February 2019, Volume 69, Issue 2

Research Article

Frequency of risk factors, vaccination status and outcome of tetanus in children at the Children's Hospital Lahore

Mubeen Nazar Duggal  ( The Children's Hospital and Institute of Child Health, Lahore - Pakistan. )
Attia Bari  ( The Children's Hospital and Institute of Child Health, Lahore - Pakistan. )
Fatima Zeeshan  ( The Children's Hospital and Institute of Child Health, Lahore - Pakistan. )
Uzma Jabeen  ( The Children's Hospital and Institute of Child Health, Lahore - Pakistan. )

Abstract

Objective: To determine the frequency of risk factors, vaccination status and outcome of tetanus in children beyond neonatal age at a tertiary care centre.
Methods: The prospective observational study was conducted at The Children\'s Hospital, Lahore, Pakistan, from January 2012 to December 2014, and comprised children aged between 1 month and 15 years of either gender admitted with diagnosis of tetanus. Variables recorded included age, gender, vaccination status in terms of number of diphtheria, tetanus and pertussis vaccine doses received per routine infant immunisation and booster doses of tetanus toxoid, risk factors as trauma, ear
discharge, ear prick and duration of hospitalisation and outcome. Data was analysed using SPSS 16.
Results: Of the 74 patients, there were 47(63.5%) males and 27(36.5%) females. Overall, the mean age was 6.56+3.15 years 50(67%) were unvaccinated, none (0%) had received booster dose and posttrauma immune prophylaxis. Besides, trauma was the most common risk factor in 33(44.6%) cases followed by ear discharge 15 (20.3%) and ear/nose prick 2(2.7%), while the risk factor was unknown in 24(32.4%) cases. Mean duration of hospitalisation was 14.35±11.65. Mortality rate 16(21.6%) was significantly associated with shorter duration of stay (p<0.001). Mortality was high among unvaccinated children compared to vaccinated children (p=0.01).
Conclusion: Vaccination coverage was found to be inadequate and post-trauma immune prophylaxis had been ignored.
Key Words: Tetanus, Vaccination, Risk factors, Outcome. (JPMA 69: 174; 2019)

Introduction

Tetanus is a neuromuscular disorder characterised by increased muscle tone and spasms. It is caused by tetanospasmin, a toxin released by clostridium tetani.1 Clostridium tetani, is a mobile gram-positive sporeforming obligate anaerobe with soil or dust as its natural habitat. It occurs worldwide but is endemic in developing countries and has continued to be a significant public health problem in resource-poor nations.2 Tetanus is a vaccine preventable disease and a significant cause of morbidity and mortality in developing countries. The disease is usually classified into neonatal and postneonatal tetanus in the paediatric age group.3,4 The global incidence of tetanus is estimated at onemillion cases annually with case fatality ranging 20-50%. Worldwide estimated deaths from tetanus were 61000 in children under 5 years of age and neonates. A total of 984 cases of tetanus were reported from Pakistan in 2010.1 The World Health Organisation (WHO) estimated that tetanus accounts for about 7% of neonatal deaths
globally. While majority of tetanus cases are seen in neonatal age group, postneonatal tetanus is also common.2,5 Thof entry cannot be identified.1,7 Suppurative otitis media (SOM) and circumcision by the traditional \'surgeon\' are important portals of entry of the infection. It is therefore recommended that patronage of traditional surgeons sh ould be discouraged and parents sh ould be encouraged to seek medical care from healthcare facilities. Prompt wound-care with post-exposure prophylaxis must be promoted.8 Fur th ermore, there is n eed to improve routine immunisation activities.9 Children with ear discharge should be taken as a high-risk group for tetanus and be evaluated for immunisation at first visit.7 In Pakistan, like most developing countries, tetanus is endemic and remains an important health problem, especially in rural areas.1 WHO instituted the Expanded Programme on Immunisation (EPI) in 1974 to provide vaccination to most children before their first birthday. EPI schedule of three doses of DPT during infancy with no provision for booster doses is inadequate for tetanus prevention in childhood. A clause should be added to
EPI schedule specifying at least two additional doses of tetanus toxoid (TT) at age 4-6 years and 11-12 years.5 A review of the literature shows that there are only a few studies on post-neonatal tetanus in Pakistan and that post-neonatal tetanus is a growing problem. Recently, our observations in clinical practice suggest an increase in post-neonatal tetanus cases. The current study was, therefore, planned to evaluate the risk factors with the aim of discovering the knowledge gap responsible for the persistence of tetanus in the paediatric age group.

Patients and Methods

The prospective observational study was conducted at the Department of Paediatric Medicine, The Children\'s Hospital, Lahore, Pakistan, from January 2012 to December 2014. After getting approval from the institutional review board, patients aged between 1 month and 15 years of either gender admitted with clinical diagnosis of tetanus in the emergency unit, medical ward and intensive care unit (ICU) were enrolled for the study using non-probability convenience sampling. Informed written consent was obtained from parents or guardians. Sample size was calculated using OpenEpi software10 with 80% power of test and 5% level of significance considering 20% case fatality rate of tetanus.1 Patients with acute hypertonia of other causes (e.g. meningitis, encephalitis) and those whose parents refused to give consent were excluded. Data was collected regarding age, gender, vaccination status in terms of number of diphtheria, tetanus and pertussis vaccine (DPT) doses received as part of routine infant immunisation and booster doses of TT, risk factors such as trauma, ear discharge and nose / ear prick, or
unknown aetiology, post-trauma tetanus immune prophylaxis, duration of hospitalisation and outcome. Data was analysed using SPSS 16. Age and duration of
hospitalisation were presented as mean and standard deviation (SD). Gender, vaccination status, risk factors, post-trauma tetanus immune prophylaxis and outcome were presented as frequency and percentage. Chi square test was employed and p<0.05 was considered significant.

Results

Of the 74 patients, there were 47(63.5%) males and 27(36.5%) females. Overall, the mean age was 6.56+3.15 years, and the commonest age group at presentation was
6-10 years with 38(51.4%) cases. 50(67%) were unvaccinated, none (0%) had received booster dose and post-trauma immune prophyl axis (Figure 1).



Trauma was the most common risk factor in 33(44.6%) cases followed by ear discharge 15 (20.3%) and ear/nose prick 2(2.7%), while the risk factor was unknown in 24(32.4%) cases (Figure 2).



disease is common in areas where soil is cultivated in rural areas, in warm climates, and in areas without comprehensive immunisation programme. In countries with successful immunisation programmes, neonatal tetanus is rare and affects older age groups inadequately covered by immunisation.1 Most cases of tetanus follow an acute penetrating injury. The injury may be major but often minor, so that medical attention is often not sought.1,6 Tetanus is also associated with chronic skin ulcers, abscesses, gangrene, burns, surgery, ear discharge and intravenous (IV) drug abuse. In some patients, portal Mean duration of hospitalisation was 14.35±11.65. Mortality rate 16(21.6%) was significantly associated with shorter duration of stay (p<0.001) (Figure 3).



Mortality was high among unvaccinated children compared to vaccinated children (p=0.01).

Discussion

Studies on tetanus in Pakistan have focussed mainly on neonatal and adult tetanus and data on post-neonatal tetanus is scarcely reported. Present study is an effort tohighlight disease burden in post-neonatal age group. According to results, 6-10 years was the commonest age of presentation. This finding is consistent with other studies
done in Pakistan and other developing countries.1,3,5,11 This can be explained by the fact that EPI provides tetanus immunisation only in infancy without booster doses which provide protection till 3-4 years of life, protective level of
antibodies then fall making individuals susceptible totetanus. Our study showed male preponderance as shown by other studies, including neonatal, post-neonatal and
adult tetanus.12-15 This may be due to parental preference for males to bring for medical care or adventurous behaviour of males causing injuries and subsequent tetanus infection in unvaccinated children. Tetanus is still a major public health issue in Pakistan despite the availability of an effective vaccine. In this study, unvaccinated children outnumbered partially vaccinated (1-2 doses) and completely vaccinated (3 doses) children. Predominance of unvaccinated children reflects poor
immunization coverage. These results are comparable to other studies.1,3-5According to a cohort study done in Karachi, very low proportion of children (39%) completed DPT3, and low adherence to immunisation has been found associat ed with parental socio-demographic characteristics (large family size, low parental education) and provider based characteristics (longer distance of EPI centres from home)16. Getting tetanus despite complete vaccination is worth mentioning. In our study all completely vaccinated children were above 6 years of age and none of them had received booster which is expected at 15-18 months and 4-6 years age. It has been shown in literature that 3 doses of DPT administered in infancy give protection up to 3- 4 years of age, antibodies level then wane with time.5 So, it is suggested that booster doses must be included in EPI to prevent tetanus. Our study showed trauma as the most common risk factor and none of these patients got post-trauma tetanu immune prophylaxis. This is in agreement with other studies.17-19 Public must be made aware of good wound care and physicians must be made aware of identification of tetanus-prone wounds and their appropriate prophylaxis. According to a study done in Karachi, majority of general practitioners had poor knowledge, so interventions like seminars and display of immunisation
protocols in clinics were recommended.20 Ear discharge was the second most common risk factor 15 (20.3%) in our study. Other studies also report it as an
important portal of entry.3,5,7,9 It is suggested that all children with ear discharge should be evaluated for tetanus immunisation. Ear/nose pricks accounted for 2(2.7%) tetanus cases. It is a significant risk factor as reported by a study done in Vietnam.21 No risk factor was identified in 24(32.4%) cases. This can be explained by the fact that injuries were too trivial to be recalled. This result is comparable with other studies done in paediatric hospitals in Larkana and Nijeria.1,5 Overall mortality of 21.6% in our study is comparable to other studies done in Pakistan and the developing world. A study done on post-neonatal tetanus in Larkana reported a mortality rate of 22% which is similar to our
study.1 Another study conducted in Faisalabad, including children and adults of any age, reported a mortality rate of 40.4% which is quite high.22 Varied mortality rate (4.5% to 43%) has been reported from studies in different parts of the developing world.6,9,17,19 Inadequate intensive care
facilities might be the cause of high mortality rate in our study as all tetanus cases could not be managed in ICU due to shortage of space and they had to be managed in
the wards. Observed mortality rate can be reduced by improving current intensive care facilities. Mortality rate was significantly associated with shorter duration of stay
(p<0.001) (mostly within first 3 days of hospitalisation). These findings are comparable with other studies.3-5 One of the possible reasons for shorter duration of stay in expired patients is that they may present with severe disease at admission, although we did not classify disease severity. In terms of limitations, there was no follow-up of patients who left against medical advice. It was a single-centre study and convenient sampling was used which limits the statistical power of study and generalisation of its results. We recommend primary immunisation with booster doses. Children with ear discharge should also be taken as highrisk
group and must be evaluated for tetanus immunisation.

Conclusion

Post-neonatal tetanus has high mortality. Vaccination coverage was found to be inadequate and post-trauma  tetanus immune prophylaxis had been ignored. Primary immunization with booster doses is stressed. Children with ear discharge should be taken as high-risk group and must be evaluated for tetanus immunisation.

Disclaimer: None.
Conflict of interest: None.
Source of Funding: None.
References

1. Junejo AA, Abbasi KA, Shaikh AH. A three year retrospective review of post neonatal tetanus at Children hospital, Chandka Medical College, Larkana. Pak Paed J 2012; 36: 7-11
2. Emodi IJ, Ikefuna AN, Obichukwu C. Incidence and outcome of neonatal tetanus in Enugu over a 10 year period. South Afr J Child Health 2011; 5: 117-9
3. Oyedeji OA, Fadero F, Medewase VJ, Elemile P, Oyedeji GA. Trends in neonatal and post neonatal tetanus admissions at a Nigerian teaching hospital. J Infec t Dev Ctries 2012; 6: 847-53
4. Worku T, Bayou A, Aseffa A. Tetanus in rural hospital in Northeast Ethopia. Ethiop J Health Dev 2004; 18: 55-6.
5. Fatundae OJ, Familusi JB. Post neonatal tetanus in Nigeria: A need for booster doses of tetanus toxoid. Nigerian J Paediatr 2001; 28: 35-8.
6. Anah MU, Etuk IS, Ikpeme OE, Ntia HU, Inej EO, Archibong RB. Post neonatal Tetanus in Calabar, Nigeria: A 10 year review. Nigerian Med Pract 2008; 54: 45
7. Mondal TI, Aneja S, Tyagi A, Kumar P, Sharma D. A Study of childhood tetanus in post neonatal age group in Delhi. Indian Pediatr 1994; 31: 1369-72.
8. Woldeamanuel YW. Tetanus in Ethopia: Unveiling the blight of an entirely vaccine preventable disease. Curr Neurol Neurosci Rep 2012; 12: 655-65.
9. Akuhwa RT, Alhaji MA, Bello MA, Bulus SG. Post neonatal Tetanus in Nguru, Yobestate, North Eastern Nigeria. Nigerian Med Pract
2010; 57.
10. Sullivan M K, Dean A. OpenEpi: A web-based epidemiologic and statistical calculator for public health. Public Health Rep 2009; 124: 471-4.
11. Amsalu S, Lulseged S. Tetanus in Children Hospital in Addis Ababa: review of 113 cases. Ethiop Med J 2005; 43: 233-40.
12. AHM Feroz, Rahman H. A Ten-year Retrospective Study of Tetanus at a Teaching Hospital in Bangladesh. Journal of Bangladesh College of Physicians and Surgeons 2007; 25: 62-9.
13. Marulappa VG, Manjunath R, Babu NM, Maligegowda L. A Ten Year Retrospective Study on Adult Tetanus at the Epidemic Disease (ED) Hospital, Mysore in Southern India: A Review of 512 Cases. J Clin Diagn Res 2012; 6: 1377-80.
14. Aliyu A, Dahiru T, Obiako RO, Amadu L, Biliaminu LB, Akase EI. Pattern and outcome of tetanus in a tertiary health facility in north west Nigeria. J Trop Med 2017; 19: 1-5.
15. Sathirapanya P, Sathirapanya C, Limapichat K, Setthawacharawanich S, Phabphal K. Tetanus: a retrospective study of clinical presentations and outcomes in a medical teaching hospital. J Med Assoc Thai 2009; 92: 315-9.
16. Usman HR, Kristensen S, Rahbar MH, Vermund SH, Habib F, Chamot E. Determinants of third dose of diphtheria-tetanus-pertussis (DTP) completion among children who received DTP1 at rural immunization centres in Pakistan: a cohort study. Trop Med Int Health 2010; 15: 140-7.
17. Aniasahun BA, Gbelee OH, Ogunlana AT, Njokanma OF, Odusanya O. Profile and outcome of patients with post-neonatal tetanus in a tertiary centre in south west Nigeria: any remarkable reduction in the scourge? Pan Afr Med J 2015; 21: 254.
18. Chukwuka JO, Ezeudu CE, Nnamani KO. Neonatal and postneonatal tetanus in Nnamdi Azikiwe University Teaching Hospital, Nnewi, South East, Nigeria: A 10year review. Tropi J Med Res 2015; 18: 30-3.
19. 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.
20. Ahmed SI, Siddiqui MI, Jafery SI, Baig L, Thaver IH, Javed A. Knowledge, Attitudes and Practices of General Practitioners in Karachi District Central about Tetanus Immunization in Adults. J Pak Med Assoc. 2001; 51: 367-9.
21. 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.
22. Muazzam M, Mansoor SA, Badar S, Nadeem A, Anwar B, Waseer MH, et al. Tetanus ;Still cannot be prevented, a three year retrospective study in DHQ hospital, Faisalabad. Professional Med J 2013; 20: 1026-34.

 

Journal of the Pakistan Medical Association has agreed to receive and publish manuscripts in accordance with the principles of the following committees: