Anthony Bugembe
4 January 2009
Kampala — AFTER years of waiting, Jane was blessed with a healthy baby boy.
Three days after delivery, the baby could not breastfeed. It became stiff and after a week, the baby died.
The baby, according to health experts, was suffering from neonatal tetanus (NNT). The disease occurs in newborn infants who lack protective passive immunity because the mother is not immunised against tetanus.
Usually, the antibodies provided by the vaccine given to the mother protect the newborn baby for the first two months before it is immunised.
"The deadly infection is noticed between three to 28 days after birth. There is normal sucking and crying for the first two days, followed by inability to suck.
Later, stiffness, coupled with severe muscle contractions and convulsions set in," says Dr. Prossy Mugyenyi, the programme manager of the Uganda National Expanded Programme on Immunisation (UNEPI).
Mugyenyi says neonatal tetanus is transmitted through contaminated instruments like razor blades or knives when cutting the baby's umbilical cord.
"Some people use dry reeds to cut the cord. Using dirty hands or linen during child birth also creates a risk of contracting the disease.
"Some mothers apply ash, cowdung, lizard droppings and soot on the umbilical cord so that it heals quickly. But even without these, it can heal," Mugyenyi adds.
The disease kills about 450,000 newborns a year globally. Almost all these deaths are in less developed countries. Uganda had 102 reported cases in 2007.
The World Health Organisation (WHO) estimates that only 5% of neonatal tetanus cases are reported, even from well-developed surveillance systems.
This underreporting, according to UNEPI, has led to the disease being referred to as the silent killer.
"In Uganda, cases of neonatal tetanus are recorded in all districts. Districts that report more than one case per 1,000 live births are considered high risk," says Tabley Bakyaita UNEPI's senior health educator.
Uganda aimed at eliminating NNT by 2005. This would involve vaccinating at least 80% of all women of child-bearing age (13-49 years) in high-risk districts with at least three rounds of Tetanus Toxoid (TT) vaccine.
However, the target failed and health officials are optimistic that it will be achieved in the near future.
According to the 2008 State of Uganda's Population Report, 51% of women receive two or more doses of TT during their last pregnancy. This leaves a sizeable number at risk of contracting maternal tetanus. It also exposes their newborn babies to neonatal tetanus.
"The campaign is focusing on girls and women because we do not have enough money to immunise everyone," says Mugyenyi, adding that the health ministry aims at reducing the incidence of the disease to less than one case per 1,000 live births in every district.
Vaccination against tetanus using TT involves five doses: TT1, TT2 (at least a month later), TT3 (six months later) TT4 (a year after) and TT5 (at least a year after TT4).
A single dose of TT costs sh99. One requires five doses to be fully-protected against the disease for 30 years. Under the national maternal neonatal tetanus elimination campaign, the health ministry selected high-risk districts: districts where the reported neonatal incidence rate was greater than one case per 1,000 live births.
The campaign has so far been implemented in four phases. The first one in 2002/2003 covered Bugiri, Iganga, Jinja, Kamuli and Mayuge districts. Phase Two was in Arua, Nebbi, Yumbe, Kayunga, Luweero and Tororo in 2004/2005, while the third covered Masaka, Ssembabule, Kiboga, Kamwenge, Kasese, Bundibugyo, Pallisa, Kapchorwa and Hoima in 2005/2006.
Under the fourth phase (2008/2009), women in Busia, Nakapiripirit, Mityana, Mubende and Kibaale have been immunised. In April 2009, UNEPI will provide the third dose to girls and women in the five districts.
"In February, we shall revisit Masaka and Kiboga because the vaccination coverage there was below the recommended 80%," says Mugyenyi.
She adds: "The disease is fatal. Without treatment, almost all affected patients will die. Even with specialised treatment, the death rate may be as high as 50%.
Since we started the immunisation campaigns, the numbers of NNT cases reported have reduced from 667 in 2002 to 102 in 2007, an 84.7% reduction.
"We encourage pregnant women to give birth in health facilities with skilled personnel. We also discourage traditions and customs like applying cowdung, lizard droppings, soot or herbs on umbilical cords of babies because they increase the risks," Mugyenyi said.
According to the 2008 State of Uganda Population Report, 42% of pregnant women give birth with the assistance of a skilled birth attendant. The others give birth at home in unclean environments.
Treatment
According to the Centre for Disease Control and Prevention, tetanus is a medical emergency requiring hospitalisation, immediate treatment with tetanus immune globulin, a tetanus toxoid booster, agents to control muscle spasm, and, if indicated, aggressive wound care and antibiotics.
Facts about Tetanus
Tetanus is a bacterial disease commonly called lockjaw. It affects muscles causing intermittent spasms or twitches. The bacteria are found primarily in soils and intestinal tracts of animals and humans.
It also grows in decaying matter, manure, dust, animal fecal material and rusty tools.
Tetanus affects men and women of all age-groups, but is mainly common in newborn babies (neonatal tetanus). Most infants who get it die.
The disease is common in rural areas where most deliveries are at home without adequate sterile procedures.
To prevent maternal and neonatal tetanus, tetanus toxoid should be given to the mother before or during pregnancy. Health workers and attendants should also ensure clean delivery and cord care.
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