Elsevier

The Lancet

Volume 370, Issue 9603, 8–14 December 2007, Pages 1947-1959
The Lancet

Seminar
Maternal and neonatal tetanus

https://doi.org/10.1016/S0140-6736(07)61261-6Get rights and content

Summary

Maternal and neonatal tetanus are important causes of maternal and neonatal mortality, claiming about 180 000 lives worldwide every year, almost exclusively in developing countries. 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. Survival of tetanus patients has improved substantially for those treated in hospitals with modern intensive-care facilities; however, such facilities are often unavailable where the tetanus burden is highest. The Maternal and Neonatal Tetanus Elimination Initiative assists countries in which maternal and neonatal tetanus has not been eliminated to provide immunisation with tetanus toxoid to women of childbearing age. The ultimate goal of this initiative is the worldwide elimination of maternal and neonatal tetanus. 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. The renewed worldwide commitment to the reduction of maternal and child mortality, if translated into effective action, could help to provide the systemic changes needed for long-term elimination of maternal and neonatal tetanus.

Section snippets

Microbiology and pathophysiology

Tetanus is caused by a neurotoxin produced by Clostridium tetani, a gram-positive, obligate anaerobic rod-shaped bacterium that forms spores. C tetani spores occur worldwide as constituents of soil and in the gastrointestinal tracts of animals (including human beings), and can contaminate many surfaces and substances. The spores are extremely hardy; destruction requires autoclaving or prolonged exposure to iodine, hydrogen peroxide, formalin or gluteraldehyde.21, 22 Infection begins when

Clinical manifestations

Tetanus 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. Maternal and neonatal tetanus are both forms of generalised tetanus (the most common manifestation of the disease), and have similar courses. The time from inoculation of tetanus spores into damaged tissue to the appearance of the first symptom, or incubation period, is usually 3–21 days36, 37

Treatment

The mortality and morbidity of tetanus patients admitted to hospital decreased substantially in the 1960s and 1970s, with the advent of mechanical ventilation and the introduction of benzodiazepines, with their high efficacy and wide therapeutic index. Mortality rates of less than 20% are increasingly common for both neonatal and non-neonatal tetanus if patients have the benefits of care in a modern intensive-care unit.38, 39, 47, 49, 62, 72 Even in settings with limited resources, if basic

Immunology

Although some researchers have suggested that natural immunity against tetanus toxin can be induced by gut carriage of C tetani,83, 84, 85 the serological and epidemiological evidence in support of this hypothesis is unconvincing.22, 74 The only reliable immunity against tetanus is that induced by vaccination with tetanus toxoid. Tetanus toxoid vaccine is one of the most effective, safe, stable, and inexpensive vaccines ever developed, and can be given safely during pregnancy and to

Distribution and risk

Maternal and neonatal tetanus cases are clustered in poor, remote, and disenfranchised communities where unhygienic obstetric and postnatal practices prevail, and access to maternal tetanus toxoid immunisation is poor. Differences in neonatal tetanus incidence and mortality of at least an order of magnitude have been identified between regions and countries, and between urban and rural areas within countries.1, 2, 41, 113 In industrialised countries, neonatal tetanus ceased to be a substantial

Prevention

Maternal and neonatal tetanus prevention relies on avoidance of unsafe delivery, abortion, and umbilical cord care practices, and promotion of maternal tetanus immunisation. The powerful effect that puerperal and umbilical stump hygiene have on prevention of neonatal tetanus is evident from the history of developed countries before the availability of tetanus toxoid. In the first half of the 20th century, neonatal tetanus in Denmark and the USA steadily decreased to 0·05 and 0·02 cases per 1000

Control: the Maternal and Neonatal Tetanus Elimination Initiative

Tetanus toxoid vaccination of pregnant women to prevent neonatal tetanus was included in WHO's Expanded Program on Immunization a few years after its inception in 1974. By contrast with the notable gains in child immunisation achieved in the 1980s, only 27% of pregnant women were receiving at least two doses of tetanus toxoid by 1989 (figure 1).155 In recognition of the substantial burden of neonatal tetanus in developing countries, the 1989 World Health Assembly (WHA) adopted a resolution to

Sustaining elimination

Sustaining elimination of maternal and neonatal tetanus will be a challenge, especially in places where the high-risk approach is needed. Worldwide, 62% of deliveries are attended by trained personnel, with skilled attendant coverage of only 32% in the least developed countries. Antenatal care attendance (at least one visit) is far below 50% in many countries in which neonatal tetanus has yet to be eliminated.165 Routine immunisation with tetanus toxoid has been stagnant over the past decade,

Search strategy and selection criteria

We searched PubMed without date or language restrictions for the terms: “tetanus”, “Clostridium tetani”, “tetanus toxin”, and “tetanus toxoid”, alone and in combination with relevant secondary terms (“physiopathology”, “therapy”, “diagnosis”, “complications”, “mortality”, “immunology”, “neonatal” “maternal”, “epidemiology”, and “prevention and control”). Additional references were identified from citations in articles retrieved in the initial search. We searched the Cochrane database for

References (173)

  • JH Kerr et al.

    Involvement of the sympathetic nervous system in tetanus. Studies on 82 cases

    Lancet

    (1968)
  • M Seydi et al.

    Current aspects of pediatric and adult tetanus in Dakar

    Med Mal Infect

    (2005)
  • N Saltoglu et al.

    Prognostic factors affecting deaths from adult tetanus

    Clin Microbiol Infect

    (2004)
  • SY Maselle et al.

    Neonatal tetanus despite protective serum antitoxin concentration

    FEMS Microbiol Immunol

    (1991)
  • FM Abrahamian et al.

    Fatal tetanus in a drug abuser with “protective” antitetanus antibodies

    J Emerg Med

    (2000)
  • FD Dastur et al.

    Response to single dose of tetanus vaccine in subjects with naturally acquired tetanus antitoxin

    Lancet

    (1981)
  • O Simonsen et al.

    Evaluation of vaccination requirements to secure continuous antitoxin immunity to tetanus

    Vaccine

    (1987)
  • HE de Melker et al.

    A population-based study on tetanus antitoxin levels in The Netherlands

    Vaccine

    (1999)
  • E Relyveld et al.

    Antibody response of pregnant women to two different absorbed tetanus toxoids

    Vaccine

    (1991)
  • JP Stanfield et al.

    Single-dose antenatal tetanus immunisation

    Lancet

    (1973)
  • JP Stanfield et al.

    Neonatal tetanus in the world today

    Bull World Health Organ

    (1984)
  • A Galazka et al.

    Tetanus

  • Expanded programme on immunization. The global elimination of neonatal tetanus: progress to date

    Wkly Epidemiol Rec

    (1993)
  • WHA 42.32 Expanded Programme on Immunization

    World Health Assembly Resolutions and Decisions

    (1989)
  • Maternal and neonatal tetanus elimination by 2005

    Strategies for achieving and maintaining elimination. WHO/V&B/02.09

    (2000)
  • Expanded programme on immunization. Progress towards the global elimination of neonatal tetanus, 1989–1993

    Wkly Epidemiol Rec

    (1995)
  • Expanded programme on immunization. Global advisory group part II

    Wkly Epidemiol Rec

    (1994)
  • Expanded programme on immunization. The “high risk” approach: the WHO-recommended strategy to accelerate elimination of neonatal tetanus

    Wkly Epidemiol Rec

    (1996)
  • Expanded programme on immunization. Progress towards the global elimination of neonatal tetanus, 1990–1998

    Wkly Epidemiol Rec

    (1999)
  • State of the world's vaccines and immunization

    (2003)
  • Validation of neonatal tetanus elimination in Andhra Pradesh, India

    Wkly Epidemiol Rec

    (2004)
  • Tetanus Vaccine: WHO position paper

    Wkly Epidemiol Rec

    (2006)
  • FB Pascual et al.

    Tetanus surveillance—United States, 1998–2000

    MMWR Surveill Summ

    (2003)
  • AA Rushdy et al.

    Tetanus in England and Wales, 1984–2000

    Epidemiol Infect

    (2003)
  • The World health report 2003: Shaping the future

  • AD Lopez et al.

    Global Burden of Disease and Risk Factors. Table 3B.9

    (2006)
  • Immunization surveillance, assessment and monitoring. Maternal and neonatal tetanus (MNT) elimination

  • SM Feingold

    Tetanus

  • SGF Wassilak et al.

    Tetanus Toxoid

  • DM Gill

    Bacterial toxins: a table of lethal amounts

    Microbiol Rev

    (1982)
  • G Schiavo et al.

    Neurotoxins affecting neuroexocytosis

    Physiol Rev

    (2000)
  • WJ Laird et al.

    Plasmid-associated toxigenicity in Clostridium tetani

    J Infect Dis

    (1980)
  • JC Marvaud et al.

    TetR is a positive regulator of the tetanus toxin gene in Clostridium tetani and is homologous to botR

    Infect Immun

    (1998)
  • G Schiavo et al.

    Tetanus and botulinum-B neurotoxins block neurotransmitter release by proteolytic cleavage of synaptobrevin

    Nature

    (1992)
  • R Pellizzari et al.

    Tetanus and botulinum neurotoxins: mechanism of action and therapeutic uses

    Philos Trans R Soc Lond B Biol Sci

    (1999)
  • JJ Farrar et al.

    Tetanus

    J Neurol Neurosurg Psychiatry

    (2000)
  • TP Bleck et al.

    Tetanus

  • J Herreros et al.

    Lipid microdomains are involved in neurospecific binding and internalisation of clostridial neurotoxins

    Int J Med Microbiol

    (2002)
  • G Lalli et al.

    Analysis of retrograde transport in motor neurons reveals common endocytic carriers for tetanus toxin and neurotrophin receptor p75NTR

    J Cell Biol

    (2002)
  • L Weinstein

    Tetanus

    N Engl J Med

    (1973)
  • Cited by (0)

    View full text