Preventing and treating tetanus
BMJ 2003; 326 doi: https://doi.org/10.1136/bmj.326.7381.117 (Published 18 January 2003) Cite this as: BMJ 2003;326:117
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despite widespread immunisation, incidence of tetanus is very high.
neonatal tetanus, still a killer disease,is due to severing of umbilicus
with unsterilised blade and application of cowdung considered sacred by
many.in punjab, it is called "8th day disease". trauma is another common
cause.puerperal tetanus also common in villages. quite frequently, cases
of otogenic tetanus are seen among children. children may introduce
matches, beads, pencils and other infected foreign bodies into their
ears.in some cases there is no portal of entry. either microscopic trauma,
inhalation of spores or intestinal absorption of tetanus toxins are
postulated.
as no treatment exists except nursing and prevention of asphyxiation
during laryngeal spasms, immunisation on a war-footing is the only
answer.antibiotics like penicillin do not affect spores but readily kill
tetanus bacilli. long acting penicillin like benzathine penicillin may
give a 21 day protection against bacilli which may emerge from spores. an
alternative is erythromycin. however these are not subsitute for
immunisation.
Competing interests:
None declared
Competing interests: No competing interests
The first step taken in reducing the very high incidence of tetanus
in Zulu neonates was to teach mothers not to put cow dung on the severed
umbilical cord after their babies had been born.
Competing interests:
None declared
Competing interests: No competing interests
It is difficult not to share the pessimism of your editorialists with
respect to the incidence and burden of tetanus worldwide (1). However,
physicians practicing in developed countries can help to reduce the
incidence of tetanus and tetanus mortality by implementing the proven
strategy of prevention. This is especially important for the elderly who
might not have been immunized earlier in life, as your editorialists state
(1,2). Recognition of this fact might prevent many deaths from tetanus in
the first world.
Effective interventions to improve immunization rates in developed
countries do exist(3). While we should all work as citizens to improve
immunization rates throughout the world, physicians practicing in
developed countries should continue to strive to reduce deaths from
tetanus, even as populations in these countries achieve longer and longer
average age, and the proportion of older adults susceptible to tetanus
remains large. The challenge remains for us to implement these proven
interventions.
1.Thwaites CL, Farrar JJ. Preventing and treating tetanus. BMJ
2003:326:117-8.
2.Richardson JP, Knight AL. The prevention of tetanus in the elderly.
Arch Intern Med 1991;151:1712-7.
3. Richardson JP, Michocki RJ. Removing barriers to vaccination use by
older adults. Drugs & Aging 1994;4:357-65.
Competing interests:
None declared
Competing interests: No competing interests
You state: "In fact, the governess's tetanus probably resulted from
chronic dental infection or using a dirty needle, not the nerve injury the
doctor supposed." I know of no evidence linking chronic dental infection
with tetanus. Please would you advise further?
Competing interests:
None declared
Competing interests: No competing interests
Tetanus with protective serum immunity
SD asked for permission 3.2.03
Although the importance of tetanus in developing countries was well
stressed by a recent editorial (1), tetanus is rare in developed countries
and thus the complacency in both prevention and diagnosis of this disease
is widespread.
McQuillan and colleagues report that only 72.3% of
Americans 6 years of age or older had protective levels of tetanus
antibody (2). Certainly, an improvement is needed in the implementation
of an immunization program. On the other hand, protective immunity
attained by vaccinations is not a guarantee for the protection against
this daunting disease. We report a case of cephalic tetanus with
protective serum antibody.
In April 2002, we saw a 35-year-old previously healthy male with a 2-day
history of left facial dystonia. Two weeks prior to hospitalization, he
described minor trauma to several fingers while performing repairs at his
fiancé’s apartment. About 5 days prior to admission, the patient suffered
an outbreak of nasolabial HSV and a cut in the region of the HSV lesions
from shaving with a disposable razor. Both lesions were partially healed
and dry at presentation. He was not receiving any medication and denied
use of illicit substances. His last immunization against tetanus and
diphtheria was in 1991.
On physical examination upon admission, the patient was afebrile and
revealed left facial spasticity and hyperreflexia, which were provoked by
smiling, chewing, and any contact with left facial structures.
MRI and MRA of the head showed no anatomical abnormalities. The lumbar
puncture demonstrated a normal opening pressure and cerebrospinal fluid
which was acellular with normal protein and glucose levels, no
microorganisms, and a negative cultures. HSV1 and HSV2 were not detected
in the CSF by PCR. An EMG showed non-specific hyperactivity. Lyme
serologies were negative. Serum tetanus antitoxoid antibody level on
admission was 3.37 IU/ml, which was above “protective” levels (>0.01
IU/ml). Nevertheless, the clinical diagnosis of cephalic tetanus was
made. The patient was treated with tetanus toxoid, tetanus immune
globulin, metronidazole, and benzodiazepines. His neurological symptoms
improved slowly but did not resolve completely.
Although tetanus is still a rare disease, the clinician should remain
alert to the possibility of this diagnosis, particularly with the shortage
of the toxoid (3). Tetanus is diagnosed clinically. Cases of tetanus with
“protective” antibody level are reported (4). The presence of antibody
level will not confirm the absence of the disease.
1. Thwaites CL, Farrar JJ. Preventing and treating tetanus. BMJ
2003:326:117-8.
2. McQuillan GM, Kruszon-Moran D, Deforest A, Chu SY, Wharton M. Serologic
immunity to diphtheria and tetanus in the United States. Ann Intern Med.
2002;136:660-666.
3. Notice to readers: Update: Supply of diphtheria and tetanus toxoids and
acellular pertussis vaccine. MMWR Morb Mortal Wkly Rep. 2002;50:1159.
4. Crone NE, Reder AT. Severe tetanus in immunized patients with high anti
-tetanus titers. 1992;42:761-764
Competing interests:
None declared
Competing interests: No competing interests