EPIDEMIOLOGY OF TETANUS

PRESENTED
BY
ALKAMIS RABIU USMAN
SUPERVISED
BY
Dr DEEPAK VISHWAKARMA
PUBLIC HEALTH DEPARTMENT,

SCHOOL OF CONTINOUS EDUCATION PPSAVANI UNIVERSITY, SURAT

OUTLINE
• Introduction
• Causative agent
• Pathogenicity
• Types
• Epidemiology
• Transmission,
• Sign and symptoms
• Management
• Prevention,
Introduction

Tetanus is an acute infectious disease caused by

toxigenic strains of the bacterium Clostridium tetani
(C. tetani).
The spores of C. tetani are present in the
environment irrespective of geographical location
and enter the body through contaminated skin
wounds or tissue injuries
Cont.
The majority of tetanus cases are birth associated
occurring in low income countries among insufficiently
vaccinated mothers and their newborn infants,
following unhygienic deliveries and abortions and
poor postnatal hygiene and cord care practice
 Cont.
The disease remains an important public health
problem in many parts of the world where
immunization programs are suboptimal,
particularly in the least developed part of the world
(WHO,2017)
 CAUSATIVE AGENT

• Tetanus is Caused by Anaerobic Motile Gram-positive bacilli,

CLOSTRIDIUM TETANI
• It is Oval, colorless, terminal spores bacteria found worldwide
in soil, animal faeces & occasionally human faeces
Incubation period

– In non-neonatal tetanus, it varies

between 3 and 21 days after infection.
– In neonatal tetanus, symptoms usually
present 3 to 14 days, averaging 7 days,
after birth in 90% of cases
Diagnosis
The diagnosis is entirely clinical and does not depend on
bacteriological confirmation, viiz
1. Sample: Wound aspirated pus or discharge if found
transported to the lab immediately or in anaerobic transport
system.
2- Direct Gram stain: Gram-positive bacilli with drumstick
terminal spore may be seen.
3- Culture: On blood agar incubated anaerobically, or
on Robertson cooked meat medium
Cont.

Animal pathogenicity (Toxin detection):

- When a mouse is injected I.M. with isolated organism
from culture, the animal will develop spastic paralysis
starting in the tail and site of injection and spreading to
all over the body (ascending paralysis
- NB; C. tetani is recovered from the wound in only 30% of
cases and can be isolated from patients who do not have
tetanus
Types
1. local:
2- Cephalic:.
3- Generalized tetanus(80%)
4. Neonatal
Pathogenicity
c. tetani usually enters body
through a wound. In the presence
of anaerobic conditions, the spores
germinate and produce toxins.
Toxins disseminated via blood and
lymphatics system
Cont.
Toxins act at CNS sites including
peripheral motor end plates, spinal
cord, and brain, and in the
sympathetic nervous system.
The toxin interferes with the release of
inhibitor neurotransmitters, Leading to
muscle contraction and spasm
Cont.
EPIDEMIOLOGY
▪ Tetanus is an international health problem, as
spores are ubiquitous. The disease occurs almost
exclusively in persons who are unvaccinated or
inadequately immunized.
▪ Tetanus occurs worldwide but is more common in
hot, damp climates with soil rich in organic
matter.
▪ More common in developing and under
developing countries
Cont.
▪ More prevalent in industrial establishment, where
agricultural workers are employed.
▪ Case fatality rates vary from 10% to 70% depending
on treatment, age and general health of the
patient.
▪ Among patients in the youngest and oldest age
groups without intensive care, case fatality rates
approach 100%.
▪ Tetanus neonatorum is common due to lack of
MCH care.
Cont.
• Depending on neonatal tetanus incidence rates,
immunization coverage levels, proportion of clean deliveries
by trained personals, Districts are divided into;

NT High risk – Rate > 1/1000 live births or

TT2 coverage < 70% or attended deliveries < 50%

NT Control – Rate < 1/1000 live births or

TT2 coverage > 70% or attended deliveries > 50%

NT Elimination – Rate < 0.1/1000 live births or

TT2 coverage > 90% or attended deliveries > 75%
Factors Responsible
.Agent Cl. Tetani
• Oval, colorless, terminal spores
• Spores are highly resistant to a number of injurious
agents, including boiling, phenol and autoclaving for
15 min at 120°c.
2.Reservoir of infection-:
• Natural Habitat such as Soil & Dust
• Also found in intestine of- Cattle, horses, goats, sheeps
and excreted in faeces
• Can survive for years in nature without causing
ill effects
Cont.
3.Toxins
Cl spores grows and multiplies and most importantly produces two
types of tetanus toxin,
Tetanospasmin and Tetanolysin.
• Tetanolysin is not believed to be of any significance in the
clinical course of tetanus.
• Tetanospasmin is a neurotoxin and causes the clinical
manifestations of tetanus.
Cont.
• Lethal Dose-: 0.1mg for a 70 kg-man
• The toxin acts on 4 areas of nervous system-:
−Motor End Plates in Skeletal System
−Spinal Cord
−Brain
−Sympathetic System
• Principal Action is to block inhibition of spinal
reflexes.
Cont.

Spores are extremely stable, but immersion in

boiling water for 15 minutes kills most spores.
Exposure to saturated steam under high
pressure for 15-20 minutes at 121°c is highly
effective against spores
 Cont.
Sterilization by dry heat is slower than by moist heat
(1 -3 hrs at 160 °C),but it is also effective against
spores.
Ethylene oxide sterilization is also sporocidal
Autoclaving at 121°C for 15min kills the spores readily.
Iodine (1% aqueous soon) and H2O2 (10 volume) kills
spores within few hours
Host factor
• Age: It is the disease of active age (5-40 years), New
born baby, female during delivery or abortion
• Sex: Higher incidence in males than females
• Occupation: Agricultural workers are at higher risk
• Rural –Urban difference: Incidence of tetanus in
urban areas is much lower than in rural areas
• Immunity: Herd immunity does not protect the
individual
Environmental and social factors
• Tetanus is a positive environmental hazard.
Depends upon man’s physical and ecological
surroundings.
Factors Contributing-:
-Unhygienic custom habits
-Unhygienic delivery practices -
Ignorance of infection &
-Lack of primary health care services
Route of transmission
− Skin Abrasion
-Puncture wounds, Burns, Human Bites
− Animal bites and stings
− Unsterile Surgery, IUD
− Bowel Surgery & Dental Extraction
− Injections, Unsterile division of Umbilical
Cord
Clinical features
 Spasms and stiffness in your jaw muscles (trismus)
 Stiffness of your neck muscles
 Difficulty swallowing
 Stiffness of your abdominal muscles
 Painful body spasms lasting for several minutes, typically triggered
by minor occurrences, such as a draft, loud noise, physical touch or
light(opisthotonus)
 other signs and symptoms include:
 Fever Sweating Elevated blood pressure Rapid heart rate
, , ,
Management
Medical Treatment
• Human tetanus immune globulin (TIG).
• Antibiotics. Inj Benzathine Penicillin is the drug of

choice or Tabs erythromycin

• Benzodiazepines. E.g. diazepam
• Supportive care. Antipyretic
• Tetanus prophylaxis
Prevention
Tetanus can be prevented by vaccination with
tetanus toxoid(TT). TT vaccine was first produced in
1924 and used extensively for the first time among
soldiers during World War II. Since then, immunization
programs using TTCVs have been successful in
preventing maternal and neonatal tetanus as well as
injury related tetanus
 Immunization schedule(active )
WHO recommends a 3 dose primary series:

• The first dose of TTCV should be administered as early as 6 weeks

of age.

• Subsequent doses should be given with a minimum interval of 4

weeks between doses.

• The third dose of the primary series should ideally be completed by

6 months of age.
Booster dose
In order to provide lifelong protection, WHO recommends 3
TTCV booster doses, ideally, with at least 4 years between
.

booster doses.

These should be given at:

• 12–23 months of age

• 4–7 years of age

• 9–15 years of age

Vaccine effectiveness

A non-randomized controlled trial reported vaccine

effectiveness
during pregnancy to prevent neonatal tetanus:
– 94% for 3 doses;;
– 65% for 2 doses;;
– No effect for 1 dose
Prevention of neonatal tetanus
• Clean delivery practices alone are effective. (about
90%)
• 3 cleans: clean hands, clean delivery surface, clean
cord care
• Tetanus toxoid protects both mother & child
Unimmunized pregnant women: 2 doses tetanus toxoid
(16th-36th week) 1st dose as early as possible
during pregnancy
2nd dose – at least a month later / 3 weeks
before delivery
Active and passive immunization
• In non-immunized persons
• 1500 IU of ATS / 250-500 units of Human Ig in
one arm & 0.5 ml of adsorbed Tetanus Toxoid
(PTAP or APT) into the other arm /gluteal
region
• Followed 8 weeks later by 0.5 ml of Tetanus
Toxoid
• 1 yr later, 0.5 ml of Tetanus Toxoid 3rd dose
• Again at 5yr and 10 yrs
Complication
Complications of tetanus infection may include:
 Broken bones. The severity of spasms may
cause the spine and other bones to break.
 Blockage of a lung artery (pulmonary
embolism). A blood clot that has traveled from
elsewhere in your body can block the main
artery of the lung or one of its branches.
Cont.

Death. Severe tetanus-induced (tetanic) muscle

spasms can interfere with or stop your breathing.
Respiratory failure is the most common cause of
death. Lack of oxygen may also induce cardiac arrest
and death. Pneumonia is another cause of death
Reference

1. https://www.mayoclinic.org/diseases-conditions/tetanus/diagnosis-treatment/drc-
20351631
2. https://www.who.int/health-topics/tetanus/