This editorial discusses the ongoing issue of tetanus in Pakistan. While tetanus has been almost eradicated in developed nations through effective immunization programs, it remains a major problem in Pakistan. Tetanus mortality rates in Pakistan range from 19.3% to 57.69% for non-neonatal cases and 22% to 36.58% for neonatal cases. The editorial calls for a renewed national commitment to address this issue, including establishing a comprehensive national immunization authority and public awareness campaigns to promote vaccination and hygienic practices.

1. How to cite this article: Muhammad Saaiq, Khaleeq-Uz-Zaman. The scourge of tetanus: Time for
critical re-appraisal of the issue in a broader national perspective. Ann Pak Inst Med Sci 2007; 3(2):
65-6.
Editorial
The Scourge of Tetanus: Time for
Critical Re-appraisal of the Issue in a
Broader National Perspective
Muhammad Saaiq*
Khaleeq-uz-Zaman**
* Senior Registrar,
Department of Surgery.
** Professor and Head,
Department of Neurosurgery,
Pakistan Institute of Medical Sciences
(PIMS), Islamabad.
Effective immunization programme has almost
eradicated tetanus in the developed world. In the United
States, there has been a steady decline in the incidence
of tetanus since 1940s. An annual average of 43
tetanus cases were reported in the United States
between 1998 and 20001
. An all time low of 20 cases
(0.01 cases per 100,000) were reported in 2003. Only
two cases of neonatal tetanus have been reported
in US since 19891, 2
.
While the developed world and most developing
countries are winning their battle against both neonatal
as well as non-neonatal tetanus, the killer disease
still continues to play havoc with precious human
lives in our country. Ours is among the countries with
highest incidence of tetanus. In fact each dying
Pakistani tetanus patient reminds and re-emphasizes
the importance of primary tetanus immunization and
follow- up boosters for all at risk patients. At national
level tetanus is reported from all parts of the country.
The locally reported mortality is disconcertingly high,
ranging from 19.3% to 57.69% for non-neonatal
tetanus3-9
while 22% to 36.58% for neonatal
tetanus10-12
.
Tetanus is in fact not a new entity, with its
earliest descriptions being found in the writings of
ancient Egyptians as well as those of the Hippocrates.
Tetanus toxoid was developed by Descombey in
1924 and was first widely used during World War II
while passive immunization was successfully employed
for the treatment and prophylaxis of tetanus during
World War I. Because of the extreme potency of
tetanospasmin, tetanus disease does not confer any
immunity and even a small dose of the toxin can trigger
the disease in a person who has previously suffered
an attack17-19
. Hence proper antitetanus vaccination is
mandatory even among those who have suffered from
tetanus.
Why are we losing our battle against
tetanus? In fact a multitude of issues are operative.
There is lack of a broad based, realistic and an
all-encompassing antitetanus programme at national
level. The ongoing antitetanus vaccination programme
which is part of the expanded programme on
immunization (EPI) is presently focusing on children and
women of child bearing age and that too has pathetically
failed to ensure adequate antitetanus immunization of its
target groups13
. Even our doctor community at the
gross root level still continues to be largely ignorant
regarding antitetanus coverage to the patients at
their disposal14
. Traditional birth attendants (TBAs) or
dais who continue to enjoy the status of being the
key players in the maternal and child health in a
larger segment of our population still exercise unsafe
and unhealthy practices.15
Not surprisingly, we do come
across instances in which our miserable patients have
contracted tetanus purely because of the ignorant
medical practices of our quacks e.g. excision of mole
with horse hair.16
The pathetic state of affairs is best
reflected by the fact that cow dung, desi ghee and
surma etc. still continue to be applied to the umbilical
wound stumps of the newborn babies in our villages.12
All these key issues are compounded by the prevalent
environment of public apathy, political expedience and
professional dominance. Hence the dream of tetanus
eradication is not coming true.
Almost all cases of tetanus occur in persons
who have either never have been vaccinated or
competed a primary series but have not had a
booster in the preceding 10 years. Routine boosters are
recommended every 10 years because the antitoxin
levels gradually decline with time and by the time of 10
years it reaches the minimum protective level. To
ensure protective antitoxin levels, individuals sustaining
wound that is otherwise clean and minor should receive
Ann. Pak. Inst. Med. Sci. 2007; 3(2): 65-6. 1

2. How to cite this article: Muhammad Saaiq, Khaleeq-Uz-Zaman. The scourge of tetanus: Time for
critical re-appraisal of the issue in a broader national perspective. Ann Pak Inst Med Sci 2007; 3(2):
65-6.
a tetanus booster if more than 5 years have elapsed
since the last dose1-2
. The Centres for disease control
and prevention (CDC) recommend that tetanus toxoid
should be given in combination with diphtheria toxoid,
since periodic boosting is needed against both the
diseases.20
In the United States, puncture wounds
constitute the most common cause of tetanus related
injury, followed by lacerations and abrasions. Tetanus
exposure is also reported to come from predictable
sources such as nails, splinters, barbed wire and tools.
Tetanus infections following a spider bite, tattoo and
rose bush have also been reported1
. The risk of tetanus
in natural disaster is known to be higher and has been
reported both locally as well as internationally.3, 4, 21
.
Tetanus is fatal in at least 11% of the reported cases
from the United States1, 2
. Understandably the mortality
is much higher in our prevalent health care set-up of
recognized limitations.
The dismal scenario of this vaccine preventable
disease in our country demands for vigorous
implementation of certain key interventions. We
would make the following recommendations in
order to fight off the existing challenges in this
regard:
1. There is dire need of a renewed commitment for
eradication efforts at national level. All doctors,
public health authorities and non-governmental
organizations should make collaborative efforts to
address this challenging public health issue.
2. A national antitetanus vaccination authority should
be established with the primary task of establishing
a comprehensive and meaningful antitetanus
vaccination system countrywide. The programme
should ensure universal immunization, not merely of
children and child bearing age women.
3. Legislators and parliamentarians should formulate
laws to ensure that all health care facilities are
well equipped with the necessary protocols,
vaccines and trained staff. This will ensure strict
implementation of the national recommendations
in clinical practice with close monitoring for
eradication.
4. All hospitals and institutions of higher medical
education should start training programmes for
doctors especially general practitioners, nursing
staff, first aiders, lady health workers (LHWs) and
TBAs / dais etc.
5. Print and electronic media should be re-activated to
launch public awareness campaigns and address
the issues of inadequate vaccination, non-hygienic
home deliveries, unsafe practices by TBAs, use of
unsterilized cutting materials for dividing umbilical
cord of the newborn and application of damaging
materials over the umbilical stumps etc.
6. Prevention should be the key task, however those
with established tetanus should also receive
adequate care including both active as well as
passive immunization in addition to other necessary
measures.
References
1. CDC. Tetanus surveillance - United States, 1998-2000. MMWR
Surveill Summ. 2003 ; 52 (SS-3): 1-8.
2. CDC. Preventing tetanus, diphtheria, and pertussis among
adolescents: use of tetanus toxoid, reduced diphtheria toxoid and
acellular pertussis vaccines. Recommendations of the advisory
committee on immunization practices (ACIP). MMWR Recomm
Rep. 2006; 55(RR-3): 1-34.
3. Raza SH, Akhtar N, Chaudhry A, Amir S, Jamal M, Hassan M.
Factors affecting mortality in the patients with tetanus after a mass
disaster. Ann Pak Inst Med Sci 2006; 2: 38-41.
4. Niazi R, Tahir F, Kiani I, Bangash WUK. Management of tetanus: Is
metronidazole superior to benzyl penicillin? Does early tracheostomy
improve the outcome? Ann Pak Inst Med Sci. 2007 ; 3: 60-4.
5. Mahsud IU, Khan HU, Khattak AM, Wazir FU, Shah H. Mortality rate
in adult tetanus patients in district DI Khan, NWFP, Pakistan
Biomedica 2005; 21 : 86-9.
6. Raza MA, Abbas MH. Tetanus disease patterns observed in a
specialist unit. J Coll Physicians Surg 2000; 10: 249-54.
7. Ahmed F, Afridi MJ, Khan H. Demographic and prognostic factors in
tetanus patients. Pakistan J Med Res 2006; 45: 82-6.
8. Talati N, Salahuddin N. Factors affecting tetanus mortality in a
tertiary care hospital in Pakistan. Infect Dis J 2001; 10: 13-5.
9. Ali G, Khan W. An audit of mortality in tetanus patients admitted to
general intensive care unit. J Postgrad Med Inst 2005; 19: 429-32.
10. Khattak MA, Aqeel M, Alam F. Neonatal tetanus: disease pattern
in Peshawar (NWFP). Pak Paed J 2005; 29: 193-6.
11. Ali M, Mazhar AU, Haq MIU. Tetanus neonatorum. Pak Paed J
2002; 26: 187-90.
12. Rehman A. Clinical study of neonatal tetanus at tehsil headquarter
hospital. Pak Paed J 2007 ; 31 : 34-7.
13. Afridi NK, Hatcher J, Mahmud S, Nanan D. Coverage and factors
associated with tetanus toxoid vaccination status among females of
reproductive age in Peshawar. J Coll Physicians Surg 2005 ; 15 :
391-5.
14. Ahmed SI, Baig LA, Thaver IH, Siddiqui MI, Jafery SI, Javed A.
Knowledge, attitudes and practices of general practitioners in Karachi
district Central about tetanus immunization in adults. J Pak Med
Assoc 2001 ; 51 : 367-9.
Ann. Pak. Inst. Med. Sci. 2007; 3(2): 65-6. 2

3. How to cite this article: Muhammad Saaiq, Khaleeq-Uz-Zaman. The scourge of tetanus: Time for
critical re-appraisal of the issue in a broader national perspective. Ann Pak Inst Med Sci 2007; 3(2):
65-6.
15. Habib F, Baig L, Aziz S. The role of the birth attendants in decreasing
neonatal deaths due to tetanus. Ann Abbasi Shaheed Hosp Karachi
Med Dent Coll 2002; 7: 383-6.
16. Khan A. Horse hair and tetanus, a case study. J Surg Pakistan 2002;
7: 52-3.
17. Tetanus. In: Atkinson W, Wolfe C, Humiston S, Nelson R, eds.
Epidemiology and Prevention of Vaccine-Preventable Diseases.
(The Pink Book). 9th ed. Atlanta, Ga: CDC; 2006: 69-78.
18. Plotkin SL, Plotkin SA. Tetanus toxoid. In: Plotkin S, Orenstein W,
Offit P, eds. Vaccines. 4th ed. Philadelphia, Pa: W.B. Saunders;
2004:745-81.
19. Oladiran I, Donald E. Meier, Ojelade AA, David A, Olorun O,
Adeniran A, Tarpley JL. Tetanus: Continuing problem in the
developing world. World J Surg 2002; 26: 1282-5.
20. CDC. Epidemiology and Prevention of Vaccine-Preventable
Diseases. Atkinson, W., Hamborsky, J., & Wolfe, S., eds. 8th ed.
Washington, DC: Public Health Foundations, 2004.
21. Nufer KE, Wilson-Ramirez G. A comparison of patient needs
following two hurricanes. Prehospital Disaster Med 2004; 19:
146-9.
Ann. Pak. Inst. Med. Sci. 2007; 3(2): 65-6. 3