseases of the WHO Expanded Program on Immunization since 1974. The central emphasis of the EPI is on eradicating NT from developing nations.
Neonatal Tetanus in the Past
In the eighteenth and nineteenth centuries, Tetanus was common in the Scottish Islands, Iceland, Westmann Islands, Faroe Islands, and Greenland. On the Scottish island of St. Kilda, 40 miles west of the Outer Hebrides, the inhabitants were increasingly killed off by NT.
In 1764 Rev. Kenneth MacAuley wrote: The St. Kilda babies are strangely liable to a most remarkable sort of sickness: on the fourth, fifth or sixth night after birth, many of them abandon sucking on the seventh, their gums are so locked together, that it is not possible to pass anything down their throats. Shortly after this symptom sets in, they are overcome with convulsive fits and, after fighting against excessive agony until their meager strength is spent, die typically on the eighth day.
Weakness of Routine Surveillance Systems
Tetanus is a very underreported disease, even among regions with well-developed disease surveillance systems. Early in the 1980s, WHO calculated that routine reporting systems detected no more than 5% of tetanus cases that were occurring globally. The majority of unreported cases take place in rural, poor settings where babies are born at home by poorly trained or untrained attendants.
Underreporting is also caused by the relative lack of concern for neonates in health care and traditional beliefs regarding neonatal deaths in some societies. NT occurs in the initial days of life when the child remains confined to the home. Stigmas shared with many traditional belief systems or because of linkage with unclean delivery practices act as disincentives to treatment-seeking. The case fatality rate is high, and the small number of surviving infants do not develop overt disabilities to detect that the disease has taken place.
Surveillance data are not a good representation of worldwide trends in NT incidence. Though 90% of nations currently report NT cases separately from other types of tetanus, routine reporting systems only detect a small fraction of the NT cases estimated to occur worldwide. Tetanus is not an individually reportable disease in China, vaccination, booster vaccine, childhood vaccines, pertussis, immunization the world’s most populous nation.
The magnitude of the Problem Knowledge regarding the size of NT has been significantly enhanced by the findings from the community surveys following a protocol established in India. In the 1980s, over 40 developing nations carried out NT mortality surveys. They observed NT mortality between 1 to 2 deaths per 1000 live births in Jordan and Sri Lanka up to 67 deaths per 1000 live births in some parts of India.
These initial studies were made before the implementation of immunization and clean delivery programs came out and discovered that about 1 million babies get tetanus yearly, of whom 800,000 died. Through their discovery of NT mortality rates, the community surveys played a major role in reshaping the outlook of health policymakers and in providing political momentum to NT control and elimination. Developing country studies find that NT causes 8%-69% of neonatal deaths.
In India, a prospective community study in 1983-1984 revealed that NT was the second leading cause of neonatal deaths after septicemia, and the mortality rate due to NT was 9.7 per 1000 live births. Risk Factors Surveys of community-based NT mortality have validated the significance of risk factors for NT, including failure to receive immunization with tetanus toxoid pregnancy, home delivery, dirty cutting of the umbilical cord, application of possibly infectious material to the umbilical stump, and history of NT in a previous child.
A case-control study in Pakistan revealed that the use of clarified butter ghee in the initial few days after birth was a major risk factor. In a survey, a high risk for NT was found with unwashed hands, tetanus shot, td shot, tt vaccine, att vaccine, tena shot which indicates the possible contamination source of spores could be the hands of the birth attendant.
The method of tool used to sever the cord does not necessarily have to be a significant risk factor. The primary route of contamination can be poor dressing of the umbilical stump. The findings of all these studies indicate that educating mothers and birth attendants in simple hygienic practices has a drastic influence on NT mortality.
Maternal Tetanus
Maternal tetanus refers to tetanus in pregnancy or up to 6 weeks post termination of pregnancy. This comprises postpartum or puerperal, most often due to septic operations at delivery, postabortion tetanus due to septic maneuvers during induced abortion, and tetanus in pregnancy. The maternal incidence is unknown. Most data are from hospital-based studies, but since only a minority of women in developing countries give birth in hospitals, these data are not population-representative. In recent maternal morbidity and mortality reviews, tetanus is seldom listed as a cause of maternal death or disease. In the WHO Factbook, India, Malawi, Nigeria, and Sudan alone reported 2 % to 10% of maternal deaths due to as the cause.
Conclusion
The control of NT is based on the principle that tetanus antitoxin passively transferred from the immunized mother to the fetus gives temporary protection to the newborn infant against tetanus. Early investigations revealed that levels of tetanus antitoxin in cord serum and maternal serum were generally equal, though, in 20%-30% of instances, the cord serum was of a lower titer than maternal serum. It was noted more recently that the cord/maternal ratio of antibodies is greater in Europe than in Africa.
The passage of antibodies is based on the amount and quality of antibodies, and both these factors can vary based on the immunization regimens employed. Elevated levels of immunoglobulin in African mothers who have been exposed to multiple antigenic stimuli could be responsible for the degree of placental transfer of antibodies. No factors are known to influence the transplacental passage of tetanus antibodies, and those mechanisms governing the passage of immunity from mother to offspring have not been adequately examined. With new vaccines against other major neonatal pathogens in the works or soon available, such as group B streptococcus and respiratory syncytial virus, there has been increasing interest in the possible transmission of protective immunity during pregnancy.