1) Tetanus is an acute disease caused by Clostridium tetani bacteria, characterized by muscular rigidity and spasms. 2) In Nepal, tetanus vaccination targets have been met for some but not all districts and coverage rates remain below targets. 3) The bacteria forms spores that can survive in soil and dust and are transmitted through contamination of wounds. Proper immunization and wound care can help prevent transmission and disease.

1. TETANUSDR. PARTH GURAGAIN

2. TETANUSAn acute disease caused by exo-toxin of Clostridium tetani.Characterized by:Muscular rigidity present throughout the illnessParoxysmal spasm of voluntary musle.Masseter (lock jaw or trismus )Facial muscle (risussardonicus)Muscle of back and neck(opisthotonus)Muscle of lower limb and abdomenMortality is very high(40-80%)

3. Datas regarding tetanus in NepalAchievement in fiscal year 2064/65 unit target achievement ach in %TT2 preg 984,251 409,032 79%VaccSchool grade1 131,368 101,734 77.4%School immunization was targeted in 12 district however only 5 district completedDPT3 Coverage in FY 2062/63-93%,2063/64-84.3%,2064/65-81.9%TT2 Coverage 2062/63-51.3%,2063/64-49.7%,2064/65-59% INDICATORSImmunization coverage for TT2 Vaccine=Number of pregnant women immunized with TT2 /Total estimate number of pregnant women × 100NT Surveillance=Number of NT cases/number of live birth×1000 per district

4. EPIDEMIOLOGICAL DETERMINANTAgent factora. AgentCltetani is gram positive,anaerobic,spore-bearing organism which is drum stick in appearanceThe spores are resistant to number of agents(boiling,phenol,cresol,autoclavingfor 15 min at 120°The spore germinate under anaerobic condition and produce exotoxin”tetanospasmin”

5. Reservoir of infectionThe natural habitat of organism is soil and dust.The bacilli is found in intestine of many herbivorous animals and are excreated in their feaces. The bacilli may also be found in human intestine without causing ill effects.ExotoxinIt is highly lethal.Lethal dose for 70kg man -0.1mgThe toxin acts on nervous system ie,motor end plate in skeketal system, brain, spinal cord, sympathetic system.d.CommunicabilityNot transmitted from perso to person

6. 2. Host factor AgeIt is disease of active age(5-40 yrs)Tetanus in new-born is k/a neonatal tetanusBirth under aseptic condition or if umbilical stump is dressed improperly.SexMales there is higher incidenceFemales are more exposed to risk of tetenus during delivery or abortion leading to ‘puerperal tetanus’OccupationAgricultural worker

7. d. Rural-urban differenceMore in rural areae. ImmunityNo age is immune unless previously immunized2 injection of tetanus toxoid can provide immunity which can last for several yearsAn immunity less than 6 month can be transferred to baby if mother is immunized during pregnancy .

8. ENVIRONMENTAL AND SOCIAL FACTORENVIRONMENTSoil, agriculture, cattles.SOCIAL Application of dust or animal dung in wound.Unhygienic delivery practice.

9. MODE OF TRANSMISSIONFirst there is contamination of wound by spores. Then germination and elaboration of exotoxin takes place. Finally there is binding of exotoxin to the receptors.The range of injuries and accident that lead to tetanus can bePin prickSkin abrasionPuncture woundBurnsHuman biteAnimal bite Sting etc

10. Incubation period- Usually 6-10 days , but can range from 1 day to several months.TYPES OF TETANUSTraumaticPuerperalOtogenicIdiopathic -microtrauma, absorption of tetanus toxin from intestine, inhalation of tetanus spores.Tetanus neonaturum

11. PREVENTIONACTIVE IMMUNIZATIONWith tetanus toxoidToxoid stimulates the production of anti-toxinThe aim of vaccination is to maintain the level of anti-toxin ie, 0.01 IU/ml serum throughout the life.PREPARATION FOR IMMUNIZATIONCombined vaccine-DPTMonovalent vaccinePlain or fluid(formal) toxoidTetanus vaccine, absorbed(PTAP,APT)

12. Combined vaccine-DPT Tetanus vaccine is given along with diphtheria and pertusis vaccine.The WHO EPI schedule is 6week,10week and 14week.National schedule for India is 6week,10week,14 week followed by booster of DPT at 18 mth, booster of DT at 5-6yrs and booster of TT at 10 years.

13. MONOVALENT VACCINEPurified tetanus toxoid have largely replaced plain toxoid coz it stimulate a higher and long-lasting immunity response than plain toxoid.1st dose-------1-2month-------2nd dose-----1year----1st booster-------5year------2nd booster.

14. PASSIVE IMMUNIZATIONTemporary protection against tetanus can be provided byHuman tetanus hyperimmunoglobulin(TIG)ATS(Equine)ACTIVE AND PASSIVE IMMUNIZATIONIn non-immune person 0.5ml in one arm and 1500 IU ATS(equine) or 250-500 IU(HTIG) in another arm .Followed by 6 week later 0.5 ml of tetanus toxoid and third 1 year later.

15. ANTIBIOTICSSingle injection (IM) Benzathine Penicillin 1.2 mega unit.For person sensitive to penicillinErythromycin estolate-500mg×6hrly×7daysAntibiotics treatment should not be relied if patient is seen 6 hour after injury.It is not sure whether antibiotics reach the bacilli if dead tissues are present around.

16. PREVENTION OF NEONATAL TETANUSClean delivery practice reduce neonatal tetanus.Three cleans prevents neonatal tetanusClean handsClean surfaceClean cord care