A new drive to reduce maternal and child mortality globally could effectively set in motion the much needed systemic changes required for the long-term elimination of maternal and neonatal tetanus, according to a Seminar published in The Lancet.
According to Dr Jos Vandelaer, World Health Organization, Geneva, Switzerland, and team “Although easily prevented by maternal immunization with tetanus toxoid vaccine, and aseptic obstetric and postnatal umbilical-cord care practices, maternal and neonatal tetanus persist as public-health problems in 48 countries, mainly in Asia and Africa.”
Spores of Clostridium tetani are present globally in soil, the gastrointestinal tracts of animals, and also the gastrointestinal tracts of humans. Clostridium tetani produces a neurotoxin which causes tetanus. A patient with tetanus experiences extreme muscle rigidity and painful muscle spasms – the tetanus toxins block inhibitory neurons that generally oppose and modulate the action of excitatory motor neurons. Muscle rigidity typically starts in the masseter muscles – the patient will eventually suffer from lockjaw (trismus).
The majority of infants infected with tetanus will have symptoms within 3-14 days of being born. As the severity of the tetanus advances, the muscle rigidity spreads and spasms commence. Generalized contractions of all muscle groups can happen in advanced cases; the patient will still be conscious, making the illness a “truly dreadful” one, say the authors.
Since mechanical ventilation was introduced in the late 1960s, and benzodiazepines* were developed, tetanus mortality rates of 20% or less have become more and more common for patients lucky enough to have access to IC wards.
* (benzodiazepines – a type of psychoactive drug, considered to be minor tranquilizers. They have sedative, anticonvulsant and muscle relaxant properties.)
The authors stress, though, that even where resources are limited, it is still possible to keep mortality rates below 50% if basic medication, combined with experienced medical care and high-quality nursing are maintained.
The Seminar looks at the benefits/methods of vaccinating against tetanus, as well as the immunology of the disease. The authors also discuss the maternal and neonatal tetanus elimination initiative which started in 1990. Since its inception the initiative has made great strides towards the elimination of tetanus.
The authors say that all but 11 countries** in the world could be tetanus-free by 2009, i.e. eliminating maternal and neonatal tetanus completely. This could be achieved with available and pledged funding, they write.
** (Central African Republic, Chad, China, Liberia, Mauritania, Nigeria, Philippines, Papua New Guinea, Somalia, Sudan, and some States in India.)
However, getting there will be simpler than staying there, they stress. Improvements will need to be carried out on antenatal care practices, women of childbearing age will have to be routinely vaccinated, and deliveries will need to be attended by well-trained personnel.
The writers conclude “The rejuvenated worldwide commitment to improvement of maternal and child health, and special attention to the importance of neonatal survival, catalyzed by the child and maternal mortality Millennium Development Goals, is heartening. Since tetanus spores cannot be removed from the environment, sustaining elimination will require improvements to presently inadequate immunization and health-service infrastructures, and universal access to those services.”
“Seminar – Maternal and neonatal tetanus”
Martha H Roper MD, Jos H Vandelaer MD and François L Gasse MD
The Lancet DOI:10.1016/S0140-6736(07)61261-6
Written by: Christian Nordqvist