ORIGINAL

Niger J Paed 2013; 40 (2): 154 –157

Alhaji MA

Akuhwa RT

Mustapha MG

Ashir GM

Mava Y

Post-neonatal tetanus in University

of Maiduguri Teaching Hospital,

North-eastern Nigeria

Elechi HA

Bukar FL

DOI:http://dx.doi.org/10.4314/njp.v40i2,9

Accepted: 24th August 2012

Abstract Background: Tetanus is a

public health problem in Nigeria.

This study examines the demo-

graphic and clinical profile of post-

neonatal tetanus (PNT) seen in

University of Maiduguri Teaching

Hospital (UMTH), North- eastern

Nigeria.

immunized. No booster immuniza-

tion was received by any of the

eligible children. The portal of en-

try of the infection was injury to the

lower limbs and otogenic route in

53.9% and 33.3% respectively. Ma-

jority of patients were of low socio-

economic status. The duration of

hospital stay ranged between 1-50

days with mean + SD (18.68+

11.51).The mortality rate was

Alhaji MA

(

)

Akuhwa RT, Mustapha MG, Ashir GM

Mava Y, Elechi HA

Department of Paediatrics,

University of Maiduguri Teaching

Hospital,

P.M.B. 1414, Maiduguri,

Borno State - Nigeria.

Email: m_alhaji@hotmail.com

Tel: +2348065703378

Methods: This is a hospital-based

prospective study of PNT. All chil-

dren beyond the neonatal period to

1

Paediatrics unit of UMTH,

Maiduguri from June 2009 to July

2

were studied.

Results: A total of 39 cases of PNT

were admitted over the period un-

der review. The male: female ratio

was 2.3:1.0. Their ages at presenta-

tion ranged between 16 months and

1

3

children were either not immunized

against tetanus or their immuniza-

tion status was unknown and only

two of the children were fully

4 years of age admitted into the

(7)18 %.

Bukar FL

Conclusion: Tetanus still remains a

major cause of childhood morbidity

and mortality in Nigeria. Severe

disease and the first one week of

admission are the main variables

identified to influence outcome.

Therefore, there is need to

strengthen routine immunization

and booster doses of tetanus toxoid

(TT) should be mandatory at pri-

mary and secondary school entry.

Close monitoring of patients with

severe tetanus during the critical

period is imperative for successful

management.

Department of Community Medicine,

College of Medical Sciences,

University of Maiduguri,

PMB 1069, Maiduguri,

Borno State – Nigeria.

011 with the diagnosis of PNT

4 years, with mean +SD of 6.9+

.87 years. Over 90 percent of the

Introduction

A study of all cases of post-neonatal tetanus (PNT) man-

aged at the University of Maiduguri Teaching Hospital

(UMTH) was conducted to highlight factors associated

with acquisition of this preventable disease, document

the clinical profile and outcome in our environment, and

proffer possible suggestions on reducing or eliminating

the disease.

Tetanus is prevalent with high morbidity and mortality

in develo_-₇ping countries of Africa and Asia, including

1

Nigeria. Tetanus is the seventh childhood killer dis-

8

ease in Central African Republic. Three and half dec-

ades after the adoption of Expanded Programme on Im-

munization (EPI) in Nigeria, tetanus still remains a pub-

9

lic health problem unlike in the developed countries.

Reasons attributed to high burden of the disease in Nige-

ria and other developing countries include low immuni-

zation coverage, lack of sustainability of immunization

programmes and deficient booster doses of tetanus

toxoid at appropriate period to eligible children.

Tetanus is a vaccine preventable disease caused by Clos-

Materials and Methods

4

,5,10

All cases of post-neonatal tetanus admitted into the Pae-

diatrics unit of the UMTH over 2 year period, June 2009

to July 2011 were consecutively enrolled into the study.

tridium tetani.

1

55

Post-neonatal patients with diagnosis of tetanus were

admitted into the Emergency Paediatrics Unit (EPU)

first, and subsequently transferred to Paediatric Medical

Ward (PMW) when stable and nursed in a quiet room

with minimal stimulation.

illness. Lower limb injury was the commonest portal of

entry in 21(53.9%) of the cases, while suppurative otitis

media (SOM) was documented in 13 (33.3%) of the

cases. There was no documented case of traditional cir-

cumcision or uvulectomy as a portal of entry in this

study. The duration of hospital stay ranged between a

day and 50 days, with mean + SD (18.68+ 11.51). Infor-

mation on socio-economic class showed that only one

(2.6%) patient each were in the socio-economic class I

and 11, while 7(17.9%), 8(20.5%), and 22(56.4%) of

the children were from the socio-economic classes III,

IV, and V, respectively.

Information obtained at presentation include age, sex,

date of admission, immunization status, social back-

1

ground of the patients using Oyedeji’s classification.

Associated morbidity/complications and the duration of

hospital stay, and outcome were also documented.

The diagnosis of tetanus w₁a₂s clinical, based on the dis-

ease characteristic features.

Permission to conduct the study was obtained from the

Research and Ethical Committee of UMTH.

Table 1 shows demographic and the clinical profile of

the patients studied.

Table 1: Demographic and clinical profile of the study

population.

Age distribution

Disease classification into mild, moderate, and severe

was based on the presence of trismus, risus sardonicus,

but no spasm; presence of minimal provoked spasms;

and sustained and sp₁₃ontaneous spasms and or opist-

hotonus, respectively.

Number of cases (%)

Less than 5 years

15

16

8

38.5

41.0

20.5

5

-10 years

Above 10 years

Gender distribution

Male

Female

Each patient was managed with the use of anti-tetanus

serum (ATS) for passive immunotherapy to neutralize

the toxins, sedation and spasms control with drug com-

bination therapy; phenobarbitone, chlorpromazine, and

diazepam, given parenterally, until spasms were fully

controlled before changing to oral. Breakthrough

spasms, defined as spasms occurring after initial control

of spasms, were treated with diazepam. Antibiotics, in-

cluding procaine penicillin or metronidazole were given

to eradicate organisms. Nutrition was maintained with

high protein pap, given by naso-gastric tube feeding,

until patients could tolerate orally. With severe spasms,

intravenous fluids were administered until spasms sub-

sided before commencing feeding. Tetanus toxoid (TT)

was also given to all patients for active immunization

before discharge.

27

12

69.2

30.8

Immunization status

Fully immunized

Unimmunized

Uncertain/unknown

Incomplete/partial immunization

Portals of entry of infection

Injuries to lower limbs

Suppurative otitis media

Unidentified

2

5.0

22

15

1

56.4

36.1

2.5

21

13

4

53.9

33.3

10.3

2.5

Others

Duration of hospital stay

1

<

1 week

3

7.7

1

3

-2 weeks

-4 weeks

16

14

6

41.0

35.9

15.4

>

4 weeks

Outcome

Discharged

Left against medical advice

Died

Data obtained were analysed using SPSS version 11.0

30

2

7

77.0

5.0

18.0

(

Chicago, Illinois, USA). Comparisons between cate-

gorical variables were done with appropriate Chi-square

2

x ) test. A p-value of < 0.05 was considered significant.

(

Tables were used for data presentation where necessary.

Twenty (51.3%) of the children had identified co-

morbidities which include: bronchopneumonia (10),

malaria (9), and measles (1). Of the 20 children with co-

morbidities, six (30%) had multiple co-morbidities. The

overall mortality was seven (18%). Six (86%) each of

the mortality cases had severe disease at presentation

and died within one week of admission respectively. All

the mortality cases except one patient were in the low

social class. Lower limb injuries and otogenic route, as

portals of entry were significantly observed in school

age (≥ 5 years) and pre-school age (< 5 years) respec-

tively (p = 0.00013). There was no statistical relation-

ship observed between mortality and variables such as

age, incubation period, period of onset, and portal of

entry as shown in table 2.

Results

There were 39 cases of PNT out of the total of 2814

admissions into the Paediatric unit over the two year

study period, accounting for an incidence of 1.4%. There

were 27 males and 12 females, giving a male: female

ratio of 2.3: 1.0. Their ages ranged between 16 months

and 14 years, with mean +SD of 6.9+ 3.87. Fifteen

(

38.5%) of the children were under 5 years. Only 2(5%)

of the patients were fully immunized and none of the 18

eligible children received booster doses of tetanus

toxoid. Generalised tetanus was seen in 38(97.4%) cases

while localised tetanus was documented in only 1(2.6%)

case which involved the left lower limb, following intra-

muscular injection to the left gluteal region for a febrile

1

56

Table 2: Comparison of variables with outcome in study

population

factor for tetanus in susceptible individuals, vaccination

with tetanus toxoid₁d₈oes not confer 100 percent protec-

tion against tetanus.

Variables

Age

Outcome

Died Survived Lama

p-value

*0.44

Majority (61.5%) of the subjects were aged five years

and above, and hence, eligible for booster doses of TT,

1,4, 10

but none had one, consistent with previous findings.

<

5 years

2

13

5

17

0

2

≥

The major portals of entry identified in this study were

injury to the lower limbs, followed by the otogenic route

of the i₁n_,₃f_,e₁₇ction which agrees with findings from other

studies.

Incubation period (days)

<

7

2

1

0

4

10

4

6

1

*0.50

7

-14

0

1

0

>

Unknown

14

10

Period of onset (days)

The mean duration of hospitalization of 18.68+

<

3

2

0

3

8

4

6

1

0

1

0

*0.63

*0.65

1

1.51days ( range of 1-50 day₅s) is comparable to the

3

-7

>

7

report from Calabar, Nigeria. Prolonged duration of

hospital stay has a negative impact on hospital resources

as well as an increased cost of health care for the family

in addition to social burden. This was seen in one of the

patients whose parents left against medical advice be-

cause of increasing cost of health care and social pres-

sure. Most of the patients in this study were from lower

Unknown

12

Portal of entry

Lower limb injury

SOM

Others

SOM = Suppurative Otitis Media

Lama = Left against medical advice

3

2

15

11

4

1

4

0

*

Fisher exact test

1

social classes, sim₇ ilar to reports by Akuhwa et al and

1

Adegboye et al. This has been attributed to the inter-

play of ignorance, poverty and infection which is often

seen among the low social class. The influence of socio-

economic and cultural fact₁o₉rs in health and certain dis-

eases has been highlighted.

Discussion

This study reveals that post-neonatal tetanus is still

prevalent in our environment despite the availability of

effective vaccines. Thirty nine cases of PNT reported in

this study in 2 years were higher than the 12 cases of

Bronchopneumonia being a predominant co-morbidity

with fatal outcome in patients with tetanus has been re-

2

0

1

4

ported. It could be due to restrictive defect from mus-

cular rigidity and spasms of the chest wall, poor cough

and increased bronchial secretions resulting in atelecta-

sis with seconda₂₀ry bacterial infection or due to aspira-

tion pneumonia.

PNT over 4 year period reported by Bondi and Alhaji

in the same centre, 2 decades ago. This could be ex-

plained by the fact that, there was an intense immuniza-

tion against the six killer diseases including tetanus,

with high immunization coverage in Borno State (1988-

The influence of the severity of the disease at presenta-

tion on outcome in this study is similar to reports by

1

991) and apparent reduction in morbidity from the dis-

ease. However, the immunization programme was not

sustained due to ineffective primary health care services

and lack of political will among others. This led to re-

surgence of vaccine preventable disea_,₁s₅es, including teta-

5

Anah et al. This could be attributed to airways obstruc-

tion from laryngospasm, bronchial secretions and auto-

nomic dysfunctions. Most of the patients died within the

first week of admission and therefore, is a critical period

for patient ca₀re in order to minimize the risk of death.

5

nus, in Nigeria as earlier reported. In many parts of

Northern Nigeria, the study centre inclusive, only about

2

Cook et al have earlier reported that mortality due to

1

cines.

0 pe₁r₆cent of children receive all of their routine vac-

tetanus occurs soon after admission from acute compli-

cations such as airways obstruction among others.

The observation that the predominant portals of entry

among children beyond 5 years of age and the under-

five children as the lower limb injury and SOM respec-

The preponderance of tetanus among the school aged

and in m₁_,₄a_,l₅e_,₁s₀ is in consonance with other reports from

Nigeria.

This could be attributed to their explora-

1

tively is in agreement with previous report. This may be

tory nature which exposes them to injury and thus,

causal organism, C. tetani. Another reason could be due

to lack of protective footwear among school children

that predisposes then to penetrating injuries as most of

the cases had lower limb injury as portal of entry.

attributed to the fact that the older children are more

predisposed to lower limb injuries from their adventur-

ous nature, whereas, acute respiratory infections is more

common among the under-fives that makes them sus-

ceptible to SOM.

Majority of the children were unimm₁_-₇u_.n₁₅i_-z₁e₇d, which is

The overall mortality in this study is comparable to pre-

similar to reports by other workers.

Two of the

5

vio₁₇us study but lower than the report by Adegboye et

patients that were fully immunized in in₃ fancy developed

5

al with case fatality rate of 62.1 percent. The variance

may be due to the fact that, the later study included both

neonatal and post-neonatal tetanus.

tetanus, similar to reports by Nte et al, Anah et al, and

10

Fatunde et al. A possible explanation include waning

of the protective levels of neutralizing antibodies in

older children especially, if booster doses of tetanus

toxoid were not given, as is the case in these two chil-

dren. Although lack of immunization is the greatest risk

A similar lack of significant statistical difference noted

in the outcome of the under-fives₇ and older children was

earlier reported by Mondal et al.

1

57

The findings in this study that both incubation period

and period of onset were not related₀to outcome, sharply

It is therefore suggested that health education on immu-

nization be intensified and the inclusion of booster doses

of TT at primary and secondary school entry to₇_,₁t₀he NPI

schedules as earlier proposed by other workers.

2

contrast with established literature and previous stud-

22,23

ies,

especially in neonatal tetanus, that both variables

correlates inversely to outcome. The reason for these

inconsistent findings is not clear but could be due to

small study population to deduce a more meaningful

statistical inference.

Contribution to Authors: The corresponding author

conceived the idea and together with all the co-authors

was involved in data collection, data analysis and

writing of the manuscript.

Conflict of interest: None.

Funding: None.

The risk of death had no relationship to the portals of

entry of the infection in this study, a finding previously

2

1

reported by Yadav et al, which implies that site of

wound or injury does not influence the severity and

prognosis of tetanus.

Tetanus remains a major public health problem in Nige-

ria and contributes to considerable morbidity and mor-

tality of children. Severe disease and the first one week

of admission are the main determinants of outcome, and

therefore, extra attention should be paid to these pa-

tients, especially during this critical period of admission

in order to minimize the risk of death.

Acknowledgement

We are grateful to all medical and nursing staff who

were involved in the care of the patients.

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