TETANUS / TETANUS

NEONATORUM
 DEFINISI
• Tetanus : penyakit kekakuan otot
(spasme) yang disebabkan oleh
eksotoksin (tetanospasmin) dari
organisme penyebab penyakit tetanus.

• Tetanus neonatorum umumnya terjadi

karena persalinan di luar rumah sakit atau
oleh dukun bayi tradisional
 EPIDEMIOLOGI
• Insidensi tetanus di perkotaan ; 6-7/1000
kelahiran hidup
• Di daerah pedesaan 11-23/1000 kelahiran
hidup
• Jumlah kematian sekitar 60.000 bayi/th
• SKRT 1995, AKB di Indonesia masih
cukup tinggi yaitu 58/1000 kelahiran hidup.
• Merupakan urutan ke-5 penyebab
kematian bayi di Indonesia
• Ismoedijanto  survei di 5 RS (1991-1996) ;
rata-rata 10 – 25 kasus per tahun per RS
dengan angka kematian 7 – 23%

• Tertinggi penderita golongan usia bayi (26%),

balita 15%, usia 5-9 th (19%), dan >10 th 12%.

• Eliminasi TN per-kab/kota adalah < 1/1000 bayi

lahir hidup
• Pada lingkungan yg tdk kondusif, bakteri
 spora (tahan panas, perebusan,
kekeringan dan desinfektan), hidup
bertahun-tahun dan menyebar di mana
saja.

• Habitat utamanya adalah tanah yang

mengandung kotoran ternak, kuda, dan
hewan lainnya
 Tetanus neonatorum
• Important cause of newborn deaths a few
decade back

• Universal tetanus toxoid vaccination of

mother has led to eradication of this
disease .
 Etiopathogenesis
• Caused by : Gm positive motile non-
encapsulated , anaerobic , spore bearing
bacillus ------ Clostridium tetani

• Open wound --------- body ----- produce

tetanospasmin ( powerful neurotoxin )------ toxin
enters the circulation----------- carried to motor
end plate ------- interfering with neurotransmitter
release and blocking inhibitor impulses lead to
uncontrollable muscle contractions
 Clinical features
• Start by 5 to 10 days after birth
Initial symptoms :
– Excessive unexplained crying
– Refusal of feeding and
– Apathy
– Mouth is slightly open ( due to spasm of the neck
)
– Dysphagia and choking ( pharyngeal muscle
spasm )
– Constipation persists until the spasm are
relieved
 Cont …
• Lock – jaw followed by spasm of limbs

• Generalised rigidity and opisthotonos ( rigid

spasm of the body with the back fully arched
and the heels and head bent back ) in extension
• Spasm of larynx and respiratory muscles
characteristically induced by stimuli of touch ,
noise and bright light in episodes of apnea and
cyanosis
 PENULARAN
Melalui luka yang dalam dengan suasana
anaerob, sebagai akibat dari :
1. Kecelakaan
2. Luka tusuk
3. Luka operasi
4. Karies gigi
5. Radang telinga tengah
6. Pemotongan tali pusat
 PENULARAN
• Penyebab tersering masuknya spora tetanus 
kebiasaan memberi ramuan dedaunan untuk
perawatan tali pusat, dll terutama pada kelahiran
dng pertolongan tenaga non medis

• Survei di 4 RS kota besar ; pintu masuk adalah

radang telinga tengah (39%), luka (38%), karies
gigi (10%)

• Masa inkubasi 5-14 hr (rata2 6 hr)

 GEJALA & TANDA
• Gejala awal ; kekakuan otot rahang untuk
mengunyah  trismus (pd bayi ‘mecucu’)
• Sulit menelan, gelisah, mudah terkena
rangsang
• Kekakuan otot wajah (rhesus sardonicus)
• Kekakuan otot tubuh (punggung, leher dan
badan)  spt busur
• Kekakuan otot perut
• Kejang-kejang
Photo Courtesy of U.S. Centers for Disease
Control and Prevention
Newborn
showing risus
sardonicus and
generalized
spasticity
 Incubation Period
• Varies from 1 day to several months. It is
defined as the time from injury to the first
symptom.
 Period of onset
• It is the time from first symptoms to the
reflex spasm.

• An incubation period of 4 days or less

or
• A period of onset of less than 48 hr is
associated with the development of severe
tetanus.
 pathogenesis

1. C. tetani enters 2. Stays in sporulated

body from through form until anaerobic
conditions are
wound. presented.

3. Germinates under 4. Tetnospasmin spreads

using blood and lymphatic
anaerobic conditions and system, and binds to motor
begins to multiply and neurons.
produce tetnospasmin.

6. Binds to sites responsible

5. Travels along the
for inhibiting skeletal muscle
axons to the spinal cord. contraction.
•Initially binds to peripheral
nerve terminals
•Transported within the axon
and across synaptic junctions
until it reaches the central
nervous system.
•Becomes rapidly fixed to
gangliosides at the presynaptic
inhibitory motor nerve endings,
then taken up into the axon by
endocytosis.
 Diagnosis
 There are currently no blood tests that can be used to
diagnose tetanus. Diagnosis is done clinically.

Differential Diagnosis
 Masseter muscle spasm due to dental abscess
 Dystonic reaction to phenothiazine
 Rabies
 Hysteria
 Diagnosis Of Tetanus
Clinically it is confirmed by noticing
the following features:
1. Risus sardonicus or fixed sneer.
2. Lock jaw.
3. Opisthotonos (extension of lower
extremities, flexion of upper extremities
and arching of the back. The examiners
hand can be passed under the back of
the patient when he lies on the bed in
supine position.)
4. Neck rigidity
 Type of Tetanus

• Traumatic tetanus
• Puerperal tetanus
• Otogenic tetanus
• Idiopathic tetanus
• Tetanus Neonatorum
•Local tetanus is an uncommon form of the disease,in which
patients have persistent contraction of muscles in the same
anatomic area as the injury. Local tetanus may precede the
onset of generalized tetanus but is generally milder.Only
about 1%of cases are fatal.
•Cephalic tetanus is a rare form of the disease,occasionally
occurring with otitis media (ear infections)in which C.tetani is
present in the flora of the middle ear,or following injuries to
the head.There is involvement of the cranial nerves,especially
in the facial area.
•The most common type (about 80%)of reported tetanus is
generalized tetanus .The disease usually presents with a
descending pattern.
 Principle of Treatment
• 1. Neutralization of unbound toxin with
Human tetanus immunoglobulin / ATS
• 2. Prevention of further toxin production by
-Wound debridement
-Antibiotics (Metronidazole)
 3. Control of spasm
- Nursing in quiet environment
- avoid unnecessary stimuli
- Protecting the airway
 4. Supportive care
- Adequate hydration
- Nutrition
- Treatment of secondary infection
- prevention of bed sores.
 Three Objectives of Management of
Tetanus
• (1)To provide supportive care until the
tetanospasmin that is fixed in tissue has been
metabolized

• (2)To neutralize circulating toxin

• (3)To remove the source of tetanospasmin.

The rating scale for the severity and the prognosis of tetanus is described below.
•Score 1 point for each of the following:
•Incubation period less than 7 days : 1
•Period of onset less than 48 hours : 1
•Acquired from burns, surgical wounds, compound fractures, or septic
abortion : 1
•Narcotic addiction : 0
•Generalized tetanus : 1
•Temperature greater than 104°F (40°C) : 1
•Tachycardia greater than 120 beats per minute (>150 beats per min in
neonates) :
•Total score indicates the severity and the prognosis as follows:
•Score of 0-1 indicates mild severity with less than a 10% mortality rate.
•Score of 2-3 indicates moderate severity with a 10-20% mortality rate.
•Score of 4 indicates severe tetanus with a 20-40% mortality rate.
•Score of 5-6 indicates very severe tetanus with greater than a 50%
mortality rate. (http://www.emedicine.com/ped/topic3038.htm)

Phillips, Dakar,. Udwadia Score

 PENGOBATAN
• Harus dirawat di RS
• Kecepatan merujuk sangat berpengaruh thd
angka kematian kasus
• Pengobatan RS umumnya meliputi ;
1. Pemberian antibiotik
2. Pemberian anti kejang
3. Perawatan luka atau penyakit penyebab
infeksi
4. Pemberian ATS
 PENCEGAHAN
1. Immunisasi aktif dengan toxoid; WUS
mendapat 5x TT sebelum hamil (status
tetanus toxoid 5 dosis yg memberi
perlindungan 25 th)
2. Perawatan luka ; dgn H2O2
3. Persalinan yang bersih; bersih alat,
tempat, dan tangan penolong persalinan.
 Pencegahan
• Spora sangat stabil, meskipun perendaman
dalam air mendidih selama 15 menit membunuh
sebagian besar spora. Paparan uap jenuh di
bawah 15 lb. Tekanan selama 15-20 menit pada
121 ° C sangat efektif terhadap spora. Sterilisasi
oleh panas kering lebih lambat daripada dengan
panas lembab (1-3 jam pada 160 ° C), tetapi
juga efektif terhadap spora. Sterilisasi etilen
oksida juga bersifat sporosidal
 Fumigation
• Sterilisasi ruang operasi
• 500 ml formalin, 200 gram Pot.permanganate /
30 cu.meters ruang
• Semua jendela dan pintu ditutup kecuali satu
• Celah antara panel pintu dan jendela ditutup
dengan pita perekat
• Setelah 12 jam, pintu dan jendela dibuka dan
teater ditayangkan selama 24 jam sebelum
menonaktifkannya
• Active Immunization
• Passive Immunization
• Active and passive
Immunization
• Antibiotics
 TETANUS TOXOID
• Tetanus toxoid was developed by Descombey in 1924,
• Tetanus toxoid immunizations were used extensively in
the armed services during World War II.
• Tetanus toxoid consists of a formaldehyde-treated toxin.
• There are two types of toxoid available —adsorbed
(aluminum salt precipitated)toxoid and fluid toxoid.
• Although the rates of seroconversion are about equal,the
adsorbed toxoid is preferred because the antitoxin
response reaches higher titers and is longer lasting than
that following the fluid toxoid.
Tetanus Toxoid Adsorbed USP,for intramuscular use,is a sterile
suspension of alum-precipitated (aluminum potassium sulfate)toxoid in
an isotonic sodium chloride solution containing sodium phosphate
buffer to control pH.The vaccine,after shaking,is a turbid liquid,whitish-
gray in color.
Clostridium tetani culture is grown in a peptone-based medium and
detoxified with formaldehyde.The detoxified material is then purified by
serial ammonium sulfate fractionation,followed by sterile filtration,and
the toxoid is adsorbed to aluminum potassium sulfate (alum).The
adsorbed toxoid is diluted with physiological saline solution (0.85%)and
thimerosal (a mercury derivative)is added to a final concentration of
1:10,000.
Each 0.5 mL dose is formulated to contain 5 Lf (flocculation units)of
tetanus toxoid and not more than 0.25 mg of aluminum.
The residual formaldehyde content,by assay,is less than 0.02%.The
tetanus toxoid induces at least 2 units of antitoxin per mL in the guinea
pig potency test.
 Active Immunization
• 1st dose - 6th week
• 2nd dose - 10th week
• 3rd dose - 14th week
• 1st booster - 18th month
• 2nd booster - 6th year
• 3rd booster - 10th year
 Passive Immunization
1. ATS(equine) Ig- 1500 IU/s.c after
sensitivity test
(or)
2. ATS(human) Ig- 250-500 IU, no
anaphylactic shock, very safe and
costly.
Persons Seven Years of Age or Older Who
Have Not Been Immunized

Immunization requires at least three doses of

Td.
1st dose should be administered on the First
visit
2nd dose 4 – 8 weeks after the first dose of Td
and 3rd dose after 6 months of the second
Td.
A booster dose of Td should be repeated
every 10 years throughout life
 Management tetanus
neonatorum
• Active immunization of the pregnant women with
two injections of T.T given at monthly intervals
during the pregnancy
• Public health education while cutting the
umbilical cord at home delivery
Good supportive measures :
• Maintenance of oxygen
• Nursed in a quite room
• I.M injections must be avoided
• Oropharyngeal secretion should be cleared
periodically
 Cont…
Nutrition, fluid and electrolytes :

• Oral feeding should be stopped and an I.V line

should be established for providing adequate
fluids , calories and electrolytes and for
administration of various drugs

• After 3 to 4 days of Tx. , milk feeding through NG

tube may be started

Antibiotic : penicilin or cephalosporin

 Cont ..
Tetanus anti – toxin :
---- Neutrlizes the circulating toxins , but it cannot dislodge
the toxin already fixed to the nerve roots
---- Recovery of nerve function from tetanus toxins requires
sprouting of new nerve terminals and formation of new
synapses.
• Dose : 500 U
Tracheostomy and assisted ventilation : -
• If the infant gets frequent episodes of laryngeal spasm ,
apneic attacks with cyanosis or respiratory failure.
Control of spasm :
• Diazepam : I .V , 0.5 – 5 mg / kg every 2 – 4 hours
 Prognosis
Prognosis is worse : -
• Onset of symptoms occurs within the first weeks
of life

• Interval between lock – jaw on onset of spasm is

less than 48 hours

• High fever and tachycardia

• Spasm especially of larynx resulting in apnea

 PEMBERANTASAN
1. Tujuan
Sesuai kesepakatan global, Depkes
menetapkan tujuan umum yaitu tercapainya
maternal-neonatal tetanus elimination (MNTE)
di tiap kab/kota akhir 2005, sdgkan tujuan
khususnya adalah ;
a. Semua WUS kab berisiko tinggi  TT 5 dosis
b. Semua WUS di SMA & tempat kerja  5 dosis
 PEMBERANTASAN
2. Kebijakan
a. Immunisasi TT pada WUS utk memberi
perlindungan seumur hidup
b. Immunisasi TT pada WUS dilaksanakan
terpadu lintas program
c. Kegiatan akselerasi imunisasi
 PEMBERANTASAN
3. Strategi
a. Prioritas imunisasi WUS pada daerah berisiko
tinggi
b. Diarahkan pada WUS yang terkelompok ( mis.
Pada industri, perdagangan atau perkebunan )
c. Imunisasi TT pada anak SMA
d. Imunisasi pada calon pengantin dan ibu hamil
tetap diteruskan
e. Promosi kesehatan
 PEMBERANTASAN
4. Kegiatan
a. Pertemuan lintas sektor
b. Pendataan semua WUS berusia 15 – 39
tahun
c. Pemetaan dengan sistem skoring
d. Pembuatan jadwal pelaksanaan
imunisasi ( Januari – Februari )
e. Pelaksanaan imunisasi
 Elimination of Neo natal
tetanus
1. High risk district:
a) Neo natal death rate > 1/1000 live births
b) 2 doses of tetanus toxoid coverage < 70%
c) Deliveries attended by trained dais < 50%
2. Medium risk district:
a) Neo natal death rate < 1 / 1000 live births
b) 2 doses of tetanus toxoid coverage> 70%
c) Deliveries attended by dais > 50%
3. Low risk district:
a) NNT <0.1/1000 Live Birth
b) 2 Doses of T.T Coverage >90%
c) Delivery attended by Trained Dais >75%
 PREVENTION OF NEONATAL
TETANUS
• 2 doses of T.T to all pregnant women between 16 to
36 weeks of pregnancy with an interval of 1 to 2
months between the two doses.
• The first dose as early as possible & the second dose
a month later preferably 3 weeks before delivery.
• If the pregnant woman is previously immunized, a
booster dose is sufficient.
• If the pregnant woman is not immunized, then the
new born should be protected against tetanus by
giving tetanus human immunoglobulin 750 IU with in
6 hours of birth.
 REFERENCE
• http://www.medindia.net/health_statistics/diseases/
tetanusTetanus J J Farrara b, L M Yenc, T Cookd, N
Fairweathere, N Binhc, J Parrya b, C M Parrya b
• http://www.who.int/immunization_monitoring/diseases/
Tetanus_map_cases.jpg
• Txt book of preventive and social medicine 18 th edition
by K.PARK
• Text book of community medicine by T. Bhaskar Rao
• Management and Prevention of Tetanus
• Richard F.Edlich,MD PhD,?Lisa G..Hill,?Chandra
A..Mahler, 툺 ary Jude Cox,MD,?Daniel G..Becker MD,?
Jed H..Horowitz,MD 4 Larry S.Nichter MD MS,4 Marcus
L.Martin,MD 5 &William C.Lineweaver MD6
. www.rxlist.com/cgi/generic/tettoxpi.htm - 22k
. Manson’s Tropical diseases 21 st edition
 evaluasi

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