Tetanus; a forgotten infection disease: a report of two cases

BACKGROUND

Tetanus is an infectious disease that can be seen in all age groups in underdeveloped and developing countries, where vaccination programs are inadequate. In developed countries, it is reported more frequently in the adult age group, where the protection of vaccination is diminished and the doses are delayed.

CASE

In this report, we present generalized tetanus, which was observed in two male patients aged 12 and 6 years, admitted at different times, together with clinical course and treatment approaches. Both patients belong to different nationalities, who immigrated a couple of months before their application to our hospital. They applied with similar histories and complaints and were not vaccinated during infancy.

CONCLUSION

With the development of vaccination programs, this disease with high morbidity and mortality can be prevented.

Tetanus Toxin cis-Loop Contributes to Light-Chain Translocation

How protein toxins translocate their catalytic domain across a cell membrane is the least understood step in toxin action. This study utilized a reporter, β-lactamase, that was genetically fused to full-length, nontoxic tetanus toxin (βlac-TT) in discovery-based live-cell assays to study LC translocation. Directed mutagenesis identified a role for K⁷⁶⁸ in LC translocation. K⁷⁶⁸ was located between α15 and α16 (termed the cis-loop). Cellular assays showed that K⁷⁶⁸ did not interfere with other toxin functions, including cell binding, intracellular trafficking, and pore formation. The equivalent K⁷⁶⁸ is conserved among the clostridial neurotoxin family of proteins as a conserved structural motif. The cis-loop appears to contribute to LC translocation.

The clostridial neurotoxins (CNTs) comprise tetanus toxin (TT) and botulinum neurotoxin (BoNT [BT]) serotypes (A to G and X) and several recently identified CNT-like proteins, including BT/En and the mosquito BoNT-like toxin Pmp1. CNTs are produced as single proteins cleaved to a light chain (LC) and a heavy chain (HC) connected by an interchain disulfide bond. LC is a zinc metalloprotease (cleaving soluble N-ethylmaleimide-sensitive factor attachment protein receptors [SNAREs]), while HC contains an N-terminal translocation domain (HCN) and a C-terminal receptor binding domain (HCC). HCN-mediated LC translocation is the least understood function of CNT action. Here, β-lactamase (βlac) was used as a reporter in discovery-based live-cell assays to characterize TT-mediated LC translocation. Directed mutagenesis identified a role for a charged loop (⁷⁶⁷DKE⁷⁶⁹) connecting α15 and α16 (cis-loop) within HCN in LC translocation; aliphatic substitution inhibited LC translocation but not other toxin functions such as cell binding, intracellular trafficking, or HCN-mediated pore formation. K⁷⁶⁸ was conserved among the CNTs. In molecular simulations of the HCN with a membrane, the cis-loop did not bind with the cell membrane. Taken together, the results of these studies implicate the cis-loop in LC translocation, independently of pore formation.

IMPORTANCE How protein toxins translocate their catalytic domain across a cell membrane is the least understood step in toxin action. This study utilized a reporter, β-lactamase, that was genetically fused to full-length, nontoxic tetanus toxin (βlac-TT) in discovery-based live-cell assays to study LC translocation. Directed mutagenesis identified a role for K⁷⁶⁸ in LC translocation. K⁷⁶⁸ was located between α15 and α16 (termed the cis-loop). Cellular assays showed that K⁷⁶⁸ did not interfere with other toxin functions, including cell binding, intracellular trafficking, and pore formation. The equivalent K⁷⁶⁸ is conserved among the clostridial neurotoxin family of proteins as a conserved structural motif. The cis-loop appears to contribute to LC translocation.

Immunity status against tetanus in young migrants: a seroprevalence study

BACKGROUND AND AIM OF THE WORK

Thanks to the highly effective vaccine, tetanus became sporadic in high-income countries with well-established primary childhood immunization programs, but it is common in low-income countries. The migrants, leaving countries with poor immunization programs or where vaccinations have been interrupted, may represent a new risk group for tetanus in host countries. A seroprevalence study was conducted to estimate the immunological status against tetanus in young migrants without vaccination documentation.

METHODS

After a careful assessment by vaccination services of the Local Health Authority, all migrants recently arrived in Italy were included in the serosurvey. Titers of anti-tetanus toxoid were measured using a commercial ELISA kit. Subjects were stratified by age and by WHO region. Antibody titers <0.10 IU/ml were considered to be seronegative, between 0.10 and 1.00 IU/ml as intermediate protection, and >1.00 IU/ml high protection.

RESULTS

From January 2004 to December 2019, 2,326 blood samples were collected. Mean age was 13.9 years with no differences between WHO regions. The percentage of the subjects without protective antibodies was 22.3%, with an intermediate level was 45.2%, with high titer was 32.5%. Among migrant coming from African and Eastern Mediterranean WHO regions, the highest percentages of seronegative titers and, at the same time, the low percentages of high protective levels were found. Titers decreased with age.

CONCLUSIONS

The significant proportion of seronegative migrants and the decrease of protective titers increasing age, confirm the importance of the evaluation of the immunological status to employ the appropriate vaccination strategy.

Tetanus: epidemiology and Factors Associated with Death in the Departement of Tropical and infectious diseases of Donka National Hospital, Guinea

In developing countries, tetanus remains a public health problem because of its frequency, severity, and still high mortality. The objective of this study was to describe the epidemiological profile of patients hospitalized for tetanus and to identify the factors associated with dying from it. This retrospective, descriptive, and analytical study reviewed hospital records of all patients, of all ages and genders who were treated for tetanus in our department over a 5-year period. Among 3549 patients during the study period, 75 had tetanus (2.11%), and 71 of them were included in our study. The median age of patients was 35 years (range: 11-70 years) with a male prevalence of 80%. The most frequently affected socio-professional categories were students (21.1%), farmers (18.3%), workers (15.5%), and shopkeepers and tradespeople (15.5%). The main entry points were post-traumatic (40.9%), cutaneous (33.8%), and post-surgical (16.90%). Paroxysm (95.8%), trismus (93.0%), generalized contracture (67.6%), and dysphagia (46.5%) were the most frequent signs. Among these cases, 40.9% were severe (40.85%), 49.3% moderate (49.30%), and 9.6% benign. We recorded 34 deaths (48%). Factors associated with death were age> 60 years (P = 0.01), fever (P = 0.01), hypertension (P = 0.02), and HIV infection (P = 0.01). Tetanus remains a frequent disease with high lethality. Death is associated with specific factors that should be taken into account in the criteria for assessing its prognosis.

Tetanus in animals

Tetanus is a neurologic disease of humans and animals characterized by spastic paralysis. Tetanus is caused by tetanus toxin (TeNT) produced by Clostridium tetani, an environmental soilborne, gram-positive, sporulating bacterium. The disease most often results from wound contamination by soil containing C. tetani spores. Horses, sheep, and humans are highly sensitive to TeNT, whereas cattle, dogs, and cats are more resistant. The diagnosis of tetanus is mainly based on the characteristic clinical signs. Identification of C. tetani at the wound site is often difficult.

Intrathecal baclofen use in the management of tetanus related spasm: A case report

Şık G, Aydoseli A, Çıtak A. Intrathecal baclofen use in the management of tetanus related spasm: A case report. Turk J Pediatr 2019; 61: 126-129. Tetanus is an infectious disease of the central nervous system with high mortality rates characterized with respiratory distress and tonic muscle spasms. The most common cause of mortality is cardiovascular complications (40%) and respiratory distress (15%). Despite vaccination programs, tetanus remains to be a significant healthcare issue in developing nations. Prolonged sedation and administration of muscle relaxants prolongs the period on mechanical ventilation and duration of hospitalization in severe tetanus cases. However, intrathecal baclofen (ITB) therapy might shorten the duration of stay at intensive care units, improve patient outcomes, and constitute a treatment option alternative to paralytic agents and sedation. In this manuscript, we present a 12-years-old case diagnosed with tetanus and treated with ITB upon observation of spasms refractory to high dose sedation and muscle relaxants.

Tetanus in Poland in 2017

INTRODUCTION

In the last decade, the number of tetanus cases in Poland has not exceeded 20 cases. Since 1984, neonatal tetanus has not been reported.

OBJECTIVE OF THE WORK

The aim of the study is to present the data of epidemiological surveillance of tetanus in 2017 in a historical perspective, taking into account the role of protective vaccination and a reference to activities for the elimination of neonatal tetanus on a global scale. SUMMARY AND CONCLUSIONS. Tetanus is an infectious disease acquired in the environment and associated with wound pollution. Few cases of illness in Poland are associated with non-compliance with recommendations for booster vaccinations.

MATERIAL AND METHODS

The material of the study are individual reports on tetanus sent to the Department of Epidemiology, NIZP-PZH and the bulletin “Infectious diseases and poisoning in Poland in 2017. The historical data is based on earlier Polish and foreign studies.

RESULTS

In 2017, 11 cases of tetanus were reported. Four men and seven women got sick. One man died in the age > 69.

Diagnosis and Management of Cryptogenic Occupational Tetanus: A Case Report from Rajasthan, India

The reported cases of non-neonatal tetanus have doubled from 2015 to 2017 in India, while neonatal tetanus has declined by half during this period. Most of these non- neonatal tetanus are acquired by occupational exposure especially in high risk populations such as agricultural workers, industrial workers and health care workers secondary to increased spore exposure or risk for minor injuries. We report a case of occupational tetanus in a steel worker and discuss the importance of recognising tetanus as an occupational hazard and address issues related to its early diagnosis and management. The report also highlights the need for policymakers and health practitioners in India to evolve a robust understanding of the needs and vulnerabilities of high risk occupational groups in order to apply specific and effective interventions to prevent occupational tetanus.

[The opinion of private duty nurses in Martinique on the vaccination of elderly subjects]

Improving immunisation coverage for older adults is a public health issue. Since 2008, nurses have been authorised to vaccinate this population against influenza without a medical prescription. One study examined the opinions of a sample of 78 private duty nurses in Martinique on influenza and anti-tetanus vaccination of elderly populations. The majority of nurses said they were not in favour of vaccination.

DTaP5-HBV-IPV-Hib pediatric hexavalent combination vaccine for use in children from 6 weeks through to 4 years of age

Introduction: Combination vaccines reduce the number of injections received by children, hence improving timeliness and coverage, and general acceptability among caregivers and health-care providers. The most recent hexavalent vaccine, DTaP5-HBV-IPV-Hib, has been also approved by the FDA.Areas covered: DTaP5-HBV-IPV-Hib has demonstrated good immunogenic and safety profiles, not inferior to other hexavalent vaccines already in use in the European market. Either (2p+1/3p+1) immunization schedules can be used with no significant differences. A low incidence of severe adverse events has been shown, similar to other combination vaccines. No issues have arisen when concomitantly administered with other vaccines.Expert opinion: The inclusion of two additional acellular pertussis components (FIM2 and FIM3) might yield better protection against the disease, but this remains to be clinically proven. The new vaccine uses Hib with unique protein carrier (PRP-OMPC) which elicits higher earlier immune response without compromising safety. Compliance with the immunization schedules is expected to increase by decreasing the number of injections needed in combined vaccines for a single visit. In addition, the improvements on the ease-of-use by its liquid-formulation, makes the vaccine preparation more acceptable for use in clinics and may reduce the odds of administration errors.

Tables of Toxicity of Botulinum and Tetanus Neurotoxins

Tetanus and botulinum neurotoxins are the most poisonous substances known, so much so as to be considered for a possible terrorist use. At the same time, botulinum neurotoxin type A1 is successfully used to treat a variety of human syndromes characterized by hyperactive cholinergic nerve terminals. The extreme toxicity of these neurotoxins is due to their neurospecificity and to their metalloprotease activity, which results in the deadly paralysis of tetanus and botulism. Recently, many novel botulinum neurotoxins and some botulinum-like toxins have been discovered. This large number of toxins differs in terms of toxicity and biological activity, providing a potential goldmine for novel therapeutics and for new molecular tools to dissect vesicular trafficking, fusion, and exocytosis. The scattered data on toxicity present in the literature require a systematic organization to be usable by scientists and clinicians. We have assembled here the data available in the literature on the toxicity of these toxins in different animal species. The internal comparison of these data provides insights on the biological activity of these toxins.

Cross-sectional study on vaccination coverage in newly diagnosed HIV-infected persons in the Czech Republic

OBJECTIVES

Individuals with HIV infection are at an increased risk for a number of infectious diseases, some of which are preventable by vaccination. Unfortunately, little is known about the attitudes of this population group to vaccination, therefore, we decided to find out vaccination coverage against 5 infections among newly diagnosed HIV-infected patients in the Czech Republic.

METHODS

This cross-sectional study was conducted on newly diagnosed patients who started their follow-up care at the HIV Clinic of Na Bulovce Hospital during the two following years. Vaccination history data and results of serological tests were collected from all participants.

RESULTS

Enrolled were 269 HIV-positive subjects (94.1% males) with a mean age of 34.4 years, 64 subjects (23.8%) had tertiary education, 229 (85.1%) were men having sex with men, 32 (11.9%) were heterosexual, and 8 (3.0%) were injection drug users. The mean CD4+ T-lymphocyte count was 556.2/µL, with 149 persons (55.4%) who had a CD4+ T-lymphocyte count &gt; 500/µL, and 68 (25.3%) individuals were late presenters with CD4+ T-lymphocyte count &lt; 350/µL. A vaccination against tetanus was reported by 262 subjects (97.4%), against influenza by 18 subjects (6.7%), against tick-borne encephalitis by 18 subjects (6.7%), against viral hepatitis A by 78 persons (29.0%), and against hepatitis B by 104 subjects (38.7%). For influenza, tick-borne encephalitis and hepatitis A, a significant positive impact of tertiary education was found (p-values &lt; 0.001-0.044). Vaccination coverage against both types of hepatitis was significantly lower in late presenters (p = 0.044 and p = 0.004, respectively).

CONCLUSIONS

Vaccination rates found in our cohort were except tetanus and hepatitis B in young people low, especially for influenza and tick-borne encephalitis. Higher level of education and less advanced HIV infection were associated with higher vaccination rates. To improve this unsatisfactory situation, more attention should be paid to vaccination.

Pediatric Tetanus in Central Pennsylvania

Approximately 20% of the nationally reported tetanus infections in children aged 0 to 14 years that occurred in the United States between 2005 and 2015 were treated at Penn State Children's Hospital. With an electronic medical record search, we identified 5 cases of pediatric tetanus; 100% of these cases occurred in unimmunized children. Their median length of stay was 10 days, and the costs were significant.

Severe Tetanus Complicated by Takotsubo Cardiomyopathy

A 70-year-old woman was admitted to our hospital due to difficulty in moving her limbs. She had trismus and a necrotic and contaminated wound in her left lower leg. A diagnosis of tetanus was confirmed and intensive care was started. On the second day, her blood pressure fell and a ST segment elevation on electrocardiography (ECG) was detected. She was diagnosed with takotsubo cardiomyopathy by echocardiogram and improved undergoing conservative therapy.

Blue Nevus Developing at a Combined Tetanus, Diphtheria, and Pertussis (Tdap) Vaccination Site: Case Report and Summary of Vaccine-Associated Cutaneous Lesions

Skin reaction may develop at the site of vaccine administration. A 54-year-old woman who developed a cellular blue nevus at the site of the combined tetanus, diphtheria, and acellular pertussis (Tdap) vaccine injection four years prior to presentation is described. In addition to blue nevus, other reactions at combined tetanus, diphtheria, and pertussis vaccine injection sites include abscess, deep reactive nodular infiltrates of mixed inflammation, and necrotizing granuloma. In conclusion, blue nevus can be added to the list of cutaneous events that can occur at Tdap vaccination sites.

Tetanus presenting primarily as periocular discomfort in a patient who underwent surgery for sleep apnea: A case report and brief literature review

RATIONALE

Tetanus is caused by a neurotoxin (tetanospasmin) secreted by a spore forming gram-positive, anaerobic rod-shaped motile bacillus, Clostridium tetani. The most common symptoms of tetanus are trismus (100%), dysphagia (70.5%), dysarthria (35.2%), and neck stiffness (29.4%). Respiratory failure, laryngeal spasm, seizure, chest pain, nausea/vomiting, opisthotonus, back pain, and rigid abdominal wall can also be observed during progression of the disease. However, there has been no report of periocular discomfort as an initial manifestation after endoscopic sleep surgery in a patient with tetanus. Here, we report a patient who underwent endoscopic sleep surgery with a concurrent diagnosis of tetanus infection presenting with atypical periocular discomfort as the initial symptom.

PATIENT CONCERNS

A 63-year-old man complaining of sleep apnea, snoring, and daytime sleepiness visited our department. He subsequently underwent sleep surgery (anterior pharyngoplasty with tonsillectomy, septoplasty, microdebrider-assisted inferior turbinoplasty, and an endoscopic sinus surgery) for the treatment of his newly diagnosed obstructive sleep apnea. After 3 weeks of surgery, he visited the outpatient clinic of our department with right side periocular discomfort.

DIAGNOSES

Four days after presenting with periocular discomfort, he was diagnosed with tetanus by presenting trismus, jaw pain, dysphagia, and ptosis at an emergency department of a different hospital.

INTERVENTIONS

Tetanus immunoglobulin and antibiotics were administered.

OUTCOMES

His symptoms then resolved after a month without sequelae.

LESSONS

Although periocular discomfort is atypical and is not uncommon after nasal and oral surgeries, care should be taken when patients present with periocular pain because it could be a rare initial symptom of tetanus.

Clinical features and outcomes of tetanus: a retrospective study

Background: Tetanus is a serious disease resulting in muscle spasm, and even death. Methods: A retrospective, single-center study was conducted by analyzing demographic and clinical parameters. Results: The study included 12 males (70.6%) and 5 females (29.4%). The mean age of the patients was 56.71±9.05 years. Patient occupations included farming (47.0%), retired (23.5), homebound (23.5), and workers (6.0%). The causes of patient injuries were as follows: metal injury (52.9%), deep injury (29.4%), electrical injury (5.9%), maxillofacial region and knee injury (5.9%), and skin ulceration (5.9%). The disease duration ranged from 3 to 36 days, and the mean incubation period was 12.65±10.17 days. Four patients had co-morbidities. The infected patients were given tetanus antitoxin (TAT) and antibiotics treatment. One patient was given continuous renal replacement therapy (CRRT) and only one patient died. Conclusions: In our department, although tetanus is a serious disease, with effective treatment, patients have reasonable cure and low death rates.

Determinants of Tetanus Vaccination among Adult Immigrants: Findings from the Portuguese National Health Survey 2014

Vaccination is an effective strategy to prevent tetanus, and in Portugal this service is provided free of charge. Despite this, immigrants reported lower tetanus vaccination coverage than did Portuguese natives. The objective of this study was to identify sociodemographic, migration-related, and access-to-care factors associated with tetanus vaccination coverage among adult immigrants, using data from the Portuguese National Health Survey 2014. For the sample of 1277 immigrants aged ≥18 years, we estimated self-reported tetanus vaccination within the preceding 10 years and its determinants using complex samples logistic regression. The overall self-reported tetanus vaccination coverage was 79.5% (95% CI: 75.8-82.8). Age (adjusted odd ratio (aOR) per 1 year age increase = 0.97, 95% CI: 0.95-0.99), higher household income per adult (aOR = 0.42, 95% CI: 0.19-0.96), having Portuguese citizenship (aOR = 2.30, 95% CI: 1.25-4.24), having private health insurance (aOR = 1.99, 95% CI: 1.06-3.71), and contact with family/general physician in the last 12 months (aOR = 1.59, 95% CI: 1.01-2.51) were associated with self-reported tetanus vaccination coverage among adult immigrants. We also found significant disparities in coverage between regions of residence. This study identified several determinants associated with self-reported tetanus vaccination coverage among adult immigrants in Portugal. These findings may help policymakers to design specific interventions to increase tetanus vaccination coverage among this population.

Awareness, Knowledge, and Coverage of Vaccination Against Tetanus, Diphtheria, and Pertussis Among Medical Students of Karachi: A Cross-sectional Analysis

Background Along with reducing the global burden of diphtheria, pertussis and tetanus, the DPT3 (diphtheria-pertussis-tetanus) vaccine protects health care professionals (HCPs) as well as vulnerable patients in their care. This study evaluates awareness, knowledge and coverage of DPT3 vaccine and boosters among medical students of public university in Karachi, Pakistan. Methods A cross-sectional study consisting of 281 participants selected through convenience sampling was conducted from July 2017 to July 2018 using a self-administered questionnaire. Results While 93% participants received childhood doses of DPT3, only 39.2% received adult boosters. Students with positive immunization history in childhood and family vaccination routines were more likely to get adult boosters. Eighty-six percent of the students were unaware that their university had a recommended vaccination program as a part of the admission process. The assessment of awareness and knowledge revealed that only 10.5% individuals could be regarded as well-aware, 20.3% (n = 58) students as unaware, and 69.2% (n = 198) participants as moderately aware. Conclusion The level of awareness, knowledge and coverage of DPT3 vaccine is insufficient among medical students of a public university of Karachi; universities are recommended to take measures to enhance knowledge and ensure strict adherence of students to appropriate vaccination programs.

Immunogenicity and safety following primary and booster vaccination with a hexavalent diphtheria, tetanus, acellular pertussis, hepatitis B, inactivated poliovirus and Haemophilus influenzae type b vaccine: a randomized trial in the United States

Combined hexavalent diphtheria-tetanus-acellular pertussis-hepatitis B-inactivated poliomyelitis and Haemophilus influenzae type b vaccine (DTaP-HBV-IPV/Hib) can further reduce the number of injections in pediatric immunization schedules of countries currently using pentavalent DTaP combination vaccines. This open-label, randomized, multicenter study (NCT02096263) conducted in the United States evaluated the immunogenicity and safety of DTaP-HBV-IPV/Hib vaccine compared with concomitant administration of DTaP-HBV-IPV and Hib_A or DTaP-IPV/Hib and HBV vaccines. We randomized (1:1:1) infants to receive 3-dose priming with DTaP-HBV-IPV/Hib boosted with DTaP+ Hib_B, DTaP-HBV-IPV+ Hib_A boosted with DTaP+ Hib_A, or DTaP-IPV/Hib+ HBV boosted with DTaP-IPV/Hib, at 2, 4, 6, and 15-18 months of age. We enrolled and vaccinated 585 participants, 486 received a booster, and 476 completed the study. Of these, 466 participants were included in the primary and 408 in the booster according-to-protocol cohorts for immunogenicity. We demonstrated non-inferiority of DTaP-HBV-IPV/Hib vaccine to DTaP-HBV-IPV+ Hib_A co-administered vaccines in terms of geometric mean concentrations for pertussis antibodies post-primary vaccination. Post-primary vaccination, seroprotection/seropositivity rates for all vaccine antigens were similarly high between DTaP-HBV-IPV/Hib (≥ 94.8%), DTaP-HBV-IPV+ Hib_A (≥ 98.1%) or DTaP-IPV/Hib+ HBV (≥ 97.8%) groups. We observed robust immune responses post-booster, indicating effective priming by the 3 regimens. Reactogenicity was similar in the 3 groups. Twenty-eight serious adverse events were reported during the study; 3 were considered related to vaccination and resolved by the end of the study. These results confirm that DTaP-HBV-IPV/Hib could be a valuable additional source of pediatric DTaP, IPV, HBV, and Hib-containing vaccine in countries that currently use multivalent vaccines.

Tetanus outbreak in a sheep flock due to ear tagging

Tetanus is an acute, often fatal, infectious neuromuscular disease in all farmed mammals caused by Clostridium tetani. The disease is sporadic but outbreaks of tetanus have been described, as a result of wound contaminated with spores of C. tetani, which sporulates to the vegetative form and produce toxins. The present study reports an outbreak of tetanus in a sheep flock, shortly after ear tagging. Three sheep from a large flock (with a population of 1000 sheep) were presented with signs of: convulsion, limb stiffness, incoordination and trismus (“lock jaw”). There were wounds and scabs in most livestock where ear tags had been attached 1 week prior. Clinical examination revealed tachycardia, dyspnoea with dilated nostrils, mild fever, erected ear pinnae, teeth grinding, mild bloat, muscles rigidity, prolapse of third eyelid and anxiety. According to the history stated by the owner, the case fatality rate of the disease from the beginning was 50% during the outbreak. Necropsy did not reveal any significant finding. Gram‐positive bacilli with terminal spores representing C. tetani were isolated in anaerobic cultures which were taken from ear wounds. Procaine penicillin G was administrated at 20 000 IU/kg BW for 5 days, but antiglobulin was not available to treat affected animals. Mortality significantly declined one day after onset of treatment. In this report, the organism was probably introduced by contaminated instruments which were used for ear tagging of sheep. Wound exudation and adhesion following rubbing, created a favourable anaerobic condition for the spores to germinate with production of neurotoxin. Vaccination can protect animals against tetanus, but it does not preclude the need to apply standard hygienic principles when performing management procedures causing wounds. In pasture holding system, many pathogens are present in environment, so tetanus should be considered important in farm animals, because of its high fatality rate and the long course of convalescence.

Immunogenicity and safety of a combined DTPa-IPV/Hib vaccine administered as a three-dose primary vaccination course in healthy Korean infants: phase III, randomized study

We assessed the immunogenicity and safety of a three-dose primary vaccination schedule with the combined diphtheria-tetanus-acellular pertussis-inactivated poliovirus/Haemophilus influenzae type b vaccine (DTPa-IPV/Hib) in Korean infants. In this phase III open-label, multicenter study (NCT01309646), healthy infants aged 42-69 days (randomized 1:1) received three doses of either pentavalent DTPa-IPV/Hib (DTPa-IPV/Hib group) or DTPa-IPV and Hib vaccines administered separately (DTPa-IPV+Hib group) at 2, 4, 6 months of age. The primary objective was to demonstrate non-inferiority of DTPa-IPV/Hib compared to DTPa-IPV+Hib vaccines in terms of immune responses to all vaccine antigens, 1 month post-dose 3. Solicited symptoms (local and general) were recorded during 4 days, and unsolicited adverse events (AEs) during 31 days, after each vaccination. Serious AEs (SAEs) were recorded throughout the study duration. The immunogenicity of the pentavalent DTPa-IPV/Hib vaccine was non-inferior compared to concomitant administration of DTPa-IPV+Hib vaccines. One month post-dose 3, nearly all infants had antibody levels above the seroprotective thresholds for anti-diphtheria toxoid, anti-tetanus toxoid, anti-polyribosyl-ribitol phosphate, and anti-poliovirus type 1, 2 and 3, and had antibody levels above the seropositive thresholds for anti-pertussis toxoid (PT), anti-filamentous hemagglutinin (FHA) and anti-pertactin (PRN) antibodies. A vaccine response for PT, FHA and PRN was observed in at least 96.7% of study participants. Anti-PRP geometric mean concentrations appeared lower for the DTPa-IPV/Hib group (8.456 µg/mL) than for the DTPa-IPV+Hib group (18.700 µg/mL). In both groups, the most common solicited symptoms were injection site redness and irritability. Fifty-seven SAEs were reported throughout the study; none were considered to be vaccination related.

Association between clinically probable REM sleep behavior disorder and tetanus in dogs

BACKGROUND

Abnormal sleep behavior has been reported in 5 dogs during recovery from tetanus.

HYPOTHESIS

REM sleep behavior disorder (RBD) is a more common consequence of tetanus than previously reported in veterinary literature and easily confused for epileptic seizures.

ANIMALS

Sixty-one client-owned dogs diagnosed with tetanus at 2 UK referral centers.

METHODS

A retrospective review of medical records was combined with a questionnaire sent to owners of surviving dogs, to identify cases that developed clinically probable RBD and determine its clinical progression and effect on quality of life of affected dogs and their owners. Descriptive statistical evaluation was performed.

RESULTS

Eleven dogs (18%) died or were euthanized before discharge. At least 46% surviving dogs developed abnormal "dream enactment" clinically consistent with RBD. Twitching, running, and vocalization were new sleep behaviors in 53, 80, and 60% of affected dogs. Clinically probable RBD was described as violent or "nightmare"-like in 36% affected dogs, and like an epileptic seizure in 40% affected dogs. When trialed, antiepileptic medications were ineffective. Onset occurred before discharge in 25% cases. For dogs that developed clinically probable RBD postdischarge, onset occurred within 2 weeks of discharge in 77% dogs. Clinically probable RBD did not worsen in severity or frequency in any dog, and spontaneously resolved within 6 months in 43% cases.

CONCLUSIONS AND CLINICAL IMPORTANCE

Clinically probable RBD is a common sequel to canine tetanus with many clinical similarities to epileptic seizure activity. Owners should be made aware of its potential development and care taken to avoid misdiagnosis with epileptic seizure activity.

Tetanus after application of traditional topical treatment to a severe burn

A 2-year-old child was accompanied by his parents to the pediatric emergency room for refusal to eat, trismus and generalized contractures four days after the application of a traditional topical treatment (Cassava leaves) on lesions of a severe thermal burn. A temperature of 38̊C, a heart rate of 114 beats/min, and a blood pressure of 90/60 mm Hg were recorded. The tetanus vaccination was not up to date. The diagnosis of tetanus was immediately suggested. Antitetanus serum (immunoglobulin), an antibiotic (amoxicillin and clavulanic acid), and a myorelaxant (benzodiazepine) were administered. Local treatments were also performed. The child died within 24 hours.

A Pilot Study: Factors Influencing Compliance With Tetanus-Diphtheria Vaccine in Katsina State, Northwestern Nigeria

Background

Tetanus-diphtheria vaccine (Td+) coverage has been steadily declining in Katsina State, Nigeria. The pilot study was guided by The Andersen and Newman Framework of Health Services Utilization. The goal of the pilot study was to identify the Td+ vaccination coverage and identify any association between maternal residence, educational status, occupational status, access to routine immunization services, availability of routine immunization services, perceived need for Td+, perceived severity of maternal and neonatal tetanus (MNT), and compliance with Td+ in Katsina State.

Methods

A cross-sectional survey of 309 randomly selected women in Charanchi district of Katsina State, Nigeria, was conducted. Data were collected using structured questionnaire and analyzed using logistic regression model.

Findings

The Td+ coverage was low at 23%. Bivariate analysis showed that age, maternal residence, educational status, availability of Td+, perception of Td+, and perception of MNT significantly affected compliance with Td+ (P < .05, P < .05, P < .05, P < .001, P < .001, P < .001, respectively). Multiple logistic regression findings were inconclusive.

Conclusion

Effective strategies to improve compliance were awareness creation on Td+ immunization schedule, risk factors associated with MNT, vaccine availability, and safety. Additionally, improving access to routine immunization services, especially in underserved communities, and effective use of Td+ coverage data were used as strategies.

Implications

The pilot study suggests that the design can be used to realize more conclusive and generalizable multivariate findings in future studies.

Clinical Profile and Outcome of Pediatrics Tetanus: The Experience of a Tertiary Hospital in Ethiopia

Background

Tetanus is an acute vaccine preventable illness manifested by neuromuscular dysfunction due to a potent exotoxin, tetanospasmin produced by Clostridium tetani. It is a common health problem in developing countries like Ethiopia. The aim of this study was to assess clinical profile and outcome of Pediatrics tetanus in a referral hospital, South Ethiopia.

Methods

This is a retrospective cross-sectional study of medical records of 24 Pediatric tetanus patients who were admitted from July 2014 to June 2016 to the Pediatrics Department of Hawassa University Comprehensive Specialized Hospital, Hawassa-Ethiopia. Tetanus was diagnosed clinically. Data were entered and analyzed using SPSS statistical software.

Results

The median age at diagnosis was 8 years with 19 (79.2%)of the study subjects being males. There were 3 male neonatal tetanus cases with 2 deaths. From post-neonatal cases, only 8(38.1%) were fully vaccinated for infant Expanded Period of Immunization (EPI). Booster vaccination with TT (tetanus toxoid) was only given to 5(29.4%) of discharged patients. Trauma was common in above 5 years of age and documented in 19(79.2%) of patients. All tetanus cases were generalized type with mild, moderate and severe grades comprising 7(29.2%), 8(33.3%), 7(29.2%) and 2(8.3%) respectively. Case fatality rate was 29.2% (7) with more deaths in higher grades. Respiratory failure 6(85.7%), and aspiration pneumonia 1(14.3%) were causes of death.

Conclusion

In this study, case fatality rate was high. Hence, health promotion with scale-up of EPI for infant tetanus immunization and large scale studies to provide support for booster vaccination schedules are recommended.

Impact of Mothers' Schistosomiasis Status During Gestation on Children's IgG Antibody Responses to Routine Vaccines 2 Years Later and Anti-Schistosome and Anti-Malarial Responses by Neonates in Western Kenya

The potential consequences of parasitic infections on a person’s immune responsiveness to unrelated antigens are often conjectured upon in relationship to allergic responses and autoimmune diseases. These considerations sometimes extend to whether parasitic infection of pregnant women can influence the outcomes of responses by their offspring to the immunizations administered during national Expanded Programs of Immunization. To provide additional data to these discussions, we have enrolled 99 close-to-term pregnant women in western Kenya and determined their Schistosoma mansoni and Plasmodium falciparum infection status. At 2 years of age, when the initial immunization schedule was complete, we determined their children’s IgG antibody levels to tetanus toxoid, diphtheria toxoid, and measles nucleoprotein (N-protein) antigens using a multiplex assay. We also monitored antibody responses during the children’s first 2 years of life to P. falciparum MSP1₁₉ (PfMSP1₁₉), S. mansoni Soluble Egg Antigen (SEA), Ascaris suum hemoglobin (AsHb), and Strongyloides stercoralis (SsNIE). Mothers’ infections with either P. falciparum or S. mansoni had no impact on the level of antibody responses of their offspring or the proportion of offspring that developed protective levels of antibodies to either tetanus or diphtheria antigens at 2 years of age. However, children born of S. mansoni-positive mothers and immunized for measles at 9 months of age had significantly lower levels of anti-measles N-protein antibodies when they were 2 years old (p = 0.007) and a lower proportion of these children (62.5 vs. 90.2%, OR = 0.18, 95% CI = 0.04–0.68, p = 0.011) were considered positive for measles N-protein antibodies. Decreased levels of measles antibodies may render these children more susceptible to measles infection than children whose mothers did not have schistosomiasis. None of the children demonstrated responses to AsHb or SsNIE during the study period. Anti-SEA and anti-PfMSP1₁₉ responses suggested that 6 and 70% of the children acquired schistosomes and falciparum malaria, respectively, during the first 2 years of life.

Maternal immunization

Pregnant women, neonates, and infants are at higher risk for severe infections due to vaccine-preventable diseases. Very young infants rarely respond well to vaccination due to poor immunogenicity and interference from maternal antibody. Maternal immunization protects the mother and fetus from disease and protects the infant through transplacental antibody transfer through the first 6 months of life. Currently, immunizations routinely recommended during pregnancy include inactivated influenza, tetanus toxoid, and acellular pertussis vaccines. Promising maternal vaccine candidates in development include a group B streptococcus vaccine and a respiratory syncytial virus vaccine. Birth Defects Research 109:379-386, 2017. © 2017 Wiley Periodicals, Inc.

Immunogenicity and safety of a second booster dose of an acellular pertussis vaccine combined with reduced antigen content diphtheria-tetanus toxoids 10 years after a first booster in adolescence: An open, phase III, non-randomized, multi-center study

Pertussis is a highly contagious disease, for which periodic peaks in incidence and an increasing number of outbreaks have been observed over the last decades. The reduced-antigen-content tetanus-diphtheria-acellular pertussis vaccine (Tdap) can be used to boost individuals aged ≥10 years, vaccinated in infancy with a diphtheria-tetanus-acellular pertussis vaccine (DTaP), to reduce pertussis morbidity and maintain protection against diphtheria and tetanus throughout adolescence and adulthood. This phase III, open-label, non-randomized, multicenter follow-up study (NCT01738477) enrolled 19–30-year-old participants from the United States who had received booster vaccination 10 years earlier with either Tdap (Tdap group) or Td (Td group). In total, 128 (Tdap group) and 37 (Td group) participants received Tdap vaccination. After administration of Tdap, all participants were seroprotected (antibody concentrations ≥0.1 international units [IU]/ml) against diphtheria and tetanus. Immune responses to a second Tdap dose in the Tdap group were shown to be non-inferior to responses elicited by a first Tdap dose in the Td group for diphtheria and tetanus and to a 3-dose DTaP vaccination during infancy for pertussis antigens (primary objectives). Post-booster vaccination, all participants in both groups had antibody concentrations above assay cut-offs and antibody geometric mean concentrations increased by 3.8–15.5-fold compared to pre-booster levels for all antigens. The incidence of adverse events was similar in the Td (80.6%) and Tdap (85.6%) groups (no serious adverse events reported). A Tdap dose administered after previous Td or Tdap vaccination was shown to be immunogenic and well-tolerated in young adults, supporting repeated vaccination with Tdap at 10-year intervals.

Generalized tetanus in adults without antitetanus booster vaccination in southern Mauritania

Tetanus has become rare in countries with high levels of vaccination coverage and hygiene but may still occur in adults without booster vaccination. In addition to the expanded program on immunization for children and maternal immunization against neonatal tetanus, a systematic vaccination of the population, including boosters, is recommended.

Tetanus after a penetrating injury to the right globe: a case report

A 24-year-old man attended the emergency department with a penetrating injury to the right globe after a road traffic accident. He later contracted tetanus for which he was given human tetanus immunoglobulin. Although it is rare, tetanus is life-threatening and a thorough immunisation history should be obtained before treatment of tetanus-prone injuries.

Tetanus without apparent history of trauma

A-68-year-old male was admitted due to tetanus without apparent history of trauma. Trismus was observed on admission and was improved after treatment.

Randomized Controlled Trial of the Safety and Immunogenicity of Revaccination With Tetanus-Diphtheria-Acellular Pertussis Vaccine (Tdap) in Adults 10 Years After a Previous Dose

BACKGROUND

Reduced-antigen-content tetanus, diphtheria, and acellular pertussis (Tdap) vaccine is recommended in many countries for boosting immunity in adolescents and adults. Although immunity to these antigens wanes with time, currently available Tdap products are not labeled for repeat administration in the United States.

METHODS

We performed an observer-blinded, randomized controlled trial in 1330 adults aged 18 to <65 years who received either the Tdap (n = 1002) or tetanus-diphtheria (Td) (n = 328) vaccine 8 to 12 years after a dose of Tdap vaccine administered previously. Solicited adverse events following immunization were documented for 7 days after vaccination, and serious adverse events and adverse events of medical significance were documented for 6 months after vaccination. Levels of antibodies against component vaccine antigens were measured before and 1 month after vaccination.

RESULTS

A solicited adverse event was reported by 87.7% of Tdap and 88.0% of Td vaccine recipients. We found no significant differences in the rates of injection-site reactions, systemic reactions, or serious adverse events between the vaccine groups. A robust antibody response to each pertussis antigen in the Tdap-vaccinated group was found; postvaccination-to-prevaccination geometric mean antibody concentration ratios were 8:1 (pertussis toxoid), 5.9 (filamentous hemagglutinin), 6.4 (pertactin), and 5.2 (fimbriae 2 and 3). Postvaccination geometric mean concentrations of tetanus antibody (4.20 and 4.74 IU/mL, respectively) and diphtheria antibody (10.1 and 12.6 IU/mL, respectively) were similar in the Tdap and Td groups, and the rates of seroprotection against tetanus and diphtheria were >99% in both groups.

CONCLUSIONS

A second dose of Tdap vaccine in adults approximately 10 years after a previous dose was well tolerated and immunogenic. These data might facilitate consideration of providing Tdap booster doses to adults.

Tetanus: A Report of Two Cases and Review of Literature - A Continuing Threat to the Elderly in Japan

Tetanus has become rare in industrialized countries, largely due to the effectiveness of immunization. However, the elderly are susceptible to tetanus because many have not received primary immunization; the incidence of tetanus in Japan is still 120 cases/year. The initial symptoms of tetanus, such as trismus and dysphagia, are observed in the orofacial region. However, because of the disease's rarity, the clinician may be unfamiliar with the clinical presentation and may not suspect tetanus. We report two cases of elderly patients with generalized tetanus. Both patients presented trismus and/or dysphagia and consulted three different departments before the diagnosis of tetanus. Japanese clinicians will encounter tetanus more frequently than practitioners in other countries. Dental surgeons should be familiar with the clinical appearance of tetanus and should consider this disease in a nonimmunized patient presenting as an atypical case of trismus and dysphagia.

A Rare Case of Localized Tetanus

Tetanus is a severe and potentially fatal infection caused by the bacterium Clostridium tetani. Presentations of tetanus include generalized tetanus, neonatal tetanus, cephalic tetanus, and localized tetanus, the latter two being much rarer. We present case of a 55-year-old male farmer, presented with an injury to the left toe. A surgical wound exploration and washout with administration of human tetanus immunoglobulin and tetanus toxoid were given as treatment with antibiotic support. This case report points out the importance of the early recognition of a rare form of this fatal infectious disease, which may present with prodromal symptoms before the generalized form shows its clinical effects. Successful management includes prompt diagnosis, neutralization of circulating toxin and elimination of C. tetani infection, control of spasms, maintenance of the airway, and management of respiratory failure and autonomic dysfunction.

Tetanus in Poland in 2016

THE PURPOSE OF THE STUDY

The purpose of the study was to provide data on tetanus incidence in 2016 in the basic categories of epidemiological surveillance.

MATERIAL AND METHODS

The study is based on the individual forms of tetanus cases submitted to the NIZP-PZH Epidemiology Department and the data of the bulletin “Infectious Diseases and Poisoning in Poland in 2016.

RESULTS

The number of tetanus cases in 2016 was 12, exactly as it was in the previous year 2015. Among the infected people there were six men and six women. Among the infected people two men and one women died. All the fatalities were in the age groups of 70 and older.

SUMMARY AND CONCLUSIONS

The environmental nature of tetanus infections makes the immunity of individual exposed persons the basic preventive tool, which underlines the role of individual vaccinations.

Nanoporous Microneedle Arrays Effectively Induce Antibody Responses against Diphtheria and Tetanus Toxoid

The skin is immunologically very potent because of the high number of antigen-presenting cells in the dermis and epidermis, and is therefore considered to be very suitable for vaccination. However, the skin's physical barrier, the stratum corneum, prevents foreign substances, including vaccines, from entering the skin. Microneedles, which are needle-like structures with dimensions in the micrometer range, form a relatively new approach to circumvent the stratum corneum, allowing for minimally invasive and pain-free vaccination. In this study, we tested ceramic nanoporous microneedle arrays (npMNAs), representing a novel microneedle-based drug delivery technology, for their ability to deliver the subunit vaccines diphtheria toxoid (DT) and tetanus toxoid (TT) intradermally. First, the piercing ability of the ceramic (alumina) npMNAs, which contained over 100 microneedles per array, a length of 475 µm, and an average pore size of 80 nm, was evaluated in mouse skin. Then, the hydrodynamic diameters of DT and TT and the loading of DT, TT, and imiquimod into, and subsequent release from the npMNAs were assessed in vitro. It was shown that DT and TT were successfully loaded into the tips of the ceramic nanoporous microneedles, and by using near-infrared fluorescently labeled antigens, we found that DT and TT were released following piercing of the antigen-loaded npMNAs into ex vivo murine skin. Finally, the application of DT- and TT-loaded npMNAs onto mouse skin in vivo led to the induction of antigen-specific antibodies, with titers similar to those obtained upon subcutaneous immunization with a similar dose. In conclusion, we show for the first time, the potential of npMNAs for intradermal (ID) immunization with subunit vaccines, which opens possibilities for future ID vaccination designs.

Equine Vaccines: How, When and Why? Report of the Vaccinology Session, French Equine Veterinarians Association, 2016, Reims

To date, vaccination is one of the most efficient methods of prevention against equine infectious diseases. The vaccinology session, which was organised during the annual meeting of the French Equine Veterinarians Association (AVEF) at Reims (France) in 2016, aimed to approach three subjects of importance for the equine industry. Vaccination against three major equine diseases were used as examples: equine influenza (equine influenza virus), rhinopneumonitis (equine herpes virus 1/4), and tetanus (Clostridium tetani neuro-toxin). (1) Emergency vaccination: while it has been very successful to reduce the impact of equine influenza epizooties and it is also recommended for tetanus in case of surgery and accident, the benefit of emergency vaccination against equine herpes virus 1/4 remains arguable; (2) Compatibility of equine vaccines from different brands: despite being a frequent concerns for equine veterinarians, little information is available about the compatibility of equine vaccines from different commercial origins. The consequence of mixing different equine vaccines targeting the same disease is believed to be limited but scientific evidences are sparse; and, (3) Laps vaccination and vaccine shortage: they could have serious consequences in terms of protection and their impact should be evaluated on a case by case basis, taking into account the risk of contact with the pathogen and the effect on herd immunity.

A Cell Line for Detection of Botulinum Neurotoxin Type B

Botulinum neurotoxins (BoNTs) type A and type B are commonly used as biopharmaceutics for neurological diseases, uniquely allowing months-long paralysis of target muscles. Their exquisite neuronal specificity is conferred by a multistep process of binding, internalization, cytosolic escape and cleavage of the neuron-specific proteins, SNAP-25 and vesicle-associated membrane proteins (VAMPs), ultimately to inhibit secretion of neurotransmitters. Currently the mouse lethality bioassay is the only available method for quality control testing of VAMP-cleaving botulinum products. Refined assays for botulinum product testing are urgently needed. Specifically, in vitro replacement assays which can account for all steps of BoNT intoxication are in high demand. Here, we describe a novel SiMa cell-based approach where re-engineering of the VAMP molecule allows detection of all BoNT/B intoxication steps using a luminescent enzymatic reaction with sensitivity comparable to mouse LD50 bioassay. The presented one-step enzyme-linked immunosorbent assay meets 3Rs (replacement, reduction, and refinement of the use of animals) objectives, is user-friendly and will accelerate development of new botulinum drugs. The sensitive enzymatic reporter cell line could also be adapted for the detection of toxin activity during the manufacture of botulinum and tetanus vaccines.

A case of tetanus secondary to an odontogenic infection

Tetanus is a life-threatening clinical syndrome that commonly presents with muscular spasms, rigidity, and autonomic instability. It is considered rare in industrialized countries, and tetanus occurring secondary to dental abscesses, procedures, or infections has been infrequently reported. We describe the case of a patient inadequately immunized for tetanus, who presented to the emergency department with muscular spasms, rigidity, and autonomic instability in the setting of an odontogenic infection. A clinical diagnosis of tetanus was made and subsequently managed successfully.

Subcutaneous diphtheria and tetanus vaccines in children with haemophilia: A pilot study and review of the literature

INTRODUCTION

Subcutaneous (SQ) vaccination has emerged as standard of care in children with severe bleeding disorders to reduce unnecessary factor exposure and avoid provoking an intramuscular bleed, but little is known about comparative immunogenicity to intramuscular (IM) vaccination.

AIM

To confirm immunogenicity of Diphtheria Tetanus acellular Pertussis (DTaP) vaccines administered SQ to individuals <6 years old with haemophilia.

METHODS

We performed a retrospective and prospective pilot study of tetanus and diphtheria antibody titres among patients evaluated at our Haemophilia Treatment Centre between 2015-2016. Children with haemophilia who had received three to four doses of DTaP containing vaccine administered SQ were eligible.

RESULTS

Eight children met inclusion criteria. The mean age at the time of diphtheria and tetanus antibody testing was 21.1±17.8 months. All children who received SQ diphtheria and tetanus developed a positive antibody titre to both antigens. There was no statistically significant difference in distribution of titre values. The average time between the last dose of vaccine and antibody testing was 6.6±3.9 months among SQ vaccinated subjects. Minor injection site reactions were common with SQ vaccines.

CONCLUSION

SQ administration of diphtheria and tetanus vaccination appears to be immunogenic in a pilot study of Haemophilia patients and supports this practice as the standard of care for this population.

Examining evidence on dog bite injuries and their management in children

Dog bites are common injuries in children. The effects of such injuries can be devastating for the children concerned and their families. It is therefore important to provide holistic care and to consider psychological well-being as well as physical recovery. There should be clear guidelines for professionals about reporting dog bites and safeguarding. The literature recommends primary closure of the dog bite wound unless an infection is present. Literature also suggests that prophylactic antibiotics are ineffective in preventing infection except in hand injuries, although they are still routinely used in practice. This article recommends further research, support and education on dog bites in children, as well as national guidelines.

Immunogenicity and safety of primary and booster vaccination with 2 investigational formulations of diphtheria, tetanus and Haemophilus influenzae type b antigens in a hexavalent DTPa-HBV-IPV/Hib combination vaccine in comparison with the licensed Infanrix hexa

Safety and immunogenicity of 2 investigational formulations of diphtheria, tetanus and Haemophilus influenzae type b antigens of the combined diphtheria-tetanus-acellular pertussis-hepatitis B-inactivated poliomyelitis-Hib vaccine (DTPa-HBV-IPV/Hib) were evaluated in a Primary (NCT01248884) and a Booster vaccination (NCT01453998) study.

In the Primary study, 721 healthy infants (randomized 1:1:1) received 3 doses of DTPa-HBV-IPV/Hib formulation A (D_AT_APa-HBV-IPV/Hib), or B (D_BT_BPa-HBV-IPV/Hib) or the licensed DTPa-HBV-IPV/Hib vaccine (Infanrix hexa, GSK; control group) at 2, 3, 4 months of age. Infants were planned to receive a booster dose at 12–15 months of age with the same formulation received in the Primary study; however, following high incidence of fever associated with the investigational formulations in the Primary study, the Booster study protocol was amended and all infants yet to receive a booster dose (N = 385) received the licensed vaccine.

In the Primary study, non-inferiority of 3-dose vaccination with investigational formulations compared with the licensed vaccine was not demonstrated due to anti-pertactin failing to meet the non-inferiority criterion. Post-primary vaccination, most infants had seroprotective levels of anti-diphtheria (100% of infants), anti-tetanus antigens (100%), against hepatitis B (≥ 97.5% across groups), polyribosyl-ribitol-phosphate (≥ 88.0%) and poliovirus types 1–3 (≥ 90.5%). Seropositivity rates for each pertussis antigen were 100% in all groups.

Higher incidence of fever (> 38°C) was reported in infants receiving the investigational formulations (Primary study: 75.0% [A] and 72.1% [B] vs 58.8% [control]; Booster study, before amendment: 49.4% and 46.6% vs 37.4%, respectively).

The development of the investigational formulations was not further pursued.

Progress towards achieving and maintaining maternal and neonatal tetanus elimination in the African region

Despite the availability of effective tetanus prevention strategies, as of 2016, Maternal and Neonatal Tetanus Elimination (MNTE) has not yet been achieved in 18 countries globally. In this paper, we review the status of MNTE in the World Health Organization African Region (AFR),and provide recommendations for achieving and maintaining MNTE in AFR. As of November 2016, 37 (79%) AFR countries have achieved MNTE, with 10 (21%) countries remaining. DTP3 coverage increased from 52% in 2000 to 76% in 2015. In 2015, coverage with at least 2 doses of tetanus containing vaccine (TT2+) and proportion of newborns protected at birth (PAB) were 69% and 77%, compared with 44% and 62% in 2000, respectively. Since 1999, over 79 million women of reproductive age (WRA) have been vaccinated with TT2+ through supplementary immunization activities (SIAs). Despite the progress, only 54% of births were attended by skilled birth attendants (SBAs), 5 (11%) countries provided the 3 WHO-recommended booster doses to both sexes, and about 5.5 million WRA still need to be reached with SIAs. Coverage disparities still exist between countries that have achieved MNTE and those that have not. In 2015, coverage with DTP3 and PAB were higher in MNTE countries compared with those yet to achieve MNTE: 84% vs. 68% and 86% vs. 69%, respectively. Challenges to achieving MNTE in the remaining AFR countries include weak health systems, competing priorities, insufficient funding, insecurity, and sub-optimal neonatal tetanus (NT) surveillance. To achieve and maintain MNTE in AFR, increasing SBAs and tetanus vaccination coverage, integrating tetanus vaccination with other opportunities (e.g., polio and measles campaigns, mother and child health days), and providing appropriately spaced booster doses are needed. Strengthening NT surveillance and conducting serosurveys would ensure appropriate targeting of MNTE activities and high-quality information for validating the achievement and maintenance of elimination.