Maternal tetanus: Magnitude, epidemiology and potential control measures

Inr J Gynecol Obstet, 1993, 40: 3-12 International Federation of Gynecology and Obstetrics

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Maternal tetanus: Magnitude, epidemiology and potential control measures V. Fauveaua’*, M. Mamdani”, R. Steinglassb and M. Koblinsky” “Center for Population Studies and Maternal and Child Epidemiology Unit, London School 01 Hygiene and Tropical Medicine, 99 Gower Street, London WClE 6AZ (UK), ‘Resources for Child Health (REACH), John Snow, Inc. and cMotherCare, John Snow Inc., 1616 N. Fort Myer Drive. 11th Floor, Arlington, VA, 22209 (USA) (Received January lSth, 1992) (Revised and accepted May Zlst, 1992)

AbStIWt

A. Introduction

Maternal tetanus, defined as tetanus occurring during pregnancy or within 6 weeks after any type of pregnancy termination, is one of the most easily preventable causes of maternal mortality. It includes postpartum or puerperal tetanus resulting from septic procedures during delivery, postabortal tetanus resulting from septic abortion and tetanus incidental to pregnancy, resulting from any type of wound during pregnancy. This review of published and unpublished hospital and community studies concludes that between 15 000 and 30 000 cases of maternal tetanus occur each year. Complete coverage of reproductive-aged women by tetanus toxoid is the most cost-effective way to eliminate this often neglected cause of maternal death.

It is estimated that 500 000 women die annually from complications of pregnancy, abortion and childbirth, 99% of them in developing countries [l]. In view of the magnitude of the problem of maternal mortality, it is tempting to focus on the few specific causes, if any, that can be averted through simple and effective control measures. Maternal tetanus is one of them, but the importance of its contribution to maternal mortality and morbidity is still unknown. We define as maternal tetanus any case of clinical tetanus occurring to a woman during pregnancy or during the six weeks following the termination of a pregnancy, regardless of the way it was terminated. This definition, in line with the recent discussions on the definition of a maternal death, includes three main categories that we propose as a convenient classification for future comparative studies: (i) postpartum or puerperal tetanus, usually resulting from septic procedures during delivery, (ii) postabortal tetanus, following septic maneuvers during induced abortion and (iii) tetanus during pregnancy, generally resulting from inoculation through a nongenital portal of entry. This latter category is

Keywords: Maternal tetanus; Maternal mortality; Tetanus; Puerperal sepsis; Postabortal tetanus; Induced abortion; Developing countries; Tetanus immunization.

*Present address: c/o SCFNK, P.D.R.

BP 1146, Vientiane, LAO

0020-7292/93Ro6.00

0 1993 International Federation of Gynecology and Obstetrics Printed and Published in Ireland

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Faveau et al.

included in the definition for three reasons: it is often accounted for in studies of maternal mortality and may represent a sizeable proportion of maternal tetanus in certain settings; it is often impossible to determine the underlying cause of the inoculation (i.e. pregnancy or concomitant cause); and this category shares similar management and preventive features as the other two. To date, much attention has been focused on neonatal tetanus and very little is known about maternal tetanus. As part of a World Bank review of health sector priorities for the 199Os, Steinglass et al. [53] calculated a preliminary estimate of 30 000 women dying annually from maternal tetanus and called for a global review of the problem. The first published reviews of the subject date from 1898 [49], 1941 for postabortal tetanus [61] and 1955 for puerperal tetanus [3]. The paucity of publications on maternal tetanus in the infectious disease literature as well as in the maternal health literature reflects the relative state of neglect of the issue. This may be due in part to the absence of good epidemiological surveillance and good clinical data in areas where the disease is most common, and in part to the sensitive and confidential nature of this disease, often the result of an illegal abortion. In this paper we review published and unpublished studies of maternal tetanus in the developing world, estimate the magnitude of the problem worldwide, describe distribution and risk factors, summarize clinical and therapeutic patterns and discuss specific control measures. B. Sources of data There are four distinct sources of data concerning maternal tetanus: (1) hospital studies analyzing series of admissions and deaths in tetanus-specialized wards; (2) single case studies published in obstetric or infectious disease literature and relating unusual forms; (3) hospital-based studies of maternal deaths occurring in obstetric wards; and (4) com1~11 J Gynecol Obsrer 40

munity-based studies analyzing maternal deaths collected through surveillance systems. Table 1 summarizes the distribution by type of the 60 studies from developing countries reviewed for this assessment (not all of them reported cases of maternal tetanus). In addition, 7 studies reporting maternal tetanus in developed countries were also reviewed [3,9,26,27,50,61,62]. In the present review, we found a total of 1101 published cases of maternal tetanus reported from developing countries between 1958 and 1990 and an additional 21 cases reported from developed countries between 1941 and 1964. Out of the cases reported from developing countries, 47% were found in India, 4% in Bangladesh, 1% in other Asian countries, 34% in Nigeria, 9% in Senegal, 3% in other parts of Africa and 1% in Latin America. Details of clinical patterns, including portal of entry and case fatality, are available for 484 cases. The etiologic distribution of maternal tetanus in the 197

Table 1. Maternal tetanus studies reviewed, by type of study (developing countries only). Type of study

A. Hospital studies: Series of admissions in tetanusspecialized wards B. Hospital studies: Single case studies of maternal tetanus C. Hospital studies: Series of admissions in obstetric wards D. Communitybased studies of maternal mortality Totals

No. of studies reviewed

No. reporting case5 of maternal tetanus

cases of maternal tetanus reported

29

20

1027

3

3

3

11

3

22

17

11

49

60

37

1101

Maternal tetanus

studies specifying this information is as follows: 67% postpartum, 27% postabortal and 6% incidental to pregnancy (Table 2). C. Etiology

and pathgenesis

Tetanus is due to an ubiquitous, grampositive, rod-shaped, anaerobic, sporeforming bacillus called Clostridiumtetani. Its natural habitat is soil, mostly moist and rich soil manured by animal feces. Tetanus infection results from the introduction of spores into the body through accidental or surgical wound, or through the genital tract. Once in a wet, poorly oxygenated, necrotic tissue such as a piece of retained placenta, spores germinate and start producing toxins. These toxins progress along neural paths to reach the spinal cord and the central nervous system where they affect the control of vital functions. D. CIinkal features D. 1. Incubation The incubation period, which is the time between the introduction of spores in the body and the first clinical symptoms, varies from not less than 3 days to several weeks. The duration of incubation, as well as the interval between first symptoms and generalised spasms (the period of onset), determine the severity of the disease and therefore the prognosis. Table 2. Etiologic distribution of maternal tetanus in published studies. Postabortal

Postpartum

Tetanus

(PAT)

(PPY)

incidental to pregnancy (PRT)

Community-based studies of maternal mortality: 10 (20%) 39 (So?/) -

Total

49 (100%)

Hospital-based studies of tetanus: 43 (29%) 94 (64%) 11 (7%)

148 (100%)

Total 53 (27%)

197 (100%)

133 (67%)

11 (6%)

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In a review of 17 postabortal tetanus patients in South Africa, the mean incubation period was 11.8 days, with a range of between 4 and 42 days; the mean duration of stay in hospital was 37 days, ranging from 15 to 55 days [ 121. A definite inverse relationship was noted between the incubation period and the duration of stay in hospital. In addition, in all three patients who died, the symptoms of tetanus started less than 10 days after the abortion. In a hospital-based study in Nigeria, the duration of the disease from the time of admission until death varied from a few hours to 50 days, with 9 out of 12 deaths occurring within 10 days [2]. The average duration of incubation and hospitalization for the 14 postpartum tetanus cases observed in Dakar, Senegal, were 17 and 26 days, respectively [19]. In 3 postpartum tetanus cases from Bangladesh, the incubation period ranged from 2 to 3 weeks [17]. 0.2. Symptoms and complications The clinical diagnosis of maternal tetanus is generally not as straightforward as that of neonatal tetanus, because there are several clinical forms which can be misleading, particularly in the early stages of the disease. There were three degrees of severity in the cases reviewed. The mild forms had long incubation periods and trismus (lockjaw), neck stiffness and risus sardonicus were the only symptoms. There were no convulsions and no general toxic disturbances such as hyperpyrexia. The prognosis was generally good with no case fatality. Moderate forms were characterized by generalized spasmodic contractions with opisthotonos, but they were only provoked by external stimuli such as skin punctures, nasopharyngeal suction, loud noise or intense light. There was abdominal pain and backache, but no fever. The prognosis was less good. In the severe forms, with short incubation periods, generalized convulsions were spontaneous and long-lasting, with frequent Special Review Article

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Faveau et al.

episodes of apnea, cyanosis and asphyxia. There were central nervous system disturbances such as hyperpyrexia, tachycardia or cardiac arrest. Even with specialized intensive care including respiratory assistance, the prognosis is extremely poor. Vaginal bleeding and discharge were found in all postpartum and postabortal cases, although bacteriological examination of the vaginal discharge did not help in the diagnosis. 0.3. Case fatality In this review, the case fatality ratio (CFR), defined as the ratio of deaths over 100 diagnosed cases, had a median of 52% (range 16-80) in hospital studies in Africa and 54% (range 42-64) in Asia (Table 3). The lowest reported figures were 16% in Cape Town, reportedly due to the presence of an intensive care unit [12]. Earlier reviews of maternal tetanus in Europe and the USA before 1960 showed CFRs of between 57% and 85% in postabortal tetanus and between 75% and 100% in postpartum tetanus [3,61]. In contrast, CFRs in this review were generally lower for postpartum tetanus than for postabortal tetanus. This is probably because the former were referred to hospital at a relatively earlier Table 3.

stage and thus had less associated bacterial infection and also because illegally-induced abortion carries a greater potential for heavy contamination. D. 4. Differential diagnosis

The diagnosis of maternal tetanus in its mild form (lockjaw) must exclude dental and pharyngeal abscesses, mandibular fracture or arthritis, diphtheria and mumps. In the more severe forms with opisthotonos and generalized symptoms, it is necessary to exclude meningitis, strychnine poisoning, epilepsy, tetany, hysteria, retroperitoneal abscess and rabies. In case of a postabortal tetanus, other septic complications of induced abortion must also be considered, including septicemia due to Clostridium perfringens.

The most important differential diagnosis in community-based studies is postpartum eclampsia. Precise information on timing of symptoms is crucial, however, because postpartum eclampsia rarely occurs more than 4 days after delivery, while postpartum tetanus cannot occur earlier than 4 days after delivery. E. Epidemiology: Distribution and risk factors The

distribution

of

Case fatality ratios (CFRs) of maternal tetanus in hospital-based studies in Africa and Asia.

Study, place, authors, year of study

Number of cases

CFR (%)

Africa

Dakar, Senegal, Diop-Mar et al., 1982-1983 (PPT)* Dakar, Senegal, Diop-Mar et al., 1982-1983 (PRT)* Lagos, Nigeria, Adadevoh & Akinla, 1963-1967 (PAT)* Lagos, Nigeria, Adadevoh & Akinla, 1963-1967 (PPT)* Lagos, Nigeria, Bandele et al., 1974-1984 Ibadan, Nigeria, Johnstone, 1954-1955 Cape Town, South Africa, Bennett, 1965-1972

14 10 22 5 54 20 19

50 80 52 20 70 60 16

67 216 71 113

64 59 50 42

Asia

Delhi, Delhi, Delhi, India,

maternal

India, India, India, Bhatt

Pate1 et al., 1960 Vaishnava et al., 1961-1963 Suri, 1963-1965 & Anwikar, 1962

*PPT, postpartum; PAT, postabortal; PRT, tetanus incidental to pregnancy. Int J Gynecol Obstet 40

tetanus

Maternal tetanus

depends on the distribution of spores, of pregnancies and of accidental contact between spores and pregnant or postpartum women. E. 1. Geographic distribution E.1.1. Asia. Several community-based maternal mortality studies undertaken in Bangladesh between 1967 and 1985 - four in Matlab and one in Jamalpur district reported that between 1% and about 10% of the maternal deaths were due to tetanus, mainly postpartum [ 17,2 1,29,33] (Table 4). In these studies, tetanus-attributable maternal mortality rates ranged from 9 to 56 per 100 000 live births. Results of other community-based studies undertaken in Indonesia [23] and India [ 133 showed between 4.7% and 2.8% of the maternal deaths to be due to postpartum tetanus; tetanus-attributable maternal mortality rates were 34 and 22 per 100 000 live births, respectively. Several hospital-based -studies undertaken during the early 1960s in Asia - seven in India and one each in Japan, Singapore, and Vietnam - have shown that postpartum and postabortal tetanus collectively accounted for between 3.3% and 22.2% (3-113 cases) of all cases of tetanus, with high CFRs ranging from 64% to 72% [ 161. In a review of 981 tetanus patients admitted to one New Delhi hospital from 1963 to 1965 [55], postabortal

T&k 4.

I

and postpartum tetanus accounted for 47% of the 150 cases occurring in women 15 to 50 years of age, 25% of the 280 female nonneonatal cases and 7% of all tetanus cases. E. 1.2. Africa. There was only one community-based study (in Egypt), where 0.2% of all maternal deaths were reported to be due to postpartum tetanus [23,24]. The tetanus-attributable maternal mortality rate was about 4 per 100 000 live births. Most of the available data for Africa is from hospital-based studies, mainly from Nigeria where from 1% to 10% of the maternal deaths were due to tetanus. In one Nigerian hospital-based study, of the 72 tetanus patients in whom the uterus was determined to be the portal of entry, 52 (72%) contracted postpartum tetanus following unhygienic delivery at home and 12 (16.7%) developed tetanus following illegally induced abortion [6]. Maternal tetanus accounted for 20% of the 100 cases of tetanus treated at Ibadan, Nigeria, in 1954- 1955 [28]. Reported cases of postabortal tetanus appear to be more common in Africa than in Asia. In a review of 12 736 cases of abortion admitted over the 1972- 1986 period in one Nigerian hospital, 0.4% (53) were reported to have died of illegally induced abortion and 3.8% (2) of these deaths were due to tetanus [5]. During 1965 to 1972, a total of 13,681 patients with incomplete abortions were admit-

Proportion of maternal deaths due to maternal tetanus in 9 community studies.

Study, place, author, year

Maternal deaths

Maternal tetanus

Percentage

Menoutia, Egypt, Fortney et al., 1988 Bali, Indonesia, Fortney et al., 1988 Matlab, Bangladesh, Chen et al., 1974 Matlab, Bangl., Lindpainter et al., 1982 Matlab, Bangladesh, Fauveau et al., 1988 Jamalpur, Bangladesh, Khan et al., 1986 Anantapur, India, Bhatia et al., 1985 Rio, Brazil, Tavares, 1970 Addis-Ababa, Ethiopia, Kwast et al., 1986

431 295 41 39 219 58 284 146 26

1 14 3 4 6 4 8 7

I

0.2 4.7 1.3 10.3 2.1 6.9 2.8 4.8 3.8

Total

1545

48

3.1

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Faveau et al.

ted to Groote Schuur Hospital in Cape Town, South Africa [ 121. The reported incidence of postabortal tetanus was 1.3% of all incomplete abortions, accounting for 34.7% of all cases of tetanus in women of childbearing age. In another study in Nigeria, of the 27 cases of maternal tetanus seen at Lagos University Teaching Hospital between 1963 and 1967, 81% were postabortal following illegally induced abortion [2]. The CFR was 20% for postpartum tetanus and 52% for postabortal tetanus. In Zaria, Northern Nigeria, Harrison [25] reported 4 out of 219 maternal deaths (1.8O/, to be due to tetanus. E. 1.3. South America and the Caribbean. There is not much information available on maternal tetanus in the Caribbean. We found one case report of tetanus following an unsafe abortion in Barbados [39]. There was only one community-based study from Brazil where postabortal tetanus accounted for about 5% of the non-neonatal cases of tetanus [571. E.2. Distribution of tetanus spores

While factors influencing the distribution of C. tetani spores in human environments are not fully known, some climates, soils, and agricultural economies, particularly those raising cattle, are associated with higher risk than others [16]. In fact, in some places the incidence of tetanus in animals may be a useful indirect indicator of potential human risk [48]. Alternatively, the presence and density of cattle in a rural environment might be used as a presumptive risk of developing tetanus [51]. In general, unimmunized rural populations are said to develop tetanus at higher rates than urban populations [54,55]. E.3. Distribution of pregnancies, abortions and traditional practices

In many parts of the world, means to limit family size and to space pregnancies are not available, or not utilized, or limited to traditional and frequently unsafe practices. Based on a survey covering 60 developing countries in 1977, Rochat et al. [46] estimated that Int J Gynecol Obstet 40

about 13.7 million induced abortions occur each year, yielding a ratio of 207 abortions per 1000 live births ranging from 9 in East Africa to 325 in Latin America. It is likely that the incidence of postabortal tetanus closely follows the incidence of septic abortion, though much of both goes unreported. A majority of the births in most developing countries, particularly in the rural areas, takes place at home, usually assisted by relatives or traditional birth attendants (TBAs). Frequent vaginal examinations with unclean hands and the application of animal dung and herbal medicines to the vulva or the vagina are some of the practices which may cause genital infection and tetanus in the postpartum period. In a hospital-based study in Delhi, almost all the postpartum cases of tetanus occurred among women whose deliveries were assisted at home by TBAs; CFR in this group was 59% as compared to 40% in non-postpartum women with tetanus in the same age group [58]. It is noteworthy that about 80% of the postpartum cases came from rural areas and the rest mostly from Old Delhi where sanitary conditions are usually quite poor. In another hospitalbased study from India, all of the 16 obstetric tetanus cases who came from the rural areas were attributed to deliveries or abortions conducted by untrained TBAs and 6 of the 8 urban obstetric cases had home deliveries t351. Similarly, the majority of maternal deaths are from rural areas and for the most part related to inaccessibility and poor utilization of health services, particularly obstetric services, and poor quality of these services. In the Zaria study in Nigeria, all four cases of maternal tetanus occurred in unbooked patients [25]. In Matlab, Bangladesh, all of the six reported cases of maternal tetanus were from the comparison area, with a low coverage of health services (Fauveau, unpublished data). E.4. Distribution of portals of entry

The majority of maternal tetanus cases have been attributed to contamination of the

Maternal tetanus

puerperal uterus due to unhygienic delivery practices or to abortion induced by vaginal insertion of roots, twigs or herbs [2,5,6,12, 19,34,36,39,40]. Female circumcision which is practised in different parts of the world carries a high risk of tetanus infection, but the association has not been described. Maternal tetanus may follow surgery, mainly when cesarean sections or other operations are performed with improperly sterilized instruments, or when infected dust reaches the wound. Such situations, however, have not been specifically described in the publications reviewed. In the particular case of tetanus incidental to pregnancy, the portal of entry was not necessarily genital. Diop-Mar et al. [19] and Zohoun [63] report cases of maternal tetanus after intramuscular injection, most commonly quinine (Quinimax). Other possible portals of entry include chronic otitis, ear piercing, and chronic leg ulcer including guinea-worm ulcer in Nigeria [6]. E.5. Age, parity, marital status The distribution of maternal tetanus cases depends on the age and parity distribution of high risk pregnancies and of induced abortions. In a community-based study in Addis Ababa, Ethiopia, Kwast et al. [31] found that six (46%) of the 13 women who died from abortion - mainly induced illegally - were single, and four (31%) were below 20 years of age. In a hospital-based study in Cape Town, South Africa, nearly 50% of the maternal tetanus patients - most of them postabortal - were under 25 years of age [ 121. In one study in Nigeria, a majority of the maternal tetanus patients were young single women [2]. Likewise, a majority of the patients in another hospital-based study in Nigeria were young unmarried students who did not have easy access to contraceptives and feared expulsion from school on the grounds of pregnancy [5]. E.6. Socioeconomic status None of the reviewed studies showed evidence of a relationship between maternal

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tetanus and socioeconomic status. In general, however, socioeconomic disadvantage, social problems and low status of women are important determinants of maternal mortality, induced abortion and therefore maternal tetanus. E. 7. Seasonal variation Considering all tetanus cases, the season of peak incidence usually coincides with the warm, damp season and the time of the most intensive work in the fields [ 10,16,58]. No clear seasonal pattern of maternal tetanus emerged from the present review. E.8. Reporting problems and extrapolation attempts Maternal deaths have been shown to be under-reported wherever they have been validated by independent studies [ 13,3 1,601. Compulsory registration of tetanus morbidity and mortality has not been established in most developing countries and all forms of tetanus remain also substantially underreported [ 10,16,52]. Postpartum tetanus therefore probably follows the same patterns of under-reporting as maternal deaths, while postabortal tetanus, linked to induced abortion, is likely to be even more under-reported. Table 4 attempts to extrapolate from available community-based data an estimate of the number of deaths due to maternal tetanus that can be expected to occur annually worldwide. If an average of 3.1% of all maternal deaths are due to maternal tetanus and 500 000 maternal deaths occur annually, it can be calculated that at least 15 000 maternal tetanus deaths occur each year in the world. Taking into account a likely high proportion of under-reporting, perhaps one out of two cases of maternal tetanus, the range may be 15 000-30 000. F.

Control measnres

F. I. Curative measures There is no curative treatment per se for tetanus, including maternal tetanus. The Special Review Article

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Faveau et al.

guiding principles for case management remain (i) to prevent more toxin from being released and reaching the central nervous system, through injection of antitoxin and cleaning of the wound site and (ii) to control the symptoms caused by the toxin already in the central nervous system until spontaneous recovery. This is through sedation, muscle relaxation and artificial maintenance of vital functions, according to the severity of the case. In cases of postpartum and postabortal tetanus, dilatation and curettage are necessary to remove necrotic tissue and retained placenta. All authors except two [3,8] agreed on this. Hysterectomy has been proposed but it does not seem to bring significant benefits. Penicillin is recommended in the early stage to attack the toxin-producing germs still in the infected wound. Alternatively and to avoid spasmodic contractions caused by intramuscular injections, metronidazole can be used. The whole process of case management requires levels of technical competence and cost that are only found in well-trained intensive care units [44], which in a few developing countries are found in central and provincial hospitals. Clearly preference should be given to preventive measures. F.2. Preventive measures Ideally, simple avoidance of introducing tetanus spores (i.e. dust or dirt) into the genital tract during pregnancy, delivery, abortion or the postpartum period should be enough to eliminate maternal tetanus. Several interventions can help to reach this goal: training medical staff, midwives, traditional birth attendants and community health workers in clean obstetric procedures, providing safe abortion, distributing simple delivery kits to pregnant women who intend to deliver at home, promoting family planning programs to reduce the number of unwanted pregnancies. Such programs have been promoted in most developing countries. Progress, however, will be slow and special efforts should be focussed on implementing the imIn1 J Gynecoi Obstet 40

munization of women with tetanus toxoid [43,47]. Considerable progress has been achieved in the past 30 years in developing immunization programs to provide passive immunity to newborns against neonatal tetanus by means of maternal immunization [20,38,48]. An effective, stable, cheap toxoid has been available for more than 50 years and is produced by many developing countries. The current challenge is to make good quality vaccines available to all women entering their reproductive age. That women need to be protected in their own right against the septic risks associated with pregnancy and delivery needs to be emphasized. Schofield [48] and Steinglass et al. [53] provide comprehensive reviews of possible strategies for controlling tetanus and their cost-effectiveness. In general, at the very least, one should aim for continuous immunization of all women of childbearing age, whether pregnant or not, through MCH clinics where feasible or with the assistance of village midwives or community volunteers where MCH clinics and associated facilities (e.g. adequate refrigeration) are scarce. Not only integration of immunization programs with MCH services is needed, but tetanus toxoid coverage should be a fundamental performance indicator for MCH services. The definition of a ‘fully immunized child’ should include the concept of a child who not only has directly received all required vaccinations, but who also was born protected from tetanus to a woman herself protected from the risk of maternal tetanus. The cost for this protection is affordable by most countries. The extent to which political and financial resources are mobilized will determine whether or not 150 000-300 000 women will die of maternal tetanus during the 1990s. Acknowledgements This study was initiated and funded by the Resources for Child Health (REACH) and MotherCare Projects of John Snow, Inc.

Matema!

under contracts (numbers DPE 5982-Z-00903440 and DPE 5966-Z-00-8083-00) with the United States Agency for International Development. References

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