Tetanus And Public Health: Surveillance, Prevention, And Control Measures

Overview

Tetanus is a disease that can be prevented by vaccination. It is caused by a bacteria named Clostridium tetani. Its spores (very resistant cells that are produced by the bacteria to protect themselves) can live for years on different surfaces such as the skin, rusty tools, dust, or soil.¹ These spores enter the human body through a wound, deep burn or cut, and between 3 and 21 days after the infection, they damage the nervous system by liberating toxins, causing painful muscular contractions that put life at risk.² The World Health Organisation (WHO) explains that tetanus is relevant to public health because, in places where vaccination coverage is short, newborns are at high risk of contracting the disease. 

Epidemiology  

Any person at any age can be affected by tetanus. Nevertheless, it is more common in persons who have not been vaccinated, for example, newborns, or in partially vaccinated persons. According to the WHO, there was a reduction of 97% of deaths from tetanus in newborns from 1988 (787,000 deaths) to 2018 (25,000 deaths). It is still common, however, in low-income countries because of the lack of resources or easy access to vaccination. 

The European Centre for Disease Prevention and Control (ECDC) reports that the disease is rare in Europe. However, there have been some cases as a consequence of non-vaccinated and not fully vaccinated persons. The UK Health Security Agency reports that since 2001, the coverage in babies of 2 years of age has been approximately 95% in England and Wales.

Classification 

There is a classification of tetanus that depends on the manifestations of the disease:²

Generalised

It is the most common form of tetanus, with 80% of the cases. It starts with contractions in the muscles of the face. These spams produce the effect of a rigid smile, also known as risus sardonicus, and a stiff jaw called lockjaw.¹ Then, there are spasms of the muscles of the neck and back known as opisthotonos.²

Neonatal

This is a generalised form that happens in newborns. It occurs when the material used to cut the umbilical stump is contaminated or it can be transmitted from the mother to the newborn if the mother was not vaccinated before or partially vaccinated.^1,2 

The WHO defines a neonatal tetanus case when in the 1^st and 2^nd days of life, a baby is able to cry and suck but it is then incapable of doing so between days 3 and 28. Infected babies can be irritable, with rigidity, and have serious contractions triggered by touching them. Survivors usually have complications, such as deficits in language, speech or gross motor development.¹ 

Localised 

This form is rare and occurs when there are spasms and muscular rigidity only where the injury happened.² Usually, it lasts for a few weeks, but it can evolve to the generalised form and therefore, become a life-threatening condition.¹ 

Cephalic

This is a localised form that can also evolve into generalised.¹ It happens as a consequence of a lesion in the head.² Cranial nerves are affected after a skull fracture, eye infections, ear infections, dental procedures, or other injuries.

Signs and symptoms

After approximately 10 to 14 days of the infection, clinical manifestations start, some of the most common are:

• Inability to open the mouth because of a stiff jaw
• Difficulty swallowing
• Difficulty breathing
• Muscle spasms in the neck, back, arms, hands, abdomen, legs or feet
• Painful muscle spasms that appear because of sudden noises  
• High temperature
• Headache
• Fast heartbeat
• Changes in blood pressure
• Seizures

In neonatal tetanus:

• Babies are very irritable with excessive crying
• There is an inability to suck making breastfeeding difficult 
• Rigidity 

Public health and surveillance Public health is the science and art in charge of preventing diseases, promoting health and prolonging life in populations around the world. Surveillance is a tool used in public health, with the objective of collecting data that guides making informed decisions, which leads to accurate interventions for the health of the population.³ Therefore, the participation of the population, researchers, practitioners, countries and international institutions is necessary for having a good surveillance system.

Maternal and neonatal tetanus elimination (MNTE)

In 1988, the elimination of neonatal tetanus was established as a public health problem at the World Health Assembly. In 1999 WHO, UNICEF and the United Nations Population Fund (UNFPA) started the Maternal and Neonatal Tetanus Elimination (MNTE) initiative to reduce neonatal tetanus in the world. 

WHO mentioned that in July 2023, 11 countries had not accomplished the MNTE. However, one of the main problems in MNTE surveillance is the unreported cases, hence, it is very important to have more trustworthy global data to improve the district-level data analysis.⁴ The UK Health Security Agency has reported that to improve tetanus surveillance, data sources should be diverse, for example, death registrations, NHS laboratory reports, and individual case reports including vaccination history.

Prevention 

Prevention strategies in public health are the measures taken to avoid a disease or to diminish its impact, as well as its complications in people’s lives.⁵ Vaccination and adequate wound care are essential for the prevention of tetanus.² In addition, it is important to remember that regular hand washing is part of good basic hygiene, and it helps to prevent the infection of wounds.

Vaccination

In the case of vaccination, the two objectives are:⁴

• To succeed in maternal and neonatal tetanus elimination
• To guarantee lifetime protection against tetanus 

The WHO recommends 6 doses of tetanus-toxoid-containing vaccine (TTCV), 3 primary doses plus 3 booster doses. 

• The first dose is at 6 weeks of age, the second after 4 weeks as a minimum, and the third at 6 months of age
• For the booster doses (with at least 4 years of difference between them) the first dose should be between 12-23 months of age, the second between 4-7 years of age and the third between 9-15 years of age
• For pregnant persons, when they have not received the three booster doses, it is important to receive two doses with 4 weeks of difference between them

There are different types of vaccines that contain TTCV, and are combined with vaccines for other illnesses:

• Tetanus, diphtheria and pertussis (Tdap) vaccines
• Diphtheria, tetanus and pertussis (DTaP) vaccines
• Tetanus and diphtheria (Td) vaccines
• Diphtheria and tetanus (Dt) vaccines

It is important to mention that national vaccination schedules can be adjusted depending on the necessities of the population of each country.⁴ In the case of the UK, the NHS vaccination schedule contains 5 doses. The UK Health Security Agency explains that the aim of the vaccination schedule is to supply 5 doses of TTCV at adequate intervals for the population.

In the case of wounds, people must be vaccinated if it is unclear if they received all the doses of the vaccine, if the wound is contaminated, or if there is damage in the tissues.² 

Control measures

The control measures vary depending on the severity of the disease. These are the general objectives of the treatment:

• A prompt application of human tetanus immunoglobulin, which is passive immunisation, with the aim of giving the body defences to fight against the infection^1,2  
• Remove damaged, infected or dead tissue from the wound
• Different medications, such as antibiotics or medicines helpful in controlling stiffness and muscle spasms
• The use of different accessories to monitor and maintain vital signs at an adequate level

The recovery from tetanus can take months, and the person can be infected again; thus, vaccination is required.

Summary

Tetanus can have devastating consequences for anyone who gets it, but it is even more devastating in newborns, which is why it is a relevant disease for public health. Surveillance is useful to obtain data about the persons that present the disease in different parts of the world, and with that information, it is possible to adjust the vaccination schedules when it is required. Preventing tetanus is a goal that can be achieved with the participation of everybody, mainly by receiving the vaccine and completing the required doses according to the vaccination schedule in each country.