|Year : 2015 | Volume
| Issue : 1 | Page : 30-33
Neonatal and post-neonatal tetanus in Nnamdi Azikiwe University Teaching Hospital, Nnewi, South-East, Nigeria: A 10-year review
John Onuora Chukwuka, Chijioke Elias Ezeudu, Kenechi Ogbodo Nnamani
Department of Paediatrics, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria
|Date of Web Publication||4-Mar-2015|
Dr. Chijioke Elias Ezeudu
Department of Paediatrics, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra
Introduction: Tetanus, a disease that is easily preventable by vaccination continues to be a public health problem in Nigeria and other developing countries. This study reviewed the socio-demographic and clinical characteristics of children admitted with tetanus in NAUTH over a 10-year period. Materials and Methods: This is hospital based 10-year retrospective study. Medical records of all the children admitted with tetanus in both neonatal and post-neonatal wards of NAUTH between January 2003 and December 2012 were retrieved and studied. Data was analyzed using SPSS version 16 and a P value < 0.05 was considered significant. Results: There were 26 cases of neonatal and post-neonatal tetanus. Three out of the 26 were from the neonatal group, while remaining 23 were from the post-neonatal group. All the patients in the neonatal group were males aged 2-10 days, with a mean of 5.66 ± 4.04 days. Fourteen (60.9%) of the post-neonatal group were males while nine (39.1%) were females. Their age ranged from 2 to 16 years with a mean of 9.8 ± 4.5 years. Eleven (47.8%) were aged 6 years and above, 9 (39.1%) were aged 5-10 years. Majority of the patients 21 (91.3%) among the post-neonatal group and all the patients in the neonatal group were from the rural area. Twenty-one (91.3%) of all post-neonatal patients were either not immunized at all or were not sure of their immunization status during infancy. Lower limb injury was the most common source of infection accounting for 56.5% of cases in the post-neonatal group while infected cord accounted for 66.6% of cases in the neonatal group. Thirteen (56.5%) of all the post-neonatal cases were discharged home, nine (39.1%) died while one was discharged against medical advice. Mortality was very high at 100% in the neonatal group. There was no statistical association between portal of entry and outcome. Conclusion: Tetanus remains a significant contributor to childhood morbidity and mortality in Nigeria. There is strong need to strengthen the present immunization coverage especially in the rural communities of our country.
Keywords: Neonatal, post-neonatal, tetanus
|How to cite this article:|
Chukwuka JO, Ezeudu CE, Nnamani KO. Neonatal and post-neonatal tetanus in Nnamdi Azikiwe University Teaching Hospital, Nnewi, South-East, Nigeria: A 10-year review. Trop J Med Res 2015;18:30-3
|How to cite this URL:|
Chukwuka JO, Ezeudu CE, Nnamani KO. Neonatal and post-neonatal tetanus in Nnamdi Azikiwe University Teaching Hospital, Nnewi, South-East, Nigeria: A 10-year review. Trop J Med Res [serial online] 2015 [cited 2019 Jan 23];18:30-3. Available from: http://www.tjmrjournal.org/text.asp?2015/18/1/30/152552
| Introduction|| |
Tetanus is a vaccine-preventable disease continues to be a public health problem worldwide, but more importantly in the developing countries. Although there is wide spread availability of effective vaccine against it following the introduction of Expanded programme on immunization (EPI) by WHO about 40 years ago in Nigeria, and subsequent conversion to National programme on immunization (NPI), in 1996, this ancient disease remains a major cause of neonatal and post-neonatal morbidity and mortality in Nigeria and other developing countries of the world.
Annually tetanus causes 309,000 deaths and an estimated one million cases occur especially in the developing countries.  It is no longer debatable that tetanus can be markedly decrease and prevented through effective immunization programme, whereas mortality rate is as high as 28 per 100,000 population in developing countries where immunization coverage is very low; in the North America it is as low as 0.1 per 100,000 because of wide spread immunization coverage. 
In the western and northern parts of Nigeria, reasonable data is available on the trends, prevalence and burden of both neonatal and post-neonatal tetanus. However, review of literature revealed very scanty data on this subject in the South-eastern Nigeria. It is therefore necessary to review the trends and morbidity as well as mortality burden of this old disease that continues to kill children in our locality.
A 10 year review of all the cases of neonatal and post-neonatal tetanus admitted at the Nnamdi Azikiwe University Teaching Hospital, Nnewi, and South-eastern Nigeria was carried out with a view of highlighting the current situation, sociodemographic and clinical characteristics as well as modes of contact of the infection and possibly recommend solution on how to stop this scourge.
| Materials and Methods|| |
This study is a retrospective hospital-based study carried out at Department of Pediatrics Nnamdi Azikiwe University Teaching Hospital Nnewi, South-east Nigeria. Nnewi is a commercial city located in Nnewi North Local Government Area of Anambra state, south-East, Nigeria. Its population based on 2006 census estimate is 391,227. The people are predominantly Igbo-speaking and mainly traders and civil servants. Nnewi is located on latitude 6 0 01'N and longitude 6 0 55'E. Nnamdi Azikiwe University Teaching Hospital is a tertiary institution in the State and enjoys huge patronage and referrals of patients from all over Anambra State and neighboring states such as Abia and Imo states.
Medical records of all neonatal and post-neonatal patients admitted with tetanus as final diagnosis between December 2003 and January 2012 were retrieved and analyzed. Data obtained from the patients folder includes: Age, sex, date of admission, place of domicile, duration of hospitalization before discharge or death, immunization status, possible portal of entry as well as possible outcome.
Data were analyzed using SPSS version 16, Chicago, Illinois. A P < 0.05 was considered statistically significant.
| Results|| |
A total of 33 patients were selected for the study but only 26 qualified for analysis. Seven were excluded on the basis incomplete information from the folder. These 26 patients represent 0.07% of 33,306 pediatric admissions during the period under review. Three out of the 26 were from the neonatal group, while remaining 23 are from the post-neonatal group. All the patients in the neonatal group are males with age ranging from 2 to 10 days and a mean of 5.66 ± 4.04 days. Fourteen (60.9%) of the post-neonatal group are males while nine (39.1%) are females. Their age ranged from 2 to 16 years with a mean of 9.8 ± 4.5 years. Eleven (47.8%) are aged 6 years and above, 9 (39.1%) are aged 5-10 years. The remaining are less than 5 years.
Majority of the patients, 21 (91.3%), are from the rural area among the post-natal group while the remaining 2 (8.7%) are from the urban area, all the patients in the neonatal group are from the rural. [Table 1] displays the characteristics of the subjects. The number of days on admission ranged from 1 to 45 days with a median of 13 days. Two (8.7%) of the patients in the post-neonatal group claimed to have completed immunization during infancy, 21 (91.3%) are either not immunized at all or are not sure of their immunization status during infancy. In the neonatal group, one of the mothers of the patients claimed to have received two doses of tetanus toxoid.
|Table 1: Demographic and clinical characteristics of children with neonatal and post-neonatal tetanus |
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Lower limb injury was the most common source of infection accounting for 56.5% of cases in the post-neonatal group, upper limb injury and otitis media accounted for 21.7% and 4.3%, respectively. Infected cord accounted for 66.6% of cases in the neonatal group. Thirteen (56.5%) of all the post-neonatal cases were discharged home, nine (39.1%) died while one was discharged against medical advice. Mortality was very high at 100% in the neonatal group. There was no significant statistical relationship between the portal of entry and mortality (P=0.841, [Table 2]).
|Table 2: Comparison of portal of entry with outcome in the post-neonatal group |
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| Discussion|| |
This study revealed that there are 26 cases of neonatal and post-neonatal tetanus during the 10 year period from January 2003 to December 2012. Although this is quite low compared to a similar study in Enugu  the same south-Eastern Nigeria over a 10 year period (1998-2008) and that of Alahaji et al.  in Maidugari north-eastern Nigeria yet, this is not acceptable as tetanus is a vaccine-preventable disease whose vaccine is readily and easily available.
It must also be emphasized that the retrospective nature of this study may have impacted fairly negatively on the number of cases noted during this period as poor record keeping is quite prevalent in our environment. Also, 26 cases of neonatal and post-neonatal tetanus reported in this study are comparable to 30 cases of neonatal and post-neonatal tetanus reported by Oyedeji et al.  in Osogho South-Western Nigeria over a 3 year period between 2006 and 2008. More so, the finding of just three cases of neonatal tetanus in the study could suggest a downward decline which agrees with other studies. 
The finding of majority of patient with post-neonatal tetanus being males 14 (60.9%) compared to the females that are just 9 (39.1%) is not surprising. This finding is consistent with reports from other authors. ,, This trend is not far from the expected, younger male children are likely to be more daring and involved in other risky behaviors that makes them easily vulnerable to clostridium tetani that causes tetanus.
Since most of these children, 21 (91.3%), are from the rural area, possibilities are that they are likely to be walking bare footed another factor that also expose them to injuries, lack of awareness, lower educational levels, lack of access and poor health facility could also explain the reason for more rural dwellers to have tetanus. In our setting health facilities in the rural areas are usually poorly equipped and sometimes access road is not available reducing the chances of these rural dwellers from getting immunization.
The average age of onset of tetanus in the post-neonatal group was 9.82 years which is similar to the report by Emodi et al.  The possible explanation is the declining levels of tetanus antibodies among this age group. This is further buttressed by the fact that most (87%) of the subjects in this study are aged 5 years and above. Aboud et al.  in Tanzania reported low levels of protective neutralizing antibodies to tetanus among children aged 6-15 years after routine immunization in infancy. Although it is not a routine practice in our setting/country, these children would have been eligible for booster doses of tetanus toxoid as is obtained in other countries like the United States. In the present study only two (8.7%) of our patient claimed to have completed their routine immunization during infancy, the remaining either did not receive any immunization or are not sure of their immunization status among the post-neonatal group. One of the three mothers in the neonatal group also claimed to have received two doses of TT. These reaffirm the fact that immunization remains a major weapon against childhood tetanus.  As in our finding several other studies have also documented low levels of immunization among children with tetanus. ,, Thus, this further strengthens the need to improve and enhance immunization coverage in our country.
Among the major identified portals of entry, namely lower limb injury, upper limb injury and otitis media, majority of the patients, 13 (56.5%), had lower limb injury as a portal of entry. Studies in the past have documented similar findings. ,,, Even though Joshi et al.  had reported that upper limb injury was the most common portal of entry in a study among adults with tetanus, the reason for this is understandable, most of the children in the study group are from the rural area where occupation is mostly farming and they are likely to follow their parents to the farm where injury to the lower limb is very common. Additionally, the children in this age group who are also from the rural area (that constitute majority of our subjects) are likely to be walking bare footed, thus exposing themselves to unnecessary lower limb injury.
Mortality rate in this study is high at 9 (39.1%) among the post-neonatal group and 100% in the neonatal group. This underscores the fact that tetanus remains a public health problem. Finding in this study is similar to that reported by Oyelami et al.  and other studies elsewhere. 
There was no statistical relationship observed between mortality and portal of entry (P = 0.841). This was documented by Yadav et al.  in a study of site and nature of injury in the prognosis of tetanus. The implication is that mortality and prognosis of tetanus are independent of portal of entry, thus implying that every case of tetanus must be managed aggressively irrespective of portal of entry.
| Conclusion|| |
Tetanus remains a major public health problem and a significant contributor to childhood morbidity and mortality in Nigeria. There is a strong need to strengthen present immunization coverage especially in our rural communities where majority of cases of tetanus comes from. Also, it will be worthwhile to introduce a booster dose of tetanus toxoid after age of 5 years in our current routine immunization schedule.
| Acknowledgments|| |
Authors are grateful to the staff of medical records department for the help in record identification and retrieval.
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[Table 1], [Table 2]