Dr Jos Vandelaer, World Health Organisation, Geneva, Switzerland, say: "Although easily prevented by maternal immunisation with tetanus toxoid vaccine, and aseptic obstetric and postnatal umbilical-cord care practices, maternal and neonatal tetanus persist as public-health problems in 48 countries, mainly in Asia and Africa."
Tetanus is caused by a neurotoxin produced by Clostridium tetani, spores of which occur worldwide in soil and in the gastrointestinal tracts of animals, including humans. The condition is characterised by muscle rigidity and painful muscle spasms caused by tetanus toxin's blockade of inhibitory neurons that normally oppose and modulate the action of excitatory motor neurons. Tetanus muscle rigidity usually begins in the masseter muscles, resulting in trismus (lockjaw). About 90% of newborn babies with tetanus develop symptoms within the first 3-14 days of life. As disease severity increases, muscle rigidity extends and spasms begin. In severe tetanus, sudden generalised contractions of all muscle groups can occur, while consciousness is preserved, making the disease "truly dreadful."
The advent of mechanical ventilation in the 1960s and 70s, plus the development of benzodiazepines, means that mortality rates of 20% or less are increasingly common for tetanus patients who have access to a modern intensive care ward. However, even in limited resources, basic medication, experienced medical supervision and high-quality nursing can bring the mortality rate down below 50%. The Seminar discusses the immunology of tetanus and the benefits/ methods of vaccination against it, and also the maternal and neonatal tetanus elimination initiative, which since its inception in 1990 has made great progress towards eliminating the disease.
With available and pledged funding, the authors believe that elimination of maternal and neonatal tetanus can be expected in all but 11 countries* by 2009. However sustaining elimination could be problematic, with improvements in the number of deliveries attended by trained personnel, improvements in antenatal care practices, and routine vaccination of women of childbearing age all required.
The authors conclude: "The rejuvenated worldwide commitment to improvement of maternal and child health, and special attention to the importance of neonatal survival, catalysed by the child and maternal mortality Millennium Development Goals, is heartening.
"Since tetanus spores cannot be removed from the environment, sustaining elimination will require improvements to presently inadequate immunisation and health-service infrastructures, and universal access to those services."
Tony Kirby | alfa
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