Tetanus in a rural Ethiopian hospital

Introduction

Tropical Doctor has published a number of reports on tetanus cases in Nigeria and Ethiopia. ^1–4 However, most of the reports are from tertiary or university hospitals which have intensive care units (ICU). ^1–3 The experiences of small hospitals in rural areas are rarely seen as they have fewer resources to facilitate an investigation. We reviews our experiences with tetanus cases seen during five years in a rural general hospital in Ethiopia which is situated between the Arsi and East Shoa regions, 250 km south of Addis Ababa. There were no ICUs in this hospital.

Methods and results

We reviewed the medical charts of all patients admitted to the hospital with clinical case definitions of tetanus between 11 September 2000 and 10 September 2005. We used the clinical case definitions of tetanus that are used in the paper by Ogunrin and Unuigbe. ¹

A total of 45 patients with tetanus were admitted: six (13.3%) neonates, 39 (75.6%) children under 15 years old and five (11.1%) adults. The percentage of children admitted was 0.36% (45 from 12,523 admissions) and the percentage of adults was 0.16% (five from 3053 admissions). The incidence of tetanus varied over the five-year period: 16 cases in 2004; 12 in 2001; six in 2000 and 2003; and five in 2002. Table 1 shows the details of their age, sex, time of onset, duration of hospital stay, treatment received and outcome, according to the type of tetanus. Nineteen (42.2%) females and 26 (58.8%) males; 82.3% of the neonatal tetanus cases were girls – significantly higher than for tetanus in infancy, where 38.3% were girls, and in adults, where 20% of cases were women (P = 0.05).

None of the children had been vaccinated, or had been given an incomplete immunization. A traumatic wound was found to be the portal of entry in all of the adults, but only in five of the 34 (14.8%) infants (P < 0.001). In children, the main portal of entry of Clostridium tetani was via dermatoses/erosive skin diseases from tungiasis (85.2%). The median of the time of onset of symptoms was three days (range = 1–18 days). All were treated with diazepam and the chlorpromazine and tetanus antitoxin (TAT). The TAT was administered intramuscularly only in 33 (73.3) cases and intravenously and intramuscularly in 12 (26.7%). Thirty-nine (86.7%) of the 45 tetanus patients were treated with penicillin, 13 (28.9%) with phenobarbital and eight (17.8%) with metronidazole: 13 (29.8%) of 45 patients died. The mortality was significantly higher in neonatal tetanus (66.7% versus 17.8%; P = 0.048). There was no reduction in the mortality rate in the succeeding years. Mortality was not related to the type of treatment used.

Discussion

In this study, tetanus is shown to be mainly a disease of children and the young. The high proportion of tetanus in children and young adults in our environment could be a reflection of the inadequate tetanus immunization coverage and the fact that most of children go barefoot.

The treatment of tetanus with TAT reduces the mortality rate. ¹ The route of administration most commonly used was intramuscular. In this report, the use of the intravenous and intramuscular routes was no more successful than the use of just the intramuscular route. ⁵ However, the treatment of tetanus with antitetanus immunoglobulin via the intrathecal route has been associated with an improved clinical progression. ⁵ More recently, the administration of baclofen intrathecal in cases of severe tetanus has significantly reduced the mortality rate. ³ However, this drug is not readily available in many Africa countries. ³

The mortality rate in tetanus neonatorum was as high as in other countries. ^2,4 However, the mortality rate in children and adults with tetanus was 17.8%, less than in the study by Ojini and Danesis which ranged from 20% to 60%. ³ This could be due to the fact that in three cases the patients' relatives took them home to die and, therefore, the outcome was not recorded.

In view of this and other reports, it is important that tetanus immunization programmes in children are implemented in addition to the active and passive immunization of adults who receive wounds.