Story of Ashok

Ashok was very excited as his summer

vacations had begun.

1 10/21/2024
 His mom took him to his favorite park too.
However, Ashok was so happy that he
forgot his shoes, even if his mom told him
to get them!

2 10/21/2024
 Then, he felt something sharp under his
foot.

He didn’t mind it though…. For now.

3 10/21/2024
 The pain was a lot worse now, so much that
he ran to his mother crying.

4 10/21/2024
 His mom looked at his foot, seeing that he
had something stuck in it.
She cleaned the wound and put a bandage
on it, thinking that it was only a scratch.

5 10/21/2024
 Ashok did not get better though he started
complaining about his jaw cramping, stiff
muscles and muscle pains, having a
headache, sweating and a fever! Poor
Ashok

6 10/21/2024
 Ashok’s mom decided to take him to the
hospital.

7 10/21/2024
 TETANUS

Dr. Prashant Kumar

Assistant Professor
Dept of Community Medicine
ESICMC Gulbarga
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 TETANUS - Introduction

 Tetanus is an acute disease caused by an exotoxin

produced by the bacterium Clostridium tetani.

 Mortality tends to be high without treatment.

 Characterized by generalized rigidity, painful &

paroxysmal convulsive spasms of voluntary muscles.

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 Usually involving masseters (Lock-jaw), the facial

muscles (Risus sardonicus), the muscles of back

and neck (Opisthotonus).

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 History
 Tetanus was first described in Egypt over 3000 years

ago (Edwin Smith Papyrus).

 Described by Hippocrates and Susruta.

 Comparatively rare in developed countries.

 Common in Third World countries—causing several

hundred thousand deaths per year

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 Problem Statement
Rare disease in developed countries
CFR (in absence of treatment)  80 – 90%.
In 1980s over 1 million deaths occurred every year
attributed to tetanus.
Preventable cause
WHO adopted a resolution to eliminate NT by
1995  TT inj, clean deliveries and improved
surveillance.

12 10/21/2024
 The elimination of NT was defined as <1 case per
1000 live births.
In 1990 maternal tetanus accounted for 5% of
maternal mortality every year.
Hence, in 1999 elimination of MT was added to
the goals of elimination program for NT and the
program was changed to Maternal and Neonatal
Tetanus Elimination (MNTE)

13 10/21/2024
 MNTE in India
Acceleration of TT immunization coverage
Systematic vaccination
Promotional of institutional deliveries
Various IEC programs
Distribution of DDK to SBA
Operationalization of SC, PHCs and CHCs to
provided 24 hrs services.
Training for SBA
Engagement of more ASHAs
Financial assistance.
14 10/21/2024
 On Dec 2014, 30 of the 36 states/UTs were
validated as having achieved MNT elimination.

In May 2015, India was officially certified as

achieving maternal and neonatal elimination.

15 10/21/2024
 Agent
 Clostridium tetani is an anaerobic, gram- positive rod,

exists in both vegetative & sporulated forms.

 The spores are terminal – drum-stick appearance

 Highly resistant and can survive for years in nature.

 The spores are destroyed by autoclaving at 121 ͦ C for 20

minutes or by Gamma irradiation.

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 Agent

 The spores germinate under anaerobic conditions and

produce two exotoxins, tetanolysin and tetanospasmin.

 The function of tetanolysin is not known with certainty.

 Tetanospasmin is a neurotoxin and causes the clinical

manifestations of tetanus.
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 Agent
 RESERVOIR : Natural habitat is soil and dust.

 Also found in intestines-cattle, horses, goats, sheep

and are excreted in faeces.

 Not transmitted from person to person.

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 Host
 It is commonly a disease of the active age (5-40 yrs).

 Also occurs in newborns – “Neonatal tetanus”

 Higher incidence is found in males.

 Agricultural workers are at special risk.

 Incidence is much lower in urban than in rural areas.

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 Environmental factors
 Tetanus – positive environmental hazard

 Compounded by social factors- unhygienic conditions

and habits
 Mode of Transmission: Transmission is primarily by

contaminated wounds, tissue injury (surgery, burns, deep

puncture wounds, crush wounds, Otitis media ,dental
infection, animal bites, abortion, and pregnancy).
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 TETANUS
 Peak in winter and summer season

 Incubation Period : 6-10 days, also prolonged by

prophylaxis
 Immunity : No natural immunity

Even clinical infection does not confer immunity.

Acquired only by active immunization

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 2. Stays in
1. C. tetani enters sporulated form
body from through until anaerobic
wound. conditions are
presented.

3. Germinates under 4. Tetnospasmin

spreads using blood
anaerobic conditions
and lymphatic
and begins to multiply system, and binds to
and produce motor neurons.
tetnospasmin.

6. Binds to sites
5. Travels along the
responsible for
axons to the spinal inhibiting skeletal
cord. muscle contraction.
 DIAGNOSIS
 The diagnosis of tetanus depends on clinical signs and

symptoms rather than laboratory confirmation

 Clinically it is confirmed by noticing the following

features:
a. Risus sardonicus.
b. Lock jaw.
c. Opisthotonus
d. Neck rigidity

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DIAGNOSIS

Risus sardonicus Trismus (Lock-jaw)

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Opisthotonus
The spatula test
 It is one diagnostic bedside test.
 This simple test involves touching the
oropharynx with a spatula or tongue
blade.
 This test typically elicits a gag reflex,
and the patient tries to expel the spatula
(ie, a negative test result).
 If tetanus is present, patients develop a
reflex spasm of the masseters and bite
the spatula (ie, a positive test result).
 Sensitivity of 94% and a specificity of
www.medicalgeek.com

100%.[2]
TYPES OF TETANUS

A. Puerperal tetanus

B. Idiopathic tetanus

C. Tetanus Neonatorum

D. Traumatic tetanus

E. Otogenic tetanus
Maternal tetanus
• Tetanus occurring during pregnancy or within 6 weeks
after any type of pregnancy termination, is one of the
most easily preventable causes of maternal mortality.
• It includes postpartum or puerperal tetanus
(i) postpartum or puerperal tetanus, usually resulting
from septic procedures during delivery,
(ii) post-abortal tetanus, following septic maneuvers
during induced abortion
 Neonatal Tetanus
Tetanus neonatorum (8th day disease)
Usually fatal if untreated
Children born to inadequately immunized
mothers, after unsterile treatment of umbilical
stump
During first 2 weeks of life.
Poor feeding, rigidity and spasms
It is easily preventable by 2 tetanus toxoid
injections and ‘5 cleans’ while conducting
deliveries.
www.medicalgeek.com
 Prevention and Control

A. Active Immunization

B. Passive Immunization

C. Active and passive Immunization

D. Antibiotics

29
 Prevention and Control
A. Active Immunization :
 Two preparations are available

a. Combined vaccine – Pentavalent & DPT

b. Monovalent vaccines

a. Plain or fluid toxoid

b. Tetanus vaccine, adsorbed (PTAP,APT)

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 Prevention and Control
a. Combined vaccine – DPT
 Primary course consists of 3 doses

 1st dose - 6 weeks (Pentavalent )

 2nd dose - 10 weeks (Pentavalent )
 3rd dose - 14 weeks (Pentavalent )
 1st booster - 16 - 18 months (DPT)
 2nd booster - 5-6 years (DPT)
 3rd booster - 10 year (TT)

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 4th booster - 16 years (TT)
 Prevention and Control
b. Monovalent vaccines

 Primary course – two doses of tetanus toxoid adsorbed

each 0.5ml deep I.M given at 1-2 months interval

 First booster to be given A year after the initial two

doses.
 Second booster dose after 5 years

 Monovalent vaccines are given to immunize adults and

32
pregnant women
 Prevention and Control
B. Passive Immunization :
 Temporary protection against tetanus infection can be

provided by injection of Human tetanus hyper-

immunoglobulin (TIG) or Anti-tetanus serum (ATS).

1. TIG(human) Ig- 250 IU, no anaphylactic shock, very safe

and costly.(protection - 30 days)

2. ATS(equine) Ig- 1500 IU/s.c after sensitivity test ( lasts7-

10 days)
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 Prevention and Control
C. Active and passive Immunization :

 Simultaneous active and passive immunization in non-

immune persons
 1500 IU of ATS or 250 IU of (TIG) Human Ig in one arm and
0.5ml of adsorbed tetanus toxoid (PTAP or APT) into the other
arm or gluteal region.
 Followed by a third dose of 0.5ml of Tetanus toxoid 1 year later.

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 Prevention and Control
D. Antibiotics :

 A single intramuscular injection of 1.2 mega units of

Benzathine penicillin
(or)
 For those sensitive to Penicillin, a seven day course of

Erythromycin 500mg 6th hourly orally

 Antibiotic therapy is not a substitute to immunization
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Principle of Treatment
1. Neutralization of unbound toxin
-TIG/ATS
2. Prevention of further toxin
production
-Wound debridement & antibiotics
3. Antibiotics
4. Control of spasm
-Anticonvulsants, Sedatives, Muscle
relaxants etc.
5. Management of autonomic
dysfunction
-MGSO4,www.medicalgeek.com
Betablockers etc.
 Treatment
 Very difficult to treat once symptoms have developed

 Antitoxin is administered
 Muscle relaxants
 Supportive therapy (ventilator)

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 Prevention of Neonatal
Tetanus

 Neonatal tetanus (NNT), a disease preventable by

immunization.
 Antenatal TT immunization

 Clean delivery practices

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 Prevention of Neonatal
Tetanus
 “5 cleans”
1. Clean hands
2. Clean delivery surface
3. Clean cord
4. Clean blade
5. Clean tie for the cord

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 Prevention of Neonatal
Tetanus
 2 doses of T.T to all pregnant women between 16 to

36 weeks of pregnancy with an interval of 1 to 2

months between the two doses.
 If the pregnant woman is previously immunized, a

booster dose is sufficient. (3 yrs)

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 If the pregnant woman is not immunized, then
the new born should be protected against
tetanus by giving tetanus human
immunoglobulin 750 IU within 6 hours of
birth.

41
 Prevention of Tetanus
after injury

42 10/21/2024
 n k
h a
T u
Y o
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