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Indian Journal of Community Medicine

Epidemiological Study of Tetanus Cases Admitted to a Referral Hospital in Solapur

Author(s): A.B. Pawar, A.P. Kumavat, R.K. Bansal

Vol. 29, No. 3 (2004-07 - 2004-09)

Abstract

Objectives: To study the epidemiology of tetanus.

Study design: Prospective cum retrospective epidemiological study.

Design Settings: Dr. V.M. Medical college, Solapur.

Participants: All the 76 tetanus cases admitted to Civil hospital, Solapur.

Statistical Analysis: Percentages, chi-square test.

Results: The factors associated with an increased risk of the disease include paediatric age group, rural habitat, low socioeconomic class, agriculture, illiteracy, mud and cow dung smeared houses, incomplete immunisation or its absence, history of trauma and delay in seeking medical advice. The gradation of severity of the disesase, presence of complications and the presence of convulsions were directly associated with higher mortality.

Conclusion: The findings are in line with known epidemiological facts and would be significant in the prevention, management and prognosis of the patients suffering from the disease.

Key Words: Tetanus, Prospective study; Retrospective study; Epidemiology; Solapur

Introduction

Tetanus remains a public health problem in India, though its incidence has decreased subsequent to the Universal Immunization Programme. Cases continue to occur for a plethora of reasons as incomplete immunisation, ignorance, customs and beliefs present in the community as regards injuries and so on. Two important facets of the disease are under-reporting, in particular neonatal tetanus, and a high case fatality even in treated cases. Mortality tends to be very high, varying from 40 to 80 per cent. In neonatal tetanus cases, even with treatment, the case fatality rate can be 80-90 per cent1. Thus this disease accounts for significant preventable deaths.

Material and Methods

This is a prospective and retrospective study of all tetanus cases admitted to the General Hospital, Solapur, which is the teaching hospital of Dr. V.M. Medical College. All cases admitted during a one-year duration from April 1995 to March 1996 were enrolled prospectivity. The prospective cases were interviewed every day from the time of admission until their recovery, death or discharge from the hospital, to elicit information pertaining to the study variables. The medical records analysis was done retrospectivity for cases repored from April 1993 to March 1995. In case any information pertaining to the study variables was unavailable then these cases were traced to retrieve the required information.

Observations and Discussion

Hospital records analysis revealed a steady declining rate of admissions from the disease from a high of 94 cases and 42 deaths in 1983 to a low of 43 cases and 5 deaths in 1993. This is in line with national trends following the launching of Universal Immunisation Programme. The maximum number of cases occur during the dry months of October to January. This could be attributed to abundant dust found in these months, which harbors Clostridium tetani spores.

In the present study a total of 76 cases were studied. More than half of the cases (60.5%) belonged to the pediatric age group. This figure is disturbing as it reflects the incomplete immunisation coverage in children. Almost 70 per cent (49) of cases belonged to the 0 to 20 years age group.

There was a rural preponderance (67.6%). Agricultural labourers and farmers appeared to be at a greater risk of suffering from this disease. The majority of cases were illiterate (80.3%), residing in mud or cow dung smeared houses (54.5%). Almost all of the cases 66 (93%) belonged to the lower socioeconomic class, as per modified B.J. Prasad's classification. These findings are in line with the known epidemiological facts of the disease2.

Only 4.2 percent of the patients suffering from the disease reported of a history of complete immunisation. However, none of them had any documentary proof of complete immunisation. It has been documented worldwide that the pre-ponderance of cases belong to the non-immunised category. Yet, cases do seldom occur in the fully immunised persons.

The types of cases in descending incidence were post-traumatic 46 (60.5%), otogenic 18 (23.7%), neonatal 5 (6.6%), post-operative 1 (1.3%), puerperal 1 (1.3%) and idiopathic 5 (6.6%). The neonatal cases have been clubbed in one category, as it is virtually impossible to establish their type. These findings follow the established epidemiological profile of the disease and points out to the fact that almost all of these cases could have been avoided, had the patients sought proper medical advice.

The distribution of cases according to the first symptom reported by the patients were trismus 58 (81.7%), convulsions 6 (8.5%), fever 5 (7%), dysphagia 1 (1.4%) and difficulty in walking 1 (1.4%). These figures exclude neonatal tetanus case in whom the presenting symptoms were inability to feed. This is similar to the observations made by Weinstein L.3, who had reported that trismus was the presenting symptom and sign in over 50 percent of tetanus cases. The first symptom with which a patient reports to a health facility is of significance, as these should raise the suspicion of this disease in the health care providers.

Complications occurred in 26.3 percent of the cases. The commonest complication encountered was respiratory failure (45%), followed by cardiac arrrest (25%), pulmonary infection (20%), septicaemia (5%) and hyperpyrexia (5%). Harding Goldson4 had also reported of a preponderance of respiratory complications. It was observed that the mortality rate was high in cases with these complications (75%).

The incubation period exhibited an inverse ralationship with mortality, being 75 percent in those with an estimated incubation period of upto 7 days and only 6.3 percent in those with an incubation period greater than 7 days. This difference was statistically significant (Chi Square = 24.40, p<0.001). There have been contradictory findings reported by various workers on this issue. Patel J.C.5 has reported of a similar pattern as observed in this study, whereas according to Cole L.6 longer incubation period does not necessarily signify that the attack would be mild. This is again an important observation for a health care provider.

The difference in the timings of the appearance of the first symptom and the onset of convulsions was highly significant. The mortality rate was 100 percent in those with a difference less than 48 hours and only 20 percent in those with a difference greater than 48 hours. Various workers5 have corroborated this pattern of findings. This is an important prognostic pointer, as lesser the difference, the worse the prognosis.

The gradation of severity had exhibited a direct relationship with mortality. It was 4.3 percent in grade I and II, 7.7 percent in grade III, 62.5 percent in grade IV and 100 percent in grade V. This relationship appears logical and similar findings had been reported by others.

Recommendations

The study points out to the need to accelerate and maintain universal immunisation strategies, particularly in the high risk individuals or subsequent to high risk events; improve environmental and living conditions; ensure universal literacy; assure prompt medical attention of trauma and strengthen health education activities.

Acknowledgements

The authors acknowledge the help of Dr. A.A. Parulkar, Dr. P.G. Gaikwad, Dr. M. Rayate, Dr. M. Zambre, Dr. V. Tapre, Dr. L. Godale, Dr. Mali, Mr. Sangam and other doctors of V.M. Medical College in the study.

References

  1. Park K. Park's textbook of Preventive and Social Medicine. 16th ed., Jabalpur : Banarsidas Bhanot, 2000 : 235.
  2. Patodi R.K. A study of tetanus patients admitted at M.T. and M.Y. hospitals, Indore, M.P. Indian Journal of Preventive & Social Medicine 1974; 5 : 55-58.
  3. Weinstein L. Current concepts : tetanus. New England Journal of Medicine 1973; 289 (24) : 1293-96.
  4. Harding Goldson H.E. Tetanus : a recurring intensive care problem. Journal of Tropical Medicine and Hygiene 1995; 98 (3) : 179-84.
  5. Patel J.C. et al. Tetanus experience with 4718 patients. Indian Journal of Child Health 1960; 9: 459.
  6. Cole L. The treatment of tetanus with observations on the rate of injected antitoxin. Quarterly Journal of Medicine 1935; 4:295.

1 - Deptt. of Community Medicine, Surat Municipal Institute of Medical Education and Research, Umarwada, Surat - 395010, Gujarat

2 - Deptt. of Community Medicine, Dr. V.M. Medical College, Solapur - 413 003, Maharshtra

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