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Tetanus neonatorum: Review Of twenty-six cases
61. Stephensen CB, Franchi LM, Hernandez H, Campos M, Gilman RH, Alvarez JO. Adverse effects of high-dose vitamin A supplements in children hospitalized with pneumonia. Pediatrics 1998;101:e3.
62. Darnton-Hill I, Sibanda F, Mitra M, Ali MM, Drexler AE, Rahman H, et al. Distribution of vitamin-A capsules for the prevention and control of vitamin-A deficiency in Bangladesh. Food Nutr Bull 1988; 10:60-70.
50 Years Ago in The Journal of Pediatrics TETANUS NEONATORUM: REVIEW OF TWENTY-SIX CASES Spivey OS, Grulee CG Jr, Hickman BT. J Pediatr 1953;42:345-51 It is sobering to remember that neonatal tetanus (NT) was still a problem in the United States 50 years ago. Spivey, Grulee, and Hickman described 26 infants with neonatal tetanus cared for at Charity Hospital in New Orleans during a 6.5-year period. Although NT occurred equally among male and female infants, there was a marked increase among black newborns. Only one infant was known to have been delivered in-hospital; 18 were born at home (15 by midwives, and one each by a physician, grandmother, and the mother alone). Clinical management was discussed in 5 areas: antitoxin, sedation, antibiotics, surgery, and nutrition and fluids. The authors wrote, “No single factor is more important in caring for the infant with tetanus neonatorum than the constant attention of a highly skilled nurse.” Despite the most advanced care available at the time, 77% of infants died. Today neonatal tetanus is rare in the United States—only 3 cases have been reported since 1984.1 However, neonatal tetanus remains an important cause of neonatal mortality in many parts of the developing world. In 1998, the World Health Organization estimated that approximately 350,000 cases occur annually, with almost 250,000 deaths.2 The high fatality rate reported in 1953 continues in most developing countries. The 1953 paper described an inverse relationship between incubation period and death rate. Of interest, a recent paper from Nigeria3 that reviewed 174 patients with NT (of whom 58% died) confirmed that an incubation period of ≤6 days was a strong predictor of mortality (OR, 3.1; P = .003). A short incubation period may reflect increased virulence of the infecting agent, increased inoculum size, or decreased host resistance. The great tragedy of neonatal tetanus is that it is completely preventable through a combined strategy of maternal tetanus immunization before or during pregnancy, and ensuring a clean delivery, clean cutting of the umbilical cord, and proper care of the cord in the early days of life. The authors of the 1953 paper wrote, “The provision of universally adequate obstetrical care would promptly eliminate tetanus neonatorum.” Studies performed after 1953 demonstrated that tetanus toxoid given to the mother prevents neonatal tetanus.4-6 A recent study documented long-lasting (12 years) protection after 2 doses of tetanus toxoid.7 Maternal immunization protects the mother as well as the infant against disease. Moreover, clean delivery practices have the additional benefit of preventing other maternal and neonatal infections that can cause morbidity and mortality. Although written in 1953, the following is relevant to the global effort to eliminate NT today: “Complex problems in public education, training of professional personnel, and distribution of medical services must be solved before tetanus neonatorum can be eliminated.” Barbara J. Stoll, MD Department of Pediatrics Emory University School of Medicine Atlanta, GA 30322 YMPD125 10.1067/mpd.2003.125
REFERENCES 1. CDC Morbidity and Mortality Weekly Report. Neonatal tetanus—Montana, 1998. MMWR Morb Mortal Wkly Rep 1998;47:928-30.2. WHO Vaccines, Immunization, and Biologicals. Neonatal tetanus. Progress towards the global elimination of neonatal tetanus, 1990-1997. Available at: http://www.who.int/vaccines-diseases/diseases/NeonatalTetanus.shtml. 3. Davies-Adetugbo AA, Torimiro SEA, Ako-Nai KA. Prognostic factors in neonatal tetanus. Trop Med Int Health 1998;3:9-13. 4. Schofield FD, Tucker VM, Westbrook GR. Neonatal tetanus in New Guinea. Effect of active immunization in pregnancy. BMJ 1961;2:785-9. 5. Newell KW, Duenas Lehmann A, LeBlanc DR, et al. The use of toxoid for the prevention of tetanus neonatorum. Final report of a double-blind controlled field trial. Bull World Health Org 1966;35:863-71. 6. Black RE, Huber DH, Curlin GT. Reduction of neonatal tetanus by mass immunization of non-pregnant women: duration of protection provided by one or two doses of aluminum-adsorbed tetanus toxoid. Bull World Health Organ 1980;58:927-30. 7. Koenig MA, Roy NC, McElrath T, et al. Duration of protective immunity conferred by maternal tetanus toxoid immunization: further evidence from Matlab, Bangladesh. Am J Public Health 1998;88:903-7.
304 Grotto et al
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62. Darnton-Hill I, Sibanda F, Mitra M, Ali MM, Drexler AE, Rahman H, et al. Distribution of vitamin-A capsules for the prevention and control of vitamin-A deficiency in Bangladesh. Food Nutr Bull 1988; 10:60-70.
50 Years Ago in The Journal of Pediatrics TETANUS NEONATORUM: REVIEW OF TWENTY-SIX CASES Spivey OS, Grulee CG Jr, Hickman BT. J Pediatr 1953;42:345-51 It is sobering to remember that neonatal tetanus (NT) was still a problem in the United States 50 years ago. Spivey, Grulee, and Hickman described 26 infants with neonatal tetanus cared for at Charity Hospital in New Orleans during a 6.5-year period. Although NT occurred equally among male and female infants, there was a marked increase among black newborns. Only one infant was known to have been delivered in-hospital; 18 were born at home (15 by midwives, and one each by a physician, grandmother, and the mother alone). Clinical management was discussed in 5 areas: antitoxin, sedation, antibiotics, surgery, and nutrition and fluids. The authors wrote, “No single factor is more important in caring for the infant with tetanus neonatorum than the constant attention of a highly skilled nurse.” Despite the most advanced care available at the time, 77% of infants died. Today neonatal tetanus is rare in the United States—only 3 cases have been reported since 1984.1 However, neonatal tetanus remains an important cause of neonatal mortality in many parts of the developing world. In 1998, the World Health Organization estimated that approximately 350,000 cases occur annually, with almost 250,000 deaths.2 The high fatality rate reported in 1953 continues in most developing countries. The 1953 paper described an inverse relationship between incubation period and death rate. Of interest, a recent paper from Nigeria3 that reviewed 174 patients with NT (of whom 58% died) confirmed that an incubation period of ≤6 days was a strong predictor of mortality (OR, 3.1; P = .003). A short incubation period may reflect increased virulence of the infecting agent, increased inoculum size, or decreased host resistance. The great tragedy of neonatal tetanus is that it is completely preventable through a combined strategy of maternal tetanus immunization before or during pregnancy, and ensuring a clean delivery, clean cutting of the umbilical cord, and proper care of the cord in the early days of life. The authors of the 1953 paper wrote, “The provision of universally adequate obstetrical care would promptly eliminate tetanus neonatorum.” Studies performed after 1953 demonstrated that tetanus toxoid given to the mother prevents neonatal tetanus.4-6 A recent study documented long-lasting (12 years) protection after 2 doses of tetanus toxoid.7 Maternal immunization protects the mother as well as the infant against disease. Moreover, clean delivery practices have the additional benefit of preventing other maternal and neonatal infections that can cause morbidity and mortality. Although written in 1953, the following is relevant to the global effort to eliminate NT today: “Complex problems in public education, training of professional personnel, and distribution of medical services must be solved before tetanus neonatorum can be eliminated.” Barbara J. Stoll, MD Department of Pediatrics Emory University School of Medicine Atlanta, GA 30322 YMPD125 10.1067/mpd.2003.125
REFERENCES 1. CDC Morbidity and Mortality Weekly Report. Neonatal tetanus—Montana, 1998. MMWR Morb Mortal Wkly Rep 1998;47:928-30.2. WHO Vaccines, Immunization, and Biologicals. Neonatal tetanus. Progress towards the global elimination of neonatal tetanus, 1990-1997. Available at: http://www.who.int/vaccines-diseases/diseases/NeonatalTetanus.shtml. 3. Davies-Adetugbo AA, Torimiro SEA, Ako-Nai KA. Prognostic factors in neonatal tetanus. Trop Med Int Health 1998;3:9-13. 4. Schofield FD, Tucker VM, Westbrook GR. Neonatal tetanus in New Guinea. Effect of active immunization in pregnancy. BMJ 1961;2:785-9. 5. Newell KW, Duenas Lehmann A, LeBlanc DR, et al. The use of toxoid for the prevention of tetanus neonatorum. Final report of a double-blind controlled field trial. Bull World Health Org 1966;35:863-71. 6. Black RE, Huber DH, Curlin GT. Reduction of neonatal tetanus by mass immunization of non-pregnant women: duration of protection provided by one or two doses of aluminum-adsorbed tetanus toxoid. Bull World Health Organ 1980;58:927-30. 7. Koenig MA, Roy NC, McElrath T, et al. Duration of protective immunity conferred by maternal tetanus toxoid immunization: further evidence from Matlab, Bangladesh. Am J Public Health 1998;88:903-7.
304 Grotto et al
The Journal of Pediatrics • March 2003