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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 15  |  Issue : 2  |  Page : 105-108

How common is post-neonatal tetanus in Rasheed Shekoni Specialist Hospital, Jigawa, North Western Nigeria?


1 Department of Paediatrics, Rasheed Shokone Specialist Hospital, Dutse, Jigawa State, Nigeria
2 Department of Paediatrics, Bayero University/Aminu Kano Teaching Hospital, Kano, Nigeria

Date of Web Publication14-Sep-2018

Correspondence Address:
Dr. Umar Also
Department of Paediatrics, Rasheed Shokone Specialist Hospital, Dutse, Jigawa State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njbcs.njbcs_14_18

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  Abstract 


Background: Tetanus, caused by Clostridium tetani neurotoxin, is still an important cause of morbidity and mortality in children in developing countries. Children usually present with trismus followed by spasms of skeletal muscles. Tetanus infection can easily be prevented through immunization. However, despite provision of routine immunization schedule by government-based hospital at all levels of care, there is still poor immunization uptake which in association with dangerous traditional practices in the area leads to high burden of the disease. Materials and Methods: This was a retrospective hospital-based study. It was conducted at the Department of Paediatric of Rasheed Shekoni Specialist Hospital, Dutse, Nigeria. Medical records of all children between the ages of 1 month and 13 years, who were admitted between May 2014 and April 2017, with a diagnosis of tetanus were retrieved and analyzed. Diagnosis of tetanus is clinical based on the presence of trismus and spasms. Information obtained included biodata, immunization status, onset and duration of symptoms, length of hospitalization, and outcome. Results: Children admitted with tetanus in the period of study were 25, but only 20 qualified for analysis. The prevalence of tetanus was 1.03%. Twelve (60%) were in the 5–9 years age group. Majority (75%) were males, from rural areas (75%), and did not receive any immunization (65%). Circumcision was the portal of entry in 30%. All had generalized tetanus, and mortality rate was 25%. Conclusion: There is need to strengthen routine immunization and introduce booster immunization into the area to prevent post-neonatal tetanus.

Keywords: Children, Clostridium tetani, immunization, Jigawa, Nigeria, tetanus


How to cite this article:
Also U, Gwarzo GD. How common is post-neonatal tetanus in Rasheed Shekoni Specialist Hospital, Jigawa, North Western Nigeria?. Niger J Basic Clin Sci 2018;15:105-8

How to cite this URL:
Also U, Gwarzo GD. How common is post-neonatal tetanus in Rasheed Shekoni Specialist Hospital, Jigawa, North Western Nigeria?. Niger J Basic Clin Sci [serial online] 2018 [cited 2018 Sep 22];15:105-8. Available from: http://www.njbcs.net/text.asp?2018/15/2/105/241153




  Introduction Top


Tetanus is an acute, spastic paralytic illness historically called lockjaw that is caused by neurotoxin produced by Clostridium tetani.[1] Tetanus is preventable through immunization. Three and half decades after the adoption of Expanded Programme on Immunization (EPI) in Nigeria and some developing countries, tetanus still remains a public health problem unlike in the developed countries.[2] Post-neonatal tetanus is still a major problem in developing countries including Nigeria.[3],[4] Low immunization coverage (which includes tetanus toxoid) and deficient booster doses of tetanus toxoid at appropriate time to eligible children are some of the reasons contributing to high burden of the disease in Nigeria.[3],[5],[6] Annually, tetanus causes 309,000 deaths and an estimated one million cases occur especially in the developing countries.[7] Mortality rate is as high as 28/100,000 population in developing countries where immunization coverage is very low. In contrast, it is as low as 0.1/100,000 in North America because of good immunization coverage.[7]

There appears to be an increase in the number of tetanus cases in our hospital from December 2016 to April 2017. Many of these cases followed traditional circumcision by local barbers. Besides, there was no known study on post-neonatal tetanus from Jigawa state, Nigeria. It is therefore important to conduct such study to know the trends of post-neonatal tetanus in the area. Therefore, the objectives of this study are to review the trends, morbidity, and mortality of post-neonatal tetanus in Rasheed Shekoni Specialist Hospital. The findings of the study may be used to support the advocacy to government and community to eliminate the disease through strengthening of routine immunization.


  Materials and Methods Top


The study was a hospital-based retrospective study, conducted at the Department of Paediatric of Rasheed Shekoni Specialist Hospital, Dutse, north western Nigeria. Dutse is the state capital of Jigawa state. The state is located on the latitude 11.00 N to 13.00 N and longitudes 8.00 E to 10.15 E.[8] It has an estimated population of 4,348,649 according to 2006 population census.[8] The hospital is government-owned and serves as a referral center for the entire state and parts of neighboring states including Kano, Bauchi, and Yobe.

Medical records of all children between the ages of 1 month and 13 years, who were admitted between May 2014 and April 2017, and with a diagnosis of tetanus were retrieved and analyzed. Diagnosis of tetanus was made based on clinical findings. These included presence of trismus, risus sardonicus, abdominal wall rigidity, opisthotonus, and spasms. Other causes of such signs (trismus) were excluded. Each case was managed with antibiotic metronidazole 20 mg/kg/day in 2DD intravenously, anti-tetanus serum 10,000 IU after test dose, and triple anti-convulsant drugs (phenobarbitone 5 mg/kg 6 hourly, diazepam 1 mg/kg 6 hourly, and chlorpromazine 1.5 mg/kg 6 hourly all in stagger doses 2 hourly). Appropriate nursing care such as oral toileting, regular turning, and nasogastric tube feeding and wound debridement were done. Subsequently, active immunizations with tetanus toxoid were administered.

Data obtained from the patients' folder included the following: age, sex, date of admission, place of domicile, onset and duration of symptoms, duration of hospitalization before discharge or death, socio-economic class using Oyedeji's classification,[9] complications such as aspiration pneumonia, immunization status, possible portal of entry, and outcome.

Disease classification was as follows: mild presence of trismus, risus sardonicus, but no spasm; moderate presence of minimal provoked spasms; and severe – sustained and spontaneous spasms and/or opisthotonus.[3],[10]

Ethical clearance for the study was obtained from the Research and Ethics Committee of Rasheed Shekoni Specialist Hospital before commencement of the study.

Data were analyzed using SPSS version 16, Chicago, IL, USA. A P value of < 0.05 was considered statistically significant.


  Results Top


A total of 2431 children were admitted in the emergency pediatrics unit of the hospital between May 2014 and April 2017 (3 years). Of these, 25 (1.03%) children had post-neonatal tetanus. However, only 20 patients were qualified for further analysis (5 patients were excluded on the basis of incomplete information for further analysis). There were 15 (75.0%) males and 5 (25%) females, giving a male-to-female ratio of 3:1. All the cases presented with generalized tetanus with trismus preceding the onset of spasms. The ages of the patients ranged from 10 months to 13 years with a mean age 6.34 3.19 years. The age distribution of the study subjects is shown in [Table 1]. Twelve (60%) patients were in the 5–9 years age group. None of the patients with tetanus in this study was fully immunized according to Nigerian National Programme on Immunization (NPI). Thirteen (65%) of them were not immunized at all, whereas only 10% (2) received two doses of DPT immunization. Fifteen (75%) of the patients resided in rural areas (towns and villages outside the local government headquarters or that lack general hospital), and the remaining lived in urban areas. In terms of portal of entry, lower limb injury accounted for the highest portal of entry of 40%, whereas circumcision accounted for 30% of all the cases of tetanus seen in that period. Other ports of entry are shown in [Table 1]. The duration of hospitalization ranged from 20 h to 43 days with a mean of 15.59 12.19 days. All the five mortalities occurred during the first 7 days of admission. Approximately 45% stayed for 3–4 weeks on admission. None of the patients belonged to social classes I or II [Table 1]. The social class of seven patients was not determined due to incomplete records.
Table 1: Demographic and clinical profile of 20 children with tetanus

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[Figure 1] shows the outcome of the study subjects in which 65.0% (13) patients were discharged home and 25% (5) died while on admission. All five mortalities were within 1 week of admission and had severe disease. Two (10.0%) were discharged against medical advice and were lost to follow-up. Seven (35%) of the 20 cases had comorbidities – 6 had aspiration pneumonia whereas 1 had laceration of the tongue because of spasm. There was no significant statistical relationship between outcome and age, sex, and immunization status [Table 2]. However, there was significant relation between outcome and duration of hospital stay where all the patients who remained on admission for 1 week or more survived (P = 0.0014).
Figure 1: Clinical outcome of 20 patients with tetanus. DAMA: Discharged Against Medical Advice

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Table 2: Outcome of 20 children with tetanus based on demographic variables, immunization status, and duration of hospitalization

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  Discussion Top


This study revealed that there were 20 cases of post-neonatal tetanus over a 3-year review period. This shows that post-neonatal tetanus is common in the area. Similarly, 18 cases were reported by Akuhwa et al.[12] in Nguru, north-eastern Nigeria, over a 4-year period. In south-eastern Nigeria however, Chukwuka et al.[11] reported only 23 cases of tetanus in Nnewi over a 10-year period. The finding of more males with post-neonatal tetanus in our study is consistent with other findings.[11],[12],[13] This could possibly be attributed to their risky behavior such as lack of protective foot wear which puts them at high risk of poorly managed injuries.[13] Such a contamination of those injuries and a background inadequate immunization lead to tetanus. Male circumcision also puts boys at risk as it accounted for a significant route of transmission in this study and contributed to the male preponderance.

A majority of the children were not immunized against tetanus at all. This is similar to reports by other workers such as by Gbadegesin et al. in Ibadan who reported 64.3% as unimmunized and Alhaji et al. in Maiduguri who reported 56.4% of the patients studied as unimmunized against tetanus.[3],[13] This is worrisome because it indicates poor immunization either due to poor NPI vaccination coverage or uptake in the area because tetanus toxoid is given along with four other vaccines (diphtheria, pertussis, hepatitis B, and Hib) or inefficient vaccines.

The mean age at presentation of 6.34 ± 3.19 years is similar to other works reported by Alhaji et al.[13] and Animasahun et al.[14] (6.5±±3.2 year) in Maiduguri and Lagos, respectively. This is the age group where most children are circumcised in the communities around the study area. The circumcision methods are commonly unsafe and conducted with unsterilized instruments which increase the risk of tetanus. Children around this age need booster tetanus vaccine even if they received the primary vaccines based on NPI. The booster doses are seldom available to them.

The major identified portal of entry was from lower limb injuries (40%), followed by traditional circumcision (30%) and otitis media (10%). Akuhwa et al.[12] reported similar high transmission through circumcision and otitis media. The high prevalence was not surprising since both studies were performed among rural populace. In these communities, parents still engaged in traditional circumcision by barbers. The barbers use unsterilized knives for circumcision followed by application of traditional medicine to the wound, which might be contaminated with C. tetani spores that exist freely in the soil and environment.[12] Therefore, in addition to improving immunization coverage, parents must be educated and encouraged to utilize safer circumcision practice for their children, avoid walking bare footed, and discourage from engaging in rough play that predispose to lower limb injuries. Moreover, prompt and appropriate wound care following injuries is important in preventing the disease.

The mean length of hospitalization of 15.59 ± 12.18 days is similar to that reported by other authors.[11],[12],[13] This means loss of school hours by children (in school-age group), disruption of family dynamics, and monetary loses through payment of hospital bills; all of this can be easily prevented by adequate, timely, and provision of both scheduled and booster immunization of children.

Complications such as aspiration pneumonia occurred in 30% of our patients. Similar complications were previously reported by other authors.[3],[13],[14] Aspirations may be due to poorly control spasms in earlier part of admission and pooling of secretions in respiratory system due to spasm of respiratory muscles. Deep tongue laceration occurred in one of our patients due to recurrent spasm before control was achieved. This patient spent 43 days on admission and had glossoplasty by MFU surgeon before discharge.

The overall mortality in this study was 25% and presented with severe disease, which is comparable to those reported by other authors such as Anah et al.[5] in Calabar, Chukwuka et al.[11] in Nnewi, and Ide and Uchenwa-Onyenegecha [15] in Port Harcourt. This is higher than that reported by other authors.[3],[12],[13],[14] Alhaji et al. in Maiduguri reported mortality rate of 18%,[13] while Animasahun et al. had a case fatality of 4.1% in their study in Lagos.[14] A similar lack of significant statistical difference noted in the outcome and age was similar to report by Alhaji et al. in Maiduguri.[13] The reason why could be part of future study.


  Conclusion Top


The prevalence of post-neonatal tetanus is still high in the community of review. This was due to poor immunization uptake, lack of booster immunization at an appropriate age, and dangerous aseptic traditional practices leading to high burden of the disease. There is need to enlighten the public on harmful traditional practices and to strengthen routine immunization and provide booster tetanus vaccines to prevent tetanus at all ages.

Acknowledgement

The HOD Record and his staff are appreciated for retrieval of medical records of the patients.

Financial support and sponsorship

Nil.

Conflicts of Interest

There are no conflicts of interest.



 
  References Top

1.
Arnon, SS. Tetanus (Clostridium tetani). In: Nelson Textbook of Paediatrics. 20th Edition. Philadelphia: Elsevier; 2016. p. 1432-4.  Back to cited text no. 1
    
2.
Sanford JP. Tetanus – Forgotten but not gone. N Eng J Med 1995;332:812-3.  Back to cited text no. 2
    
3.
Gbadegesin, RA, Adeyemo AA, Osinusi K. Childhood post neonatal tetanus. Niger J Paediatr 1996;23:11-5.  Back to cited text no. 3
    
4.
Oyelami OA, Aladekoko TA, Ononye FO. A 10 year retrospective evaluation of cases of post neonatal tetanus seen in a paediatric unit of a university teaching hospital in south western Nigeria (1985 to 1994). Central Afr J Med 1996;42:73-5.  Back to cited text no. 4
    
5.
Anah MU, Etuk IS, Ikpeme OE, Ntia HU, Zneji EO, Archibong RB. Post neonatal tetanus in Calabar, Nigeria: A 10 year review. Nig Med Pract 2008;54:45-7.  Back to cited text no. 5
    
6.
Fatunde OJ, Familusi JB. Post neonatal tetanus in Nigeria: The need for booster doses of tetanus toxoid. Niger J Paediatr 2001;28:35-8.  Back to cited text no. 6
    
7.
Ogunrin OA. Tetanus: A review of current concept in management. Benin J Postgrad Med 2009;11:46-61.  Back to cited text no. 7
    
8.
Jigawa state. Available from: http://en.wikipedia.org/wiki/Jigawa. [Last accessed on 2017 Aug 16].  Back to cited text no. 8
    
9.
Oyedeji GA. Socio-economic and cultural background of hospitalized children in Ilesha. Nig J Paediatr 1995;12:111-7.  Back to cited text no. 9
    
10.
Ablett JL. Analysis and main experiences in 82 patients treated in the Leeds Tetanus Unit. In: Ellis M, editor. Symposium on Tetanus in Great Britain. Boston Spa, UK: National Lending Library; 1967. p. 1-10.  Back to cited text no. 10
    
11.
Chukwuka JO, Ezuedu CE, Nnamani KO. Neonatal and post neonatal tetanus in Nnamdi Azikiwe University Teaching Hospital, Nnewi, South East Nigeria: A 10 year review. Trop J Med Res 2015;18:30-3.  Back to cited text no. 11
  [Full text]  
12.
Akuhwa RT, Alhaji MA, Bello MA, Bulus SG. Post-neonatal tetanus in Nguru, Yobe State, Northeastern Nigeria. Nig Med Pract 2010;51:40-2.  Back to cited text no. 12
    
13.
Alhaji MA, Akuhwa RT, Mustapha MG, Ashir GM, Mava Y, Elechi HA, et al. Post-neonatal tetanus in University of Maiduguri Teaching Hospital, North-eastern Nigeria. Niger J Paed 2013;40:154-7.  Back to cited text no. 13
    
14.
Animasahun 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 African Med J 2015;21:254.  Back to cited text no. 14
    
15.
Ide LEY, Uchenwa-Onyenegecha TA. Post neonatal tetanus: 20 Years experience as seen at the University of Port Harcourt Teaching Hospital. Br J Med Med Res 2016;12:1-5.  Back to cited text no. 15
    


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