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Prognostic factors in neonatal tetanus
Tropical Medicine & International Health
Abstract
Neonatal tetanus (NNT) is the leading cause of neonatal deaths in developing countries. The objective of this study was to determine prognostic indicators in NNT.
We reviewed the clinical records of all neonates (n = 174) admitted to Ife State Hospital with the diagnosis of NNT from 1991 through 1995.
Delivery had occurred at home in 73.3% of cases. Only 37/164 of the mothers had had adequate immunization with tetanus toxoid. The umbilical cord appeared to be the portal of entry in 58.6% of cases. Mean age of infants at presentation was 7.2 days. Mortality was 57.5%; non-survivors succumbed after mean stay in the hospital of 5.0 days. Mortality was significantly associated with an incubation period of 6 days or less (P = 0.0026), infant's weight of less than 2.5 kg (P = 0.0113), lack of antenatal care in a health facility (P = 0.0279), birth at home (P = 0.0455), but not with lack of adequate maternal immunization (P = 0.2081; not significant). Multivariable analysis showed that a short (< or = 6 d) incubation period was the strongest predictor of mortality (OR = 3.11, P = 0.0030) while low infant weight (< 2.5 kg) was also a significant predictor (OR = 2.46, P = 0.0408).
Hygienic deliveries and adequate cord care are very important for the prevention of neonatal tetanus deaths, and universal prenatal care, including education programmes on appropriate perinatal and cord care, can significantly reduce NNT incidence and mortality in developing countries.
... Risk factors for neonatal tetanus incidence are related to prenatal (lack of antenatal care for the pregnant women in a health facility, failure of immunization with tetanus toxoid), perinatal (delivery at home, births followed by untrained persons, failure of simple measures such as hand washing, cleaning of the cordcutting tool, use of multiple cord ties, the vaginal use of coconut oil, etc.) and neonatal factors (unhygienic newborn and cord care, infant's weight less than 2.5 kg) [11][12][13][14] . Case fatality rates vary (range: 10-100%), depending on treatment, age and general health of the patient 5,6,8,9,15,16 . Infants who survive can have residual neurological injury (e.g. ...
... In newborns, the common nidus of infection is the umbilical cord, especially a septic umbilicus or any superficial wound; in many cases, it may not be detectable 15,18 . Most cases follow an acute injury, such as a puncture wound, a laceration or an abrasion. ...
... The presence of numerous risk factors (home delivery, untrained assistant, infected cord, lower birth weight, younger age at onset of symptoms, the presence of opisthotonos, and risus sardonicus, etc.), as in the described case, were associated with a higher mortality rate 5,15,21 . ...
Neonatal tetanus is a severe, often fatal disease caused by the toxin Clostridium tetani. Neonatal tetanus is a generalized tetanus, which occurs in a neonate between 3-28 days of life. The findings indicated that tetanus in a newborn of an unvaccinated mother occurred after the application of non-sterile clay to the umbilical cord. This case was a seven-day-old male baby with progressive difficulty in feeding, trismus, hypertonicity, opisthotonos, and heart murmur. The patient was afebrile and eupneic, and had a history of non-sterile home delivery. In the past, the area of Bujanovac, Medvedja and Presevo had been exposed to mass immigration (especially due to the war in the territory of former Yugoslavia), which caused a serious problem for general practitioners, who had to be vigilant and ensure that all patients registered in their practice were fully immunized. This case has provided a clear indication of the necessity for strategies of both vaccination and ensuring hygienic conditions throughout pregnancy and delivery to prevent neonatal tetanus.
... In the studies carried out by Basu et al and Anita et al, low body weight was found to be a risk factor for mortality in neonatal tetanus [6,23]. Although there was significant difference between surviving infants and deceased ones regarding body weight in our study we could not show that it constituted a risk factor for mortality. ...
... Male infants constituted 71.6% of our patients. Higher proportion of neonatal deaths due to tetanus among males than females were reported previously [20][21][22][23][24][25][26]. Studies conducted in Pakistan, Sudan and Egypt showed that unhygienic practices during circumcision were responsible for this disparity in the proportion of male and female NT deaths [24,25]. ...
... There are many reports stating that mortality increased considerably when the incubation period was 5-10 days or less [6,19,20,23]. Short incubation period may show increased virulence of the infectious agent, or it may designate decreased defense mechanisms of the host against the disease. ...
Neonatal tetanus (NT) is still considered as one of the major causes of neonatal death in many developing countries. The aim of the present study was to assess the characteristics of sixty-seven infants with the diagnosis of neonatal tetanus followed-up in the Pediatric Infectious Diseases Ward of Dicle University Hospital, Diyarbakir, between 1991 and 2006, and to draw attention to factors that may contribute (or may have contributed) to the elimination of the disease in Diyarbakir.
The data of sixty-seven infants whose epidemiological and clinical findings were compatible with neonatal tetanus were reviewed. Patients were stratified into two groups according to whether they survived or not to assess the effect of certain factors in the prognosis. Factors having a contribution to the higher rate of tetanus among newborn infants were discussed.
A total of 55 cases of NT had been hospitalized between 1991 and 1996 whereas only 12 patients admitted in the last decade. All of the infants had been delivered at home by untrained traditional birth attendants (TBA), and none of the mothers had been immunized with tetanus toxoid during her pregnancy. Twenty-eight (41.8%) of the infants died during their follow-up. Lower birth weight, younger age at onset of symptoms and at the time admission, the presence of opisthotonus, risus sardonicus and were associated with a higher mortality rate.
Although the number of neonatal tetanus cases admitted to our clinic in recent years is lower than in the last decade efforts including appropriate health education of the masses, ensurement of access to antenatal sevices and increasing the rate of tetanus immunization among mothers still should be made in our region to achieve the goal of neonatal tetanus elimination.
... 5 The prognosis is put aside if the child, at the moment of admission, has less than 10 days of life and has been presenting the symptoms for more than 5 days, or if he/she presents sardonic laughing, and fever. 10 Some authors state that the weight at birth does not alter the prognosis, 5,11 while others affirm that if the weight is inferior to 2,500 kg, the mortality rate is higher. 11 Davies et al. 11 state that there is a higher mortality rate if the incubation period is inferior to 6 days and in case of home delivery; these features coincide with the case described. ...
... 10 Some authors state that the weight at birth does not alter the prognosis, 5,11 while others affirm that if the weight is inferior to 2,500 kg, the mortality rate is higher. 11 Davies et al. 11 state that there is a higher mortality rate if the incubation period is inferior to 6 days and in case of home delivery; these features coincide with the case described. ...
... 10 Some authors state that the weight at birth does not alter the prognosis, 5,11 while others affirm that if the weight is inferior to 2,500 kg, the mortality rate is higher. 11 Davies et al. 11 state that there is a higher mortality rate if the incubation period is inferior to 6 days and in case of home delivery; these features coincide with the case described. ...
OBJECTIVE
Neonatal tetanus is an infection with high mortality, constituting a problem in underdeveloped countries, where there is faulty prenatal attendance. In spite of this and of the decreasing incidence of the disease in the state of Rio Grande do Sul, we report a case of neonatal tetanus identified in 1997.
METHOD
We interviewed the infantacute;s mother and verified her vaccination history. We conducted a clinical examination of the newborn, anaerobic culture of umbilical stump and review of medical records. We also reviewed the literature and verified the epidemic profile of neonatal tetanus in Rio Grande do Sul.
RESULTS
Healthy mother, with complete outline of tetanus vaccination 4 years ago, prenatal uncomplicated and hospital delivery. Family of good socioeconomic level, differing from the other cases notified in the State, in that most did not have prenatal care nor hospital delivery. The patient is a boy. In the 24th day of life he presented fever, cyanosis, lower and upper limbs muscle hypertonia and opisthotonos episodes. An anaerobic culture of the umbilical stump grew Clostridium tetani. He was treated with penicillin G, gentamicin, sedation and tetanus immunoglobulin. He left hospital in good conditions.
CONCLUSIONS
Faulty prenatal care in underdeveloped countries is the largest risk factor for high incidence of this disease in these areas. However, in pregnant women with good socioeconomic level and prenatal care, as in the case described here, this diagnosis should not be excluded if there are suggestive signs of it.
... cular route could be preferred. As regards antibiotic therapy, we have chosen to avoid competition between penicillin G and GABA by opting for metronidazole.Co-infections, suspected or recognized as in Dakar or elsewhere[11] [19], have justified the use of probabilistic antibiotic therapy. The cases of sepsis leading to death were thus treated in our study. ...
... The cases of sepsis leading to death were thus treated in our study. Sow in Dakar and Anita in Ilé Ifè[11] [19] identified them as death risk factors. The accurate causes of mortality are difficult to identify due to the lack of additional diagnostic tests in sub-Saharan settings. ...
... 4 NNT was initially planned for eradication in the year 2000 by the World Health Organization (WHO). 1 The persistence of the scourge of NNT in the developing world beyond the year 2000 have been attributed to poor tetanus toxoid (TT) coverage due to lack of acceptability despite very high awareness, 5 poor immune response of some mothers who actually had TT vaccine in pregnancy 6 and unclean deliveries, especially at home. 7 Consequently, WHO re-focused its elimination strategy on the African Region, where NNT is a major health issue, and planned its elimination from this continent by 2005. 4 In order to make the elimination strategy in Africa in the 21st century achievable, considering the immense contribution of Nigeria alone to the NNT burden, the epidemiology of the disease in Nigeria at the close of the 20th century needs to be examined. ...
... The overall CFR among these babies was similar to rates previously reported in other parts of the country 12,13 but was less than 58.7% reported previously in our center 11 and 57% reported in Ile-Ife. 7 The progressive fall in the CFR over the period studied was also reassuring. Intensive care facilities were not available in our centre, though the improved survival among babies with NNT can be explained in terms of a more aggressive and radical use of antibiotics. ...
... 33 This mortality risk is exacerbated for low birth weight neonates. 40 Case fatality rates (CFR) can vary between 10% and 70% depending on treatment, age, and the health status of the infant. 26 The incubation period is related to the prognosis -the shorter it is, the greater the CFR. ...
... 26 The incubation period is related to the prognosis -the shorter it is, the greater the CFR. 40,41 Studies have shown that the CFR may be decreasing due to targeted TT immunization in Pakistan. 33,39 In a previous hospitalbased surveillance report in Pakistan, the mean age at death was 10.7 days. ...
Pakistan is one of the 34 countries that have not achieved the neonatal tetanus (NT) global elimination target set by the World Health Organization (WHO). NT, caused by Clostridium tetani, is a highly fatal infection of the neonatal period. It is one of the most underreported diseases and remains a major but preventable cause of neonatal and infant mortality in many developing countries. In 1989, the World Health Assembly called for the elimination of NT by 1995, and since then considerable progress has been made using the following strategies: clean delivery practices, routine tetanus toxoid (TT) immunization of pregnant women, and immunization of all women of childbearing age with three doses of TT vaccine in high-risk areas during supplementary immunization campaigns. This review presents the activities, progress, and challenges in achieving NT elimination in Pakistan.
... 4 NNT was initially planned for eradication in the year 2000 by the World Health Organization (WHO). 1 The persistence of the scourge of NNT in the developing world beyond the year 2000 have been attributed to poor tetanus toxoid (TT) coverage due to lack of acceptability despite very high awareness, 5 poor immune response of some mothers who actually had TT vaccine in pregnancy 6 and unclean deliveries, especially at home. 7 Consequently, WHO re-focused its elimination strategy on the African Region, where NNT is a major health issue, and planned its elimination from this continent by 2005. 4 In order to make the elimination strategy in Africa in the 21st century achievable, considering the immense contribution of Nigeria alone to the NNT burden, the epidemiology of the disease in Nigeria at the close of the 20th century needs to be examined. ...
... The overall CFR among these babies was similar to rates previously reported in other parts of the country 12,13 but was less than 58.7% reported previously in our center 11 and 57% reported in Ile-Ife. 7 The progressive fall in the CFR over the period studied was also reassuring. Intensive care facilities were not available in our centre, though the improved survival among babies with NNT can be explained in terms of a more aggressive and radical use of antibiotics. ...
The year 2000 marked another failed World Health Organization deadline for neonatal tetanus (NNT) eradication. Existing preventive strategies can be enhanced by exploring factors involved in the persistence of the scourge. Thus, records of neonates admitted between 1996 and 2000 into the Wesley Guild Hospital, Ilesa, were analysed. Of 3051 total neonatal admissions,162 (5.3%) had NNT. Eighty-nine (54.9%) mothers had clinic-based antenatal care (ANC), but only 59 (36.4%) had tetanus toxoid (TT) vaccines. The majority (66.7%) of them delivered at home or churches and others at either private clinics or primary health centres. Overall, the case fatality rate was 43.8%, though it was significantly higher among babies whose mothers had neither clinic-based ANC (odds ratio [OR] = 2.62; 95% confidence interval [CI] = 1.33-5.18) nor antenatal TT vaccination (OR = 2.41; 95% CI = 1.17-5.03). Thus, improvement on ANC, anti-tetanus immunization and ensuring hygienic deliveries are crucial for eliminating NNT in the 21st century.
... Mothers and newborns contract tetanus, an extremely deadly and paralyzing disease, when deliveries happen in unhygienic conditions -as can be the case in remote and underdeveloped areas [8]. Risk factors for Neonatal Tetanus incidence relate to prenatal, perinatal and neonatal factors, and include lack of antenatal care for the pregnant woman, including lack of her immunization with Tetanus Toxoid (TT), and unhygienic delivery and cord care, limited access to health services, poor hygienic conditions, lack of access to sterilized childbirth delivery tools and unhygienic practices during childbirth [9,10]. ...
Aims: To assess Tetanus Toxoid (TT) vaccination uptake and dosage completion among women of reproductive age in Ilorin west Local Government area of Kwara state. Study Design: A cross-sectional study. Place and Duration of Study: Ilorin west local government, kwara state between Nov 2015 and March 2016. Methodology: The study involved women of reproductive age between 15-49 years in randomly selected in Ilorin west local government of Kwara state. The instrument was contracted to measure participants’ level of awareness of TT vaccine, uptake of the vaccine and level of completion of vaccine dosage. Data collected was analysed using Statistical Package for Social Science (SPSS) version 21. Results: There were 377 women in this study. Majority of respondents (75.6%) were between the age of 26 and 35 years old and more than half (68.2%) were married with a proportion of 45.3% having had more than 3 children. Results from this study revealed a low level of awareness on the dosage of TT vaccine and this was reflected in the 0% uptake of TT4 and TT5 by respondents. Further analysis indicated a significant association between respondents awareness and TT vaccine completion at 82.8% ((F=1811.74; R Square=0.828; P < 0.05). it was also found that uptake of TT vaccine increases with the number of children had, however, non-married and respondents with no children had not started uptake of TT vaccine. Initiation age of TT vaccination among respondents was found to 21 years of age. Findings from this study revealed that respondents’ normative beliefs has a significant association with intention of getting Tetanus Toxoid vaccine (p < 0.05, R2 = 0.014). Results also revealed that there is a significant difference in awareness across the age, marital status and number of children (p ≥ 0.05). Conclusion: From findings of this study, it is evident that uptake of TT vaccine is poor with 0% uptake of both TT4 and TT5 dosage as respondents stop uptake after child delivery, also, respondents younger than 21 years old have not commenced TT vaccination. It is hereby recommended that TT vaccination be initiated at the secondary school for females older than 15 years old to ensure completion of the vaccination and also increase awareness.
... 8,10 Most studies have been performed in adults, but several case series in neonates have found similar indicators of prognosis. [11][12][13] Lambo and Anokye recently performed a meta-analysis and included data from 4535 neonates to ascertain which features are most relevant in neonates. They concluded that low birth weight and age at onset were the most important factors in determining the outcome. ...
Objectives
Most data regarding the prognosis in neonatal tetanus originate from regions where limited resources have historically impeded management. It is not known whether recent improvements in critical care facilities in many low- and middle-income countries have affected indicators of a poor prognosis in neonatal tetanus. We aimed to determine the factors associated with worse outcomes in a Vietnamese hospital with neonatal intensive care facilities.
Methods
Data were collected from 107 cases of neonatal tetanus. Clinical features on admission were analyzed against mortality and a combined endpoint of ‘death or prolonged hospital stay’.
Results
Multivariable analysis showed that only younger age (odds ratio (OR) for mortality 0.69, 95% confidence interval (CI) 0.48–0.98) and lower weight (OR for mortality 0.06, 95% CI 0.01–0.54) were significantly associated with both the combined endpoint and death. A shorter period of onset (OR 0.94, 95% CI 0.88–0.99), raised white cell count (OR 1.17, 95% CI 1.02–1.35), and time between first symptom and admission (OR 3.77, 95% CI 1.14–12.51) were also indicators of mortality.
Conclusions
Risk factors for a poor outcome in neonatal tetanus in a setting with critical care facilities include younger age, lower weight, delay in admission, and leukocytosis.
... Short incubation and onset periods correlates with increased disease severity and higher mortality. [24][25][26][27][28] This study confirms that co-morbidities such as sepsis identified in these patients worsen the severity of the illness as previously reported, [29][30][31] that about half of the neonates with neonatal tetanus also have sepsis and contribute significantly to neonatal mortality. The overall case-fatality of 66.7% in the present study falls within the range of 3.9-79.4% reported in Nigeria. ...
Neonatal tetanus is a vaccine preventable disease and is a leading cause of neonatal mortality in developing countries. The effectiveness of immunization and hygienic umbilical cord care practices in the prevention of the disease has been established.
The objective of this study was to audit the scourge of neonatal tetanus in a tertiary health facility in a resource-limited setting.
The study was a retrospective study. Case notes of neonates admitted with clinical diagnosis of tetanus into the Special Care Baby Unit (SCBU) between January 2009 and December 2010 were retrieved and evaluated to identify socio-demographic and clinical characteristics, mode of acquisition and severity of the disease, presence of co-morbidities, duration of hospital stay and outcome.
Most of the mothers had no tetanus immunization (66.7%) and the main social class of the children was class V (45.1%) and IV (41.2%), respectively. Only 29.4% of the mothers attended ante-natal care (ANC) while majority of the patients were delivered at home (94.1%). Half of the neonates presented with the severe form of the disease (51.0%). Sepsis is a prominent co-morbidity (59.2%). Morality was high with case fatality of 66.7%.
This high prevalence of neonatal tetanus with high mortality is not only disappointing but unacceptable in the 21(st) century. Therefore, all efforts must be re-focused on current preventive strategies while pursuing new areas such as slow-release mono-dose tetanus vaccine and school health programme as well as advocacy on political will for the sustainability of immunization programmes of women of child-bearing age.
... In Zambia, more than half of women deliver at home for several reasons including lack of transportation, lack of access, lack of funds, and by preference [2,26]. Home deliveries in low resource settings and births attended by unskilled birth attendants have long been implicated in increasing the risk of neonatal tetanus, omphalitis, and sepsis [27][28][29][30][31][32]. Understanding what happens to newborns and their umbilical cords during a home birth and a facility birth are vital to planning interventions that may require behavior change. ...
Global policy regarding optimal umbilical cord care to prevent neonatal illness is an active discussion among researchers and policy makers. In preparation for a large cluster-randomized control trial to measure the impact of 4% chlorhexidine as an umbilical wash versus dry cord care on neonatal mortality in Southern Province, Zambia, we performed a qualitative study to determine local perceptions of cord health and illness and the cultural belief system that shapes umbilical cord care knowledge, attitudes, and practices.
This study consisted of 36 focus group discussions with breastfeeding mothers, grandmothers, and traditional birth attendants, and 42 in-depth interviews with key community informants. Semi-structured field guides were used to lead discussions and interviews at urban and rural sites. A wide variation in knowledge, beliefs, and practices surrounding cord care was discovered. For home deliveries, cords were cut with non-sterile razor blades or local grass. Cord applications included drying agents (e.g., charcoal, baby powder, dust), lubricating agents (e.g., Vaseline, cooking oil, used motor oil) and agents intended for medicinal/protective purposes (e.g., breast milk, cow dung, chicken feces). Concerns regarding the length of time until cord detachment were universally expressed. Blood clots in the umbilical cord, bulongo-longo, were perceived to foreshadow neonatal illness. Management of bulongo-longo or infected umbilical cords included multiple traditional remedies and treatment at government health centers.
Umbilical cord care practices and beliefs were diverse. Dry cord care, as recommended by the World Health Organization at the time of the study, is not widely practiced in Southern Province, Zambia. A cultural health systems model that depicts all stakeholders is proposed as an approach for policy makers and program implementers to work synergistically with existing cultural beliefs and practices in order to maximize effectiveness of evidence-based interventions.
... 12 On the other hand, the association between prognostic factors and mortality in NT are not well understood. Previous studies have shown that a short incubation period and low birth weight 14,15 are associated with a high mortality rate and are poor prognostic factors. ...
To determine prognostic factors for mortality in neonates with tetanus and to assess the associations between prognostic factors and neonatal tetanus (NT) mortality.
Five databases were searched for studies on prognostic factors and NT mortality published up to April 2013 to identify studies relevant to this review. Prognostic factors of interest were birth weight, age at onset of symptoms, age at presentation, delay in presentation, and duration of hospitalization. Odds ratios (ORs) for prognostic factors and mortality were estimated by random effects models and stratified analyses for all studies.
Sixteen studies including a total of 4535 neonates were included in the analysis: nine from Africa, five from Asia, and two from Europe. The prognostic factors identified consistently in the studies were birth weight, age at onset of symptoms, and age at presentation. Of the 16 studies, only one assessed all three prognostic factors, five studies assessed two prognostic factors, and 10 studies assessed one prognostic factor. Neonates with a low birth weight were more likely to have an increased odds of NT death (OR 2.09, 95% confidence interval (CI) 1.29-3.37) than normal weight neonates. This mortality risk was exacerbated for low birth weight neonates with age at onset ≤6 days (OR 6.80, 95% CI 2.42-19.11). Age at onset ≤5-7 days was associated with an increased odds of NT death.
Low birth weight predicted an increased odds of death by NT. Age at onset ≤5-7 days to diagnosis is crucial in determining survival among neonates with tetanus.
... The CFR was lower in patients that had an incubation period ≥11 days but this wasn't statistically significant (p>0.05). Similar results (with different incubation periods) were found in other studies (23,31). CFR was also significantly lower for longer onset-periods >2 days (p<0.05), ...
Despite systematic vaccination of the population, tetanus continues to be a health problem in Albania, as in some other developing countries. In this study, our intent was to evaluate prognostic factors relating to death in adult patients with generalized tetanus. METHODOLOGY AND PATIENTS: All the patients (60) included in the study were hospitalized at the regional hospitals of Shkodra and Korça, and the University Hospital Centre "Mother Theresa" of Tirana, Albania, during the period of 1984-2004. They had a mean age of 49.1+14.4 years, 43 (71.7%) were males and 40 (66.6%) of them lived in rural areas. The mean incubation period was 12 days and the case-fatality rate (CFR) was 38.3%.
The CFR in patients with an onset period ≥2 days was 21.7% and in those with <2 days was 48.6%, OR=0.29 (p<0.05). Patients >50 years old had a CFR=60.87% (OR=7, p<0.05). We found the high CFR to be significantly associated with urban residency, male gender, complicated wound, head localization, fever ≥ 38.4 °C, tachycardia > 120 beats/min, and hypertension.
The main prognostic factor of those analyzed in our study appeared to be the onset period and the age of the patients. We didn't find significant differences in CFR in patients with different incubation periods. Clinicians must take into account that wound complication and localization, tachycardia and hypertension, high fever, male gender and urban residency significantly influence the prognoses of adults with generalized tetanus.
... However, some cases of neonatal tetanus could present with a short incubation period that may not allow the caregiver to have ample time to prepare for early hospital attendance. Furthermore, the incubation period in most of those with fatal outcome was short which itself connotes poor prognosis [15]. The reason for the shorter incubation period in the present study is not certain but may be related to the high prevalence of traditional uvulectomy in the study population. ...
Neonatal tetanus is a highly debilitating disease with high mortality. Global efforts at eliminating the disease in developing countries are yielding results but slower than expected. The high case fatality of neonatal tetanus remains a therapeutic challenge to physicians and requires continuous evaluation. This study aimed to determine the incidence and outcome of neonatal tetanus in Zaria, northwestern Nigeria.
A retrospective study of neonatal tetanus was conducted at the Neonatal Unit of Ahmadu Bello University Teaching Hospital, Zaria, between January 2005 and December 2009. Data generated were analyzed using the Epi Info version 3.5.1 software and statistical significance was set at p < 0.05.
Of the 2,692 newborns admitted during the study period, 20 had tetanus, giving an overall prevalence of 0.7%. There were 14 males and 6 females (male to female ratio 2.3:1). The mean age and weight at presentation were 8.3 ± 4.0 days and 2.7 ± 0.3 kg, respectively. The mean incubation period was 3.2 ± 2.0 days. Four infants (20.0%) survived, one was discharged against medical advice and 15 (75.0%) died. Factors associated with mortality were presentation at less than seven days of life, low Hendrickse score at presentation (p = 0.0005) and hypoglycaemia (p = 0.0374).
The incidence and the mortality rate of neonatal tetanus appear to be lower than those previously reported by our centre for the same region. Therefore, the ongoing global efforts for disease elimination and further improvements in the quality of care should be sustained.
... In many other reports prognostic factors that had an effect on survival were younger age, presence of fever, 9,10 short incubation period, and low infant weight. 11 In our study, fever was found to be a strong indicator of prognosis. Body weight and incubation period did not effect prognosis. ...
Neonatal tetanus is an important health problem with an estimated 500,000 deaths per year worldwide, particularly in developing countries. We analysed 56 cases of neonatal tetanus (NNT), retrospectively, who were admitted to Diyarbakir Children State Hospital between 1994 and 2001. In 1998 an intervention in a childcare intensive unit was conducted, which included a nurse education programme, increasing the number of nurses and other health staff, and more qualified management of cases. The mean age of patients was 7.9 days at admission, and the male:female ratio was 1:6. Eleven per cent of the cases had body weight under 2500 g. The mean hospitalization period was 9.9 days. All patients were born at home without medical help and 28.6 per cent were from urban areas. The case fatality rate that was formerly 88.5 per cent, decreased to 53.6 per cent by the intervention conducted in 1998. Based on our findings, we can say that improved hospitalization conditions and intensive care may reduce mortality. Enforcing preventive policies both in rural and urban areas is of great importance in the least developed regions.
... There is an important reported difference in the fatality rate among patients with an incubation period of < 7 days compared to > 7 days [21,24], and a similar observation was made in the present study (p 0.07). Mortality was high in patients with generalised tetanus, with high fever, or with tachycardia, and in patients who had developed tetanus after injection or surgery, with an incubation period of < 7 days. ...
The objective of this study was to determine prognostic factors related to death from adult tetanus. Fifty-three cases of tetanus, 25 females and 28 males, were treated in Cukurova University Hospital during 1994-2000. The mean age was 46.6 years. Forty-one (77.7%) patients came from rural areas. Most (64.1%) cases had minor trauma, but 19 (35.8%) had deep injuries. The mean incubation period was 11.5 days. Mortality was high (52.8%), caused by cardiac or respiratory failure or complications, and was related to the length of the incubation period. In cases with an incubation period < or = 7 days, the mortality rate was 75% (p 0.07). Mortality was significantly associated with generalised tetanus (p < 0.05), fever of > or = 40 degrees C, tachycardia of > 120 beats/min (p < 0.05), post-operative tetanus (p 0.03), and the absence of post-traumatic tetanus vaccination (p 0.068). Patients who were given tetanus human immunoglobulin or tetanus antiserum (p > 0.05) had similar outcomes. Patients who were given penicillin had a mortality rate similar to patients who were given metronidazole (p 0.15). The mortality rate was higher (92%) in patients with severe tetanus than in patients with moderate disease (53%). By multivariate analysis, the time to mortality caused by tetanus, and also the mortality rate, were both related significantly to age and tachycardia.
Background
Studies on factors affecting mortality in neonatal tetanus (NNT) are mostly from other developing countries. Although NNT has been eliminated from India, cases are still occasionally reported from rural areas. Moreover, there is paucity of such studies from India. Hence, this study was aimed to identify risk factors affecting NNT mortality so that case fatality can be minimized especially in resource-limited settings.
Methods
The records of the 32 neonates diagnosed as NNT over a period of 8 years (2013-2020) were reviewed, and a statistical comparison of various variables between survivors and nonsurvivors was made.
Results
The overall case fatality rate in our study was 75%. Determinants of mortality in these cases were low birthweight, short incubation period, short period of onset, delay in seeking medical attention, presence of comorbidity, dose of tetanus immunoglobulin < 250 IU, and an unknown entry site of infection. Gender and place of delivery were not associated with increased mortality.
Conclusion
Improved maternal antenatal care (birthweight and gestation), recognition of the disease at onset of symptoms, and early hospital contact are important, in addition to optimum supportive care, to reduce NNT mortality.
Objective The aim of this study was to evaluate mortality rate and prognostic factors in neonatal tetanus cases presented to Turkey-Somalia Mogadishu Training and Research Hospital.
Methods A total of 35 neonatal tetanus cases presented to Turkey-Somalia Mogadishu Training and Research Hospital between 2014 and 2017 were included in this prospective observational study. Data on demographic, clinical and maternal obstetric characteristics, and laboratory findings including complete blood count and blood biochemistry were recorded in each patient. Study parameters were evaluated with respect to survivorship status, while multiple logistic regression analysis was performed to determine independent predictors of increased mortality risk.
Results Overall, mortality occurred in 22 (62.9%) of 35 neonates diagnosed with neonatal tetanus. Tetanus prophylaxis was absent in the majority of neonates, regardless of survivorship status (100.0% in nonsurvivors vs. 84.6% in survivors, p = 0.131). In nonsurvivor versus survivor groups, significantly higher likelihood of constipation (50.0 vs. 7.7%, p = 0.002), contracture (81.8 vs. 46.2%, p = 0.035), and ventilator support (95.4 vs. 53.8%, p = 0.006) as well as significantly lower hemoglobin (14.45 ± 2.06 vs. 17.15 ± 1.77, p = 0.003) and potassium (3.50 ± 0.86 vs. 4.14 ± 0.93, p = 0.003) levels and neutrophil (3.34 ± 1.75 vs. 4.47 ± 1.08, p = 0.047, white blood cell (WBC) (5.54 ± 2.30 vs. 7.78 ± 1.70, p = 0.003) and platelet (median [min-max] 133.5 [68–332] vs. 196 [123–550], p = 0.006) counts were noted. Presence of contracture (odds ratio [OR]: 14.525, 95% confidence interval [CI]: 1.398–150.870, p = 0.025) and ventilator support (OR: 22.282, 95% CI: 1.269–391.131, p = 0.034) was the independent determinants of increased risk of mortality.
Conclusion Our findings emphasize high mortality in neonatal tetanus cases in Somalia along with lack of maternal tetanus prophylaxis in majority of cases. Presence of contractures and ventilator support were significant determinants of poor survival, while factors such as constipation, lower hemoglobin, and potassium levels and lower neutrophil, WBC and platelet counts were also more common among nonsurvivors, albeit not found to be associated with mortality risk in the multivariate analysis.
Background: Neonates and infants comprise the majority of the 6 million annual deaths under 5 years of age around the world. Most of these deaths occur in low/middle income countries (LMICs) and are preventable. However, the clinical identification of neonates and infants at imminent risk of death is challenging in developing countries.
Objective: To systematically review the literature on clinical risk factors for mortality in infants under 12 months of age hospitalized for sepsis or serious infections in LMICs.
Methods: MEDLINE and EMBASE were systematically searched using MeSH terms through April 2017. Abstracts were independently screened by two reviewers. Subsequently, full-text articles were selected by two independent reviewers based on PICOS criteria for inclusion in the final analysis. Study data were qualitatively synthesized without quantitative pooling of data due to heterogeneity in study populations and methodology.
Results: A total of 1,139 abstracts were screened, and 169 full-text articles were selected for text review. Of these, 45 articles were included in the analysis, with 21 articles featuring neonatal populations (under 28 days of age) exclusively. Most studies were from Sub-Saharan Africa and South Asia. Risk factors for mortality varied significantly according to study populations. For neonatal deaths, prematurity, low birth-weight and young age at presentation were most frequently associated with mortality. For infant deaths, malnutrition, lack of breastfeeding and low oxygen saturation were associated with mortality in the highest number of studies.
Conclusions: Risk factors for mortality differ between the neonatal and young infant age groups and were also dependant on the study population. These data can serve as a starting point for the development of individualized predictive models for in-hospital and post-discharge mortality and for the development of interventions to improve outcomes among these high-risk groups.
Introduction: Neonatal tetanus is a major problem in Pakistan, being one of the common causes of neonatal deaths especially in the rural areas where deliveries are conducted at home by Dais in unhygienic conditions and vaccination status of the mothers is not very encouraging. Objectives: The case series was conducted to find out complications, clinical course and outcome of neonatal tetanus. Methodology: It was conducted at the department of Neonatology of the Children's Hospital and the Institute of Child Health, Lahore. This case series was carried out in a prospective manner. The sample size consisted of fifty neonates who presented with neonatal tetanus over one year. Diagnosis of neonatal tetanus was established exclusively on clinical grounds. Results: Male to female ratio was 7.3:1. Eighty percent of the cases were home delivered and in 88% cases, mothers were not vaccinated against tetanus. The umbilical cord was cut with blade in 60% and Desi Ghee was applied to the umbilical stump in 20% of cases. All the fifty neonates had poor sucking. Opisthotonos was noted in 84% cases while lock jaw was present in 78% neonates. Regarding complications, 19 patients developed aspiration pneumonia, 12 developed Jaundice, 18 neonates developed intractable fits and 12 developed acute renal failure. The overall mortality in this study was 50%; the patients who were ventilated mechanically had a mortality rate of 46.66% while those who were not ventilated had a mortality of 52.63%. The patients with shorter incubation period i.e less than 7 days (33 patients) had a worst out come with a statistically significant p-value (p <0.001). There was 100% mortality among the premature neonates with tetanus in contrast with 44.4% mortality amongst the full term neonates. Conclusion: Our experience in this study revealed that lack of tetanus immunization of mothers along with unsafe and unhygienic delivery practices are major factors responsible for the development of this disease. Wile short incubation period, prematurity and opisthotonos are associated with high mortality.
Neonatal tetanus has been largely eradicated in the developed world, but it remains a leading cause of newborn morbidity and mortality in parts of the developing world. It is caused by tetanospasmin, a neurotoxin produced by Clostridium tetani, an obligatory anaerobic Gram-positive bacillus. The predisposing factors include poor anti-tetanus vaccination during pregnancy, unhygienic delivery and poor care of wounds. The commonest portal of infection is the umbilical cord stump, and the incubation period ranges from three days to three weeks with an average of eight days. The disease is characterized by generalized involuntary muscle rigidity resulting in masklike facies known as risus sardonicus, locked jaws known as trismus, opisthotonus, generalized spasms and features of autonomic dysfunction. The management includes control of spasms with multiple sedatives, antibiotics, optimal wound care and stringent airway management. Prognosis depends on the incubation period, period of onset and quality of nursing care.
Introduction: to know the clinical aspects of neonatal tetanus including its prognostic factors. Design: Observational cohort study. Setting: Paediatric department, Tehsil Headquarter Hospital, Liaquetpur. Patients and methods: Every case of neonatal tetanus diagnosed clinically was registered for the study. Results: Forty-one case of neonatal tetanus were included. 12.19% cases were females. All were delivered at home with 97.56% delivered by untrained dais. 95.12% mothers belonged to rural and 97.56% mothers were unvaccinated. The mean age and weight at presentation were 6.341 days and 2.949 kg and mean duration of symptoms were 38.049 hours. Refusal to take feed in 100%, convulsions in 73.17%, inability to open the mouth in 97.56%, fever in 34.15% and excessive cry in 51.22% of cases were the main symptoms. For cutting of umbilical cord knife in 34.15%, blade in 19.51%, scissors in 29.27%, razor in 7.32% and unknown in 7.32% cases were used. The umbilical stump was painted with desi ghee in 19.51%, oil in 4.88%, surma in 39.02% ash in 21.95%, talcum in 2.44%, cow dung in 2.44% and unknown in 9.76% cases. Of the 41 cases, 34.14% were cured, 36.58% expired and in 29.27% the fate was unknown. The expired versus survived group showed the difference between the age of onset 4.80 vs 8.714 days (p=0.002), duration of symptoms 20.8 vs 62.571 hours (p<0.0001) and hospital stay 2.8 vs 14.571 days (p<0.0001), convulsions with apnea 7 vs 3 cases (p=0.2993), weight 2.940 vs 3.007 kg (p=0.717), female sex 2 vs 2 cases and fever 7 vs 3 cases (p=0.2993). Conclusion: The cure rate of neonatal tetanus is very low.
Neonatal tetanus is unfortunately still seen in southeast Turkey. Twenty-four patients with neonatal tetanus who were admitted to our clinic between January 1999 and December 2002 were reviewed retrospectively according to clinical features, prognostic aspects and risk factors. Sixteen of 24 cases were male and their ages were from 2 to 15 days. Fever and lack of sucking reflex were the main complaints the admission. Lack of sucking (100%), trismus (79%), fever (58%), risus sardonicus (29%), omphalitis (33%), and opisthotonus (17%) were the most common presenting signs. Untrained traditional birth attendants delivered all the patients at home, and umbilical cords were cut using non-hygienic instruments. Seventy-five percent of the patients who were admitted died. The most important risk factors were uneducated parents, birth at home, cutting of cords using non-hygienic instruments, failure to give mothers tetanus toxoid immunizations during pregnancy, and poor health and sanitary conditions of the mothers and their babies.
Introduction: Neonatal tetanus is a highly fatal disease that can be prevented by immunization and
improvement in obstetric practices. The aim of the present study was to assess the characteristics of cases
of neonatal tetanus in two large tertiary hospitals (Ghaem and Imam Reza hospitals) of Mashhad -North
East of Iran between 1984- 2001.
Methods: all cases whose epidemiological and clinical characteristics were compatible with neonatal
tetanus and were admitted into the NICU’s of these two hospitals between July 1984 to June 2001 were
analyzed from their hospital records.
Results: A total of 60 patients had been hospitalized with the diagnosis of neonatal tetanus during the
study period. All of them were delivered out of hospital by untrained birth attendants and none of the
mothers had been immunized against tetanus during pregnancy. 74% of infants died. Age younger than 7
days at the time of admission was associated with a high mortality rate.
Conclusion: Although neonatal tetanus is a highly fatal disease yet. It can be prevented with appropriate
health care practices and tetanus immunization of pregnant women
In the Eastern Mediterranean region, mass rural-to-urban migration and uncontrolled population growth in low-income countries such as Syria have given rise to sprawling unplanned peri-urban development. Virtually no data are available on the environmental conditions and health status of residents of such communities. This paper describes formative qualitative research in eight settlements in informal zones around Aleppo, Syria’s second-largest city, to assess environmental problems and health hazards. Several common themes emerged regarding community-level conditions that placed residents at substantial health risk, including sub-standard housing, limited access to high-quality health care, an absence of adequate essential services, problems with toxins and pollutants, poor educational and employment opportunities, and crime. Further research is being conducted to understand the distribution of these problems and the associations between environmental conditions and health status. Urgent action is needed to eliminate dangerous living conditions in these settlements.
This research was conducted in Ankara province for the purpose of examining the status of planning in preparation for retirement as an individual and as a family of individuals who show differences in educational level. Individuals who lived in Ankara province, who were 3 years from retirement according to age limit, and who had social security from one of the three official government plans (The Pensions Fund For Civil Servants of The Republic of Turkey, Social Insurance Institution, or Social Security Organization of Artisans, and Craftsmen and other Self-Employed People) were the research population from which 393 individuals were chosen using the Stratified Random Sampling Method. There was a higher percentage of individuals who stated that they had not planned for retirement than those who had. Of the individuals who stated that they had made plans, 80.7% had made those plans about their financial status. Individuals who thought that it was necessary to have an educational program for preparing for retirement also wanted “financial status” topics at the head of the list of topics for such a program.
The authors retrospectively analyzed the case records of all the newborns admitted with the diagnosis of neonatal tetanus (NT) over a period of 36 mo. A total of 27 cases of neonatal tetanus were admitted over a period of 36 mo. Out of these 27 neonates, 17 died and thus the overall mortality was 63%. The mean age of onset of symptoms in those who survived was 8.1 ± 2.02 d whereas in those who died was 5.7 ± 1.39 d, which was statistically significant (p = 0.001). The babies with age of onset <7 d were almost 5 times more likely to die than those manifesting at 7 d or later. Thus, NT is still contributing to neonatal deaths especially in the backward areas of the country and onset of symptoms within a wk of birth is a very high risk factor for mortality.
To estimate the incidence of neonatal tetanus (NT) and to study the factors associated with NT mortality in Dadu district, Pakistan.
This study is a retrospective analysis of surveillance data from 1993-2003. NT cases were identified from the district surveillance database and hospital records reviews. Cases were ascertained using the NT standard case definition. Clinical records of all neonates (n = 416) admitted with the diagnosis of NT from 1993 through 2003 were reviewed for clinical presentation, progression and outcome. Rates, means and frequencies were calculated. Odds ratio was calculated to determine the association between potential risk factors and NT mortality. Logistic regression models were used to compute odds ratios and their associated 95% Confidence Intervals.
Out of a total of 416 NT cases, 408 met the case definition. The overall case fatality rate (CFR) for NT was 30.1% (95% Confidence Interval (CI):25.6-34.6); CFR fell from 42% in 1993 to 29% in 2003 (p = 0.377). NT incidence decreased from 0.90/1000 live births (LB) in 1994 to 0.18/1000 LB in 2003. Multivariable analysis showed that age at admission of 8 days or less with {Odds Ratio (OR) 9.41, CI: 2.67-33.14} or without (OR 2.62, CI: 1.52-4.50) low neonatal weight was the strongest predictor of mortality.
The rate of decline of neonatal tetanus incidence and case fatality was consistent with the impact of routine and supplementary immunization activities. In addition to strengthening maternal tetanus toxoid immunization coverage and hygienic delivery practices, health education focusing on increasing awareness of NT could help reduce NT mortality.
Neonatal tetanus (NNT) is a major cause of newborn deaths especially in the developing world. While efforts aimed at eradicating NNT should be sustained, it is equally imperative to reduce death among affected infants. Therefore, the factors associated with mortality rate in this condition need to be studied.
The records of infants with NNT over a 15-year period (1991-2005) were reviewed. A statistical comparison of the survivors and fatalities for relevant clinical characteristics was done, and the determinants of fatality rate were also determined using logistic regression.
Ninety-six of 151 newborns with NNT died, giving a mortality rate of 63.6%. The case fatality rate during the study period varied between 33.3% and 100%. More deaths occurred in the infants with low birth weight (P=0.004) within 1 day at the onset of symptoms (P<0.001), whose mothers aged 18 years or less (P=0.001) belonged to socio-economic class V (P=0.001). Determinants of mortality in these infants with NNT included low socio-economic class (P=0.002), no antitetanus vaccination (P=0.006), presentation with spasms (P<0.001), and non-administration of anti-tetanus serum during treatment (P=0.013).
The mortality rate in infants with NNT remains signifi cantly high in Nigeria. Improved maternal anti-tetanus vaccination and timely recognition and treatment of affected infants may jointly reduce the incidence and fatality rate of NNT.
Although activating mutations of fibroblast growth factor receptor 3 (FGFR3) are frequent in bladder tumors, little information is available on their specific effects in urothelial cells or the basis for the observed mutation spectrum. We investigated the phenotypic and signaling consequences of three FGFR3 mutations (S249C, Y375C, and K652E) in immortalized normal human urothelial cells (TERT-NHUC) and mouse fibroblasts (NIH-3T3). In TERT-NHUC, all mutant forms of FGFR3 induced phosphorylation of FRS2alpha and ERK1/2, but not AKT or SRC. PLCgamma1 phosphorylation was only observed in TERT-NHUC expressing the common S249C and Y375C mutations, and not the rare K652E mutation. Cells expressing S249C and Y375C FGFR3 displayed an increased saturation density, related to increased proliferation and viability. This effect was significantly dependent on PLCgamma1 signaling and undetectable in cells expressing K652E FGFR3, which failed to phosphorylate PLCgamma1. In contrast to TERT-NHUC, expression of mutant FGFR3 in NIH-3T3 resulted in phosphorylation of Src and Akt. In addition, all forms of mutant FGFR3 were able to phosphorylate Plcgamma1 and induce morphological transformation, cell proliferation, and anchorage-independent growth. Our results indicate that the effects of mutant FGFR3 are both cell type specific and mutation specific. Mutant FGFR3 may confer a selective advantage in the urothelium by overcoming normal contact inhibition of proliferation.
Although neonatal tetanus (NT) can be prevented by immunization of expectant mothers and by good hygiene and asepsis during delivery, it is still a common cause of neonatal mortality in developing countries. The objective of this study was to determine indicators in NT. We reviewed the clinical records of 73 neonates admitted to the Pediatric Infectious Diseases Ward of Dicle University Hospital, Diyarbakir, Turkey, with the diagnosis of NT. Delivery had occurred at home by untrained traditional birth attendants in all cases. None of the mothers had immunization with tetanus toxoid during pregnancy. The median age of infants at presentation was 7.3 days and the mean age at onset of symptoms was 5.6 +/- 2.8 days. The overall mortality was found to be 52 percent. Mortality was significantly associated with an incubation period of 4.3 days or less and fever. The incidence of NT in Turkey is on the decline due to widespread tetanus toxoid use in pregnant women, but in some regions, especially in the so-called rural poor areas, there is still risk of preventable diseases. Hygienic deliveries and immunization of pregnant women are very important for the prevention of NT deaths, and universal prenatal care, including education programs on appropriate perinatal and cord care, can significantly reduce NT incidence and mortality in developing countries.
We report on a patient with a severe premature calvarial synostosis and epidermal hyperplasia. The phenotype was consistent with that of a mild presentation of Beare-Stevenson syndrome but molecular analysis of the IgIII-transmembrane linker region and the transmembrane domain of the gene encoding the FGFR2 receptor, revealed wild-type sequence only. Subsequently, molecular analysis of the FGFR3 receptor gene identified a heterozygous P250R missense mutation in both the proposita and her mildly affected father. This communication extends the clinical spectrum of the FGFR3 P250R mutation to encompass epidermal hyperplasia and documents the phenomenon of activated FGFR receptors stimulating common downstream developmental pathways, resulting in overlapping clinical outcomes.
Various human skeletal disorders are thought to be caused by mutations in fibroblast growth factor receptor 3 (FGFR3). These result in chronic FGFR3 hyperactivation and inhibition of bone growth. One such disorder, thanatophoric dysplasia, the most common form of sporadic, lethal dwarfism, is associated frequently with cysteine substitutions (G370C, S371C, and Y373C) in the extracellular juxtamembrane region of the receptor. These mutations have been suggested to induce disulfide-mediated receptor dimerization and constitutive activation. An adjacent cysteine substitution (G375C) leads to a less severe form of human dwarfism, achondroplasia, suggesting that the intensity of FGFR3 activation by these cross-links may be position dependent. To test this hypothesis, we have sequentially replaced each amino acid at positions 370-375 of FGFR3 with cysteine. Expression of each of these mutant forms in 293T cells led to their spontaneous, ligand-independent dimerization and increased basal phosphorylation. Wild-type (WT) FGFR3 became dimerized and phosphorylated only on FGF stimulation. Among the mutants, only two (G370C and S371C) caused high basal phosphorylation with significantly increased constitutive levels of mitogen-activated protein kinase (MAPK) phosphorylation and c-fos transcription. This activity was probably caused by mutant homodimer pairs, because WT-mutant heterodimers were observed only in the presence, but not in the absence, of FGF1. The high spontaneous activity of the mutants in positions 370-371, unlike those in 372-375, affirms their known involvement with thanatophoric dysplasia. We conclude that the G370C and S371C mutant receptors spontaneously dimerize in the correct spatial orientation required for effective signal transduction, whereas the 372-5 mutants, like the WT receptor, may achieve this orientation only on ligand binding.
ErbB4 is a member of the epidermal growth factor receptor(EGFR) family of tyrosine kinases, which includes EGFR/ErbB1, ErbB2/HER2/Neu, and ErbB3/HER3. These receptors play important roles both in normal development and in neoplasia. For example, deregulated signaling by ErbB1 and ErbB2 is observed in many human malignancies. In contrast, the roles that ErbB4 plays in tumorigenesis and normal biological processes have not been clearly defined. To identify the biological responses that are coupled to ErbB4, we have constructed three constitutively active ErbB4 mutants. Unlike a constitutively active ErbB2 mutant, the ErbB4 mutants are not coupled to increased cell proliferation, loss of contact inhibition, or anchorage independence in a rodent fibroblast cell line. This suggests that ErbB2 and ErbB4 may play distinct roles in tumorigenesis in vivo.
In order to identify genes that are associated with outer hair cell(OHC)-specific function, a plasmid library enriched with OHC-specific gene products was constructed using single cell-type-specific complementary DNA (cDNA) and a PCR subtractive hybridization strategy. As a first step, we created separate OHC and inner hair cell (IHC) cDNA pools from individually collected cells using a nonspecific reverse transcription polymerase chain reaction. Next, the OHC cDNA was subtracted against IHC cDNA using a PCR-based subtractive technique. IHCs and OHCs share many common features, making IHC cDNA an ideal 'driver' to 'subtract away' common hair cell gene products and enrich differentially expressed cDNAs, including OHC-specific genes. The subtracted OHC cDNAs were then cloned to generate an OHC - IHC subtracted cDNA plasmid library. Finally, a differential screening procedure was performed, resulting in 477 differentially positive clones. After analysis of these 477 clones, 50 known genes were identified, including two previously known OHC-specific proteins: oncomodulin and the recently described motor protein prestin. An additional 84 novel clones were also found. As this library of cDNA fragments represents differentially expressed genes in OHCs, it can be used as starting material for isolation and characterization of a complete set of OHC gene products, an important step in investigating normal and abnormal cochlear function.
To perform an updated meta-analysis of the effect of vitamin A supplementation on childhood morbidity from respiratory tract infections and diarrhea. Study design A comprehensive search of the 1966 to 2000 MEDLINE database and review of the reference lists of relevant articles identified 9 randomized controlled trials dealing with morbidity from respiratory infections and diarrhea in children 6 months to 7 years of age and provided "intention-to-treat" data.
The combined results indicated that vitamin A supplementation has no consistent overall protective effect on the incidence of diarrhea (relative risk, 1.00; 95% CI, 0.94-1.07) and that it slightly increases the incidence of respiratory tract infections (relative risk, 1.08; 95% CI, 1.05-1.11).
High-dose vitamin A supplements are not recommended on a routine basis for all preschool children and should be offered only to individuals or populations with vitamin A deficiency.
Targeted gene disruption in mice is a powerful tool for generating murine models for human development and disease. While the human genome program has helped to generate numerous candidate genes, few genes have been characterized for their precise in vivo functions. Gene targeting has had an enormous impact on our ability to delineate the functional roles of these genes. Many gene knockout mouse models faithfully mimic the phenotypes of the human diseases. Because some models display an unexpected or no phenotype, controversy has arisen about the value of gene-targeting strategies. We argue in favor of gene-targeting strategies, provided they are used with caution, particularly in interpreting phenotypes in craniofacial and oral biology, where many genes have pleiotropic roles. The potential pitfalls are outweighed by the unique opportunities for developing and testing different therapeutic strategies before they are introduced into the clinic. In the future, we believe that genetically engineered animal models will be indispensable for gaining important insights into the molecular mechanisms underlying development, as well as disease pathogenesis, diagnosis, prevention, and treatment.
Malaria in pregnancy is a major cause of poor outcomes for both mother and fetus, and malaria-induced low birth weight (LBW) may kill nearly 400,000 African infants each year. The hallmark of pregnancy malaria due to Plasmodium falciparum is the sequestration of infected erythrocytes (IEs) in the placenta. Malaria can suppress responses to immunogens, and placental malaria can impair materno-fetal antibody transfer, potentially reducing the benefits of maternal immunization strategies. Parasites infecting the placenta have been shown to have distinct adhesive and antigenic features. Women become resistant to pregnancy malaria over successive pregnancies as they acquire antibodies that recognize placental parasites, suggesting that a vaccine is feasible. Serologic evidence indicates that the target for such a vaccine is antigenically conserved, and surface proteins expressed by placental parasites have been identified as vaccine candidates. Because malaria suppresses vaccine responses and reduces the transfer of maternal antibodies to the fetus, the prevention of pregnancy malaria may benefit maternal immunization strategies that protect neonates from infections other than malaria.
Previous studies have identified various risk factors for neonatal tetanus (NNT) in rural areas of Pakistan. The present matched case control study was conducted to further evaluate these risk factors in an urban setting.
The study was carried out to identify risk factors for NNT in Karachi.
Patients of NNT (n = 125) diagnosed from January 1998 to February 2001 were recruited through a surveillance system of Expanded Programme on Immunization (EPI). Two neighbourhood controls (n = 250) were matched for each case for gender and date of birth of the case.
Conditional logistic regression was performed to assess the independent effect of factors associated with NNT.
The final multivariable model identified subsequent application of substances on the umbilical cord (adjusted matched odds ratio [adj. mOR] = 5.1 [2.7-9.7]), home delivery (adj. mOR = 1.8; 95% CI: 1.1- 3.1) and illiterate mother (adj. mOR = 1.6; 95% CI: 1.0- 2.0) as risk factors for NNT after adjusting for other variables in the model. Population attributable risk per cent (PAR %) for subsequent cord application was 69% and PAR % for home delivery was 31%.
Health planners, while formulating control strategies through immunization programmes should also take into account the impact of post-delivery practices, such as 'subsequent cord application' along with pre-delivery practices. Health awareness regarding appropriate post-delivery practices should be promoted and counselling of pregnant women for giving preference to health care setting for delivery is also crucial.
At Ethio-Swedish Children's Hospital Addis Ababa, Ethiopia, children admitted with a diagnosis of tetanus during January 1989- December 1998 were studied. During the 10 year study period there were 113 patients admitted with a diagnosis of tetanus. Sixty two (54.9%) of them were newborns and the rest 51 (45.1%) were children between the age of 1 and 12 years. Fifty six (90.3%) of the newborns were born at home and 43 (69.4%) of the mothers didn't have antenatal care. The median age on admission was 7 days. The umbilicus was assumed to be the portal of entry for all the cases with neonatal tetanus. Forty six (74.2%) of those with neonatal tetanus died in the hospital. Significantly high case fatality rate was seen in neonates with incubation period less than 7 days, onset time 48 hours or less, high pulse rate >140/minute and in those having fever. In non-neonates, the median age at admission was 9 years and the commonest site of entry was lesion on the lower extremities. Sixteen (31.4%) died in the hospital. The outcome was poor in those with onset time of 48 hours or less and in those presenting within 72 hours after the onset of illness. The overall mortality is high. Due attention needs to be given to children with tetanus having poor prognostic factors, particularly among newborns. Antenatal care needs to be promoted. A community based study is recommended to determine the true magnitude of the problem.
As part of the global strategic plan to reduce the number of measles deaths in India, the state of Tamilnadu aims at > or =95% measles vaccination coverage. A study was conducted to measure overall coverage levels for the Poondi Primary Health Center (PPHC), a rural health-care facility in Tiruvallur District, and to determine whether any of the PPHC's six health subcenters had coverage levels <95%.
The Lot Quality Assurance Sampling (LQAS) method was used to identify health subcenters in the PPHC area with measles vaccination coverage levels <95% among children aged 12-23 months. Lemeshow and Taber sampling plans were used to determine that the measles vaccination status of 73 children aged 12--23 months had to be assessed in each health subcenter coverage area, with a 5% level of significance and a decision value of two. If more than two children were unvaccinated, the null hypothesis (i.e., that coverage in the health subcenter was low [<95%]) was not rejected. If the number of unvaccinated children was two or fewer, the null hypothesis was rejected, and coverage in the subcenter was considered to be good (i.e., > or =95%). All data were pooled in a stratified sample to estimate overall total coverage in the PPHC area.
For two (33.3%) of the six health subcenters, more than two children were unvaccinated (i.e., coverage was <95%). Combining results from all six health subcenters generated a coverage estimate of 97.7% (95% confidence interval = 95.7-98.8) on the basis of 428 (97.7%) of 438 children identified as vaccinated.
LQAS techniques proved useful in identifying small health areas with lower vaccination coverage, which helps to target interventions. Monthly review of vaccination coverage by subcenter and village is recommended to identify pockets of unvaccinated children and to maintain uniform high coverage in the PPHC area.
Beginning in late 2003, a substantial outbreak of influenza A (H5N1) virus spread among poultry in Thailand. On January 23, 2004, the Ministry of Public Health (MPH) detected the first confirmed human case of H5N1 infection in humans.
During February-November 2004, the MPH's Bureau of Epidemiology and provincial health offices worked together to investigate the H5N1 outbreak in humans. Two studies were conducted: a descriptive study to describe clinical manifestations and epidemiologic characteristic of the cases and a matched case-control study to determine risk factors for persons who might subsequently become ill with H5N1.
A total of 16 patients with confirmed H5N1 were identified for the case-control study. Fever and respiratory symptoms predominated. Leucopenia and thrombocytopenia were present respectively in nine (100%) and four (44%) persons aged <15 years. Direct touching of unexpectedly dead poultry was the most significant risk factor (odds ratio = 29.0; 95% confidence interval = 2.7-308.2). Overall mortality was 75%; mortality for persons aged <15 years was 90%, compared with 57% for persons aged > or =15 years.
Avian influenza was more severe in children, who should avoid handling dead poultry during epizootics. Early avian influenza in children resembled the more common dengue fever, but presence of cough and absence of hemoconcentration distinguished avian influenza, which often progressed rapidly to acute respiratory distress syndrome, requiring intensive care.
Epidermal nevi are common congenital skin lesions with an incidence of 1 in 1,000 people; however, their genetic basis remains elusive. Germline mutations of the FGF receptor 3 (FGFR3) cause autosomal dominant skeletal disorders such as achondroplasia and thanatophoric dysplasia, which can be associated with acanthosis nigricans of the skin. Acanthosis nigricans and common epidermal nevi of the nonorganoid, nonepidermolytic type share some clinical and histological features. We used a SNaPshot multiplex assay to screen 39 epidermal nevi of this type of 33 patients for 11 activating FGFR3 point mutations. In addition, exon 19 of FGFR3 was directly sequenced. We identified activating FGFR3 mutations, almost exclusively at codon 248 (R248C), in 11 of 33 (33%) patients with nonorganoid, nonepidermolytic epidermal nevi. In 4 of these cases, samples from adjacent histologically normal skin could be analyzed, and FGFR3 mutations were found to be absent. Our results suggest that a large proportion of epidermal nevi are caused by a mosaicism of activating FGFR3 mutations in the human epidermis, secondary to a postzygotic mutation in early embryonic development. The R248C mutation appears to be a hot spot for FGFR3 mutations in epidermal nevi.
Neonatal tetanus (NNT), a preventable disease, remains an important cause of infant mortality in developing countries such as India.
To evaluate the demographic and clinical data of NNT in North Bengal, India and determine the risk factors for mortality.
Hospital records of all cases of NNT admitted over a 7-year period (1997-2003) were analysed. Demographic data, clinical presentation, progression and outcome were evaluated and comparisons made between the group who survived and those who died.
The overall mortality was 66.3%. The group who survived had a significantly greater mean bodyweight on admission, later onset of the disease and were hospitalised early. Risus sardonicus, generalised rigidity, fever, intercurrent infections and respiratory arrest were significantly more common in the fatal group.
Although over the 7 years improvement was observed in admissions for NNT, maternal literacy and the economic status of families, there is a persisting lack of awareness regarding antenatal care, and deliveries are still conducted unhygienically by untrained persons.
More than 60% of low-grade non-invasive papillary urothelial cell carcinomas contain activating point mutations of fibroblast growth factor receptor 3 (FGFR3). The phenotypic consequences of constitutive activation of FGFR3 in bladder cancer have not been elucidated and further studies are required to confirm the consequences of inhibiting receptor activity in urothelial cells. We measured FGFR3 transcript levels and demonstrated that transcript levels were significantly more abundant in low-stage and grade tumours. We identified a tumour cell line, 97-7, expressing the most common FGFR3 mutation (S249C) at similar FGFR3 transcript levels to low-stage and grade tumours. In these cells, S249C FGFR3 protein formed stable homodimers and was constitutively phosphorylated. We used retrovirus-mediated delivery of shRNA to knockdown S249C FGFR3. This induced cell flattening, decreased cell proliferation and reduced clonogenicity on plastic and in soft agar. However, no effects of knockdown of wild-type FGFR3 were observed in telomerase immortalized normal human urothelial cells, indicating possible dependence of the tumour cell line on mutant FGFR3. Re-expression of S249C FGFR3 in shRNA-expressing 97-7 cells resulted in a reversal of phenotypic changes, confirming the specificity of the shRNA. These results indicate that targeted inhibition of S249C FGFR3 may represent a useful therapeutic approach in superficial bladder cancer.
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.
The incidence of poliomyelitis and neonatal tetanus in llorin Local Government Area was estimated using a 40-cluster, retrospective
survey of neonatal tetanus deaths and lameness from poliomyelitis in March and April 1988. The survey identified 19 neonatal
tetanus deaths among 1601 livebirths, giving an incidence rate of 14.9/1000 livebirths. Some 31 residual paralytic polio cases
were identified among 4576 children aged five to nine years, giving a prevalence rate of 6.8/1000 children in this age group
and an annual incidence rate of 38.3/100 000 general population. Immunization of pregnant women with tetanus toxoid, had a
greater impact on mortality from neonatal tetanus than delivery in hospital or birth at home attended by a traditional birth
attendant. Antenatal coverage with two doses of tetanus toxoid was 62.6%. Poliomyelitis and neonatal tetanus still constitute
important causes of childhood morbidity and mortality in llorin and antenatal tetanus immunization coverage is not yet sufficient
to control neonatal tetanus in this population. The target age for immunization with tetanus toxoid should be extended to
include all women of childbearing age. Further retrospective surveys from other Nigerian states are needed to determine the
magnitude of the neonatal tetanus problem throughout the country.
Conventional methods of classifying causes of death suggest that about 70% of the deaths of children (aged 0-4 years) worldwide are due to diarrhoeal illness, acute respiratory infection, malaria, and immunizable diseases. The role of malnutrition in child mortality is not revealed by these conventional methods, despite the long-standing recognition of the synergism between malnutrition and infectious diseases. This paper describes a recently-developed epidemiological method to estimate the percentage of child deaths (aged 6-59 months) which could be attributed to the potentiating effects of malnutrition in infectious disease. The results from 53 developing countries with nationally representative data on child weight-for-age indicate that 56% of child deaths were attributable to malnutrition's potentiating effects, and 83% of these were attributable to mild-to-moderate as opposed to severe malnutrition. For individual countries, malnutrition's total potentiating effects on mortality ranged from 13% to 66%, with at least three-quarters of this arising from mild-to-moderate malnutrition in each case. These results show that malnutrition has a far more powerful impact on child mortality than is generally appreciated, and suggest that strategies involving only the screening and treatment of the severely malnourished will do little to address this impact. The methodology provided in this paper makes it possible to estimate the effects of malnutrition on child mortality in any population for which prevalence data exist.
Despite broad agreement that severe malnutrition contributes to child mortality in developing countries and that malnutrition has a physiologically synergistic relationship with morbidity, evidence of an epidemiologic synergism has been lacking. Also, the literature provides conflicting evidence concerning the existence of elevated mortality among children with mild to moderate malnutrition. A review of published population-based studies of anthropometry-mortality relationships was undertaken to clarify these relationships.
Six studies with the relevant data were reanalyzed to test for synergism and elevated mortality in mild to moderate malnutrition.
The results demonstrate that mortality increases exponentially with declining weight for age. This effect is consistent across studies and there is no apparent threshold effect on mortality. The primary difference across studies is in baseline levels of mortality, which determine the quantitative impact of malnutrition on mortality in a population.
These results indicate that mild to moderate malnutrition is associated with elevated mortality and that there is an epidemiologic synergism between malnutrition and morbidity. This previously undemonstrated finding has significant implications for child survival policies and research.
In a house-to-house survey in Kilifi District, Kenya, mothers of 2556 liveborn children were interviewed about neonatal mortality, especially from neonatal tetanus (NNT). The crude birth rate was 60.5 per 1000 population, the neonatal mortality rate 21.1 and the NNT mortality rate 3.1 per 1000 livebirths. The neonatal and NNT mortality rates were higher in boys than in girls. Neonatal tetanus was not associated with mother's age, parity, or history of previous child death. The majority of the children (72%) were adequately protected at birth against NNT; in those with documented protection NNT mortality was 0, in those with undocumented protection 1.2 and in other children 8.5 per 1000 livebirths. Other risk factors for NNT included home delivery, untrained assistance during delivery, unhygienic cord cutting and application of potentially infectious substances on the umbilical stump. The survey indicates that over the past decade the surveyed area has greatly reduced neonatal and NNT mortality. Possible strategies for accelerated NNT control have been identified by the survey.
Tetanus continues to be a leading cause of neonatal death in Bangladesh as in other developing countries, yet little is known about risk factors or the efficacy of tetanus toxoid in this setting.
In May 1990, mothers of 6148 infants born alive between March 15, 1989, and March 14, 1990, in 30 rural unions of Rajshahi Division in Bangladesh were interviewed. Three surviving controls for each neonatal tetanus death were matched for sex, residence, and date of birth.
Of 330 neonatal deaths, 112 met the case definition for tetanus. Risk was increased with a history of neonatal tetanus in a previous child, application of coconut oil to the vagina, and use of multiple ties on the umbilical cord. Risk was reduced by the birth attendant washing hands and using a cleaned cord-cutting tool. Risk was not reduced by a maternal history of two doses of tetanus toxoid (TT2), although estimated efficacy of TT2 was 45% (95% confidence interval = 16% to 64%). Subsequent to the survey, a reference laboratory reported to potency in three consecutive lots of tetanus vaccine from the production laboratory in Bangladesh.
These findings identify high-risk mothers, stress the importance of washing hands and cleaning the cord-cutting tool, and demand improved quality control of tetanus vaccine production.
Tetanus in general, particularly tetanus neonatorum is a great public health problem in tropical area. Our study concerned 1,159 cases admitted at the Infectious Diseases Department of Fann Hospital (Dakar, Senegal) from January 1979 to December 1989. The high frequency of tetanus neonatorum in developing countries was related to certain delivery conditions and lack of generalized antitetanus immunization. Therefore it is necessary to emphasize on health education to decrease the frequency of the disease and to improve tetanus neonatorum prognosis which mortality rate fluctuated between 60% and 90%.
Using the ELISA technique to estimate serum antibodies against tetanus toxin, seven neonates with clinical tetanus were found to have antibody levels 4-13 times higher than the presumed minimum protective level of 0.01 IU/ml. All but one of their mothers had been vaccinated with tetanus toxoid in pregnancy. In two other neonates, whose mothers had received multiple booster doses of toxoid during pregnancy, the anti-toxin concentrations were 100- and 400-times the presumed protective level. Therefore the toxin dose may overwhelm the pre-existing anti-toxin level and produce disease. Furthermore, multiple booster injections of tetanus toxoid may not only enhance serum anti-toxin titres, but could also lead to an ineffective immune response.
A hospital-based case-control study was conducted to further examine the risk factors for neonatal tetanus (NNT) in the North-west Frontier Province of Pakistan. Three control infants were concurrently evaluated for each of 102 consecutively diagnosed NNT cases hospitalized over an 8-week period. Application of clarified butter (ghee) during the first few days of life was shown to be a significant risk factor, confirming our previously reported finding. However, the risk appeared to be limited to ghee made in the home from cow's milk. The tool used to cut the umbilical cord was again refuted to be a risk factor; application of topical antibiotics conferred significant protection. Multivariate analysis of the matched data showed that delivery by persons with academic training (physicians, nurses, and lady health visitors) was also protective. Mothers with a past history of NNT babies were shown to have a significantly increased risk, and accounted for more than one-third of all cases in the present study. The findings suggest possible ways to augment the effectiveness of NNT elimination programmes.
Two-hundred-and-thirty-seven consecutive cases of neonatal tetanus treated in a rural health facility in Nigeria were reviewed. In spite of a high proportion of short incubation cases, a relatively simple, low-cost protocol yielded results compatible with those obtained in tertiary care settings in Africa. An incubation period of 6 days or less was the strongest predictor of mortality. Other prognostic factors were related to cord care and affected boys more than girls. Incidence was 40 per cent greater during the rainy season than during the dry season.
The aim of the study was to compare the placental transfer of tetanus toxoid antibodies (TTAB) and total IgG in Africa, where we had previously demonstrated a lack of transmission from mother to the newborn of measles antibodies. Two series of mother-child pairs, 45 in Paris and 134 in Libreville, Gabon, Central Africa, were measured after full-term pregnancies and normal deliveries. Means of ratios of cord/mother concentrations for TT AB and IgG were, respectively, 2.52 and 1.28 in Paris and 0.98 and 0.82 in Gabon. In 11 pairs from Libreville no TT AB were found in mother and cord blood, but in four other African newborns (3 per cent), the mother transmitted TT AB which were lower than protective level against tetanus. Other data (negative correlation between mother IgG and cord/mother ratio of corresponding TT AB concentrations, and better transmission of TT AB in the low range of maternal IgG) indicate that the limitation of active placental transfer of antibodies is related to the high maternal IgG level common in Africa.
In mountain villages of Chitral District in northwestern Pakistan, dried cow dung is used as Westerners would use talcum powder when babies are swaddled and rock salt is consumed in tea and other foods. Both substances are esteemed as conveying beneficial 'heat' and 'strength'. Unfortunately, however, cow dung sometimes contains a bacterium that causes neonatal tetanus, and the resulting toxin may enter through the baby's unhealed umbilical cord and cause death. Further, rock salt contains no iodine, and Chitral's soil is so iodine-deficient that goiter is very common. Thus local health workers advocate use of talcum powder rather than cow dung, immunization against tetanus, and replacement of rock salt by powdered iodized salt. The present report documents widespread community acceptance of these innovations despite the fact that the biomedical model of tetanus and goiter was not well understood and indigenous concepts of the causes of the diseases remained virtually undisturbed. Most of the villagers were Ismaili Muslim followers of the Aga Khan; their receptivity to such health messages was influenced by the high value that their religion places on advancement through 'education' and was correlated with their proximity to Ismaili health workers whom they trusted. A major implication of this research for primary health care programs is that when one is attempting to change existing health practices, explication of biomedical models should not be the only focus of concern. Attentiveness to the context in which behavior changes are introduced and interpreted is at least equally important. Further, the fact that new knowledge was added to the old without replacing it illustrates the complexity of human cognition and points to limitations in the KAP (knowledge-attitude-practice) model of health belief and behavior. This report adds to a small but important body of literature documenting the dynamic nature of medical pluralism in the developing world.
Neonatal tetanus is an important cause of avoidable morbidity and mortality. In the past this disease was overlooked by the health services of many developing countries, but recently the extent and magnitude of neonatal tetanus has become clearer and shown that it is a very serious health problem in the developing countries. The results of community-based surveys show that neonatal tetanus mortality rates range from less than 5 to more than 60 per 1000 live births; these deaths represent between 23% and 72% of all neonatal deaths. The results so far suggest that this disease claims the lives of over half a million new-born children every year. All forms of tetanus, and especially neonatal tetanus, remain substantially under-reported in many countries, and routine reporting systems identify only about 2-5% of the estimated number of tetanus cases (based on the results of community surveys). More reliable and accurate estimates of the incidence and mortality from tetanus are therefore required.The elimination of neonatal tetanus is an essential and attainable goal. It may be achieved by combining two approaches: (1) increasing the immunization coverage of women of child-bearing age, and especially pregnant women, with tetanus toxoid, and (2) improving maternity care, with particular emphasis on increasing the proportions of deliveries that are attended by trained persons.Neonatal tetanus mortality should serve as an index of the quality and the extent of utilization of the maternal health services, of the impact of immunization programmes, and of the progress being made in achieving the WHO goal of "Health for All by the Year 2000".The elimination of neonatal tetanus calls for a full commitment by governments and by other bodies, public and private, with a responsibility for the care of women and children. The occurrence of even a single case of neonatal tetanus is witness to failures in the health system, for prevention is possible through the actions of trained health staff in contact with the mother.
A follow-up study was conducted in six community health centres during the period April 1989 to March 1990 to determine the risk factors which influence neonatal survival in central Sudan. The estimated neonatal mortality rate ranged between 20.0 and 36.0 per 1000 live births per year, and the major cause of death was tetanus neonatorum (29% of neonatal deaths). The mortality rate was lowest when tetanus toxoid was received during pregnancy and the umbilical cord was cleaned by a modern hygienic method (mortality rate of 11 per 1000). In contrast, the mortality rate was highest when no tetanus toxoid was received and no or traditional cord cleaning was used (mortality rate of 62 per 1000; relative risk (RR) = 5.6, 95% confidence interval (CI) 2.0-14.9). The major predictors of neonatal mortality were tetanus, short birth-to-conception interval, multiparity, reported malaria during pregnancy, low birthweight, low maternal weight and low socio-economic status. The population attributable risks were high, and the preventable factors collectively accounted for 93.5% of neonatal mortality. Safe deliveries and wider immunization coverage are needed to control neonatal tetanus in this community. Other interventions to lower neonatal mortality in central Sudan should include accessible family planning programmes and measures to lower the incidence of low birthweight.
Over a 12-month period, a cluster survey on Neonatal tetanus (NNT) mortality was conducted in Northern Nigeria. The relative contributions of knowledge, attitude and practice (KAP) to certain epidemiological factors associated with NNT deaths were evaluated. NNT mortality was 20.6/1000 live-births (i.e. over 65% of neonatal mortality). Poor cord management showed the strongest association with NNT mortality with comparable contributions from KAP. Less than 40% of 2,623 live-births recorded during the survey followed two or more ante natal visits. This was significantly associated with NNT mortality with virtually equal contributions from KAP. Over 60% of the births had traditional surgeries performed with highly significant association with NNT mortality. Knowledge deficit was the most important contributor to performance of traditional procedures. Tetanus toxic coverage (32.0%) was also associated with NNT mortality with knowledge and attitudinal deficits accounting for over 75% of poor coverage. Most deliveries were outside hospitals and related facilities with highly significant association with NNT deaths. Attitude and practice contributed over 80% to this observation. In view of the associated epidemiological factors, and the relative roles of KAP, community--specific prevention strategies are suggested. Training and involvement of traditional birth attendants is emphasized. Domicilliary service are also suggested in view of the widely practised purdah system.
We sought to estimate the proportion of women immunized against tetanus while attending prenatal care in the developing countries.
We computed the ratio of the percentage of births to women immunized against tetanus to the percentage of births to women with prenatal care (TP ratio). A TP ratio is lower than 100% if not every woman attending prenatal care is immunized. We used 1986-1992 Demographic and Health Surveys data from 38 countries.
The mean TP ratios were 86% in Africa (n = 23), 79% in Asia (n = 6) and 60% in Latin American and the Caribbean (n = 9). The TP ratio was lower than 75% in 15 countries. Of these, four had a TP ratio lower than 50%.
In many countries the number of pregnant women immunized against tetanus is lower than the number of women attending prenatal care, suggesting that prenatal services are missing opportunities to immunize attending women.
The relationship between neonatal tetanus (NT) on one hand, and maternal tetanus immunization and other prenatal and natal practices on the other hand, was examined in a case-control study done at San Lazaro Hospital (SLH) in Manila from late 1990 to mid 1991. Included as cases were 54 patients diagnosed as NT on the basis of WHO criteria, and 50 controls who were patients 0-4 months of age, hospitalized at SLH during the study period and with no past history of tetanus. The result showed that the following were statistically associated with the risk of NT: home delivery (OR = 30.5); delivered by a traditional birth attendant (OR = 5.2); use of instrument other than scissors to cut the cord (OR = 19.3); traditional birth attendant who dressed the cord (OR = 12.7); and having less than two doses of tetanus toxoid (OR = 15.3). The need to intensify prenatal tetanus immunization, health education of the mothers as well as the training of birth attendants is evident from this study if NT has to be prevented.
The aim of this study was to assess the efficacy of the tetanus toxoid immunization programme in Nigeria, specifically the placental transfer of antibody to newborn Nigerian babies. Tetanus toxoid antibody levels were measured in 39 mother-baby pairs in Ibadan, Nigeria and compared with 78 British mother-baby pairs. Geometric means of the ratios of cord/mother (sequestration index SI) were 0.776 for Nigerian pairs and 1.306 for British pairs, indicating a limitation in the placental transfer of tetanus toxoid in the Nigerian population. These findings confirm that there is a block in the placental transfer of anti-tetanus toxoid antibodies in African populations which will affect current immunization programmes and requires further investigation.
A total of 2623 live births were recorded over a 12-month period during a cluster survey on neonatal tetanus (NNT) mortality
in Kano Metropolis, Northern Nigeria. The survey involved a two-stage cluster sampling technique. Some aspects of the clinical
features of NNT were evaluated. There were 79 neonatal deaths and 54 NNT deaths with NNT mortality rate of 20.6/1000 live
births. The mean incubation period for NNT was 7.3 days, while the mean age at death was 12.7 days. The peak age at death
was 8 days. Interval between mean age at onset and mean age at death was 5.4 days. Mean delay in presentation at health facilities
for treatment was 4.8 days. The possible significance of these features in prognosis is highlighted.
Neonatal tetanus is associated with a high mortality rate, despite intensive care. Although it can be prevented by immunization of expectant mothers and by good hygiene and asepsis during delivery, neonatal tetanus is still a common cause of neonatal mortality in underdeveloped countries. In our study, hospital records of 133 newborns with neonatal tetanus were evaluated to identify the possible factors affecting prognosis of neonatal tetanus; 79 were males and 56 females, and 54 (41.6%) of the 133 died. Sex and birth weight did not affect the prognosis. As a result of our study, we found that age on admission < 10 days, symptoms < 5 days and presence of risus sardonicus and fever indicate a poor prognosis in neonatal tetanus.
Clinical charts of 44 neonates admitted to the National Institute of Pediatrics with the diagnosis of neonatal tetanus from 1970 to 1990 were reviewed. All patients had an epidemiologic and clinical findings compatible with neonatal tetanus. Delivery had occurred at the homes of the patients in 89% of the cases and in 11% at clinics. The incubation periods ranged from 2 to 10 days, with a mean of 6.2 days. Cole's periods varied from 1 to 144 hours, with a mean of 21 hours. Spasticity, irritability, refusal to feed, lack of sucking and trismus were present in all cases. Thirty-three patients (70.4%) developed complications, the most frequent being sepsis and bronchopneumonia. The most frequent noninfectious complication was atelectasis, followed by renal failure and electrolytic imbalance. Overall mortality was 25%. It is noteworthy that in the most recent decade (1980 to 1990) mortality was 12.9%, considerably lower than that of the previous decade (1970 to 1980) which was 46.6% (P < 0.008). This decrease was probably a result of the greater availability of mechanical ventilation and the intensive care offered at neonatal services. Mortality was associated with the severity of the disease (P < 0.003) and with the presence of complications (P < 0.025).
Neonatal tetanus (NNT) is the second most frequent cause of infant mortality among the six vaccine preventable infections in developing countries. However, lack of reliable data has largely obscured the importance of the problem in these countries. A community based NNT mortality survey was conducted, using cluster sample method developed by WHO/EPI, in August 1989 in North and South Omo, Ethiopia. The study found 14 neonatal tetanus deaths among 2100 live births which occurred from 15 July 1988 to 15 July 1989, giving NNT mortality rate of 6.7/1000 LB (live births) and an estimated incidence rate of 8.4/1000 LB, accounting for 40% of all neonatal deaths. Male newborns were 2.5 times more commonly affected than females. Cutting of umbilical cord with unsterile instrument, home delivery attended by untrained TBAs, and lack of adequate tetanus TT immunization were found to be associated with increased incidence of NNT. Acceleration and promotion of TT immunization of all women of child bearing age and training of TBAs in proper obstetric care, coupled with continuous supportive supervision, is recommended in order to successfully execute the NNT elimination initiative undertaken by the Ministry of Health.
Neonatal tetanus in Calabar. A 4-year retrospective study.
- OE Antia-Obong
- NW Kpatt
- OE Antia-Obong
- NW Kpatt
Neonatal tetanus mortality survey, north and south Omo administrative regions
- A A Davies
Tropical Medicine and International Health volume 3 no 1 pp 9–13 january 1998 A. A. Davies-Adetugbo et al. Prognostic factors in neonatal tetanus References Alemu W (1993) Neonatal tetanus mortality survey, north and south Omo administrative regions, Ethiopia. Ethiopian Medical Journal 31, 99–107.
Le tetanos neonatal à Dakar. Aspects epidemiologiques, cliniques et prognostiques (à propos de 1,159 cas
- S Badiane
- Am
- Diop Bm
- Sow
Badiane S, Coll-Seck AM, Diop BM, Ould-Feil A & Sow S (1991) Le tetanos neonatal à Dakar. Aspects epidemiologiques, cliniques et prognostiques (à propos de 1,159 cas, 1979-1989). Bulletin de la Societé de Pathologie Exotique 84, 550 –557.
Neonatal tetanus in Calabar. A 4-year retrospective study Cluster survey for poliomyelitis and neonatal tetanus in Ilorin
- Oe Antia-Obong
- Kpatt
Antia-Obong OE & Kpatt NW (1991) Neonatal tetanus in Calabar. A 4-year retrospective study. Nigerian Journal of Paediatrics 18, 94-99. Babaniyi O & Parakoyi B (1991) Cluster survey for poliomyelitis and neonatal tetanus in Ilorin, Nigeria. International Journal of Epidemiology 20, 515–520.
Neonatal tetanus in Ibadan
- K Osinusi
- A H Dawodu
- O Sodeinde
- A A Adeyokunnu
Osinusi K, Dawodu AH, Sodeinde O & Adeyokunnu AA (1986)
Neonatal tetanus in Ibadan. Nigerian Journal of Paediatrics 13,
121-125.
Nigeria Demographic and Health Survey
Federal Office of Statistics (1992) Nigeria Demographic and Health
Survey, 1990. IRD/Macro International, Columbia, USA.
AA (1986) Neonatal tetanus in Ibadan
- Osinusi
- Dawodu
- O Ah Sodeinde
- Adeyokunnu
Neonatal tetanus in Calabar. A 4-year retrospective study
- O E Antia-Obong
- N W Kpatt
Antia-Obong OE & Kpatt NW (1991) Neonatal tetanus in Calabar.
A 4-year retrospective study. Nigerian Journal of Paediatrics 18,
94-99.
Ould-Feil A & Sow S (1991) Le tetanos neonatal à Dakar. Aspects epidemiologiques, cliniques et prognostiques (à propos de 1,159 cas, 1979-1989)
- S Badiane
- A M Coll-Seck
- B M Diop
Badiane S, Coll-Seck AM, Diop BM, Ould-Feil A & Sow S (1991) Le
tetanos neonatal à Dakar. Aspects epidemiologiques, cliniques et
prognostiques (à propos de 1,159 cas, 1979-1989). Bulletin de la
Societé de Pathologie Exotique 84, 550 -557.
Le tetanos neonatal à Dakar. Aspects epidemiologiques, cliniques et prognostiques (à propos de 1,159 cas, 1979‐1989).
- Badiane S
Neonatal tetanus in Ibadan.
- Osinusi K