Tetanus

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Prevalence of rabies in the area

Vaccine may not be indicated in areas which are consistently free of animal rabies.

Biting animal: its species and state of health

Carnivores are particularly important in the spread of rabies.

In the case of a dog bite, the animal should be captured alive if possible, and kept under observation for 10 days. If the animal has been killed or if it dies during the period of observation, steps should be taken to find out if it was rabid; the animal should be decapitated and the head sent to the laboratory. A dog which has been adequately vaccinated is unlikely to be rabid.

In the case of a wild animal, it should be killed and the brain examined for rabies. It must be assumed that there has been exposure to rabies in cases of unprovoked bites by wild animals, or if the biting animal has escaped or been destroyed without examination.

Occurrence:

Worldwide, but very low incidence

in developed countries as a result of

immunization programme

Organism:

Clostridium tetani

Reservoir:

Humans

Transmission:

Through wounds including the

umbilicus in newborn babies

Control:

Toilet of wounds

Clean delivery and management of

the umbilical cord

Penicillin prophylaxis

Passive immunization (antitetanus

serum)

Active immunization (tetanus toxoid)

This is an acute disease characterized by an increase in muscle tone, with spasms, fever and a high falalih rate in untreated cases. Usually the hypertonia arid the spasms are generalized, but in some mild eases the muscle rigidity may be c: a fined to a loca! area (e.g. a limb) and spasms may also be localized to the laryngeal muscles. Trismus is usually an early symptom. A peculiar grimace

Table 5.9: Guide for postexposure treatment for prevention of rabies

Category

Type of contact with a suspect or confirmed rabid domestic or wild* animal, or animal unavailable for observation

1

Touching or feeding of animals Licks on intact skin

None, if reliable case history is available

II

Nibbling of uncovered skin Minor scratches or abrasions without bleeding Licks on broken skin

Administer vaccine immediately** Stop treatment if animal remains healthy throughout an observation period*** of 10 days or if animal is euthanized and found to be negative for rabies by appropriate laboratory techniques

III

Single or multiple transdermal bites or scratches

Contamination of mucous membrane with saliva (i.e. licks)

Administer rabies immunoglobulin and vaccine immediately**

Stop treatment if animal remains healthy throughout an observation period*** of 10 days or if animal is killed humanely and found to be negative for rabies by appropriate laboratory techniques

*Exposure to rodents, rabbits and hares seldom, if ever, requires specific antirabies treatment.

**lf an apparently healthy dog or cat in or from a low-risk area is placed under observation, it may be justified to delay specific treatment.

***This observation period applies only to dogs and cats. Except in the case of threatened or endangered species, other domestic and wild animals suspected as rabid should be euthanized and their tissues examined using appropriate laboratory techniques.

*Exposure to rodents, rabbits and hares seldom, if ever, requires specific antirabies treatment.

**lf an apparently healthy dog or cat in or from a low-risk area is placed under observation, it may be justified to delay specific treatment.

***This observation period applies only to dogs and cats. Except in the case of threatened or endangered species, other domestic and wild animals suspected as rabid should be euthanized and their tissues examined using appropriate laboratory techniques.

'risus sardonicus' is often noted in these patients. In tetanus neonatorum, the first symptom is failure to suck in a baby who had sucked normally for the first few days after delivery.

The incubation period is usually between 3 days and 3 weeks. The interval between the first symptom of stiffness and the appearance of spasms is known as the period of onset.

BACTERIOLOGY

Clostridium tetani is a Gram-positive rod, an obligate anaerobe, which forms terminal spores giving it a characteristic drumstick shape. The spores are highly resistant to drying and to high temperatures: they may withstand boiling for short periods.

EPIDEMIOLOGY

Tetanus is found worldwide with a high concentration in some parts of the tropics. Farmers and others living in rural areas are usually more frequently affected than urban dwellers. With routine immunization of children and prophylactic care of wounds, the disease is now rare in the developed countries.

Reservoir and transmission

The reservoir of infection is the soil and the faeces of various animals, including man. The organism gains entry into the host through wounds; any wound may serve as the portal of entry for tetanus:

■ Post-traumatic. Deep penetrating wounds especially when associated with tissue necrosis, and particularly when contaminated with earth dung or foreign organic material. Superficial wounds including burns may alse causc tetanus. The umbilical wound is Ufc \i,srt'a) portai of neonatal tetanus.

■ Postpuerperal and postabortal rhese arire from the use of contaminated instruments and dressings

■ Neonatal tetanus is usually acquired through contamination of the umbilical wound in the newborn baby.

■ Postsurgical. These may also be from instruments and dressings, but the infection may be endogenous, from the presence of the organism in the host's bowel or wounds.

■ Chronic ulcers and discharging sinuses. Chronic ulcers, guinea-worm infections, chronic otitis media, and infected tuberculous sinuses may serve as portals of entry.

■ Cryptogenic. In a high proportion of cases, no focus is found, presumably some of these are due to minor injuries which have healed. All nonimmune persons in all age groups are susceptible. Infection does not confer immunity: repeated attacks occur.

LABORATORY DIAGNOSIS

A firm clinical diagnosis can be made without laboratory tests. The isolation of the organism from the wound is of little value since it may be recovered from the wounds of persons who show no sign of tetanus.

CONTROL

There are three main lines of prevention:

Antibacterial measures

These include the protection of wounds from contamination, adequate cleansing of wounds and careful debridement. Antibiotics especially long-acting penicillin can also be given to suppress the multiplication of Clostridium tetani. If the wound is old (i.e. more than 12 hours), tetanus may occur despite an adequate dose of penicillin.

Doctors, midwives and traditional birth attendants should use clean instruments for cutting the umbilical cord and sterile dressings to protect it until it heals.

Passive immunization

Tetanus immune globulin (TIG) from human blood is now used in place of tetanus antitoxin (ATS), which was derived from horse serum; the latter carried a serious risk of severe allergic reactions including anaphylactic shock. TIG is used to protect individuals with dirty wounds who have no clear history of active immunization with tetanus toxoid.

Active immunization

Active immunization with tetanus toxoid is the most satisfactory method of preventing tetanus. Ideally, everyone should be given a course of active immunization. This is given in combination with diphtheria toxoid and pertussis vaccine in a triple vaccine formulation (DPT). Three doses, at monthly intervals starting at 2 months, are recommended. Booster doses of tetanus toxoid can then be given periodically, for example every 5 years or whenever the person is injured. Active immunization of the pregnant woman will protect the infant from neonatal tetanus.

WHO estimates that in 1999, there were 270000 deaths from neonatal tetanus; these could have been prevented cheaply with the administration of two doses of tetanus toxoid to pregnant women. The persistence of clinical cases of tetanus in any community is a direct indictment of the health authorities of the country concerned because tetanus toxoid is simple to administer, safe, effective and cheap.

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