Outcome of Tetanus Patients Admitted in Rangpur Medical College Hospital

Background: Tetanus remains one of the major public health hazards of the developing world. Mortality is much lower in the developed world because of the availability of facilities, unlike in most developing countries' Objectives: This study was aimed to determine the outcome of tetanus patients admitted in infectious disease unit of Rangpur Medical College Hospital. Methods: A total of 91 cases of tetanus patients were seen in the 18 month period with a mean of 5 cases per month; they are diagnosed and managed for tetanus in the medical wards from January 2oll to l:une 2012' The data were retrieved from their case records and analyzed. Result: There were thirty one deaths, accounting for an overall mortality of 34.16o.Total fifty six patients were cured among which sixteen(L7.67o) were cured with complication and fow(4'47o) patient were absconded. Mortality was high 45.847o(ll patient otX of 24) in > 40 years age,whereas low 29 '857o( 20 patient out of g7) in <40 yea15 age (45.847o vs29.857o).Mortality rate was also higher among female than male patients (34.66Vo vs 33.g5 Vo,). Farmerc experienced more death than non-farmer (4l.l8%o vs 29-82Vo, P<0'05)' Mortality was higher in patients who had not received any medical treatrnent for their wound than in patients who had received it for theirwound (52.7grovs2!.gl7o,p<0.05).patientswithshortincubationperiodoflessthanoneweekhadhighermortality in comparison with those who had incubation period more than one week (53.337o vs23.257o,P<0'05)' Of the 91 patients' fifty six (64.34zo)were alive, though four remained in a persistent vegetative state due to tetanus toxin-induced brain damage and another two required a below knee amputation of the left leg. Hence, 40 were discharged well and 16 were discharged with permanent disabilities. conclusion: The case fatality rate of tetanus has remained consistently high in the medical college. Factors that were significantly associated with high mortality included older age, and incubation period of less than 7 days. It is recommended that preventive immunization against tetanus be given to all Bangladeshis with secondary vaccination at adulthood.


Introduction:
modern parlance as a reminder of one of the cardinal features of tetanus: intense painful spasms of the masseter Tetanus is a nervous system disorder characterized by muscles.muscle spasms that is caused by the toxin-producing anaerobe, Clostridium tetani, which is found in the soil' Although tetanus is now rare in the developed world, the The clinical features of tetanus and its relationship to disease remains a threat to all unvaccinated people, traumatic injuries were well known among the ancient particularly in developing countries.In contast to devel- Greeks and Egyptians and too many clinicians before the oped nations where tetanus is rare, tetanus remains introduction of vaccination with tetanus toxoid in the endemic in the developing wod, and the incidence often 1940s.Thet"*''lo"increasesfollowingnaturaldisasterssuchasearthquakes Address for Correspondence: Dr.Md.Ismail Hossain, OSD, Directorate General of Health Services, Deputed in BSMMU, Dhaka.email-dmrssel27 @ gmail.com and tsunamis.Approximately one million cases of tetanus are estimated to occur worldwide each year,with 300,000 to 500,000 deathsl.Neon atal tetanus, which the WHO targeted for elimination by Lggl, accounted for approxi- mately 59,000 deaths in 20082.While this represents a decrease in mortality of 92 percent compared with 1988, as of 2010,39 countries had still not eliminated maternal and neonatal tetanus.Most cases of tetanus follow an acute penetrating skin injury.The injury may be major but often is trivial, so that medical attention is often not sought.Tetanus is also associated with chronic skin ulcers '-0, abscesses, gangrene, burns, surgery, abortion, childbirth, and intravenous drug abuse a.In some patients no portal of entry for the organism can be identified 3.In Bangladesh, like most developing countries in the world, tetanus is endemic and remains an important health problem especially among the rural farming folks.
Although an estimated 41,000 cases of neonatal tetanus occur annuallys, the exact incidence of other types of tetanus in Bangladesh, a country with 140 million inhabit- ants, is not known, partly because of lack of compliance in reporting new cases to the authorities.The Government of Bangladesh, Bureau of Statistics has reported 7 .57o of maternal deaths or an estimated 1080 women died in 1996 from pregnancy related tetanus6.Case-fatality rates for non-neonatal tetanus in developing countries range from 8 to 50 percentT.However, the mortahty in other types of non-neonatal tetanus in Bangladesh is not known.We undertook an eighteen month retrospective study of all the tetanus cases in adults managed in infectious disease unit of our hospital, looking into its demographic and clinical profiles, risk factors for tetanus, treatment received and the outcomes.

IVlethods:
All cases of tetanus in patients from Janu ary 201 1 to July 2012, who were admitte d at the infectious disease unit of Rangpur Medical College Hosprtal, were included in this lS-month retrospective descriptive study.The tetanus cases were searched for and identified from the case record files in the Record Office of the hospital.
Selection critena for the patients consists of: (1)  Age, sex, occupation, clinical features of the individual cases of tgtanus, incubation time, identifiable injury, history of previous vaccination against tetanus, wound prophylaxis, treatment received, complication if any were noted on a standard case record form.Tables and charts were then made to summarrze the various data of interest.
Data were analyzed using SPSS .A descriptive analysis was done on all variables to obtain a frequency distribu- tion.The mean + SD and ranges were calculated for quan- titative variables.Continuous variables were compared by the Student t test.Proportions were analyzed with the chi-square test or 2-talled Fisher's exact test as appropri- ate.A P value of 0.05 or less was considered statistically significant.

Results:
There were 91 cases of tetanus in the study period with a range of 3 to 10 cases per month and a mean of about 5 cases per month.There were 65 male (71.4%o) and 26 female (28.6Vo) patients.The age and sex distribution of these 9L tetanus patients is shown in figure 1.Most cases occulred in the age groups 30-39 years and 20-29 years, with 32 and 22 cases respectively.Sixty four (70.37o) cases occurred in people less than 40 years of age.Only four patients were more than 60 years of age.The occupational groups of the patients are shown in Table 1.Thirty four (37 .47o)patients were farmer, twelve (13.27o) were laborer and industry worker, fifteen (16.57o) were housewives, eight (8.8Vo) were business- man, twelve (13.27o) were student and in ten (11.0 7o7o) patients the exact occupations of the patients were not known as the occupational history were not recorded in medical record files.Fifty two of the gl (57 .l7o)patients had a reasonably identifiable acute injury (prick, puncture wound or laceru- tion) prior to the onset of tetanus, as shown in Table II.
Twenty one (23.1%o)were the history of minor surgery (Boil, stitch in cut injury) for about a week before the first symptoms of tetanus.Other risk factors identified were abortion (6.6 7o%o), child birth (4.4%o).In three (3.3%o)patients, there was no clinically identifiable portal of entry.Thirty six (39.6vo) patients did not consider the injury severe enough to be treated either by themselves or by doctors.Of the other patients with a wound who did seek medical help, twenty (22.0%o) received an immunLza- tion with tetanus toxoid, and nineteen (20.97o) got prophylactic penicillin antibiotic in combination with an immun rzatton (Table-IID.None of the patients received tetanus immunoglobulin in prophylaxis treatment of the wound.A history of previous tetanus immunrzatton was obtained only from twelve (13.2%o) patients (Table-IV)' Four patients had received the immuntzatron more than 10 years ago.There was no written proof of the immunLza- tion schedule in any cases.Fifty five (6a.47o) patients said they never had been vaccinated.The remaining twentyfour (26.4%o) patients could not provide any information at all regarding vaccination against tetanus.Serology to detect anti-tetanus antibodies was not performed' The incubation period, defined as the time between the inoculation of the wound and the onset of the symptoms, could be evaluated in fifty eight (72.57o)patients.The mean incubation period was 10.8+2.1 days (range 3-28 days).Twenty nine patients had an incubation period of less than one week, and twelve of them suffered from severe disease.The period of onset, defined as the interval between the first symptoms and the first spasm, could not be evaluated, as it was'not recorded in case history of the patients.

Presence of injurY
Frequency Percent (%o) Acute Injury(Puncture, Prick) A11 the patients were treated in two isolated rooms to guarantee a quite environment.There was no intensive care unit at Rangpur Medical college Hospital.Table v shows a summary of the treatments given to the 9l tetanus patients.Surgical toileting and debridement of the wounds were performed in all the eighty one (89.017o)patients.Eighty-two (90.L07o) patients received intravenous crystalline penicillin as antibiotics, fifty one (56.047o)patients received it as the only antibiotics and forty-two (46.15%o) patients received it in combination with metro- nidazole.Seventy six patients (83.5 IVo) received intramuscular human antitetanus immunoglobulin.A11 the 9l (1007o) patients received intravenous drazepam infusion as an inte gral part of their management.Support- ive treatment such as balanced fluid and calorie intake, prevention of gastric stress ulcer, prevention of pressure sores were provided in all patients.Prophylactic heparin was used in fourteen patients.There were thirty one deaths, accounting for an overall mortality of 34.l7o.Tota1 fifty six patient were cured among which sixteen(L7.67o) were cured with complication and four(4.4Vo)patient were absconded.Mortality was compared between subgroups of patients.Factors associated with poor outcome were (1) age greater than 40 years (2) female sex (3) occupation as a farmer (4) lack of medical treatment for tetanus prone wound and (5) short incubation period.Eleven(45 .847o)died among 24 patients who were above 40 years of age.twenty (29.857o) died among 67 pattents who were below 40 years of old and higher rate of death was observed among that group patients (45.847o vs 29.857o, P<0.05, Fig -Z).Mortality rate was also higher among female than male patients (34.667o vs 33.857o, table: Vll).Farmers experienced more death than others (4I.187o vs 29.827o, P<0.05).Mortality was higher in patients who had not received any medical treatment for their wound than in patients who had received it for their wound (52.78VoP<0.05).Patients with short incubation period of less than one week had higher mortality in comparison with those who had incubation period more than one week (53.337ovs23.257o,P<0.05).Of the 91 patients, fifty six (64.347o) were alive, though four remained in a persistent vegeta- tive state due to hypoxic brain damage and another two required a below knee amputation of the left leg.Hence, 40 were discharged well and 16 were discharged with permanent disabilities.
For those 56 patients that were discharged alive, average length of stay of 27 days.Two patients spent more than 100 days in the hospital; one spent 106 and the other, 109 days Discussion: In this retrospective descriptive study we identified a total of 91 cases of tetanus in the eighteen month period from January 2011 to June 2012, glrng a mean of 5 cases per month.The case records of thes e 9L tetanus cases were thoroughly studied to gather various demographic and clinical dataof interest.We found regrettably that in some cases the occupational data of the tetanus patients was incompletely entered and hence, we were not able to analyze these tetanus cases in relation to the occupations of the patients.We were also unable to collect sufficient information on immuntzatron history.More detailed history taking and recording should therefore be manda- tory in the future so that important and complete data would be available for analysis to provide invaluable information 8.Most of the cases of tetanus occurred in middle aged with no prior immunization or with an unknown history of immunrzatton Waning immunity, caused by the disappearance of the protective antibody levels in subjects who did not receive a regular booster injection, may also account for Some tetanus cases to.'We observed a mean of 5 patients per month with generahzed tetanus in our referral hospital.The sex distribution analy- sis revealed that almost two-thirds of the cases (71.47o) occurred in men while a third occurred (28.67o) in women.This finding is consistent with that of other studies s' e' 10.This could be explained by the fact that men tend to spend more time outdoor, in farming activities and other types of fieldwork.Hence, they are more likely to be exposed to both the causal organism, C. tetani, which is ubiquitous in soil in a tropical country like Bangladesh and the penetrating injury necessary for the organism to enter the body.
The mean age of tetanus patients in our series was 3I.7+10.08 years.757o of the tetanus cases occulred in individuals less than 40 years of age.The possible expla- nation for this observation is that tetanus immunrzatton program was only commenced in this country in the mid-1960.Majority (37 .47o) of the tetanus patients were farmers.This pattern of occupational risk group is explained by the factthat farmers or the peoples who live in the rural aleas and engage themselves in the agricultural sector are more likely to be exposed to the causal organism as well as the injury necessary for the organism to enter the body.Fifty two (51 .l%o) of the tetanus patients had an identifiable acute skin injury; a prick, a puncture wound or a lacera- tion wound, a figure fairly consistent with that of other studiesll.Thirty-nine (48.757o) of these injuries occurred in the lower limb, while only twenty-nine (36.257o) were on the upper limbs.Other studies also reported that the majority of tetanus wounds were located on the lower limbs In 3 .37o of the patients, no probable portal of entry was identified; the injuries were likely to trivial to be recalled 3' 8'11.Body stiffness/spasm, trismus and dysphagia, in that order, were the commonest complaints of the tetanus patients in our series.Other investigators had also found trismus and rigidity to be the commonest presenting symptoms 5'".Hence, a high index of suspicion for tetanus should be exercised whenever patients present with any of these symptoms as tetanus is essentially a clinical diagno- sis and laboratory results as well as cultures ate of little diagnostic value '' t.If a patient presents with all the three complaints, the probability of tetanus would be extremely high.Tetanus patients also complained of pains involving other parts of the body, either generalized or locahzed, such as back, neck and jaw pain.If these were the only complaints, the correct diagnosis as well the appropriate management might be delay ed1a.
Nineteen patients had tracheostomy performed to circumvent the problem of laryngeal spasm (which could lead to asphyxiation and hypoxia) and to enable tracheal suction and toilet to be carried out efficiently (airway protection) 9,15 .
The mortalrty rute of tetanus in our series was 34.l%o.This finding is fairly consistent with that of other studies e, 11, 16, " .64.37Vo ofpatients of our series survived, though four remained in a persistent vegetative state due to hypoxic brain damage and another two required a below knee amputation of the left leg.Hence, 40 were discharged well and 16 were discharged with pennanent disabilities.There was a delay in the diagnosis of tetanus and the institution of appropriate management ".One more patient presented late with history of generalized convulsion.Both devel- oped hypoxic brain damage and remained in a persistent vegetative state upon discharge.The average length of hospital stay was 77 days: Two patients stayed for more than 100 days, one stayed 146 days and the other, 109 days.
In conclusion, tetanus remains in Bangladesh an impor- tant disease with substantial mortality and morbidity that primarily affects unvaccinated or inadequately vaccinated individuals (5' e' 11' 1s).As Bangladesh, like most third world countries, has very limited resources, the continued occur- rence of this preventable disease represents a drain on existing health care funds.This must be brought to the attention of institutions responsible for planning health care programs.Tetanus is highly preventable through both routine vaccination and appropriate wound management 8' 82 rr't7' 18.The method of good management emphasizes: 1) wound care, 2) neutralizatron of the toxin, 3) antibiotic therapy, 4) supportive measures including good nursing care with control of convulsions, 5) completion of active immuntzatton 8' 18.Another important aspect that was revealed in our study was the inadequate management of those patients who did seek medi cal care for their wounds.
Fatients with tetanus prone wounds and an unknown immunity for tetanus only received a booster vaccine without tetanus immunoglobulin or any prophylaxis at all.
The lack of approprrate prophylactic measure during wound management was found in other studies as well 6'e.
Tetanus is a constant danger that we must not forget but must prevent it.A case of tetanus reflects the failure of our health care delivery system to provide adequate and approp riate immun ization 3. The solution to the problem of tetanus remains prophylaxis.

Conclusion:
In this era of modern management, it is very unfortunate on our part to lose apatrent with tetanus.We should have a high index of suspicion when a patient present with features like body stiffness/spasm, trismus and dysphagia with a plausible background history so that none of the patient goes unnoticed.As well our preventive health-care services also have to be addressed side by side to prevent and or diminish the number of tetanus patients in our conrmunity.

Fig 2 :
Fig 2: Number of outcome in different age group

Table - III
patient received treatment before hospital admission

Table - V
Treatments Afforded To the Patient in Hospital