Prognostic factors in neonatal tetanus

Mortality Rate and Prognostic Factors in Neonatal Tetanus: A 3-Year Analysis of Cases Presented to Turkey-Somalia Mogadishu Training and Research Hospital

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.

Predictors of Mortality in Neonates and Infants Hospitalized With Sepsis or Serious Infections in Developing Countries: A Systematic Review

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.

Prognosis of neonatal tetanus in the modern management era: an observational study in 107 Vietnamese infants

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Large contemporary case-series in a setting of improved critical care facilities.

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Analysis of variables, some not analysed in previous studies/meta-analyses.

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Age and weight were associated with a poor outcome.

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Delay in admission to hospital and leukocytosis were also associated with a poor 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.

Local perceptions, cultural beliefs and practices that shape umbilical cord care: a qualitative study in Southern Province, Zambia

Background

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.

Methods and Findings

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.

Conclusion

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.

A review of neonatal tetanus in University of Maiduguri Teaching Hospital, North-eastern Nigeria

BACKGROUND

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.

OBJECTIVE

The objective of this study was to audit the scourge of neonatal tetanus in a tertiary health facility in a resource-limited setting.

MATERIALS AND METHODS

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.

RESULTS

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%.

CONCLUSION

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.

Neonatal tetanus: a continuing challenge

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.

Neonatal tetanus elimination in Pakistan: progress and challenges

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. A review of the literature found TT vaccination coverage in Pakistan ranged from 60% to 74% over the last decade. Low vaccination coverage, the main driver for NT in Pakistan, is due to many factors, including demand failure for TT vaccine resulting from inadequate knowledge of TT vaccine among reproductive age females and inadequate information about the benefits of TT provided by health care workers and the media. Other factors linked to low vaccination coverage include residing in rural areas, lack of formal education, poor knowledge about place and time to get vaccinated, and lack of awareness about the importance of vaccination. A disparity exists in TT vaccination coverage and antenatal care between urban and rural areas due to access and utilization of health care services. NT reporting is incomplete, as cases from the private sector and rural areas are underreported. To successfully eliminate NT, women of reproductive age must be made aware of the benefits of TT vaccine, not only to themselves, but also to their families. Effective communication strategies for TT vaccine delivery and health education focusing on increasing awareness of NT are strongly suggested. It is imperative that the private and government sectors work cooperatively to report NT cases and improve routine TT vaccination coverage.

Risk factors for mortality in neonatal tetanus: a 15-year experience in Sagamu, Nigeria

BACKGROUND

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.

METHODS

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.

RESULTS

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).

CONCLUSIONS

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.

Neonatal tetanus in Turkey; what has changed in the last decade?

Background

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.

Methods

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.

Results

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.

Conclusion

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.

Maternal and neonatal tetanus

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.

Risk factors for mortality from neonatal tetanus: 7 years experience in North Bengal, India

BACKGROUND

Neonatal tetanus (NNT), a preventable disease, remains an important cause of infant mortality in developing countries such as India.

OBJECTIVES

To evaluate the demographic and clinical data of NNT in North Bengal, India and determine the risk factors for mortality.

METHODS

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.

RESULTS

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.

CONCLUSION

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.

Prognostic factors affecting deaths from adult tetanus

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.