Tetanus

Tetanus, commonly known as lockjaw, is an  ubiquitous  (common) disease occurring in almost all the countries of the world. The rate of infection with tetanus and consequent death rates are, however, very  high in tropical countries such as India About 5-10 per cent of all infant deaths during the first month of life can be attributed to tetanus infection of the new born. 

The Disease--What causes it? Who gets it? How and when does it spread? 

Tetanus is induced by a toxin produced by bacillus-Clostridium tetani.  The organism grows at the site of injury  under anaerobic (lack of oxygen) conditions. The bacillus forms spores at its terminals which are spherical in shape. Thus, the organism appears as a drum-stick under the  microscope. The spores germinate in anaerobic conditions and the bacillus produces a potent toxin. The tetanus bacillus is a normal inhabitant of the intestines of animals such as cattle, horses, goats etc. Contamination with animal faeces, therefore, is one of  the important causes for tetanus. 

Who gets the disease? 

Age : Tetanus is a disease of active age, though it affects all ages. Generally. it is common in the age group of 5-40 years. This age group generally is predisposed to all kinds of injuries and  the risk of acquiring tetanus is higher. In India and other ,  tropical countries, tetanus of the new born infant is very common due to bad hygienic practices followed during delivery particularly for cutting the umbilical cord by the untrained traditional midwives (dais). You may be surprised to know that some midwives apply cowdung to the umbilical cord after it is cut, in  the belief  that it will help to heal the cut. This, as you  can imagine, is a dangerous practice and is the surest way of spreading tetanus. This practice should be stopped. 

Sex : Generally, tetanus is more common in males than in  females. However, in the reproductive age group of 15-45 years, females are at a higher risk, particularly after criminal abortions and deliveries conducted under primitive conditions in the rural and tribal areas. 

Socio-economic factors : The disease is more frequent in rural areas than in urban areas.  Agricultural workers are at a greater risk of getting the disease because of their contact with soil and animal faeces. Wide spread poverty, high illiteracy and consequent unhygienic practices like applying all sorts of medications, sometimes even fine sand powder on the wound without properly cleaning it, lead to tetanus infection in low income families. 

How does it spread? 

Tetanus occurs in most cases after injury. The wounds may be trivial and often are ignored or unnoticed. This is more so among labourers. Infection takes place due to contamination of wounds with tetanus spores. The contamination may happen with soil, dust or animal faeces. The tetanus bacilli are found in  the soil. 

Tetanus of the new born occurs through infection of umbilical cord, particularly due to unhygienic practices, adopted by unabashed birth attendants while cutting the cord.

Tetanus may result after surgical treatment, the spores being introduced through improperly sliced suturing material or instruments. The tetanus spores can be introduced through dressings of the wounds and plaster of paris used  for bandaging fractured limbs. 

Incubation period : The incubation period is generally 4 to 21 days. It depends on the character and extent of the wound. On an average, it is about 10 days. Most cases occur within 14 days of the  wound, but, sometimes it may take longer. 

Period of communicability : It is not directly transmitted from man to man. 

Susceptibility : Everyone is susceptible to tetanus infection. Recovery from tetanus does not result in definite protection against the disease. Second attacks can occur. However, prolonged immunity is induced by tetanus toxoid injection. 

Symptoms and  Complications 

Tetanus is an acute disease characterised by painful muscular contractions mainly of jaw  and neck muscles. This is usually followed by spasm (contraction) of muscles of trunk and spine. The common first sign suggestive of tetanus is rigidity (tightening) of abdominal muscles. Sometimes such a rigidity is confined to the site of injury only.  It is difficult to conform the diagnosis through laboratory investigations since the organism is rarely recovered from the site of infection. 

Tetanus has a high fatality rate. About 40-80 per cent of the patients die. You will appreciate how important it is to prevent it. 

Prevention and Management 

Discussed below are the preventive measures of Tetanus : 

a)  Active Immunisation : The best protection against tetanus is through routine immunisation with tetanus toxoid. Tetanus toxoid is recommended regardless of age. It is particularly important for workers who frequently come in contact with soil or domestic animals and all those with greater than usual risk of traumatic injury. These include military and police personnel.  Immunisation for different individuals include: 

• For Children : Primary course (the very first course of immunisation in children) of immunisation consists of 3 injections of tetanus toxoid (given as DFT) with an interval of about 6 weeks between injections, starting at the age of 3 months. A booster is given about one year after the  third injection. Thereafter. booster dose at intervals of 10 years  is recommended. 
• For Pregnunt Women : All the pregnant women should receive immunisation as a protective more against tetanus of the new born infant. Administration of tetanus toxoid in 3 doses during the fifth, sixth months and ninth months of pregnancy is recommended in the case of primis (first pregnancy). During the subsequent pregnancies, one injection of tetanus toxoid is suggested. 
• Temporary protection can be given to a wounded individual by an injection of anti-tetanus serum (ATs). This should be  administered only  under the supervision or a medical expert and be given after a subcutaneous test dose is given. Human immunoglobulins against tetanus are considered one of the best ways of protection against tetanus. 

b) Education : Education of the workers, about the mode of transmission of the disease is important. This would help them to take suitable preventive action like immunisation after injury. The importance of routine immunisation after injury should be emphasised. You should also stress on proper hygienic practices particularly after injury like avoiding contact with soil, animal faeces and keeping the wound calm would also help in the prevention of the disease. Training of traditional birth attendants in proper ways of cutting the cord is essential D prevent tetanus in the new born infant. You should educate the dais to use sterilised blades for cutting the cord; to wash hands thoroughly with soap before undertaking the delivery; not  to resort to applying cowdung etc. to the  cut portion of the umbilical  cord. 

Management of Tetanus : Tetanus Human Immuno globulin  is given in large doses intramuscularly to the patients. Also tetanus antitoxin should be given intravenously with adequate precautions. Remember that antitoxins can cause severe allergic reaction$ which may lead to death. Hence these should be given after testing for such allergic reactions. Intramuscular penicillin is also recommended. In severe cases, artificial mechanical respiration may have to be resorted to.