1. TETANUS DR. PARTH GURAGAIN

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

3. Datas regarding tetanus in Nepal Achievement in fiscal year 2064/65 unit target achievement ach in % TT2 preg 984,251 409,032 79% Vacc School grade1 131,368 101,734 77.4% School immunization was targeted in 12 district however only 5 district completed DPT3 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% INDICATORS Immunization coverage for TT2 Vaccine= Number of pregnant women immunized with TT2 /Total estimate number of pregnant women × 100 NT Surveillance= Number of NT cases/number of live birth×1000 per district

4. EPIDEMIOLOGICAL DETERMINANT Agent factor a. Agent Cltetani is gram positive,anaerobic,spore-bearing organism which is drum stick in appearance The 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 infection The 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. Exotoxin It is highly lethal. Lethal dose for 70kg man -0.1mg The toxin acts on nervous system ie,motor end plate in skeketal system, brain, spinal cord, sympathetic system. d.Communicability Not transmitted from perso to person

6. 2. Host factor Age It is disease of active age(5-40 yrs) Tetanus in new-born is k/a neonatal tetanus Birth under aseptic condition or if umbilical stump is dressed improperly. Sex Males there is higher incidence Females are more exposed to risk of tetenus during delivery or abortion leading to ‘puerperal tetanus’ Occupation Agricultural worker

7. d. Rural-urban difference More in rural area e. Immunity No age is immune unless previously immunized 2 injection of tetanus toxoid can provide immunity which can last for several years An immunity less than 6 month can be transferred to baby if mother is immunized during pregnancy .

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

9. MODE OF TRANSMISSION First 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 be Pin prick Skin abrasion Puncture wound Burns Human bite Animal bite Sting etc

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

11. PREVENTION ACTIVE IMMUNIZATION With tetanus toxoid Toxoid stimulates the production of anti-toxin The aim of vaccination is to maintain the level of anti-toxin ie, 0.01 IU/ml serum throughout the life. PREPARATION FOR IMMUNIZATION Combined vaccine-DPT Monovalent vaccine Plain or fluid(formal) toxoid Tetanus 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 VACCINE Purified 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 IMMUNIZATION Temporary protection against tetanus can be provided by Human tetanus hyperimmunoglobulin(TIG) ATS(Equine) ACTIVE AND PASSIVE IMMUNIZATION In 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. ANTIBIOTICS Single injection (IM) Benzathine Penicillin 1.2 mega unit. For person sensitive to penicillin Erythromycin estolate-500mg×6hrly×7days Antibiotics 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 TETANUS Clean delivery practice reduce neonatal tetanus. Three cleans prevents neonatal tetanus Clean hands Clean surface Clean cord care