Bacteria 2 (gram +ve): Tetanus

Question 1

What causes tetanus?

Answer 1

• Clostridium tetani
• Gram+ve obligate anaerobe with terminal spore
• Found in soil. Ubiquitous organism, very resistant to light and temperature

Question 2

Where is tetanus prevalent and how deadly is it?

Answer 2

• Majority: SE Asia and South America
• Commonest in neonates -> 90% of tetanus deaths in under 5-year-olds

Question 3

What is the pathophysiology of the disease?

Answer 3

Prevents release of GABA which is an inhibitory neurotransmitter, therefore symptoms of lack of normal muscle relaxation

Question 4

What are the different clinical presentations of tetanus?

Answer 4

1. Generalised
   - Disease can progress for up to 10 days after onset of symptoms
   - Fatality increases on respiratory or autonomic involvement
2. Neonatal:
   - usually due to infection of umbilical stump

Leading cause of death in tetanus: sudden cardiac death

Question 5

How is tetanus diagnosed?

Answer 5

Clinical diagnosis

WHO definition of confirmed neonatal tetanus: “an illness occurring in an infant who has the normal ability to suck and cry in the first 2 days of life, but who loses this ability between days 3 and 28 of life and becomes rigid or has spasms

Question 6

How is tetanus treated?

Answer 6

• Tetanus Ig 150iu/kg (alternatively equine Ig or normal human Ig)
• Metronidazole (preferred) or Benpen to prevent multiplication of bacteria
• Avoid stimulating environment to avoid spasms
• ITU management for airway and autonomic dysfunction as well as high doses of benzos for spasms

Question 7

How do we prevent it?

Answer 7

• Routine DRP vaccine + booster aged 4-7yrs + booster adolescence
• Single booster in adulthood: lifetime protection
• if not vaccinated in childhood, 5 boosters in adulthood 10 years apart will give lifetime protection
• tetanus prone injuries and not immunised within last 5 years: give booster
• non-immunised mother shoudl receive a single dose of tetanus toxoid -> [maternal x5 dose regime started during pregnancy or ‘high risk’ approach in unimmunised populations of x3 doses]

Infection does not confer immunity. Vaccinate after recovery

Umbilical cord care – aseptic, avoid traditional poultices, cord-care packs • Wound care – cleaning, antibiotics if infected • Tetanus vaccination [maternal x5 dose regime started during pregnancy or ‘high risk’ approach in unimmunised populations of x3 doses] • Neonatal tetanus surveillance is necessary to target elimination efforts.

Question 8

MCQ key words?

Answer 8

• Recognise the appearance of tetanus bacteria on microscopy.
• Risus Sardonicus or Opisthotonus may be photograph-based questions. Remember the distinguishing clinical features that will differentiate opisthotonus that might be seen in infective meningoencephalitis or have a similar-ish appearance rabies. People infected with tetanus may have difficulty swallowing, which is different from hydrophobia seen in rabies.
• Consider tetanus in any scenario where a neonate stops being able to feed/ suckle (even in the absence of easier clinical signs like muscle spasms).
• Know the different immunisation schedules.

Question 9

Microscopy tetanus

Answer 9

“drum stick appearance”

Question 10

Risus sardonicus

Answer 10

Question 11

SAQ: Outline clinical features of neonatal tetanus.

Answer 11

WHO definition of confirmed neonatal tetanus: “an illness occurring in an infant who has the normal ability to suck and cry in the first 2 days of life, but who loses this ability between days 3 and 28 of life and becomes rigid or has spasms”

Question 12

What are the main strategies for maternal and neonatal tetanus elimination? (12)

Answer 12

Routine DRP vaccine + booster aged 4-7yrs + booster adolescence

Infection does not confer immunity. Vaccinate after recovery

Umbilical cord care – aseptic, avoid traditional poultices, cord-care packs

• Wound care – cleaning, antibiotics if infected
• Tetanus vaccination [maternal x5 dose regime started during pregnancy or ‘high risk’ approach in unimmunised populations of x3 doses]
• Neonatal tetanus surveillance is necessary to target elimination efforts.

Question 13

What is the WHO maternal and neonatal tetanus elimination plan (MNTE)?

Answer 13

The recommended strategies for achieving Maternal and Neonatal Tetanus (MNT) elimination include:

1. Strengthening routine immunization of pregnant women with tetanus toxoid vaccine (TTCV)
2. TTCV Supplementary Immunization Activities (SIAs) in selected high risk areas, targeting women of reproductive age with 3 properly-spaced doses of the vaccine
3. Promotion of clean deliveries and clean cord care practices
4. Reliable NT surveillance including case investigation and response

Once MNT elimination has been achieved, maintaining elimination will require continued strengthening of routine immunization activities for both pregnant women and children, maintaining and increasing access to clean deliveries, reliable NT surveillance, and introduction of school-based immunization with TTCV.

Question 14

SAQ: How do you treat tetanus?

Answer 14

1. Eradicate the source of infection using antibiotics,
2. Neutralise unbound toxin with human tetanus immune globulin,
3. Control muscle spasms using muscle relaxants or neuromuscular blocking agents,
4. Establish and maintain a secure airway,
5. Stabilize autonomic effect