Abstract
Tetanus remains endemic in India. A retrospective hospital-based study was conducted to review the profile of all children admitted with diagnosis of tetanus between January 2009 and December 2010. A total of 140 cases of tetanus were admitted; 45 cases of neonatal tetanus (NT) and 77 cases of post-neonatal tetanus (PNT) were studied. Age of presentation of NT was 9.4 ± 1.2 days. Home-delivered children accounted for 86.7% of cases, with 77.8% being attended by untrained birth attendants. Unimmunized mothers accounted for 93.4%. In PNT, otogenic route of infection and trauma were present in 58.4% and 23.3% of cases, respectively. The rate of hospital admission of tetanus remains high. Unlike previously published reports, otogenic route is the most common mode of PNT infection in this study. Improving immunization, increasing deliveries by skilled birth attendants and prompt treatment of suppurative otitis media are the main areas in which public health initiatives need to be focused.
Introduction
Tetanus is an ancient disease that continues to be prevalent in a large part of the developing world. 1–4 Being a tertiary care medical centre in India, our hospital sees a substantial number of cases of tetanus in neonates and children. We studied the epidemiological and clinical profile, the outcome and the factors affecting the outcome of tetanus cases admitted in our hospital.
Materials and methods
A retrospective evaluation of the records of all children including neonates with a diagnosis of tetanus based on clinical features admitted to our hospital between January 2009 and December 2010 was done to study their socio-demographic and clinical parameters as well as immunization status. Possible factors affecting mortality were compared between survivors and non-survivors for statistical significance by using chi-square/Fisher's exact test. A P value of less than 0.05 was taken as significant; statistical analysis was performed using SPSS version 17 (SPSS Inc., Chicago, IL, USA).
Results
A total of 140 cases of tetanus – 55 neonatal (NT) and 85 post-neonatal (PNT) – were admitted; 10 cases of NT and eight cases of PNT were excluded as they left against medical advice.
Characteristics of neonatal tetanus
A total of 45 neonates (25 males, 20 females) presented at a mean age of 9.4 ± 1.2 days (range, 7–12 days) and a mean weight of 2.47 ± 0.5 kg (range, 1.7–3.2 kg); 15 (33.3%) cases had low birth weight (LBW) (weight < 2.5 kg) and seven (15.5%) were preterm. Patients from a lower socioeconomic class accounted for 82.2% of cases. None of the mothers received two complete doses of tetanus toxoid (TT) antenatally; three had received one dose only; and the rest (93.4%) were unimmunized. Thirty-nine (86.7%) newborns were delivered at home. Of these, 35 (77.8%) were attended by untrained birth attendants with history of application over umbilicus obtained in 15 (33%) cases.
Characteristics of post-neonatal tetanus
Seventy-seven cases of PNT consisted of 40 males and 37 females with a mean age of 8.65 ± 2.5 years (range, 1–16 years). Otogenic route was the most common mode of infection, being present in 58.4% of the cases; 23.3% cases were a result of trauma, remaining being idiopathic. Only two children were immunized, and even then with a mere two doses of primary vaccination. The mean incubation period in post-injury cases was 6.2 ± 2 days (range, 4–10 days). Trismus was present in all patients at the time of presentation. All, except four patients, developed spams, the average duration between trismus and onset of spasms being 30.5 ± 4.6 hours (range, 12–96 hours). Average duration of spasms was 4.76 ± 2.7 days. Autonomic dysfunction was seen in 86% cases with the most common manifestation being urinary retention. According to modified Patel and Jaog criteria of grading tetanus, 5 36 (46.7%) had mild, 25 (32.5%) patients had moderate and 16 (20.8%) patients had severe forms of tetanus. The time interval between trismus and onset of spasm was less than 48 hours in all the patients with severe grade and two of the patients with moderate grade.
Aspiration pneumonia was the most common complication, having been observed in 27.2% cases; other complications were paralytic ileus (10.3%), septicemia (9%), hypotension (7.8%), disseminated intravascular coagulation (7.8%) and gastrointestinal hemorrhage (6.4%).
Management and case fatality rate of NT and PNT cases
All of the cases were treated with human tetanus immunoglobulin (TIG), crystalline penicillin and diazepam. Dose of diazepam ranged from 15 to 60 mg/kg/day with 39 neonates and 44 children requiring maximum dose. Additional midazolam infusion was administered in 12 NT and 20 PNT cases. Also, 15 cases of PNT received chlorpromazine.
A total of 27 cases of NT expired, resulting in a case fatality rate (CFR) of 60% with 72% of the deaths occurring within seven days of admission. In case of PNT, 10 patients expired, CFR being 12.9%. Possible factors affecting mortality were compared between survivors and non-survivors of NT and PNT in Table 1 and Table 2, respectively.
Comparison of socio-demographic and clinical parameters between survivors and non-survivors amongst the cases of neonatal tetanus
Comparison of factors affecting mortality versus survival in cases of post-neonatal tetanus
DIC, disseminated intravascular coagulation
Discussion
In Western countries, the incidence of tetanus has declined dramatically since the mid-twentieth century because of widespread use of tetanus immunizations. 6 However, hospital-based data of pediatric tetanus cases from various Third World countries clearly show that the disease is still endemic in these parts of the world, with varying incidences. 1,3,4,7 This study shows relatively high average tetanus admissions in the post-neonatal age group, with nearly 42 cases per year, higher than most studies and also higher than those reported earlier from hospitals of India. 8,9 Our centre being a referral children's hospital with a special tetanus ward could possibly explain the high admission rate. The admission rate of NT is also high in our hospital, though there has been a substantial decline compared with earlier data from the same hospital. 8
Antenatal immunization coverage and the immunization status of children with PNT were dismal. WHO/UNICEF estimated protection at birth against tetanus in India to be as high as 86% in 2009. 10 Also, the estimated coverage of three doses of DPT for the country in 2005–2006 according to National Family Health Survey III data is 55%. 11 This probably suggests that immunization status of the catchment areas for this hospital is not at par with the national average.
Our study shows high rates of home deliveries, conduction of deliveries by untrained personnel and faulty practices. This underscores the need to review the quality and extent of utilization of maternal and child health services in these regions.
In our study, the most common mode of infection in PNT cases was otogenic (58.4%), a finding strikingly different from other studies in which trauma has been reported as the leading cause. 1,3,7 Thus, this study identifies an important issue of focus for health policy makers, namely that prompt treatment of suppurative otitis media and reviewing the immunization status of such patients can prevent tetanus.
In this study, the CFR in NT was 60%, comparable to that of other developing countries. 1,2,4 Absence of immunization among mothers, deliveries by untrained birth attendants and LBW neonates were significantly higher among the NT fatalities compared with survivors, similar to other studies. 1,2 In contrast to previous studies, 2,4 our study did not find early presentation to be a significant determinant of mortality in NT.
The CFR in case of PNT was low (12.9%) compared with reports from developing countries; 1,3,9 65% of the deaths occurred within three days of admission, emphasizing the crucial role of prompt management. Factors affecting mortality were similar to previous studies. 1,9 Though the study shows a large number of tetanus cases and high rates of non-immunized children and mothers, the limitation was that the design of the study did not allow assessment of the true incidence of tetanus or immunization status in the community to which the patients belong.
Conclusion
This hospital-based study shows that, despite decades of administrative efforts to prevent tetanus, the admission rate of the disease, in both the neonatal and the post-neonatal age group remain high even in recent times. The otogenic route being the most common mode of entry in PNT, the need for prompt diagnosis and treatment of suppurative otitis media and immunization of such children is highlighted. The CFR of PNT in our study was low compared with the existing worldwide evidence, pointing to the vital role of effective management in a dedicated tetanus ward. Improving maternal immunization, increasing deliveries by skilled birth attendants and prevention of LBW babies can reduce the CFR in cases of NT.