|Year : 2015 | Volume
| Issue : 1 | Page : 52-55
A 6-year review of neonatal tetanus at the Stella Obasanjo Hospital, Benin City, South-South Nigeria
Imuwahen Anthonia Mbarie1, Blessing Imuetinyan Abhulimhen-Iyoha2
1 Department of Paediatrics, Stella Obasanjo Hospital, Benin City, Edo State, Nigeria
2 Department of Child Health, University of Benin Teaching Hospital, Benin City, Edo State, Nigeria
|Date of Web Publication||17-Mar-2015|
Imuwahen Anthonia Mbarie
Department of Paediatrics, Stella Obasanjo Hospital, Benin City, Edo State
Source of Support: None, Conflict of Interest: None
Background: Neonatal tetanus is a lethal disease which has remained an important public health problem in developing countries. The global efforts at eliminating neonatal tetanus have resulted in many nations having less than one case of neonatal tetanus per 1,000 live births per district- a goal that Nigeria is striving to achieve. Objective: To evaluate the contribution of neonatal tetanus to morbidity and mortality in the neonatal unit of Stella Obasanjo Hospital (SOH), Benin City, Nigeria. Methods: A retrospective study in which records of admissions over a six-year period (June 2008 to May 2014) were obtained from the neonatal unit records paying particular attention to cases of tetanus. Information retrieved included age, sex, duration of stay in the unit and outcome. Results: A total of 2,324 patients were admitted into the neonatal unit during the study period. Of these, 23 had tetanus, giving an overall prevalence of 1.0% and an annual incidence of four cases. All the cases were out-born. Nine (39.1%) were males while 14 (60.9%) were females giving a M: F ratio of 1: 1.6. The median and modal age at presentation was seven days (range being 2-21 days). Ten (43.8%) patients were discharged home, four (17.4%) discharged against medical advice while nine died; giving a case fatality rate of 39.1% and contributing 3.1% out of the overall mortality of 286 neonates. Conclusion: Neonatal tetanus contribute significantly to morbidity and mortality. The global efforts for disease elimination should be unrelenting. To be counted among nations that have successfully eliminated the disease, we must pay particular attention to public enlightenment.
Keywords: Benin City, neonatal tetanus, outcome
|How to cite this article:|
Mbarie IA, Abhulimhen-Iyoha BI. A 6-year review of neonatal tetanus at the Stella Obasanjo Hospital, Benin City, South-South Nigeria. Afr J Med Health Sci 2015;14:52-5
|How to cite this URL:|
Mbarie IA, Abhulimhen-Iyoha BI. A 6-year review of neonatal tetanus at the Stella Obasanjo Hospital, Benin City, South-South Nigeria. Afr J Med Health Sci [serial online] 2015 [cited 2019 Sep 17];14:52-5. Available from: http://www.ajmhs.org/text.asp?2015/14/1/52/153393
| Introduction|| |
Neonatal tetanus (NNT) has remained an important public health problem in developing countries. It is a lethal disease which occurs as a result of unhygienic birth practices, most commonly when spores of Clostridium tetani contaminate the umbilical cord at the time that it is cut or dressed after delivery.  With a case fatality rate of 70-100%, NNT is responsible for 14% (215,000) of all neonatal deaths  such that efforts at reducing deaths from NNT implies significant reduction in neonatal mortality rate. However, because most of the deaths occur at home before the babies reach 2 weeks of age, and neither the births nor the deaths are reported, the number of cases reported by countries is low. For this reason, NNT is often called the invisible killer. 
Elimination of NNT is a key area in global public health policy. Although much progress has been made in a reduction of the incidence during the past decades, it remains a significant cause of preventable neonatal mortality in Nigeria.  Maternal immunization and improved obstetric and neonatal care are the main strategies in Nigeria for improving protection against NNT.  NNT elimination is defined as the reduction of NNT cases to less than one case per 1000 live births in every district of every country  a goal yet to be attained by Nigeria.
The care of the umbilical cord in newborns is critical to the development of NNT. Unhygienic cord care practices (such as the use of sand, herbs, native chalk, salt, saliva, menthol-containing balm, hot compress among others) influenced by cultural beliefs and ignorance perpetuate the continued existence of the disease, , which is caused by C. tetani, a Gram-positive, anaerobic, ubiquitous organism. In spite of tetanus toxoid (TT) vaccine made available to pregnant women and those of reproductive age group as well as health education campaigns, this preventable condition still plagues population. This study was, therefore, conducted to audit the prevalence and outcome of cases of tetanus admitted into the neonatal unit of the Stella Obasanjo Hospital (SOH) in Benin City, Southern Nigeria.
| Subjects and methods|| |
This retrospective study reviewed the admissions into the neonatal unit of SOH, Benin City, from June 2008 to May 2014. The hospital is a secondary health facility, which operates a 20 bed neonatal unit; 10 bed each in both the inborn and outborn sections. The unit is run by two consultant pediatricians, two medical officers, four house officers and eight nurses. It is equipped with four incubators, four phototherapy units and resuscitation equipment including suction machines, ambu bags and oxygen therapy units. There is a laboratory in the institution manned by qualified laboratory scientists. It is open 24 h daily and provides all routine tests with blood banking facility.
Records from the neonatal unit change book consisting of all admissions and diagnoses including outcome were utilized for the purpose of this study. Data extracted from the records included age, sex, duration of stay (DOS) in the unit and outcome of cases of NNT. Diagnosis of tetanus was on the basis of inability to suck (from trismus) and the presence of spasms. Outcome is classified as discharge, discharged against medical advice (DAMA) and death. Ethical approval was obtained from the Ministry of Health, Edo State.
The data obtained were entered into the IBM Statistical Products and Servicing Systems (SPSS Inc. 233 South Wacker Drive, 11 th Floor, Chicago, IL, IBM) version 20.0 spreadsheet and analyzed. The results were cross tabulated as frequency tables; means, standard deviations, percentages, and ranges were used as appropriate to describe continuous variables.
| Results|| |
During the period of the study, a total of 2,324 patients was admitted into the neonatal unit. Of these, 23 had tetanus, giving an overall prevalence of 1.0% and an annual incidence of four cases. All the cases were outborn. Moreover, 9 (39.1%) of them were males while 14 (60.9%) were females giving a male:female ratio of 1:1.6 [Table 1]. The median and modal age at presentation were 7 days while the mean age was 9.3 ± 5.1 days (range being 2-21 days).
The DOS in the unit ranged between 1-day and 44 days (mean DOS 17.7 ± 13.1 days). 9 (39.1%) patients died, 4 (17.4%) DAMA while 10 (43.8%) were discharged home. Majority of the newborns (77.8%) that died were females; although this was not statistically significant [Table 2]. Most of the deaths occurred within the 1 st week of admission (55. 6%) [Table 1]. The total deaths recorded in the unit for the period was 286 with NNT contributing 9 (3.1%); however, case fatality rate was 39.1%.
| Discussion|| |
Mortality from NNT remains an important, yet preventable cause of neonatal mortality. The current study revealed that NNT still contributes significantly to morbidity and mortality in our environment. The overall prevalence in the current study (1.0%) is higher than that (0.7%) recorded by Onalo et al.  in Zaria but lower than that recorded by Peterside et al.  in Bayelsa State (4.7%), both in Nigeria. Although community-based studies are better indicators of the prevalence of the disease, hospital-based studies help to monitor the progress of existing policies. For instance, the implementation of the National Immunization Policy, which recommends five doses of TT for women of childbearing age can be evaluated by accessing data from various health institutions in the nation. 
Our finding of female preponderance in the mortality of tetanus, though not statistically significant, is in contrast with other publications from Nigeria. ,,, The reason for this finding is not obvious. In consonance with previous studies, , the current study documented newborns presenting within the 1 st week of life having higher mortality rate than those seen in the 2 nd and 3 rd week of life. This finding may be related to the relationship between the response of the immune system and the toxin load at this age compared to the one of older infants with more developed immunity,  in that the relatively immature immune system of newborns in the 1 st week of life could be easily overwhelmed by the toxin load. Most of the mortalities in the present study occurred within the 1 st week of admission similar to other reports from Nigeria ,, This result may be due to persistent actions of the tissue-bounded tetanus toxins, difficulty in controlling spasm and difficulty in achieving adequate fluid and caloric balance during this period.  The 1 st week of hospitalization is, therefore, a crucial period in the management of NNT , and intervention or strategy to improve outcomes should focus on this vital period. Similar to the findings from previous studies in which a high number of neonates with NNT were outborn (with the majority delivered at home), ,, the present study revealed that all the cases were outborn.
Neonatal tetanus occurs most commonly in the lowest income countries and those with the least developed health infrastructure. Within these countries, it is frequently found among populations with little or no access to health care services or education.  The fact that all cases of NNT were born outside the institution (at home) from the present study, makes it obvious that we still have many mothers delivering outside the health facilities with most likely unhygienic delivery practices such as using unsterilized instruments for cutting the umbilical cord and tying it with dirty thread. This brings to the fore the need for training of traditional birth attendants (TBAs) to understand the reason for clean delivery kits and hygienic cord care. , The government and healthcare workers should, however, work on the improvement of acceptability, accessibility, and affordability of our health facilities to encourage mothers to attend. Stakeholders must downplay the harmful traditional/sociocultural practices of cord care in our communities, e.g., the use of harmful substances like sand, herbs, menthol-containing balm and native chalk  in the care of the infant's cord. The use of these substances for cord care is frequently harmful because they are likely to be contaminated with bacteria and spores, thus heightening the risk of infection. Also, the application of menthol-containing balm especially in newborns with glucose-6-phosphate dehydrogenase deficiency could result in neonatal jaundice from hemolysis.
The case fatality rate of 39.1% recorded in the present study is lower than the reported (43.8-75.0%) in several other studies both in Nigeria and elsewhere ,,,, but comparable with 37.5% reported in Bayelsa State  and 40.0% by Ejike et al.  in Aba, both in Nigeria. The variations in case fatality rate may be as a result of differences in factors such as time of presentation to hospital (whether early or late) and treatment modalities of various health centers among others. Reducing deaths from NNT has been regarded as one of the simplest and most cost-effective ways to reduce the neonatal mortality rate.  Immunization of pregnant women or women of childbearing age with two doses of TT was estimated to reduce mortality from NNT by 94%.  Healthcare delivery at the grass root level should be the focus. C. tetani spores are widespread, in the dirt and in the feces of human and animals, and can survive and be transmitted without human contact such that complete eradication is not an option. Hence, ongoing attention to maintaining high levels of TT immunization both to pregnant women and women of childbearing age in general, as well as strengthening national surveillance systems is encouraged.
Akani et al.  already suggested the incorporation of TT five dose schedule meant for women of childbearing age into the School Health Program (SHP). This would mean catching the female child early with the likelihood of completing the five doses of TT and acquiring life immunity before commencement of childbearing. The strategy, however, will be successful only if we develop the SHP by strengthening it where it exists in the nation and starting it in those parts where it does not.  Health education is paramount in this struggle since it will create awareness of not only the condition but also the various stages of prevention; targeting pregnant women and those of childbearing age, their spouses, TBAs, elderly women who care for nursing mothers and their babies, religious leaders and other stakeholders. Prevention includes appropriate antenatal and postnatal care especially hygienic umbilical cord care. All hands must be on deck in an effort to eliminate NNT in the country. Preventive measures in NNT are easier, cheaper and more effective than curative measures. Therefore, health education campaigns and community mobilization are expedient if we must reduce the ignorance associated with the disease. Serious public health enlightenment campaigns on the disease can be carried out by governmental agencies and nongovernmental organizations alike. Although a limited number of women attend the antenatal clinics, it can be a good venue for health education on NNT and the importance of immunization and hygienic cord care.  The involvement of the mass media (both print and electronic) in the dissemination of evidence-based health information will be a step in the right direction.
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[Table 1], [Table 2]