PRINCIPLES OF TETANUS

PROPHYLAXIS
BY DR NGOZI BUCHI
 OUTLINE
• DEFINITION • COMPLICATIONS
• HISTORICAL PERSPECTIVE • CONCLUSION
• EPIDEMIOLOGY • REFERENCES
• MICROBIOLOGY
• PATHOPHYSIOLOGY
• CLASSIFICATION
• CLINICAL FEATURES
• DIFFERENTIAL DIAGNOSIS
• TETANUS PROPHYLAXIS
• TETANUS IMMUNIZATION
 DEFINITION
• The Centres for Disease Control and Prevention (CDC) defines tetanus as
“the acute onset of hypertonia or painful muscular contractions (usually
of the muscles of the jaw and neck) and generalized muscle spasms
without other apparent medical cause.”

• Neonatal tetanus is defined by the World Health Organization(WHO) as

“an illness occurring in a child 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 and has spasms.”

• Caused by the bacterium Clostridium tetani and is preventable by

vaccination.
HISTORICAL PERSPECTIVE

• The word tetanus comes from the Greek word tetanos, meaning

"taut", which is derived from the term teinein, meaning to stretch.

• Arthur Nicolaier discovered the anaerobic bacillus Clostridium

tetani in 1885 ending an era of ignorance of the causation.

• In 1889, Koch's pupil, Kitasato Shibasaburō obtained the bacillus of

tetanus in pure culture and associated the disease to animals.

HISTORICAL PERSPECTIVE

• Tetanus toxoid vaccination was first introduced by Behring and

Knorr in 1886.

• Tetanus toxoid was developed by Descombey in 1924. It was

first widely used during World War II.

EPIDEMIOLOGY
• Tetanus is one of the target diseases of the World Health Organization
(WHO) Expanded Program on Immunization. Overall, the annual incidence of
tetanus is 0.5-1 million cases. WHO estimated there were 213,000 tetanus
deaths in 2002 with 198,000 occurring in children younger than 5 years

• It is currently responsible for 1.2 million deaths in the developing world

• The incidence of tetanus in Nigeria is higher in the hot dry season than in
the wet but a few studies reported occurrence of more cases in the wet
season.
EPIDEMIOLOGY
• Most cases occur in the younger age group although there are cases
at the extremes of life, usually associated with higher mortality.

• Persons >60 years of age are at greater risk of tetanus because

antibody levels decrease over time.

• Male preponderance

• In Nigeria, the mortality rate varies from 38% to 60%, depending on

the infrastructure facilities and personnel at the reporting centre
MICROBIOLOGY
• Clostridium tetani is a gram-positive, spore-forming, motile,
anaerobic bacillus. Typically measuring 0.3 to 0.5 μm in width and 2
to 2.5 μm in length, the vegetative form often develops long
filament-like cells in culture.

• Motility is produced by peritrichous flagellae coating the cell surface.

With sporulation, loses its flagellae and takes on the more
characteristic drumstick-like appearance reflecting spore formation in
the terminal position.
MICROBIOLOGY
• C. tetani is ubiquitous in nature, a strict anaerobe that grows optimally at
33° to 37° C; however, depending on the strain, growth can occur at 14° to
43° C.

• It can be cultured in a variety of anaerobic growth media such as

thioglycolate, casein hydrolysate and cooked meat.

• The most common source of environmental exposure to C. tetani bacilli and

spores is soil, where the organism is widely but variably distributed.
MICROBIOLOGY
• The organism exists in two forms; Spore or Dormant form and
Vegetative or Active form.

• If not exposed to sunlight, C. tetani spores can persist in soil for

months to years. Spores are resistant to boiling and a variety
of disinfectants.

• Animals are also C. tetani reservoirs. Both herbivores and omnivores

can harbour tetanus bacilli and spores in their intestines,
disseminating the organism in their faeces.

• C. tetani spores have also been detected in street dust and the dust
 PATHOPHYSIOLOGY
• Under anaerobic conditions found in necrotic or infected tissue, the maturing
tetanus bacillus secretes two exotoxins: tetanospasmin and tetanolysin.

• Tetanolysin is capable of locally damaging otherwise viable tissue surrounding

the infection and optimizing the conditions for bacterial multiplication.

• Tetanospasmin leads to the clinical syndrome of tetanus.

 PATHOPHYSIOLOGY
• Only those bacteria producing tetanus toxin (tetanospasmin) can cause
tetanus.

• This molecule is necessary for presynaptic binding and release of

neurotransmitter; thus tetanus toxin prevents transmitter release and
effectively blocks inhibitory interneuron discharge. The result is unregulated
activity in the motor nervous system.

• Similar activity in the autonomic system accounts for the characteristic

CLASSIFICATION OF TETANUS
Generalized Tetanus:

• Approximately 50-75% of patients with generalized tetanus present with

trismus (“lockjaw”), which is the inability to open the mouth secondary to
masseter muscle spasm.

• Nuchal rigidity and dysphagia are also early complaints that cause risus
sardonicus the scornful smile of tetanus, resulting from facial muscle
involvement. As the disease progresses, patients have generalized muscle
rigidity with intermittent reflex spasms in response to stimuli (e.g. noise,
touch).
CLASSIFICATION OF TETANUS
Generalized Tetanus:

• Tonic contractions cause opisthotonos (i.e., flexion and adduction of

the arms, clenching of the fists, and extension of the lower
extremities). During these episodes, patients have an intact
sensorium and feel severe pain. The spasms can cause fractures,
tendon ruptures, and acute respiratory failure.
Localized tetanus:

• In localized tetanus, there is spasticity of muscles near the entry

wound but no trismus; spasticity may persist for weeks.
CLASSIFICATION OF TETANUS

• Cephalic tetanus is a form of localized tetanus that affects the

cranial nerves. It is more common among children; in them, it may
occur with chronic otitis media or may follow a head wound.
Incidence is highest in Africa and India. All cranial nerves can be
involved, especially the 7th. Cephalic tetanus may become
generalized.
CLASSIFICATION OF TETANUS

• Tetanus neonatorum: Tetanus in neonates is usually

generalized and frequently fatal. It often begins in an
inadequately cleansed umbilical stump in children born of
inadequately immunized mothers. Onset during the first 2 wk of
life is characterized by rigidity, spasms, and poor feeding.
Bilateral deafness may occur in surviving children.
CLINICAL FEATURES

History

• Contaminated open wound

• Difficulty opening the mouth/ swallowing

• Muscle pain

• Difficulty in breathing

• Difficulty in passing urine

• Co-morbidities
CLINICAL FEATURES

Examination
• MSS: Trismus

Risus Sardonicus

Hyperreflexia

Muscle rigidity/spasm
• RESP: Laryngeal spasm

• CVS: Tachycardia

Hypertension
CLINICAL FEATURES

• GIT: Constipation

• UGS: Urinary retention

Diagnosis is Clinical

Investigation:
• Spatula test

• Other investigations are to prepare patient for treatment, D.D

and complications
DIFFERENTIAL DIAGNOSIS

• Strychnine poisoning (rat • Encephalitis

poison) • Hepatic encephalopathy
• Malignant neuroleptic • Status epilepticus
syndrome
• Malignant hyperthermia
• Dental infection with trismus

• Meningitis
TETANUS PROPHYLAXIS

• Prophylaxis is defined as a process of guarding against the development

of a specific disease by a treatment or action that affects its
pathogenesis.

• The basic principles of tetanus prophylaxis are:

• Tetanus immunization prior to injury

• Tetanus immunization at injury

• Proper surgical management of wounds

• Use of antibiotics when indicated

TETANUS PROPHYLAXIS
Forms of immunization:
• Active form, the organisms, dead, or modified are introduced into the host to
give a very mild form of the disease and thereby stimulate the reticulo-
endothelial system to produce antibodies; it is more effective but takes two or
three months to become operational. this can be achieved through the
traditional and rapid methods

• Passive form, human or equine tetanus immune globulin or anti tetanus serum
(ATS) is given to protect the victim. This is less effective and may precipitate
anaphylaxis but is immediately operational.
TETANUS PROPHYLAXIS
• Tetanus immunization prior to injury

• Traditional, to actively immunize a patient, 1 ml of toxoid is

injected and repeated 6 weeks, 6 months, 1 year after, 2
years then a booster every 10 years.

• Alternatively, this can be achieved during pregnancy by

administration of the dose
TETANUS PROPHYLAXIS

• Tetanus immunization prior to injury

• Rapid method (alum-precipitated toxoid) given at day 1, 4 and
7.
• Active immunity is demonstrable in 28 days.
TETANUS IMMUNIZATION AT INJURY
TETANUS PROPHYLAXIS

• The use of equine or bovine antitoxin is mentioned to be

discarded because of the high incidence of allergic and
sometimes anaphylactic reactions, however with the availability
of human tetanus globulin this can be avoided.
TETANUS PROPHYLAXIS

• Proper surgical management of wounds

• Wound care

• Wound debridement

• (ABCDE)

• wound dressings
TETANUS PROPHYLAXIS
Rationale for use of antibiotics

• The use of antibiotics in the proper dose should be considered to

eliminate the organism before it starts releasing its toxins.

• Penicillin is the drug of choice although metronidazole with a better

safety profile, better tissue permeability and negligible CNS excitability
(penicillin can cause seizures in high doses) seems to be replacing it in
developing countries.

• Tetracycline such as Erythromycin can also be used.

TETANUS IMMUNIZATION

• Tetanus shots are usually given intramuscularly at the deltoid

muscle.

• Children can either be given in the arm or thigh.

• Four different kinds of vaccines protect against tetanus and other

diseases. The one you get is based on your age and vaccine status.
• DTaP is given to babies and young children. It protects
against diphtheria, tetanus, and pertussis (whooping cough).
• DT is for babies and young children who’ve had a bad reaction to the
TETANUS IMMUNIZATION

• Tdap is given to older children and adults. It protects against

diphtheria, tetanus. and pertussis.

• Td is the booster shot for older children and adults that only
protects against diphtheria and tetanus.

• Children typically get five doses of the DTaP or DT vaccine at 2

months, 4 months, 6 months, between 15 -18 months and
between 4 - 6 years. Then comes one dose of Tdap between the
ages of 11 and 12, and a Td booster every 10 years.
CONTRAINDICATIONS

• Do not administer to patients with known allergy to HTIG or those

who have had a true anaphylactic reaction to the active
substance or to any of the components of the product.

• Who have severe thrombocytopenia or any coagulation disorder

that would contraindicate intramuscular injections.
COMPLICATIONS

• Laryngospasms

• Fractures

• Hypertension

• Pulmonary embolism

• Aspiration pneumonia
CURRENT TREND

• Currently the use of recombinant human immuniglobulin as

prophylaxis is gaining traction in the prophylatic management of
tetanus.
LOCAL EXPERIENCE

• In UATH, a patient with suspected contaminated wound is given

tetanus prophylaxis commonly TT.

• However, in an instance where there is high suspicion of

contamination with dirty materials the Human Tetanus
Immunoglobulin (HTIG) is given in addition.
CONCLUSION
• Tetanus is an acute disease manifested by skeletal muscle spasm and
autonomic nervous system disturbance.

• It is caused by a neurotoxin produced by the bacterium Clostridium

tetani and is preventable by vaccination.

• Prophylaxis plays a major role in prevention of tetanus.

REFERENCES
• https://www.sciencedirect.com/science/article/abs/pii/0002961069902426 assessed on the
20th of October, 2022.
• https://www.uptodate.com/contents/tetanus#H1917252 assessed on the 21st of October,
2022.
• Content by Dr Íomhar O' Sullivan. Reviewed and update by Stephanie Mulcair, CNM2,
Immunisation, CUH and byTricia Collier (Pharmacist CUH) 12/12/2008. Last review Dr ÍOS
21/06/21.
• https://www.cdc.gov/tetanus/clinicians.html assessed on the 20th of October, 2022.
• Apte NM, Karnad DR. Short report: the spatula test: a simple bedside test to diagnose
tetanus. Am J Trop Med Hyg. 1995 Oct. 53(4):386-7. [QxMD MEDLINE Link] assessed on the
20th of October, 2022.
• https://www.ncbi.nlm.nih.gov/books/NBK459217/#:~:text=The%20prognosis%20after%20t
etanus%20depends,tetanus%20have%20a%20poor%20prognosis
. assessed on the 21st of October, 2022.
• BADOE 4th edition page 19.
• Bailey & Love’s Short Practice of Surgery (26th Ed.) page 57.
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