Introduction
Tetanus is a severe, acute infectious disease caused by the bacterium Clostridium tetani. Its spores are widely distributed in the environment, particularly in soil, ash, animal and human feces, and on various surfaces including skin, nails, needles, and barbed wire. These spores are highly resistant to heat and common antiseptics, allowing them to survive in the environment for years.
Infection occurs when spores enter the body through cuts or wounds. Most cases develop within 14 days of exposure. Importantly, recovery from tetanus does not confer natural immunity, and reinfection remains possible without vaccination.
While tetanus can affect anyone, neonatal tetanus is of particular concern. It typically occurs within the first 28 days of life and is strongly associated with unvaccinated mothers and unhygienic childbirth practices.
Transmission
General Tetanus: Tetanus is transmitted through contamination of wounds with C. tetani spores. The bacteria thrive in anaerobic environments, such as deep puncture wounds, and most infections manifest within two weeks of exposure.
Neonatal Tetanus: Neonatal tetanus often results from unsafe delivery practices, such as:
- Cutting the umbilical cord with unsterile instruments.
- Applying contaminated materials to the cord stump.
- Deliveries conducted with unwashed hands or on unclean surfaces.
Clinical Features
The incubation period for neonatal tetanus ranges from 3 to 28 days, most commonly around 6 days. Symptoms usually appear 4 to 14 days after birth, with an average onset of 7 days.
Characteristic signs and symptoms of neonatal tetanus include:
- Normal sucking and crying ability for the first 2 days, followed by inability to suck or breastfeed between days 3–28.
- Muscle rigidity or spasms, including:
- Difficulty opening the mouth (trismus).
- Facial muscle spasms.
- Increased muscle tone and clenched fists.
- Persistent crying.
Diagnosis and Treatment
Tetanus is diagnosed clinically based on signs and symptoms, rather than laboratory testing. Tetanus is a medical emergency requiring hospital care. Standard management includes:
- Administration of human tetanus immune globulin to neutralize bacterial toxins.
- Aggressive wound and cord stump care.
- Antibiotic therapy.
- Medications to control muscle spasms.
- Vaccination during recovery, as natural infection does not provide immunity.
Prevention
- Primary prevention: Immunization with tetanus toxoid-containing vaccines remains the cornerstone of control.
- Neonatal protection: Immunizing women of reproductive age, particularly during pregnancy, protects newborns from neonatal tetanus.
Safe Childbirth Practices
- Use of sterilized, boiled, and cooled instruments for cord cutting.
- Wrapping newborns with clean, boiled cloths.
- Handwashing with soap by all individuals attending childbirth.
Where sinks are unavailable, alternative hand hygiene methods include:
- Use of Veronica buckets (portable handwashing stations).
- Provision of handwashing basins with soap and clean water.
- Preparation of 0.05% sodium hypochlorite solutions for daily use during supply shortages.
- Use of waterless, antimicrobial hand hygiene products when available.
Community-Based Interventions
- Education and Awareness: Conduct sensitization campaigns on neonatal tetanus risks, sterile delivery practices, and cord care.
- Capacity Building: Train midwives, traditional birth attendants, and community health workers in infection prevention and safe childbirth.
- Basic Wound Care: Encourage communities to clean wounds with boiled water and cover with sterile or clean cloths to minimize infection risk.
Conclusion
Tetanus and neonatal tetanus remain preventable public health threats. Vaccination of women of reproductive age, coupled with clean childbirth practices and strong community-based interventions, are critical to achieving elimination goals.
References
World Health Organization & UNICEF. Infection prevention and control and water, sanitation and hygiene measures in health-care settings and shelters/congregate settings in Gaza: technical note. Geneva: WHO & UNICEF; 2024. Link.
World Health Organization. Neonatal tetanus: vaccine preventable diseases surveillance standards. Geneva: WHO; 2018. Link.