Narrative review: tetanus-a health threat after natural disasters in developing countries

Disaster neurology: A new practice opportunity and challenge for the neurologist

Headlines are filled with stories of the physical disability and loss of life that results from both natural and man-made disasters. The role of a neurologist as part of the response to these tragedies has moved from a supportive role to the front line. Recent earthquakes in Haiti and Japan as well as military conflicts in Iraq and Afghanistan have demonstrated an increased need for nonsurgical neurologic care. Disaster neurology has become attractive to neurologists at many stages of their careers. Employed, academic, and private practice neurologists all have the potential to embrace this opportunity to apply their clinical skills to help others in need of care. Neurologists interested in engaging in disaster relief efforts should have the ability to respond to a situation quickly with the flexibility of devoting several weeks to the response effort.

Vitamin C for preventing and treating tetanus

BACKGROUND

Tetanus is a severe disease that can be prevented by vaccination. In developing countries vaccination coverage is not always high. Cases still occur also in developed countries, particularly in elderly people owing to their reduced immuno protection. There are about 1 million tetanus cases per year globally. In animal studies, vitamin C has protected against various infections and bacterial toxins. In a study with rats, vitamin C protected against the purified tetanus toxin.

OBJECTIVES

To assess the prophylactic and therapeutic effect of vitamin C on tetanus.

SEARCH METHODS

In May 2013 we searched the Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations ); and Ovid EMBASE for this third update.

SELECTION CRITERIA

Controlled trials of vitamin C as a prevention or treatment for tetanus, whether or not these were placebo controlled, in any language, published or unpublished. Two review authors independently made inclusion decisions.

DATA COLLECTION AND ANALYSIS

Both review authors independently extracted data from trial reports and assessed methodological quality. Since one of the cells in a 2 × 2 table had no events, we calculated the odds ratio (OR) and its 95% confidence interval (CI) for case fatality rate by using the Peto-method. Another of the 2 × 2 tables had no empty cells and the inverse-variance method was used to calculate its risk ratio (RR) estimate and 95% CI. We also used the Fisher's exact test to calculate the exact 95% CI for the OR of the 2 × 2 table with the empty cell.

MAIN RESULTS

One single trial was eligible for inclusion. This non-randomised, unblinded, controlled trial undertaken in Bangladesh involved 117 tetanus patients. Vitamin C at a dosage of 1 g/day was administered intravenously alongside conventional treatment. At recruitment, the participants were stratified into two age groups and the results were reported by age. There was a significant difference in the vitamin C effect between the two age groups (P = 0.01). In the tetanus patients aged 1 to 12 years (n = 62), vitamin C treatment was associated with a 100% reduction in case fatality rate (95% CI from -100% to -94%). In patients aged 13 to 30 years (n = 55), vitamin C treatment was associated with a 45% reduction in case fatality rate (95% CI from -69% to -5%).

AUTHORS' CONCLUSIONS

A single, non-randomised, poorly reported trial of vitamin C as a treatment for tetanus suggests a considerable reduction in mortality. However, concerns about trial quality mean that this result must be interpreted with caution and vitamin C cannot be recommended as a treatment for tetanus on the basis of this evidence. New trials should be carried out to examine the effect of vitamin C on tetanus treatment.

Infections of the developing world

Access to critical care is rapidly growing in areas of the world where it was previously nonexistent and where infectious diseases often comprise the largest disease burden. Additionally, with crowding, mass migrations, and air travel, infectious diseases previously geographically confined are quickly spread across the planet, often in shorter time frames than disease incubation periods. Hence, critical care practitioners must be familiar with infectious diseases previously confined to the developing world. This article reviews selected tropical diseases that are seen in diverse locales and often require critical care services.

Clostridium novyi, sordellii, and tetani: mechanisms of disease

Clostridia represent a diverse group of spore-forming gram positive anaerobes that include several pathogenic species. In general, diseases caused by clostridia are a result of intoxication of the infected host. Thus, clostridial toxins have been targeted for diagnostic, therapeutic, and preventive strategies against infection. Studying the mechanisms of action of clostridial toxins has not only shed light on the pathogenesis of infection but has provided important new insights into cell biology and immunology. A primary purpose of this manuscript is to provide a succinct review on the mechanisms of disease caused by intoxication by the pathogens Clostridium tetani, Clostridium novyi, and Clostridium sordellii.

Characteristics of infectious diseases in hospitalized patients during the early phase after the 2011 great East Japan earthquake: pneumonia as a significant reason for hospital care

BACKGROUND

Natural catastrophes increase infectious disease morbidity rates. On March 11, 2011, a 9.0-magnitude earthquake and associated Pacific coast tsunami struck East Japan. The aim of this study was to investigate the characteristics of patients with infectious diseases who needed hospitalization after this disaster.

METHODS

We searched the medical records of 1,577 patients admitted to Tohoku University Hospital in the Sendai area within 1 month (March 11, 2011-April 11, 2011) after the disaster. We examined (1) changes in the rates of hospitalizations for infectious diseases over time and (2) the variety of infectious diseases.

RESULTS

The number of hospitalized patients with infectious diseases increased after the fi rst week to double that during the same period in 2010. Pneumonia comprised 43% of cases, and 12% consisted of skin and subcutaneous tissue infection, including tetanus. Pneumonia was prevalent in elderly patients (median age, 78 years) with low levels of serum albumin and comorbid conditions, including brain and nervous system disorders. Sputum cultures contained Streptococcus pneumoniae, Moraxella catarrhalis, and Haemophilus influenzae , known pathogens of community-acquired pneumonia in Japan. In addition, 20.5% of patients had positive results for urinary pneumococcal antigen.

CONCLUSIONS

Among hospitalized patients, infectious diseases were significantly increased after the disaster compared with the same period in 2010, with pneumonia being prominent. The analyses suggest that taking appropriate measures for infectious diseases, including pneumonia, may be useful for disaster preparedness and medical response in the future.

Neurotoxic emergencies

This article is intended for clinicians treating neurotoxic emergencies. Presented are causative agents of neurotoxic emergencies, many of which are easily mistaken for acute psychiatric disorders. Understanding the wide variety of agents responsible for neurotoxic emergencies and the neurotransmitter interactions involved will help the psychiatrist identify and treat this challenging population.

Tetanus immunity as a surrogate for past diphtheria-tetanus-pertussis immunization in migrant children

BACKGROUND

Data on vaccination coverage in recently arrived refugee children are essential to formulate catch-up recommendations. "Overimmunizing" is costly and associated with risks of hyperimmunization, whereas assuming up-to-date immunizations may be misleading.

METHODS

We retrospectively collected data from 92 migrant children referred to our hospital between January 2009 and May 2010.

RESULTS

According to our guidelines, 68 (73.9%) children without evidence of up-to-date immunizations received a booster dose of an age-appropriate tetanus-containing vaccine. As a surrogate for diphtheria-tetanus-pertussis-poliomyelitis immunity, tetanus antibodies were measured by enzyme-linked immunosorbent assay 1 month later in 55 of 68 (80.8%) children 6 months to 16 years of age (median, 7 years) from 23 countries. All but 2 children (3.6%) had reached high antibody titers (>1.0 IU/mL) and required no further booster. Unnecessary additional tetanus immunizations thus were avoided in 53 of 55 (96.4%) patients.

CONCLUSION

Assessing antitetanus antibody responses in migrant children allows individual vaccination schedules and avoids the risks of hyperimmunization.

India is on the way forward to maternal and neonatal tetanus elimination!

Tetanus is an acute, potentially fatal disease, caused by a bacterium, Clostridium tetani. The disease usually occurs in newborns through infection of the unhealed umbilical stump, particularly when the stump is cut with a non-sterile instrument. NT contributes to 5-7% of neonatal mortality worldwide. Several thousand mothers are also estimated to die annually of maternal tetanus. MNT elimination relies on promotion of maternal tetanus immunization along with safe delivery and avoidance of unsafe abortion and umbilical cord care practices. The Government of India (1983) introduced at least two doses of tetanus toxoid vaccine (TT) to all pregnant women during each pregnancy as a part of its nationwide immunization policy. To date, a total of 15 States including union territories of the India have achieved NT elimination. The remaining Indian States need to strengthen TT coverage to save the lives of neonates as well as mothers from tetanus.

Immunotherapies in infectious diseases

The development of an infection involves interplay between the host's immune system and the virulence of the infecting microorganism. The traditional treatment of an infection involves antimicrobial chemotherapy to kill the organism. The use of immunotherapies in infections includes treatment options that modulate the immune response and can lead to control of infections. These therapies are expected to become more important therapeutic options with the increase in infections due to multidrug-resistant organisms and the increasing number of immunocompromised patients.

Polyclonal immunoglobulins and hyperimmune globulins in prevention and management of infectious diseases

Immunoglobulin therapy has a rich history of use in preventing and treating infectious diseases; however, clinical data on the efficacy of immunoglobulin is lacking for many infectious diseases. Immunoglobulin therapy is routinely used in postexposure prophylaxis for bacterial infections, including tetanus, botulism, and diphtheria, and viral infections, including hepatitis A and B and varicella. Immunoglobulin therapy has also been used in many severe and life-threatening infections where treatments are limited, including toxic shock syndrome, respiratory syncytial virus infection, and cytomegalovirus infection. The authors review the evidence for the use of immunoglobulin therapy in common adult infectious diseases.