SHORT COMMUNICATION
TETANUS IN POST 2005
PAKISTAN EARTHQUAKE
SCENARIO
Muhammad Khurram and Najia Mahmood
Tetanus is an important health problem in developing
countries. Estimated true global incidence of tetanus is
700,000 to 10,00000 cases per year. 1 Tetanus usually occurs
due to contamination of wounds by spores. Anaerobic
conditions facilitate bacterial growth. Clinical signs and
symptoms of tetanus are produced by tetanospasmin, a
neurotoxin that causes motor disinhibition leading to
unopposed generalized contraction of muscles and clinical
presentation of muscle rigidity and reflex spasms. Tetanus is
usually diagnosed on clinical grounds. It can be complicated
by laryngospam, bones fractures, autonomic failure,
nosocomial infection, and aspiration pneumonia. Treatment of
tetanus includes; wound care, immunoglobulins, and
management of complications.
A catastrophic earthquake hit Pakistan and Azad Jammu and
Kashmir in October 2005 resulting in 86,000 deaths, 80,000
seriously injured patients, and 3 million homeless persons.
Tetanus outbreak was noted in these areas which lead to 23
deaths.2 Hospitals of Rawalpindi and Islamabad managed
majority of seriously injured and tetanus patients. It was for the
first time that tetanus patients were treated in such a bulk. This
report describes the clinical features and outcome of tetanus
patients coming from earthquake affected areas.
The study was conducted at three major public hospitals of
Rawalpindi (Rawalpindi General Hospital, Holy Family
Hospital, and District Headquarter Hospital). Study period
extended from October to December 2005. All earthquake
victims, suffering from tetanus, diagnosed on clinical basis,
were included.
Ablett classification, grade I to IV, was used for assessment of
tetanus severity at presentation.3 All patients were managed in
standard way i.e. wound toilet/debridement, active and
passive tetanus immunization, antibiotics, treatment to control
fits and rigidity (diazepam, phenobarbitone, haloperidol,
magnesium sulphate, tracheostomy, and ventilatory support
etc.). Patients were kept at respective hospital until study end
point, which was either discharged healthy, or death.
Data regarding age, gender, immunization status, incubation
period (time from inoculation to first symptom), duration of
hospital stay, main presenting symptom, initial grade of
tetanus, use of ventilatory support, complications, and
Department of Medicine, Holy Family Hospital, Rawalpindi.
Correspondence: Dr. Muhammad Khurram, C-14, Medical College Staff Colony,
Rawal Road, Rawalpindi, Pakistan. E-mail: drmkhurram@gmail.com
Received November 03, 2006; accepted July 13, 2007.
JCPSP 2007, Vol. 17 (9): 577-578
outcome was collected. Statistical Package for Social
Sciences (SPSS) version 10 was used for analysis. Chi2 and
Fishers exact test were used to note statistically significant
associations between categorical variables. T-test was used,
similarly, for continuous variables. P-value <0.05 was
considered significant.
Thirty-two patients were included. Of these 53.2% (n=17) were
male and 46.8% (n=15) female. Mean patient age was 32 ±
25 years. None of the patients had received primary
immunization against tetanus before the earthquake, while
68.8% (n=22) patients were administered tetanus toxoid after
the earthquake. Mean incubation period was 13.16 ± 11.54
days. Mean duration of hospital stay was 12.9 ± 8.51 days.
Lockjaw (53.1%, n=17) and fits (31.2%, n=10) were most
frequently observed main presenting symptoms. Others
included stiffness (6.2%, n=2), fever (3.1%, n=1), dysphagia
(3.1%, n=1), and reflex spasm (3.1%, n=1). In majority (46.9%,
n=15), grade II tetanus was noted. Grade I, III, and IV were
noted in 18.7% (n=6), 18.7% (n=6), and 15.6% (n=5) patients
respectively. Autonomic dysfunction (hypertension,
tachycardia alternating with hypotension and bradycardia)
were observed in 25% (n=8) patients, 46.9% (n=15) patients
expired, while 53.1% (n=17) were discharged healthy to
various medical camps. Sepsis, asphyxia, and dysrhythmias
(autonomic dysfunction) were causes of death in 9, 4, and 2
patients respectively.
Mortality in males was 41.17% (n=7), while in females it was
57.14% (n=8, p= 0.377), 56.11% (n=11) patients with
incubation period <10 days died compared to 28.57% patients
with incubation period >10 days, (p = 0.07). Grade II, and IV of
tetanus at initial presentation were significantly associated
with discharge (p= 0.03), and death (p = 0.0009) respectively.
Mean incubation period, onset time, and duration of hospital
stay with respect to outcome are shown in Table I 15.6% (n=5)
patients received ventilatory support. Two of these patients
had grade III, while of the rest one each had grade I, II, and IV
tetanus. Sixty percent (n=3) patients, who received ventilatory
support, expired (p = 0.64).
Lack of primary immunization was the main reason for tetanus
outbreak in earthquake victims. Although 68.8% patients had
Table I: Mean incubation period, onset time, and hospital stay with
respect to outcome
Outcome
Discharge Death P- value
Incubation period 15.94 ± 14.87 10 ± 4.69 0.14
Onset time 2.55 ± 2.46 3.11 ± 3.21 0.64
Duration of hospital stay 16.35 ± 8.27 9 ± 7.15 0.01
been vaccinated against tetanus after the earthquake, such
prophylaxis may not be effective in preventing tetanus.4
Insufficient public health infrastructure, lack of awareness in
public, and health professionals, inadequate knowledge and
incorrect practices are contributory in this regard. It is also
important to consider the fact that only 4000 doses of tetanus
toxoid were initially available for millions of earthquake victims.
Tetanus-related expiries in this study comprised majority
(65.21%) of reported earthquake-related tetanus deaths.2
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Post earthquake tetanus
Outcome in tetanus depends on factors like age of patient and
facilities available at hospital premises. Mortality rates vary
from 10- > 50% in these patients. 3 Death rates in countries
with poor or no facility for prolonged intensive care and
ventilatory support are > 50%. 3 Proper intensive care facilities
were not available at any of the three hospitals, which
contributed to high mortality. Airways obstruction, respiratory
failure, renal failure, autonomic disturbances, nosocomial
infections, and sepsis are main causes of death in tetanus. 3
Causes of death in these patients were similar.
Tetanus is not a gender specific disease, however, in various
studies, men or male children constitute majority of tetanus
patients, which is attributed to higher chances of involvement
in outdoor activities and injuries. Here again, there were more
male tetanus patients compared to females (53:46%). In a
recently published study pertaining to injuries in October 2005
earthquake scenario, majority (58.3%) of victims were male.2,5
The mean age was 32 ± 25 years, which corresponds with
demographics of subjects injured in the earthquake. 5
Incubation period relates with the time taken by tetanus toxin
to travel from contaminated site to nervous system i.e., spinal
cord. Longer duration of hospital stay and shorter incubation
period or onset time are associated with severe disease and
complications in tetanus patients. 3 The observations in these
regards are somewhat different. Patients who expired had
shorter incubation period as well as hospital stay compared to
the patients who recovered. Higher grade of tetanus in these
patients seems to be responsible for the difference.
Grade II and IV of tetanus significantly correlated with outcome
in these patients, indicating that higher tetanus grades are
associated with poor outcome and vice versa.3 Assisted
ventilation requirement in tetanus is a poor prognostic factor.
About 27% patients with tetanus may require ventilatory
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support. Mortality rate among tetanus patients, who require
ventilatory support is around 30%. Mortality in these patients
receiving ventilatory support was comparatively high as most
had advanced disease i.e., 60% were in grade III or IV tetanus.
Acknowledgements: The authors would like to acknowledge
Professor Bushra Khar and Dr. Zubair Hasan, who gave
valuable suggestions for the study. Special thanks are also
due for Professor M. Hanif, Professor M. Umar, Professor
Rehana Sukhera and Dr. Irum Shakir Kyani from whose units
data was collected in addition to Medical Unit-II, Rawalpindi
General Hospital.
REFERENCES
1. Thwnites CL, Farrar JJ. Preventing and treating tetanus (editorial). BMJ
2003; 326: 117-8.
2. Asian Development Bank, World Bank. Pakistan 2005 earthquake
preliminary damage and needs assessment. [online] Available from:
http:// www.adb.org/Documents/Reports/pakistan-damage-needs-
assessment.pdf. Accessed October 10, 2006.
3. Cook TM, Protheroe RT, Handel JM. Tetanus: a review of literature. Br
J Anaesth 2001; 87: 477-87.
4. Pedalino B, Cotter B, Ciofi degli Atti M, Mandolini D, Parroccini S,
Salmaso S. Epidemiology of tetanus in Italy in years 1971-2000. Eur
Surveill 2002; 7: 103-10.
5. Mulvey JM, Qadri AA, Maqsood MA. Earthquake injuries and the use of
Ketamine for surgical procedures: the Kashmir experience. Anesth
Intensive Care 2006; 34: 1-6.
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