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Tetanus neonatorum
TETANUS NEONATORUM By
A.
MICHAEL
CRITCHLEY,
M.V., D.P.H., D.1.H.
THE following observations concerning tetanus neonatorum are submitted as being of interest, for although fortunately this disease has become rare in the United Kingdom, yet it is still quite common in countries which are less advanced in public health. During the past seven years, in my capacity of Professor of Public Health and Social Medicine at the Royal College of Medicine, Baghdad, I have held demonstrations in infectious diseases at the Baghdad Fever Hospital. It was noted that there seemed to be cases of tetanus neonatorum always available for teaching purposes. Accordingly the medical officer in charge of the fever hospital, Dr. Hussain Ali Mubarek, and his resident assistant, Dr. Hikmet Emmanuel, were asked to collect the records of the cases of tetanus neonatorum admitted to this hospital over the past few years. This request was carried out and the following information has been gathered from a study of these records. Unfortunately a large proportion of these patients, or more accurately, of their parents, were not only illiterate but also knew neither their exact address nor their age, and it was most difficult to obtain any precise or accurate information and history from them. To add to the confusion, owing mainly to the low social status of the female nurse in the Middle East there is a grave shortage of nursing staff in lraq, and this lack is most marked in the fever hospitals. However, in spite of these obstacles, it was possible to obtain information of value. Between January, 1954, and April, 1957, there were 369 cases of tetanus neonatorum admitted to the Baghdad Fever Hospital, and of these 263 died, 80 were cured, and 26 left the hospital at the request of their parents. Since the ultimate fate of the 26 cases which were removed from the hospital is not known, these cases are omitted from the charts relating to the proportions of dead and recovered, therefore the incidence of cures is based on the 344 cases whose ultimate fate is known. Graph I shows the average incidence of tetanus neonatorum according to the month of onset. It will be observed that there is a definite seasonal trend for infection ; and tetanus neonatorum is most prevalent during the period November to April, and it is least prevalent between May and October. This difference between the peak and the lowest incidence of disease is so great that it calls for explanation. First of all it is necessary to have some knowledge of the environmental conditions of the victims prior to their admission to hospital, and also to realise the modus operandi of the average confinement. 459
460
PUBLIC HEALTtl
9 12
/\
\/
VOL. LXXI
NO. 12
\
/
tl
,01 9 ti1
<
$
7
\/
6 5 4 3 1 I 0
dan
FEB
MAR
APR
MAY JUN JUL MONTH
AUG
SEP
OCT
NOV
DEC
GRAPH l.--Average Monthly Incidence of Tetanus Neonatorum. THE
USUAL
ENVIRONMENT
The cases of tetanus were almost solely confined to babies born into the lowest stratum of population. In the Baghdad area this poorest and most wretched section of the community dwell in mud huts which usually consist of a single, dark, dirty and ill-ventilated room approximately 30 • 12 • 10 ft. This room is used for all purposes, that is for living in, for the preparatibn and eating of food, and for sleeping. The average number of inhabitants, as judged by a sample survey, is six, together with any pets or poultry the inmates may possess. The material for the hut is mud dug from the immediate vicinity, so that an inhabited zone consists of a number of closely proximated mud hovels separated from each other by mud walls and narrow, tortuous and filthy tracks interspersed with borrow pits containing slime grossly polluted with rubbish, human and animal excreta, and other debris. No water is laid on, and, apart from a badly fouled open-surface water drain which brings waste from the high-class residential area of the city, there is no drainage. Since there is no proper sewage disposal system, the whole area is fouled with the excreta of the inhabitants, and in addition it is the reception area for rubbish collected by the municipal authorities and for the contents of the city's cesspits which are dumped in close proximity to these mud dwellings. Thus the entire area affords an ideal breeding ground for pathogenic organisms and flies. It is exceptional for a pregnant woman from this area to attend an antenatal clinic, and only in the case of very prolonged labour does she enter a
TETANUS NEONATORUM
461
hospital for her delivery. The usual practice is for a woman to be delivered on the bare mud floor of her dwelling. An untrained handywoman, who sits behind the squatting parturient woman, assists in the expulsion of the baby and placenta. After birth the child is laid on some garments on the floor, and in due course the " Mrs. Gamp," assisted by the mother, ties the umbilical cord with some unsterilised string, wool, or tape which is placed ready for the purpose on some handy place on the floor. The umbilicus is then severed with a razor blade or other untreated sharp instrument, and the wound is dressed with a piece of unsterilised or untreated rag, and finally the child is wrapped up tightly. Incidentally, the mother usually dears up the floor immediately after the confinement, and when the baby has received attention and the midwife left, she resumes her normal household duties. From the above description of the environmental conditions and accouchement, it is not a surprise to know that tetanus of the new-born is quite common. In fact the wonder is that any babies survive, and that the mothers do not all succumb to puerperal sepsis. Most probably the infecting organisms gain access to the umbilicus through this use of instruments, cord, or dressing, contaminated with dust or mud from the floor, which has entered the dwelling from the polluted neighbourhood. EFFECT
OF
SUN
AND
LOW
HUMIDITY.
It is unlikely, though not impossible, that the infection is fly-borne, because the incidence of tetanus neonatorum is lowest at the time when flies are most prevalent. Possibly this lowered incidence of infection during the hottest part of the year may be due to the lethal action of the sun on the pathogenic organisms in the filth lying in the open on the surrounding ground. During the summer months the shade temperature in Baghdad is often over 120~ F., and of course in the open much higher temperatures are reached and are capable of desiccating faecal matter and killing bacteria and their spores. The extremely low humidity which prevails during the hot season in Iraq further assists the desiccation of pathogenic organisms. During the winter months the temperature is much lower but rarely reaches freezing point. The humidity at this time is greater. Thus between November and April the environmental conditions are conducive to the prolongation of life and multiplication of bacteria, hence the opportunities for contracting tetanus are much greater at this time than during the summer months. A typical history given by the mother bringing up her child for the treatment of tetanus is as follows : After an easy and quick delivery the child seemed healthy and strong, and took to the breast well, sucking vigorously. A few days later the child became unable to suck properly and consequently was not getting any milk. As a result the baby was going down hill, losing weight, getting weak, and was commencing to have spasms and convulsions.
462
PUBLIC HEALTH
VOL. LXXI
NO. 12
On examination the baby is found to have trismus, and, if in a more advanced stage of disease, may have developed generalised rigidity with opisthotonus. At the time of the first examination a diagnosis of tetanus is rarely difficult to make, for usually the manifestations are pronounced and typical. In the series investigated it was found that the average date of the onset of disease in the cases terminating fatally was 6.2 days after birth. In the case of the babies which recovered the time of onset was later, being 12 days. Table I demonstrates the prognosis according to the date of onset of symptoms.
TABt.E
I
D a y of onset
No. cured
No. died
Total cases
Per cent. fatal
1-7 8-14 15-30
27 47 6
210 47 2
237 94 8
88.6 50 25
From the above table it will be noted that if tetanus develops within the first week of birth, nearly 90 ~ of the victims die, whereas those babies which develop the disease during the second week of life have a lessened mortality of 5 0 ~ . Should the tetanus not start until the third or fourth week after birth then 75~o of these babies survive. Thus the prognosis depends very greatly on the date of onset of the disease. The closer the proximity of the dates of birth and the onset of disease, the more fatal the outcome. It was also deduced that the average duration of illness in those cases which ended fatally was eight days after the onset of symptoms. Should a child survive, recovery from all symptoms of tetanus should be completed by the end of the second or third week after the commencement of the disease, and the baby is fit for discharge from hospital. TREATMENT
Preventive. The essential preventive measure to lessen the incidence of tetanus neonatorum is the improvement of the environment. This is a stupendous task but nevertheless far from hopeless. In recent years Iraq has become prosperous, a state of affairs which thanks to the golden fluid--oil--is likely to continue. The revenue from oil which the Iraq Government receives is being earmarked for the use of a Development Board which is sponsoring schemes to develop the country and improve the environmental conditions. In the course of time with wise outlay of money the slum areas will be liquidated, but it will take many years. In the meantime the risk of tetanus neonatorum can be lessened by the following measures.
TETANUS NEONATORU M
463
1. Provision of properly trained midwives--but it will take many years to recruit and educate sufficient women to serve the whole country. Until then the handywomen are still needed, so that the Iraq Health authorities are encouraging 2 (below). 2. Education of the untrained and ignorant handywomen in elementary hygiene and the management of confinements. Women are encouraged to take short courses of training, at the end of which through the auspices of UNICEF and WHO they are provided with midwifery bags. 3. Education of mothers and expectant mothers in hygiene. Active immunisation of expectant mothers living under unsatisfactory environmental conditions is worth trying as there is the possibility that the new-born child will then have sufficient immunity from its mother to protect it during the dangerous time whilst the severed umbilical cord is healing. This is a measure which has not been tried out yet. Curative. The practice in the Baghdad Fever Hospital is to give, on admission, 50,000 units of tetanus antitoxin together with 250,000 units of crystalline penicillin which is repeated 12-hourly. Mist chloral bromide is given four-hourly and 1 c.c. paraldehyde intramuscularly injected when necessary. Five per cent. of glucose in half-normal saline is given orally, and after one week 25,000 units of tetanus antitoxin are given intramuscularly. SUMMARY
Three hundred and sixty-nine cases of tetanus neonatorum were admitted to the Fever Hospital, Baghdad, during the period January, 1954, to April, 1957, and their fate is given. The average date of onset of the fatal cases was 6.2 days after birth and of those who survived it was 12 days. Prognosis depends to a great extent on the date of onset of disease :-1-7 days after birth 88.6 ~ died. 8-14 . . . . 50% ,, 15-20 . . . . 25 % ,, The average duration of life after onset in those that died was eight days. The prevention and treatment are discussed. My thanks are due to the staff of the Baghdad Fever Hospital for permission to use their records.
A.
MICHAEL
CRITCHLEY,
M.V., D.P.H., D.1.H.
THE following observations concerning tetanus neonatorum are submitted as being of interest, for although fortunately this disease has become rare in the United Kingdom, yet it is still quite common in countries which are less advanced in public health. During the past seven years, in my capacity of Professor of Public Health and Social Medicine at the Royal College of Medicine, Baghdad, I have held demonstrations in infectious diseases at the Baghdad Fever Hospital. It was noted that there seemed to be cases of tetanus neonatorum always available for teaching purposes. Accordingly the medical officer in charge of the fever hospital, Dr. Hussain Ali Mubarek, and his resident assistant, Dr. Hikmet Emmanuel, were asked to collect the records of the cases of tetanus neonatorum admitted to this hospital over the past few years. This request was carried out and the following information has been gathered from a study of these records. Unfortunately a large proportion of these patients, or more accurately, of their parents, were not only illiterate but also knew neither their exact address nor their age, and it was most difficult to obtain any precise or accurate information and history from them. To add to the confusion, owing mainly to the low social status of the female nurse in the Middle East there is a grave shortage of nursing staff in lraq, and this lack is most marked in the fever hospitals. However, in spite of these obstacles, it was possible to obtain information of value. Between January, 1954, and April, 1957, there were 369 cases of tetanus neonatorum admitted to the Baghdad Fever Hospital, and of these 263 died, 80 were cured, and 26 left the hospital at the request of their parents. Since the ultimate fate of the 26 cases which were removed from the hospital is not known, these cases are omitted from the charts relating to the proportions of dead and recovered, therefore the incidence of cures is based on the 344 cases whose ultimate fate is known. Graph I shows the average incidence of tetanus neonatorum according to the month of onset. It will be observed that there is a definite seasonal trend for infection ; and tetanus neonatorum is most prevalent during the period November to April, and it is least prevalent between May and October. This difference between the peak and the lowest incidence of disease is so great that it calls for explanation. First of all it is necessary to have some knowledge of the environmental conditions of the victims prior to their admission to hospital, and also to realise the modus operandi of the average confinement. 459
460
PUBLIC HEALTtl
9 12
/\
\/
VOL. LXXI
NO. 12
\
/
tl
,01 9 ti1
<
$
7
\/
6 5 4 3 1 I 0
dan
FEB
MAR
APR
MAY JUN JUL MONTH
AUG
SEP
OCT
NOV
DEC
GRAPH l.--Average Monthly Incidence of Tetanus Neonatorum. THE
USUAL
ENVIRONMENT
The cases of tetanus were almost solely confined to babies born into the lowest stratum of population. In the Baghdad area this poorest and most wretched section of the community dwell in mud huts which usually consist of a single, dark, dirty and ill-ventilated room approximately 30 • 12 • 10 ft. This room is used for all purposes, that is for living in, for the preparatibn and eating of food, and for sleeping. The average number of inhabitants, as judged by a sample survey, is six, together with any pets or poultry the inmates may possess. The material for the hut is mud dug from the immediate vicinity, so that an inhabited zone consists of a number of closely proximated mud hovels separated from each other by mud walls and narrow, tortuous and filthy tracks interspersed with borrow pits containing slime grossly polluted with rubbish, human and animal excreta, and other debris. No water is laid on, and, apart from a badly fouled open-surface water drain which brings waste from the high-class residential area of the city, there is no drainage. Since there is no proper sewage disposal system, the whole area is fouled with the excreta of the inhabitants, and in addition it is the reception area for rubbish collected by the municipal authorities and for the contents of the city's cesspits which are dumped in close proximity to these mud dwellings. Thus the entire area affords an ideal breeding ground for pathogenic organisms and flies. It is exceptional for a pregnant woman from this area to attend an antenatal clinic, and only in the case of very prolonged labour does she enter a
TETANUS NEONATORUM
461
hospital for her delivery. The usual practice is for a woman to be delivered on the bare mud floor of her dwelling. An untrained handywoman, who sits behind the squatting parturient woman, assists in the expulsion of the baby and placenta. After birth the child is laid on some garments on the floor, and in due course the " Mrs. Gamp," assisted by the mother, ties the umbilical cord with some unsterilised string, wool, or tape which is placed ready for the purpose on some handy place on the floor. The umbilicus is then severed with a razor blade or other untreated sharp instrument, and the wound is dressed with a piece of unsterilised or untreated rag, and finally the child is wrapped up tightly. Incidentally, the mother usually dears up the floor immediately after the confinement, and when the baby has received attention and the midwife left, she resumes her normal household duties. From the above description of the environmental conditions and accouchement, it is not a surprise to know that tetanus of the new-born is quite common. In fact the wonder is that any babies survive, and that the mothers do not all succumb to puerperal sepsis. Most probably the infecting organisms gain access to the umbilicus through this use of instruments, cord, or dressing, contaminated with dust or mud from the floor, which has entered the dwelling from the polluted neighbourhood. EFFECT
OF
SUN
AND
LOW
HUMIDITY.
It is unlikely, though not impossible, that the infection is fly-borne, because the incidence of tetanus neonatorum is lowest at the time when flies are most prevalent. Possibly this lowered incidence of infection during the hottest part of the year may be due to the lethal action of the sun on the pathogenic organisms in the filth lying in the open on the surrounding ground. During the summer months the shade temperature in Baghdad is often over 120~ F., and of course in the open much higher temperatures are reached and are capable of desiccating faecal matter and killing bacteria and their spores. The extremely low humidity which prevails during the hot season in Iraq further assists the desiccation of pathogenic organisms. During the winter months the temperature is much lower but rarely reaches freezing point. The humidity at this time is greater. Thus between November and April the environmental conditions are conducive to the prolongation of life and multiplication of bacteria, hence the opportunities for contracting tetanus are much greater at this time than during the summer months. A typical history given by the mother bringing up her child for the treatment of tetanus is as follows : After an easy and quick delivery the child seemed healthy and strong, and took to the breast well, sucking vigorously. A few days later the child became unable to suck properly and consequently was not getting any milk. As a result the baby was going down hill, losing weight, getting weak, and was commencing to have spasms and convulsions.
462
PUBLIC HEALTH
VOL. LXXI
NO. 12
On examination the baby is found to have trismus, and, if in a more advanced stage of disease, may have developed generalised rigidity with opisthotonus. At the time of the first examination a diagnosis of tetanus is rarely difficult to make, for usually the manifestations are pronounced and typical. In the series investigated it was found that the average date of the onset of disease in the cases terminating fatally was 6.2 days after birth. In the case of the babies which recovered the time of onset was later, being 12 days. Table I demonstrates the prognosis according to the date of onset of symptoms.
TABt.E
I
D a y of onset
No. cured
No. died
Total cases
Per cent. fatal
1-7 8-14 15-30
27 47 6
210 47 2
237 94 8
88.6 50 25
From the above table it will be noted that if tetanus develops within the first week of birth, nearly 90 ~ of the victims die, whereas those babies which develop the disease during the second week of life have a lessened mortality of 5 0 ~ . Should the tetanus not start until the third or fourth week after birth then 75~o of these babies survive. Thus the prognosis depends very greatly on the date of onset of the disease. The closer the proximity of the dates of birth and the onset of disease, the more fatal the outcome. It was also deduced that the average duration of illness in those cases which ended fatally was eight days after the onset of symptoms. Should a child survive, recovery from all symptoms of tetanus should be completed by the end of the second or third week after the commencement of the disease, and the baby is fit for discharge from hospital. TREATMENT
Preventive. The essential preventive measure to lessen the incidence of tetanus neonatorum is the improvement of the environment. This is a stupendous task but nevertheless far from hopeless. In recent years Iraq has become prosperous, a state of affairs which thanks to the golden fluid--oil--is likely to continue. The revenue from oil which the Iraq Government receives is being earmarked for the use of a Development Board which is sponsoring schemes to develop the country and improve the environmental conditions. In the course of time with wise outlay of money the slum areas will be liquidated, but it will take many years. In the meantime the risk of tetanus neonatorum can be lessened by the following measures.
TETANUS NEONATORU M
463
1. Provision of properly trained midwives--but it will take many years to recruit and educate sufficient women to serve the whole country. Until then the handywomen are still needed, so that the Iraq Health authorities are encouraging 2 (below). 2. Education of the untrained and ignorant handywomen in elementary hygiene and the management of confinements. Women are encouraged to take short courses of training, at the end of which through the auspices of UNICEF and WHO they are provided with midwifery bags. 3. Education of mothers and expectant mothers in hygiene. Active immunisation of expectant mothers living under unsatisfactory environmental conditions is worth trying as there is the possibility that the new-born child will then have sufficient immunity from its mother to protect it during the dangerous time whilst the severed umbilical cord is healing. This is a measure which has not been tried out yet. Curative. The practice in the Baghdad Fever Hospital is to give, on admission, 50,000 units of tetanus antitoxin together with 250,000 units of crystalline penicillin which is repeated 12-hourly. Mist chloral bromide is given four-hourly and 1 c.c. paraldehyde intramuscularly injected when necessary. Five per cent. of glucose in half-normal saline is given orally, and after one week 25,000 units of tetanus antitoxin are given intramuscularly. SUMMARY
Three hundred and sixty-nine cases of tetanus neonatorum were admitted to the Fever Hospital, Baghdad, during the period January, 1954, to April, 1957, and their fate is given. The average date of onset of the fatal cases was 6.2 days after birth and of those who survived it was 12 days. Prognosis depends to a great extent on the date of onset of disease :-1-7 days after birth 88.6 ~ died. 8-14 . . . . 50% ,, 15-20 . . . . 25 % ,, The average duration of life after onset in those that died was eight days. The prevention and treatment are discussed. My thanks are due to the staff of the Baghdad Fever Hospital for permission to use their records.