|Year : 2017 | Volume
| Issue : 1 | Page : 1-5
Pattern and outcome of tetanus in a tertiary health facility in Northwest Nigeria
Alhaji A Aliyu1, Tukur Dahiru1, Reginald O Obiako2, Lawal Amadu1, Lawal B Biliaminu1, Ephraim I Akase2
1 Department of Community Medicine, Ahmadu Bello University, Zaria, Nigeria
2 Department of Medicine, Ahmadu Bello University, Zaria, Nigeria
|Date of Web Publication||7-Jun-2017|
Alhaji A Aliyu
Department of Community Medicine, Ahmadu Bello University, Zaria
Source of Support: None, Conflict of Interest: None
Background: Tetanus, a disease that is largely preventable, is still a major public health problem in the developing world and is associated with high morbidity and mortality rates. There is a paucity of published literature on tetanus in adults (non-neonatal) in this study area.
Materials and Methods: This was a 14-year retrospective study of patients who presented with a clinical diagnosis of tetanus in Ahmadu Bello University Teaching Hospital, Zaria, Northwest Nigeria between January 2001 and December 2014. Data were analyzed using the Statistical Package for the Social Sciences computer software package.
Results: A total of 91 cases were reviewed. The median age of patients was 14 years with a male-to-female ratio of 3:1. Majority of the patients (88%) were <40 years. Mean onset period was 19 days, majority of the patients (96.7%) had a generalized tetanus, and the most common presenting signs were spasm (93.4%) and trimus (78.0%). The most common site of injury in 64.8% of the cases was the lower limbs. The complication rate was 71.4%, and the mortality rate was 48.4%.
Conclusion: Tetanus is still a major public health problem in our centre and affects people belonging to the younger age group with a high case of fatality rate. The incidence of tetanus can be reduced drastically by an effective and sustained immunization programme.
Keywords: Clinical characteristics, mortality, northwest nigeria, outcome, tetanus in adults
|How to cite this article:|
Aliyu AA, Dahiru T, Obiako RO, Amadu L, Biliaminu LB, Akase EI. Pattern and outcome of tetanus in a tertiary health facility in Northwest Nigeria. J Med Trop 2017;19:1-5
|How to cite this URL:|
Aliyu AA, Dahiru T, Obiako RO, Amadu L, Biliaminu LB, Akase EI. Pattern and outcome of tetanus in a tertiary health facility in Northwest Nigeria. J Med Trop [serial online] 2017 [cited 2020 Aug 14];19:1-5. Available from: http://www.jmedtropics.org/text.asp?2017/19/1/1/207596
| Introduction|| |
Tetanus is caused by an anaerobic spore-forming rod, Clostridium tetani, in its vegetative form; it is a gram-positive, slender rod. C. tetani is a ubiquitous organism that develops a terminal spore and looks like a drumstick. Tetanus is a positive environmental hazard, and its occurrence depends upon an individual’s physical and ecological surroundings (soil, agriculture and animal husbandry activities) and not on the presence or absence of infection in the population. The environmental factors are compounded by social factors such as unhygienic customs and habits, unhygienic delivery practices, ignorance of infection and a lack of primary healthcare services. More than a century now, much is known about tetanus and its toxin, and the medical profession is well equipped with an antitoxin and a vaccine to prevent the disease, yet tetanus has continued to be a major public health problem throughout much of the developing world even in the new millennium. The availability of a tetanus vaccine and functional health system has enabled the developed countries to virtually eliminate the disease. However, C. tetani will never be eradicated from soil; therefore, wherever vaccination programmes are ineffective or inadequate (such as Nigeria), tetanus will continue to occur. In addition, the breakdown in public health infrastructures resulting from under-investment, wars or natural disasters, combined with growing public mistrust of immunization, means that tetanus will continue to be a major global health problem.
Tetanus almost always affects non-immunized, partially immunized or fully immunized persons who fail to maintain adequate immunity with booster doses of the vaccine. Tetanus vaccine has been available since 1923. Vaccination is started at 2 months of age with three injections at monthly intervals. The second injection confers immunity, with the third prolonging its duration. A booster is given before the age of 5 years. Similar response occurs in older children and adults. Neonatal immunity is provided through maternal vaccination and transplacental transfer of immunoglobulin; however, this can be impaired in the presence of Human immunodeficiency virus (HIV) infection. Immunity is not life long, so revaccination is recommended every 10 years.
Despite the World Health Organization’s efforts to eradicate the disease by 1995, tetanus remains one of the world’s major causes of preventable deaths with an estimated incidence of 700,000 to 1 million cases per year, causing an estimated 213,000 deaths and a case fatality rate ranging from 20 to 50%. In most cases, tetanus follows a recognized injury. However, in some situations, injuries may be trivial, and in up to 50% of cases, the injury occurs indoor and/or is not even considered serious enough to seek medical attention., In 15–25% of patients, there is no evidence of a recent wound/injury. The incubation period of the disease in human beings is usually 3–21 days. However, it may be as short as 1 day or may take several months. It is known that the greater the distance of the site of injury from the central nervous system, the longer the incubation period. Basically, there are three types of tetanus, generalized, cephalic and local. Generalized tetanus is the most common and presents with the classical signs and symptoms, whereas cephalic tetanus is the unusual form of the disease that often manifests with dysfunction of the cranial nerves (third, fourth, seventh, ninth, tenth and twelfth). The usual laboratory investigations are of little value as far as the diagnosis of the disease is concerned. The diagnosis is made based on the history of injury followed by the development of the classic symptoms of the disease.
The paucity of literature on tetanus in adults (non-neonatal) from this part of the country prompted this review. The aim of the study was to present the descriptive characteristics and outcome of tetanus cases seen at the Ahmadu Bello University Teaching Hospital (ABUTH), Zaria, Northwest Nigeria between 2001 and 2014. The study also aims to use the findings to advocate improvement in the tetanus immunization services.
| Materials and methods|| |
This was a retrospective review of all tetanus cases seen and managed at the ABUTH, Zaria, Northwest Nigeria. The period under review was from 1st January 2001 to 31st December 2014 (14 years). All the case notes/files of tetanus cases (except neonates) were retrieved from the Department of Health Management Information System (HMIS) library (medical records). A research protocol was designed and used to extract information regarding the Socio-demographic characteristics of the patients, admission notes, presenting signs and symptoms, the site of injury, the type of tetanus and outcome, the distribution of patients by departments, treatment given and the development of complications. The patients were diagnosed to have tetanus on the basis of clinical history and findings on physical examination. The criteria used for selection of cases in this study were the signs and symptoms of the disease, as have been used in previous studies., The Statistical Package for the Social Sciences (SPSS Inc., Chicago, IL, United States) software package was used for analysis, and the results were presented using frequency tables and charts; Fisher’s exact text of significance was performed where appropriate. P-values of <0.05 were considered as significant.
| Results|| |
During the period under review (2001–2014), a total of 91 cases of tetanus were admitted, giving an average of approximately 7 cases per year. The report is based on an analysis of these cases. The median age for all tetanus patients was 14.0 years; those less than 40 years were 80 (88%) in number, whereas those older than 40 years were 11 (12.1%) in number. Majority of the patients were males, 68 (74.7%) in number. and females were 23 (25.3%) in number, giving a male:female ratio of 3:1 [Table 1]. The incubation period (time interval from injury to appearance of first symptom) ranged from 5 to 49 days, with a mean onset period of 19 days. More than half of the patients (54.9%) had onset between 2 and 3 weeks, whereas for 10 (11.5%) patients, it was within a week. There was no statistically significant relationship among age, the sex of the patient and the outcome of tetanus (P = 0.41, 0.17). Majority of the cases, 88 (96.7%) in number, had generalized tetanus, and the most common presenting signs were spasm (85; 93.4%) and trimus (71; 78.0%), as shown in [Table 1]. The most common site of injury was the lower limbs (54; 64.8%), and in 4 (4.4%) cases, no portal of entry was recorded. About half (49.5%) and 39 (42.9%) of the patients were admitted in Medical and Paediatric (excluding neonates) Wards, respectively [Table 1]. Among the patients, 47 (51.6%) recovered and were discharged, whereas 44 (48.4%) died. Total cumulative case fatality rate (CFR) for the period under review was 48.4%. [Figure 1] and [Figure 2] show the distribution of outcome by year and trends in CFR by year. The year 2005 had the lowest number of cases who were either discharged or died; 2007 had equal number of cases discharged and dead, whereas 2011 had the highest number of cases discharged. The trends in mortality did not exhibit any definite pattern except that mortality was highest in 2005. It then declined in 2006; thereafter, it has been swinging. The lowest mortality was recorded in 2011. Of the 91 patients, 65 (71.4%) developed complications, out of which 29 (44.6%) had hyperpyrexia, 3 had haemorrhage (4.6%) and 1 had aspiration (1.5%). Sixty-five (71.4%) of the patients were given the following treatments: anti-tetanus toxin (66.2%), tetanus toxoid (30.8%), antibiotics (70.8%) and sedatives (70.8%). The admission ward was the only significant determinant of outcome (P = 0.01); non-significant determinants were the age and sex of the patient [Table 2].
|Table 1: Socio-demographic characteristics of tetanus cases at the Ahmadu Bello University Teaching Hospital from 2001 to 2014 (n = 91)|
Click here to view
| Discussion|| |
The study has shown that tetanus is still prevalent in our society and contributes significantly to the high morbidity and mortality rates despite effective tetanus vaccines and its availability over the past 90 years.,, The annual prevalence of cases admitted and treated in this study was 6.5 per year, which was comparatively similar to that reported from Sokoto but higher than the value of 2.5 per year reported by other workers., The high incidence of the disease in our society and indeed in the developing world, generally, may be attributed to the low levels of awareness in terms of vaccination against the disease and availability of human and material resources to manage tetanus., Consistent with previous studies in developing countries,,,,, patients with tetanus in this study were quite young (<40 years) and were predominantly males, which contrasts with the reports from developed countries., These patients are young; therefore, they engage in lots of risky physical activities such as running, playing football and farming, which makes them vulnerable to both minor and serious injuries that predispose them to tetanus infection, which is ubiquitous in the soil.
In this study, age was not a significant (X2 = 3.946; P = 0.413) determinant of outcome and is in agreement with earlier studies.,, The non-inclusion of Neonatal tetanus (NNT) cases might be responsible for age not being a determinant of outcome. Another possible reason may be the small sample size. However, in some studies, mortality varies with age; in Portugal, between 1986 and 1990, all age-related mortality varied between 32 and 59%, whereas in Africa, mortality from NNT without artificial ventilation was reported as between 63 and 79% in 1991. In a study from southeast Nigeria, the patient’s age was associated with higher CFR. The high percentage of males may be due to low vaccination rates in the community as compared to females and children who get vaccinated during pregnancy and childhood in the maternal and child health programme, respectively. In this review, the most common portal of entry was through injuries in the lower limbs; this is in agreement with previous studies.,,, The injuries in the lower limb are easily exposed and liable to contamination and infection by C. tetani. It is probable that these patients walk about in the environment barefooted without any protective footwear.
In our study, spasm, trimus, hypertonia and hyperreflexia were the most common predominating symptoms. Other researchers also reported similar findings. Complication rate of 71.4% in this study is high and agrees with what was reported in earlier studies, even though it has been said that the presence of complication does not significantly affect the outcome of patients with tetanus. However, much attention must be paid to prevent these complications through early diagnosis and management. The overall CFR was 48.4%, which is comparable with the observations reported by Chalya in Tanzania and Zziwa, in Uganda. The high CFR recorded in this study may be due to inadequate resources (human and material) required to manage these cases. It is advocated that to curb this preventable disease mortality, all persons should be immunized regardless of age. This can be achieved through re-invigoration of mass vaccination campaign against tetanus in our communities. It is also pertinent as suggested by Ogunrin and Unuigbe that healthcare providers take every opportunity to review the vaccination status of their patients especially young adults and administer the tetanus vaccine when indicated; we too recommend the same. Additionally, pre-school children should receive booster doses of the tetanus toxoid.
| Conclusion|| |
Tetanus, a disease that is largely preventable by immunization, is still common in our environment and a major cause of morbidity and mortality. Young adult males are commonly affected, yet the incidence of tetanus can be reduced drastically through effective immunization programme beyond maternal immuno-prophylaxis, with proper and adequate wound management. There is urgent need for mass vaccination regardless of age in the community.
A potential limitation to this study is the fact that information about some patients was incomplete in view of the retrospective nature of this study. This could have introduced bias in the study findings.
We are grateful to the staff of Department of HMIS for their untiring efforts in retrieving the case note/files for data collection.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Cvjetanović B, Grab B, Uemura K. Dynamics of acute bacterial diseases. Epidemiological models and their applications in public health. Part II. Epidemiological models of acute bacterial diseases. Bull World Health Organ 1978; 56(Suppl 1):25-143.
Thwaites CL, Farrar JJ. Preventing and treating tetanus: The challenge continues in the face of neglect and lack of research. BMJ 2003;326:117-8.
Cook TM, Protheroe RT, Handel JM. Tetanus: A review of the literature. Br J Anaesth 2001;87:477-87.
Ruben FL, Smith EA, Foster SO, Casey HL, Pifer JM, Wallace RB et al.
Simultaneous administration of smallpox, measles, yellow fever and diphtheria-pertussis-tetanus antigens to Nigerian children. Bull WHO 1973;48:175-81.
Myers MG, Beckman CW, Vosdingh RH, Hankins WA. Primary immunization with tetanus and diphtheria toxoids: Reaction rates and immunogenicity in older children and adults. JAMA 1982;248:2478–80.
De Moraes-Pinto MI, Almeida AC, Kenj G, Filgueiras TE, Tobias W, Nunes Dos Santos AM et al.
Placental transfer and natural acquired neonatal IgG immunity in human immunodeficiency virus infection. J Infect Dis 1996;173:1077-84.
World Health Organization (WHO). Tetanus vaccination. Wkly Epidemiol Rec 2006;81:198-208.
Stanford JP. Tetanus − Forgotten but not gone. N Engl J Med 1995;322:812-3.
Younas NJ, Abro AH, Das K, Abdou AM, Ustadi AM, Afzal S. Tetanus: Presentation and outcome in adults. Pak J Med Sci 2009;25:760-5.
Morbidity and Mortality Weekly Report. CDC; 1985. p. 34-43.
Adekanle O, Ayodeji OO, Olasunde LO. Tetanus in a rural setting of South Western Nigeria: A ten year retrospective study. Libyan J Med 2009;4:100-4.
Chukwubike OA, Godspower AE. A 10 year review of outcome of management of tetanus in adults at a Nigerian teaching hospital. Ann Afr Med 2009;8:68-72.
Reis E, Freire E, Alexandrino S. Tetanus in an ICU in Portugal: Epidemiology, incubation and complications. Int J Intensive Care 1994;1:120-1.
Chalya PL, Mabula JB, Dass RM, Mbelenge N, Mshana SE, Gilyoma JM. Ten year experiences with tetanus at a Tertiary Hospital in Northwestern Tanzania: A retrospective review of 102 cases. World J Emerg Surg 2011;6:20.
Anuradha S. Tetanus in adults − A continuing problem: An analysis of 217 patients over 3 years from Delhi, India. Med J Malaysia 2006;61:7-14.
Oladiran I, Meier DE, Ojelade AA, Olaolorun DA, Adeniran A, Tarpley JL. Tetanus continuing problem in developing world. World J Surg 2002;26:1282-5.
Ibrahim MT. Tetanus: A ten year review of cases in a teaching hospital in North Western Nigeria. Sahel Med J 2007;10:1-5. [Full text]
Ojiri FI, Danesi M. Mortality of tetanus at the Lagos University Teaching Hospital, Nigeria. Trop Doctor 2005;35:178-81.
Mchembe MD, Mwafongo V. Tetanus and it’s treatment outcome in Daar es Salaam. East Afr J Public Health 2005;2:22-3.
Dietz V, Millstein JB, van Loon F, Cochi S, Bennett J. Performance and potency of tetanus toxoid: Implications for eliminating neonatal tetanus. Bull WHO 1996;746:19-28.
Komolafe MA, Komolafe EO, Ogundare AO. Pattern and outcome of adult tetanus in Ile-Ife, Nigeria. Niger J Clin Pract 2007;10:300-3.
Feroz AH, Rahman MH. A ten year retrospective study of tetanus at a teaching hospital in Bangladesh. J Bangladesh Coll Phys Surg 2007;25:62-9.
Lau LG, Kong KO, Chew PH. A ten year retrospective study of tetanus at a general hospital in Malaysia. Singap Med J 2007;42:346-50.
Farrar JJ, Yen LM, Cook T, Fairweather N, Bin N, Parry J. Tetanus. J Neurol Psychiatry 2002;50:398-407.
Hodes RM, Teferedeges B. Tetanus in Ethiopia: An analysis of 55 cases from Addis Ababa. East Afr Med J 1990;67:887-93.
Einterz EM, Bates ME. Caring for neonatal tetanus patients in rural primary care setting in Nigeria: A review of 237 cases. J Trop Paediatr 1991;37:178-81.
Hesse IF, Mensah DK, Lartey AM, Neequaye A. Characteristics of adult tetanus in Accra. WAJM 2003;22:291-4.
Bardenheier B, Prevots DR, Khetsuriani N, Wharton M. Tetanus surveillance − US, 1995–97. CDC Morb Mortal Wkly Rep 1998;47:1-13.
Joshi S, Agarwal B, Malla G, Karmacharya B. Complete elimination of tetanus is still elusive in developing countries. A review of adult tetanus cases from referral hospital in Eastern Nepal. Kathmandu Univ Med J 2007;5:378-81.
Henderson SO, Mody T, Groth DE, Moore JJ, Newton E. The presentation of tetanus in emergency department. J Emerg Med 1998;16:705-8.
Peetermans WE, Schepens D. Tetanus − Still a topic of present interest: A report of 27 cases from Belgian referral hospital. J Int Med 1996;239:249-52.
Zziwa GB. Review of tetanus admission to a rural Ugandan hospital. Health Policy Dev 2009;7:199-202.
Ogunrin OA, Unuigbe EI. Tetanus: An analysis of the prognosticating factors of cases admitted into the medical wards of a tertiary hospital in a developing African country between 1990 and 2000. Niger Postgrad Med J 2004;11:97-102. [Full text]
[Figure 1], [Figure 2]
[Table 1], [Table 2]