The New Times (Kigali)

31 March 2014

Rwanda: Tetanus - That 'tiny' Wound Could Be the Death of You

When a hoe scrapes your big toe while busy gardening, the immediate concern would be if it is bleeding or not. As long as it does not hurt too bad to stop you from hoeing on, then work continues. Anything to tincture the bleeding such as herbs may be applied to the wound as a temporary remedy. Many a person will just slap soil on the wound to continue gardening and it would be just fine.

The wound requires dressing but there is no time for that and besides, it takes quite a lot to reach the hospital. The rust on the hoe was poisonous and later will appear that moment to pay for your negligence.

It all looks innocent; nothing wrong with a tiny wound that does not even hurt. But hey, do not tell this to Mr Death, for it lurks most where we are least expecting it. From the rust on the hoe and the dirty soil, poisonous bacteria will infect you via the wound, giving Mr Death the chance to send you tetanus and what you thought was a tiny wound could be the beginning of your end.

Across the border, Mubiru Kakebe, a photojournalist with a Ugandan daily newspaper, was on a boat cruise when he clicked his shutter release, capturing what he thought was a random picture. But a subject on the boat cruise demanded he deletes the picture. A minor scuffle ensued and a broken bottle was flung here and there. Mubiru bled a little. Nothing looked ordinary at all. Life continued, but all went from innocent to danger when he collapsed in office, was rushed to the hospital and admitted to intensive care unit.

Within just a week of a seemingly minor cut, relatives were bidding their farewell to Mubiru, who had succumbed to tetanus infection. In health matters, nothing is ever a given; even an harmless-looking wound could lead to fatal complications.

Tetanus, a bacterial disease commonly referred to as lockjaw in its advanced stages of infection, is an acute and serious infection of the central nervous system caused by bacterial infection of open wounds.

How it is caused:

The infection is caused by bacteria called clostridium tetani. Tetanus bacteria are everywhere in the environment, including soil, dust and manure.

"You can get tetanus infection when the spores enter your body through an injury or wound. The spores release bacteria that spread in the body and make a poison called tetanospasmin," says Dr Alphonse Umugire, a clinical director at Kibagabaga Hospital.

"This poison blocks nerve signals from your spinal cord to your muscles, causing severe muscle spasms. The spasms can be so powerful that they tear the muscles or cause fractures of the spine."

The disease, which can be prevented by administration of tetanus toxoid that induces specific antitoxins, is characterised by muscle spasms, initially in the jaw muscles.

As the disease progresses, mild stimuli may trigger generalised tetanic seizure-like activity, which contributes to serious complications and eventually death unless supportive treatment is given.

The World Health Organisation estimates that mortality rates vary from 48 per cent to 73 per cent worldwide. The most susceptible individuals are those who are unvaccinated, those over 60 years of age or newborns.

Although Healthy Times could not readily get the figures at the national level, officials say efforts are mainly made at fighting maternal and neonatal tetanus. Unicef says maternal and neonatal tetanus represents a very high proportion of the total tetanus disease burden due mainly to inadequate immunisation services, limited or absent clean delivery services and improper post-partum cord care.

The majority of mothers and newborns dying of tetanus live in Africa and Southern and East Asia, generally in areas where women are poor, have little access to health care, and have little information about safe delivery practices.

Once the disease is contracted, the fatality rate can be as high as 100 per cent without hospital care and between 10 per cent to 60 per cent with hospital care.

The true extent of the tetanus death toll is not known as many newborns and mothers die at home and neither the birth nor the death is reported.

Prevent or watch symptoms:

Dr Rachna Pande, a specialist in internal medicine at Ruhengeri Hospital, says in this era of antibiotics, tetanus is entirely treatable; the only thing needed is early initiation of treatment.

"The earliest sign of a typical tetanus infection is difficulty in opening the mouth, what is known as lock jaw. This may progress to stiffness of the limbs and convulsions. Left untreated a person can die of respiratory failure due to paralysis of respiratory muscles," Dr Pande says.

The biggest lapse in mindset is that once vaccinated as a child, one cannot be infected with tetanus in adult life. It is a wrong perception, says Dr Pande. One infected in childhood and even vaccinated as a child can develop infection as an adult if microbes gain entry in the body.

"This happens because one time vaccination does not provide life-long immunity as in case of viral infections," Dr Pande says.

"Prevention consists of immediate cleaning of a wound with antiseptic solution and injection of anti-tetanus toxoid after inflicted with a soiled wound which carries risk of developing tetanus. High risk groups are given booster doses of tetanus toxoid to prevent infection."

Dr Umugire says tetanus often begins with mild spasms in the jaw muscles-also known as lockjaw or trismus. The spasms can also affect the chest, neck, back, abdominal muscles, and buttocks. Back muscle spasms often cause arching, called opisthotonos.

Sometimes the spasms affect muscles that help with breathing, which can lead to breathing problems. Prolonged muscular action causes sudden, powerful, and painful contractions of muscle groups, which is called 'tetany'.

These episodes can cause fractures and muscle tears. Other symptoms include drooling, excessive sweating, fever, hand or foot spasms, irritability, swallowing difficulty, and uncontrolled urination or defecation. It can also cause destruction of elements of the nervous system through viral cell exchange.

"The incubation period of tetanus may be up to several months, but is usually about eight days," says Dr Umugire.

In general, the further the injury site is from the central nervous system, the longer the incubation period. The shorter the incubation period, the more severe the symptoms. In neonatal tetanus, symptoms usually appear from four to 14 days after birth, averaging about seven days.

Diagnosis and treatment:

In situations of injury, it is possible to take measures that guarantee your safety. It is important to provide information about how you got the injury and how you have been caring for it. The doctor will also be interested in understanding your immunisation status, whether you have any chronic illnesses or medical conditions such as diabetes, pregnancy or heart disease.

Diagnosis of the disease is usually physical basing on medical history, signs and symptoms of painful muscles, spasms and stiffness. The diagnosis is based on the presentation of tetanus symptoms and does not depend upon isolation of the bacterium, which is recovered from the wound in only 30 per cent of cases and can be isolated from patients without tetanus.

The other common misconception is that lightning does not strike the same place twice. But unlike many infectious diseases, recovery from naturally acquired tetanus does not usually result in immunity to tetanus. This is due to the extreme potency of the tetanospasmin toxin. Even a lethal dose of tetanospasmin is insufficient to provoke an immune response.

It is recommended that adults receive a booster vaccine every 10 years, and standard care practice in many places is to give the booster to any patient with a puncture wound who is uncertain of when they were last vaccinated.

The booster may not prevent a potentially fatal case of tetanus from the current wound, however, as it can take up to two weeks for tetanus antibodies to form. In children under the age of seven, the tetanus vaccine is often administered as a combined vaccine, DPT/DtaP vaccine, which also includes vaccines against diphteria and pertussis.

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CARE FOR WOUNDS:

For first aid. If wound is bleeding, direct pressure should be applied to control the bleeding. After bleeding has stopped, the wound should be kept clean with saline water. A disinfectant such as surgical spirit may be applied to the wound and then it should be covered to avoid contamination from the air.

During pregnancy. A woman is administered with a combination of inactive tetanus diphtheria and pertusis (whooping cough) either prior to conception or in the postpartum (after birth) period. This is to aid in protection against maternal and neonatal tetanus.

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