TETANUS types causes vaccines

1. TETANUS
Dr BHAGYA LEKSHMI L
MPH Scholar
AIMS

2. CONTENTS
•COMMUNICABLE DISEASE CATEGORIES
•INTRODUCTION TO TETANUS
•PROBLEM STATEMENT
•INCUBATION PERIOD AND MODE OF TRANSMISSION
•TYPES OF TETANUS
•EPIDEMIOLOGICAL DETERMINANTS
•PREVENTION
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3. COMMUNICABLE
DISEASES
RESPIRATORY
INFECTIONS
ARTHROPODE-
BORNE
INFECTIONS
ZOONOSES
SURFACE
INFECTIONS
INTESTINAL
INFECTIONS
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4. TETANUS
•Acute disease
•Caused by exotoxin of Clostridium tetani
•Clinically characterized by muscular rigidity
{The voluntary muscles, especially the masseters (trismus
or lock-jaw) , the facial muscles (risus sardonicus), the
muscles of the back and neck (opisthotonos), and those
of the lower limbs and abdomen. }
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5. 5

6. PROBLEM STATEMENT
•Tetanus is now comparatively rare disease in the
developed countries.
•Neonatal tetanus (NT) is a killer disease.
•In the absence of high quality treatment, the
case-fatality rate can be as high as 80- 90 per
cent.
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7. •Maternal and neonatal tetanus (MNT) is an
important preventable cause of neonatal and
maternal mortality, particularly in developing
countries.
•Although easily prevented by maternal
immunization with tetanus toxoid containing
vaccines (TTCV) and aseptic obstetric and postnatal
umbilical cord care practices, both maternal and
neonatal tetanus persist as public health problems.
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8. •Most cases occur in poor, remote and isolated
communities.
•The spores of tetanus are very resistant and remain
in the environment in extremes of temperature for
long periods.
•Technically it is not possible to eradicate tetanus,
including NT.
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9. •The disease is easily preventable through :-
(1) Clean delivery and umbilical cord care practices
to ensure infection is not contracted by mother or
new-born during the delivery process.
(2) Delivery of appropriate doses of TTCV to
pregnant women through antenatal care services and
other routine contacts.
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10. (3) Vaccination campaigns with TTCV targeting all
women of reproductive age in high-risk areas.
(4) Strengthening surveillance to identify women at
risk, reasons for the risk, and potential clustering.
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11. •In the 1980s, over 1 million deaths every year were
attributable to tetanus.
•The 42nd World Health Assembly adopted a
resolution to eliminate NT by 1995, through the
increased availability of TTCV, clean deliveries and
improved surveillance.
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HISTORY

12. •The elimination of NT was defined as < 1 case per
1000 live births in every district.
•As a result, in 1999, the elimination of maternal
tetanus (MT) was added to the goals of the
elimination programme for neonatal tetanus, and
the programme title was changed to Maternal and
Neonatal Tetanus Elimination (MNTE).
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13. MATERNAL AND NEONATAL TETANUS
ELIMINATION IN INDIA
The Indian Ministry of Health & Family Welfare in
collaboration with WHO India, UNICEF and other
partners, designed and implemented strategies to
control neonatal tetanus:
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14. Acceleration of TT immunization coverage
through the WHO-recommended high risk
approach and strengthening routine TT
immunization of pregnant women, and
supplemental TT immunization activities
targeting women of child-bearing age in high-risk
districts.
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15. Systematic vaccination of pregnant women
attending antenatal care (ANC) with TT vaccine.
Promotion of institutional deliveries focusing on
poor pregnant women with an institutional stay for
48 hours.
Distribution of disposable delivery kits to skilled
birth attendants for each pregnancy.
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16. Intensive communication programme targeting
communities to reduce harmful cord care practices.
Promotion of the 5 Cleans:-
1 Hand
2 Delivery surfaces
3 Instruments for cutting the umbilical cord
4 Cord tie
5 Caring of the umbilical cord
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17. •The launch of the National Rural Health Mission
(NRHM) in 2005 also helped to strengthen these
initiatives.
•Janani Suraksha Yojana (JSY) :- A conditional cash
transfer scheme, to encourage women to give
birth in a health facility.
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18. •Other interventions to improve TT protection and reduce
maternal and neonatal mortality under the NRHM
included:-
Integrating and extending outreach services through
village health and nutrition days, including vaccination of
children, adolescents and pregnant women with TT
containing vaccines.
Intense 3-week refresher training for all skilled birth
attendants.
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19. Selected sub-centres and community health centres
to provide 24-hour services 7 days per week for
obstetric and neonatal care.
Strengthening of facility-based neonatal care by
setting up new-born care corners in health facilities
where deliveries take place, special neonatal care
units in district hospitals and new born stabilization
units in first referral units for the care of sick neonates.
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20. Engagement of more Accredited Social Health
Activists (ASHA) to generate demand and
facilitate use of health-care services by
communities and poor women.
•As a result, safe deliveries rose from 52 per cent in
2007 to 76 per cent in 2009.
•Janani Shishu Suraksha Karyakram, launched in
2011 also helped.
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21. •India's successful implementation of a mix of
strategies has led to a substantial decline in the
number of MNT cases in the country.
•As of December 2014, 30 of the 36 states/UTs
were validated as having achieved MNT
elimination.
•In May 2015, India was officially certified as
achieving MNT elimination.
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22. INCUBATION PERIOD
The incubation period is usually 6 to 10 days.
However, it may be as short as one day or as long
as several months. Long incubation is probably
explained by the spores lying dormant in the
wounds.
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23. MODE OF TRANSMISSION
•Infection is acquired by contamination of wounds
with tetanus spores.
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24.  Trivial pin prick
 Skin abrasion
 Puncture wounds
 Burns
 Human bites
 Animal bites and
stings
 Unsterile surgery
 Intra-uterine death
 Dental extractions
 Unsterile Injections
 Unsterile Division of
umbilical
 Fractures
 Otitis media
 Chronic Skin ulcers
 Eye infections
 Gangrenous limbs
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25. TYPES OF TETANUS
TRAUMATIC : It is a major and important cause of
tetanus. Sometimes tetanus may result from most trivial
or even unnoticed wounds.
PUERPERAL : Tetanus follows abortion more frequently
than a normal labour. A post-abortal uterus is a favorable
site for the germination of tetanus spores.
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26. OTOGENIC : Ear may be a rare portal of entry. Foreign
bodies such as infected pencils, matches, and beads
may introduce the infection. Otogenic tetanus is a
paediatric problem, but cases, may occur in adults also.
IDIOPATHIC : In these cases there is no definite history
of sustaining an injury. Some consider it to be the result
of microscopic trauma. Others hold the view that it is
due to the absorption of tetanus toxin from the
intestinal tract. A third view is that the tetanus spores
may be inhaled and may start the infection.
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27. TETANUS NEONATORUM : The common cause is
infection of the umbilical stump after birth, the
first symptom being seen about the 7th day.
Therefore tetanus is known as “8th day disease in
Punjab. In any country where hygiene is poor,
neonatal tetanus may be common.
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28. EPIDEMIOLOGICAL DETERMINANTS
Agent factors
(a) AGENT
•C. tetani is a gram-positive, anaerobic, spore-
bearing organism.
•The spores are terminal and give the organism
a drum-stick appearance.
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29. • The spores are highly resistant to a number of
injurious agents, including boiling, phenol, cresol
and autoclaving for 15 minutes at 120 deg
Centigrade.
• They germinate under anaerobic conditions and
produce a potent exotoxin ("tetanospasmin").
•The spores are best destroyed by steam under
pressure at 120 deg. C for 20 minutes or by gamma
irradiation
29

30. (b) RESERVOIR OF INFECTION
•The natural habitat of the organism is soil and
dust.
•The bacilli are found in the intestine of many
herbivorous animals, e.g., cattle, horses, goats and
sheep and are excreted in their faeces.
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31. •The spores survive for years in nature.
•The bacilli may be found frequently in the intestine
of man without causing ill effects.
•The spores are blown about in dust and may occur
in a wide variety of situations including operation
theatres.
•Principal action is to block inhibition of spinal
reflexes.
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32. (c) EXOTOXIN
•Tetanus bacilli produce a soluble exotoxin
•It has an astounding lethal toxicity, exceeded
only by botulinum toxin.
•The lethal dose for a 70 kg man is about 0.1
mg.
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33. The toxin acts on 4 areas of the nervous system
(a) the motor end plates in skeletal system
(b) the spinal cord
(c) the brain
(d) the sympathetic system (Its principal action is
to block inhibition of spinal reflexes )
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34. (d) PERIOD OF COMMUNICABILITY
•Not transmitted from person to person.
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35. HOST FACTOR
(a)AGE
Commonly, tetanus is a disease of the active age (5
to 40 years).
•This period predisposes to all kinds of trauma and
therefore, the risk of acquiring the disease is
pretty high. Tetanus occurring in the new-born is
known as neonatal tetanus.
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36. (b) SEX
•Although a higher incidence is found in males,
females are more exposed to the risk of tetanus,
especially during delivery or abortion leading to
“puerperal tetanus”.
•Males appear to be more sensitive to tetanus toxin
than females
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37. (c) OCCUPATION
•Agricultural workers are at special risk because
of their contact with soil.
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38. (d) RURAL-URBAN DIFFERENCES
•The incidence of tetanus is much lower in urban
than in rural areas.
•For example, it was observed in one town that
tetanus was more frequent on the outskirts
where floors were earthen and animals lived
close to human beings, than in the center of the
town where there were paved and mosaic floors.
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39. (e) IMMUNITY
•The immunity resulting from 2 injections of
tetanus toxoid is highly effective and lasts for
several years.
•Immunity lasting for a few weeks (less than 6
months) can be transferred to the baby, if the
mother is immunized during pregnancy or if she
already has a high level of immunity at the time
she becomes pregnant.
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40. ENVIRONMENTAL AND SOCIAL
FACTORS
•Tetanus is a positive environmental hazard .
• Its occurrence depends upon man's physical and
ecological surroundings –
Soil
Agriculture
Animal husbandry
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41. •The environmental factors are compounded
by social factors. Such as unhygienic
customs and habit, unhygienic delivery
practices (e.g., using unsterilized
instruments for cutting the umbilical cord),
ignorance of infection and lack of primary
health care services.
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42. •In the developed countries, urbanization,
industrialization and mechanization of
agriculture have interfered with the normal
process of distribution of Cl. tetani and have
reduced the morbidity rate, as has occurred,
for example in UK, USA and Germany during
the last 40 years .
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43. PREVENTION
1. ACTIVE IMMUNIZATION
• Tetanus is best prevented by active immunization
with tetanus toxoid.
• It stimulates the production of the protective
antitoxin.
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44. •The aim should be to vaccinate the entire
community and ensure a protective level of
antitoxin approximately 0.01 IU/ml serum
throughout life.
•All persons should be immunized regardless of
age.
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45. Two preparations are available for active
immunization
a. Combined vaccine - DPT
b. Monovalent vaccines
i) Plain or fluid (formal) toxoid
ii) Tetanus vaccine, adsorbed.
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46. a. COMBINED VACCINE
Tetanus vaccine is offered routinely to infants
(Expanded Immunization Programme) in combination
with diphtheria vaccine and killed B. pertussis
organisms as DPT vaccine.
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47. •According to the National Immunization
Schedule the primary course of immunization
consists of 3 doses of DPT, at intervals of 4-8
weeks, starting at 6 weeks of age, followed by a
booster at 18 months of age, and a second
booster at 5- 6 years of age and a third booster
(Only TT) after 10 years of age.
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48. •Pentavalent vaccine:
At present pentavalent vaccine (Diphtheria,
pertussis, tetanus, hepatitis B, Haemophilus
influenza type b) is being given at 6th, 10th and 14th
weeks of age instead of DPT vaccine.
The DPT vaccine is used for booster dose.
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49. b. MONOVALENT VACCINES
•Purified tetanus toxoid (adsorbed) has largely
supplanted plain toxoid because it stimulates a
higher and longer- lasting immunity response than
plain toxoid.
•The latter may be employed for purposes of booster
injection when rapid protection is indicated.
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50. •A primary course of immunization consists of
two doses of tetanus toxoid adsorbed (each
dose 0.5 ml, injected into the arm) given at
intervals of 1- 2 months.
•The first booster dose (the third in order)
should be given a year after the initial two
doses.
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51. • The opinion was expressed that no more than
one additional booster dose (a total of 4 doses
altogether) given 5 years after the third dose is
required in adults (including pregnant women)
in developing countries.
•Frequent boosters must be avoided.
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52. •Purified tetanus toxoid should be stored
between 2 and 8 deg. C.
•It must not be allowed to freeze at any
time.
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53. PASSIVE IMMUNIZATION
•Temporary protection against tetanus can
be provided by an injection of human
tetanus hyperimmunoglobulin (TIG) or ATS
(EQUINE).
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54. i) HUMAN TETANUS HYPERIMMUNOGLOBULIN :
• It is the best prophylactic to use.
•The dose for all ages is 250 IU.
•It does not cause serum reactions.
• It gives a longer passive protection up to 30 days.
•Human tetanus lg is now available in India - it is
produced by the Serum Institute of India,
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55. (ii) ATS (EQUINE) :
•If human antitoxin is not available, equine
antitoxin (anti-tetanus serum or ATS) should be
used.
•The standard dose is 1500 IU, injected
subcutaneously after sensitivity testing.
•ATS gives passive protection for about 7- 10 days.
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56. Disadvantages of Horse ATS
Being a foreign protein, ATS is rapidly excreted
from the body and there may be very little
antibody at the end of 2 weeks. Because of this
drawback, ATS may not cover the tetanus
incubation period in all cases and becomes less
reliable as a prophylactic.
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57.  It causes sensitivity reaction in many people
because it contains foreign proteins.
Subsequent injections of horse serum may lead
to allergic reactions varying in severity from
rash to anaphylactic shock.
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58. ACTIVE AND PASSIVE IMMUNIZATION
•Simultaneous active and passive immunization is
widely carried out in non-immune persons.
• The patient is given 1500 units of ATS or 250 units of
Human lg in one arm, and 0.5 ml of adsorbed tetanus
toxoid (PTAP or APT) into the other arm or gluteal
region. This should be followed 6 weeks later by
another dose of 0.5 ml of tetanus toxoid, and a third
dose one year later. 58

59. ANTIBIOTICS
•A single intramuscular injection of 1.2 mega units of
a long-acting penicillin (e.g., benzathine penicillin)
will provide a sustained concentration of the drug for
3 to 4 weeks, which is sufficient to kill any vegetative
forms of tetanus bacilli that may emerge from the
sporulating stage. Penicillin has no effect on tetanus
spores.
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60. •For patients who are sensitive to penicillin, a 7-day
course of erythromycin estolate 500 mg 6-hourly by
mouth will kill vegetative forms of Cl. tetani but not
spores.
•Antibiotics should be given as soon as possible after
an injury, before a lethal dose of toxin is produced in
the wound, which may be as soon as 6 hours after
injury.
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61. •Antibiotic prophylaxis should not be relied upon for
patients seen later than 6 hours after injury.
• Moreover, it is not certain whether the antibiotic
can reach the bacilli, if there is dead tissue present
in the wound.
•Therefore, antibiotic alone is ineffective in the
prevention of tetanus; it is not a substitute to
immunization.
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62. PREVENTION OF TETANUS AFTER
INJURY
•All wounds must be thoroughly cleaned soon after
injury - removal of foreign bodies, soil, dust,
necrotic tissue.
•This procedure will abolish anaerobic conditions
which favour germination of tetanus spores.
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63. All wounds received surgical toilet
Wounds less than 6 hours old,
clean, non-penetrating and with
negligible tissue damage.
Immunity category
A
B
C
D
TREATMENT
Nothing more required
Toxoid 1 dose
Toxoid 1 dose
Toxoid complete course
Other wounds
Immunity category
A
B
C
D
TREATMENT
Nothing more required
Toxoid 1 dose
Toxoid 1 dose + human tet.Ig
Toxoid complete + human tet. Ig
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64. • A = Has had a complete course of toxoid or a booster dose
within the past 5 years.
• B = Has had a complete course of toxoid or a booster dose
more than 5 years ago and less than 10 years ago.
• C = Has had a complete course of toxoid or a booster dose
more than 10 years ago.
• D = Has not had a complete course of toxoid or immunity
status is unknown.
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65. THANK YOU !
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