Tetanus is a disease caused by Clostridium tetani bacteria that produces a toxin causing muscle rigidity. It remains a problem in developing areas with poor access to healthcare. While rare in developed nations, an estimated 213,000 deaths from tetanus occurred globally in 2002. In India, important endemic factors include traditional birth practices, immunization rates, and access to care. Prevention relies on clean delivery practices, routine tetanus immunization during pregnancy and of newborns, and wound cleaning plus potential antitoxin treatment and booster shots depending on immunization history after exposures. The World Health Organization announced the elimination of maternal and neonatal tetanus in India in 2016.

1. Tetanus
Dr. Sushrit A. Neelopant
Assistant Professor,
Department of Community Medicine
RIMS, Raichur

2. Defn:
• An acute disease induced by the exotoxin of
clostridium tetani and clinically characterised
by muscular rigidity which persists
throughout illness punctuated by painful
paroxysmal spasms of the voluntary muscles.

3. Problem statement
• World: Rare among developed countries
• Case fatality rate is 80-90%, tends to occur in areas
with poor access to health care – underreporting –
• Low notification efficiency WHO makes annual
estimates
• W.H.A. in 1989 resolved to eliminate neonatal
tetanus by 1995 i.e. reduce incidence <1/1000 live
births: New target date 2005,
• 2002 global deaths 213,000
• NT 180,000 & MT 15-30,000

4. Indian scenario
• Important endemic disease in India
• Behavioural factors affecting incidence:
– Hand-washing, delivery practices, traditional
birth customs, interest in immunization
– 3.5 lakh deaths prior to immunization 1978
– 93-94 2.8 lakh cases were averted
– 70,000 cases occur annually
14 July 2016 –World Health Organization announced the elimination
of yaws, and maternal and neonatal tetanus, to India and hailed its
public health achievements as examples to other countries.

5. Classification of districts
• NT high risk
– Incidence rate > 1/1000 LB or
– TT2 coverage < 70% or
– Attended deliveries <50%
• NT Control
– Incidence rate < 1/1000 LB &
– TT2 coverage >70% &
– Attended deliveries > 50%
• NT elimination
– Incidence rate < 1/1000 LB &
– TT2 coverage > 90% &
– Attended deliveries > 75%

6. • Hospitals show M > F (but no biological basis)
• Gender bias in seeking health care
• Total no. of cases = twice the no. of male cases
• 50% cases of NT occur in July, Aug & Sept
• Monthly NIL reporting from all hospitals
• Cases are reported to CMO/DHO of the dist.
• Line listing of the cases is done

7. Agent factors
• Cl. tenani is a gram positive, anaerobic,
• spore bearing organism
• Spores are terminal- drumstick appearance
• Spores are resistant to various factors
• Spores germinate & produce tetanospasmin –
lethal dose 0.1mg acts on synapse, spinal cord,
brain, sympathetic system
• Reservoir of infection: soil and dust, excreta
• Period of communicability: Nil- no person-person

8. Host factors
• Disease of active stage 5-40 yrs
• Neonatal tetanus – aseptic delivery practices
• Unclean instruments / application of ash, cow
dung, soil on umbilical stump
• Sex M > F Puerperal tetanus
• Occupation: Agri workers more at risk
• Rural > Peri-urban > Urban poor housing
• No age is immune: 2 doses of TT for at least 5 yrs
• No herd immunity: extra-human reservoir

9. Environmental & social factors
• Soil, Agri, Animal husbandry
• Unhygienic customs – cow dung application to
wounds
• Unhygienic delivery practices-
• Ignorance of infection /lack of primary care
• Western countries – urbanization,
industrialization mechanization of agriculture
has reduced incidence

10. Mode of transmission
• Contamination of wounds by tetanus spores
• Pinpricks, skin abrasions, puncture wounds, burns,
human bites, animal bites & stings, unsterile surgery,
IUD, bowel surgery, dental extractions, inj., unsterile
cutting umbilical cord, compound fractures, otitis
media, chronic skin ulcers, eye infections,
gangrenous limbs
• Sequence of events: introduction of spores,
germination, exotoxin elaboration, binding to
receptor
• Incubation period: 6-10days (1day to several
months)

11. Types of tetanus
• Traumatic: Injury/ accidents
• Puerperal: abortion> normal delivery
• Otogenic: foreign bodies kids > adults
• Idiopathic: no apparent cause
• Tetanus neonatorum – 8th day disease

12. Prevention of Tetanus
• Active immunization –
– Combined vaccines – DPT, DT, dT
– Monovalent vaccines – TT, PTAP, APT
• Passive immunization-
– HTIG 250-500 IU
– ATS -1500 IU
• Combined immunization – in different limbs
• Antibiotics – 12lakh units Benzathine Penicillin

13. Prevention of NT
• Clean delivery practices - DDK
• Training of Birth attendants
• 2 doses of T.T. in 16 - 32 weeks of pregnancy
• 1 dose if previous pregnancy within five years
• 2 doses immunization for all childbearing age
women if antenatal care is poor
• No pregnant woman should be denied of single
dose of T.T. even in late pregnancy
• Newborn infants born to non-immunized
mothers – inj. ATS 750 IU within 6 hrs of birth

14. The 5 clean practices are:
• Clean hands
• Clean delivery surface
• Clean cord care
• Clean blade for cutting cord
• Clean cord tie and no application on cord
stump

15. Post-exposure prophylaxis
• Prevention of Tetanus after injury
• All wounds must be thoroughly cleaned
• Wounds less than 6 hrs old, clean, non-
penetrating, little tissue damage
– A Nothing more required (2 doses TT in last 5 yrs)
– B TT 1 dose – (2 doses of TT in 5-10 yrs)
– C TT 1 dose – (2 doses > 10 yrs ago)
– D TT 2 doses (Not immunized or status unknown)

16. Post-exposure prophylaxis
• Other Wounds (more than 6 hrs old, unclean, -
penetrating, extensive tissue damage)
– A Nothing more required (2 doses TT in last 5 yrs)
– B TT 1 dose – (2 doses of TT in 5-10 yrs)
– C TT 1 dose + HTIg – (2 doses > 10 yrs ago)
– D TT 2 doses+ HTIg (Not immunized / status
unknown)