Tetanus-Review of literature and clinical experience with 33 Adult cases in Muhimbili medical center from 1st December 1982 to July 1983

A study of 33 cases of tetanus in adults was carried out at the Muhimbili Medical Centre, Dar es Salaam from 1st December 1982 to 31st July 1983. There were 14 severe, 14 moderate and 5 mild cases. The clinical experience at MMC is illustrated. The age distribution, clinical presentation and nature of portal of entry are preGented. In this analysis it was observed that the male to fenBle ratio was 2.7 : 1 and the majority of the patients were between 10 and 30 years with a peak prevalence rate at 20 - 30 years. Y The presenting symptoms and signs varied. The common presenting features were: Trismus,lOO percent; Painful stiff neck,90.0 percent; 3, Rigid abdamen,84.8 percent; Spasms,60.6 percent; Opisthotonus}48.9 percent; Generalized body stiffness) 36.4 precent and Fever, 33.3 percent. This correlates with the literature with trismus being present in most of patients. The criteria of severe is also outlined and the information strongly showed that the prognosis depended on the incubation period, the time of onset, the degree of fever and the severity of the spams. The prognosis was poor if the incubation period was 1E:9s than seven days, the time of onset was les6 than 48 hours, the body temperature was high (more than 390C) and the spasms were severe. The following parameters were monitored: Cardiovascular (bl'Jod pressure; pulse rate); respiratory rate, temperature, blood gases (7 patients) acid-base balance (7 patients) I fluid and electrolyte balance. (iii) Tbe form of therapy described, i.e. the conservative treatment, is the best currently-available management regime in developing countries. The regime of curarization and IPPV is definately expensive and time consuming. Thus, the problems involved in the introduction of expensive method of management in developing countries are highlighted. The encountered complications and possible causes of death comprised mainly those leading to respiratory embarassment, i.e. uncontrolled spasms, 20.3 percent; respiratory insufficiency, 7.2 percent; respiratory infection, 7.2 percent and excessive secretions 5.6 percent. Others were pyrexia, 20.3 percent; tachycardia, 14.5 percent and cardiac arrests, 5.6 percent. The respirator'! complications were the most common cause of death. Some encountered therapeutic and technical problems are also outlined. Analysis of mortality revealed an overall rate of 57.6 percent. The highest mortalit~ (63.6%) was observed in the age group 10 - 20 years. Deaths attributable to uncontrolled spasms occured in 73.7 percent and to respirator! infection in 10.5 percent. Associated factors contributing to deaths included hyperpyrexia, starvation (in one patient) and technical problems (shortage of electrical power and no suction pump) In the campaign against tetanus, prophylactic measures definately represent more effective as well as more economic measures than the treatment of manifest tetanus. Eventhough, the disease is still prevalent in most developing cotmtries. This prevalence can only be minimized by active immunization prophylaxis help a combined prophylaxis (1v) with diphtheria and tetanus toxoid eiven to all children in early life. It is simple, inexpensive, effective and readily available. On the contrary such a prophylactic measure taken on a topoeraphical or occupational basis has been found to raise greater administrative problems. Lastly some conclusions and few recommendations are made. The study has shown that the survival of severe tetanus is very low (all ~~tients in this group succumbing to death); the prognosis is best \ determined by incubation period, onset period, fever and severity of spasms; for proper management of the disease constant vigilance and sldlled nursing care are necessary; severe symptoms appear unexpectedly; Diazepam constitutes the i8ystone of the sedation regime; complications and cause of death are more often related to therapeutic and technical problems. There is great need to improve our standards of vaccination; make tetanus a notifiable disease; improve drug availability, instrument and records situation it ~~!C; the management of tetanus should be shared between physician, anaesthesiologist and surgeon; all tetanus survivals plus the injure~ to get a card showing that they have been immunized. With no doubt, there is indication for an epidemiological study of tetanus in 'Tanzania