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Introduction
Tetanus is a rapidly progressing, painful disease with a high
mortality rate, yet is inexpensive to prevent. Although tetanus
toxoid was first licensed as a vaccine in 1937, tetanus remains a
public health problem in many parts of the world and is often
fatal, even within modern intensive care facilities.1,2 According
to World Health Organization (WHO) recommendations, a series of three tetanus-toxoid-containing vaccine doses should be
given in infancy, followed by booster doses at the age of school
entry, in adolescence and in adulthood to induce longer-term
immunity.1,3 WHOs focus on the elimination of maternal and
neonatal tetanus by 2015 led to vaccination strategies targeting women of reproductive age and infants.4,5 Less attention,
however, has been given to the immunization of males after
infancy. Data on child and adult vaccination coverage and
tetanus incidence and mortality among men are limited.
Emerging reports of cases of tetanus following voluntary
medical male circumcision in different sub-Saharan African
countries drew our attention to the possibility of a gender
disparity in tetanus morbidity that disproportionately affected
men. In this paper we report a summary of the reported tetanus
cases, together with a review of the evidence on tetanus vaccination coverage and case notification in sub-Saharan Africa,
supplemented by a review of the literature on non-neonatal
tetanus over the past 10 years.
Emerging reports
Context
Voluntary medical male circumcision is an effective intervention to reduce the risk of human immunodeficiency virus
(HIV) acquisition among men. When the intervention is
scaled-up, HIV incidence is reduced and costs are saved for
Department of HIV/AIDS, World Health Organization, 20 Avenue Appia, 1211 Geneva, Switzerland.
Office of the Global AIDS Coordinator, United States Department of State, Washington DC, United States of America.
c
Department of Immunization, Vaccines and Biologicals, World Health Organization, Geneva, Switzerland.
d
Department of HIV, TB and Hepatitis, Communicable Diseases Cluster, World Health Organization Regional Office, Harare, Zimbabwe.
Correspondence to Julia Samuelson (email: samuelsonj@who.int).
(Submitted: 11 November 2015 Revised version received: 7 March 2016 Accepted: 8 March 2016 Published online: 2 June 2016)
a
613
Table 1. Key features of 13 cases of tetanus after voluntary medical male circumcision reported to the World Health Organization from
2012 to 2016
Procedure Country
date
Clients
age,
years
Mar 2016
Sep 2015
Mar 2015
Mar 2015
Nov 2014
Sep 2014
Sep 2014
Aug 2014
Aug 2014
May 2014
Jun 2013
Dec 2012
Apr 2012
34
39
11
19
18
32
11
15
19
47
18
12
16
Rwanda
Rwanda
Uganda
Uganda
United Republic of Tanzania
Uganda
Uganda
Kenya
Uganda
Rwanda
Uganda
Zambia
Zambia
Procedure
method
Days to
symptoms
Device
Device
Surgery
Surgery
Surgery
Device
Surgery
Surgery
Device
Device
Surgery
Surgery
Surgery
8
Unknown
7
10
11
7
11
11
11
12
8
5
12
11
14
10
12
16
8
12
11
12
12
15
8
12
12
N/A
12
N/A
35
14
17
13
14
N/A
N/A
9
N/A
Clean
Clean
Septic
Clean
Septic
Septic
Septic
Septic
Septic
Clean
Clean
Septic
Septic
Unclean
substance
applied to
wound
Alternate
exposure
route on
body
Unknown
Unconfirmed
Yes
Unknown
Yes
Unknown
Yes
Yes
Unknown
Unconfirmed
Unknown
Yes
Unknown
No
Yes
No
Yes
Unknown
Unknown
Yes
No
Unknown
Yes
Yes
No
No
Tetanus notifications
Table 2. Cases of non-neonatal tetanus reported in 2013, by region of the World Health
Organization
Region
African Region
Region of the
Americas
Eastern
Mediterranean
Region
European Region
South-East Asia
Region
Western Pacific
Region
Populationa
All
Neonatal
927370712
966494922
6508
457
2776
20
3732
437
4.0
0.5
612580145
1513
1280
233
0.4
906995743
1855067643
102
4153
0
721
102
3432
0.1
1.9
1857588557
2127
679
1448
0.8
Angola
Burkina Faso
Democratic Republic of the
Congo
Liberia
Madagascar
Mali
Mauritania
Niger
Nigeria
Senegal
South Sudan
Ugandad
Populationa
All
Neonatal
Nonneonatalb
21471617
16934838
67513680
360
27
1359
33
0
1327
327
27
32
15.2
1.6
0.5
4294078
22924850
15301650
3 889 882
17831269
173615344
14133280
11296174
37578880
8
556
37
4
71
556
78
32
2928
0
8
12
0
1
468
4
25
406
8
548
25
4
70
88
74
7
2522
1.9
23.9
1.6
1.03
3.9
0.5
5.2
0.6
67.1
Literature review
To supplement evidence from the surveillance data, we conducted a literature
Discussion
Our investigation into tetanus cases
identified through voluntary medical
male circumcision programmes and an
analysis of available global data highlights a gender gap in tetanus morbidity that disproportionately affects men.
The occurrence of tetanus following
voluntary medical male circumcision
was rare with 13 cases reported from
programmes that have conducted over
11 million procedures by the end of
2015 and may be no higher than the
background incidence of tetanus among
men in these countries.
National tetanus case reporting and
hospital studies suggest that the incidence
615
% of population vaccinated
80
70
60
50
40
30
20
10
0
1970
1980
1990
2000
2010
2020
Year
Western Pacific Region
European Region
Region of the Americas
Global
Eastern Mediterranean Region
South-East Asia Region
African Region
Source: World Health Organization, online database.13
% of population vaccinated
80
70
60
50
40
30
20
10
0
1975
1985
1995
2005
2015
Year
Ethiopia
Uganda
Kenya
Mozambique
United Republic of Tanzania
Rwanda
Zambia
South Africa
Zimbabwe
Note: Countries included have reported a case of tetanus after the procedure or had low DTP3 coverage
(75% in at least 2years since the year 2000).
Source: World Health Organization, online database.13
Table 4. Summary of hospital studies of non-neonatal tetanus in sub-Saharan Africa countries, 2003 to 2014
Reference
Country
Study period
United Republic
of Tanzania
Democratic
Republic of the
Congo
Guinea
20092011
Nigeria
20062011
Nigeria
20002009
Ethiopia
20012009
Mali
20042009
Cte dIvoire
Ethiopia
20032008
19962009
Nigeria
19992008
Nigeria
20052008
Fawibe (2010)25
Nigeria
20022006
Ethiopia
20032008
Mali
Uganda
Nigeria
20012004
20052008
19962005
Nigeria
20042006
Uganda
Senegal
20052006
19992006
Nigeria
Nigeria
19992003
19952004
Nigeria
19902001
Ethiopia
Senegal
19852000
19992002
Ethiopia
19891998
Senegal
Senegal
Nigeria
MarSep
2002
SepDec
2002
19901999
Senegal
20012003
20052009
20012012
Population
Total no.
of hospital
admissions
Average
age,a,b
years
Male,
%
Case
fatality
rate, %
5627
135
71.0
1029
22
39.4a
95.2
52.4
8649
239
73.0
75
9374
218
29.4a
75.6
56.2
78009
190
30.4a
75.0
16.3
68
33.8a
77.9
35.3
1839
119
32.9a
84
46.2
273c
29
171
36.0a
33.0a
79
75.4
45.0
38.0
175c
12
60.0
80.0
18
5.8a
77.0
5.9
3514
41
33.0a
85.7
57.1
29
35.0a
65.5
41.4
965
25118
8762
57
145
86
39.0a
30.2a
69.0
66.0
58.1
38.9
38.4
42.9
164
29.6a
75.6
70.1
218
27295
17
1291
9.0a
n/a
47.0
7.4
12
79
29.8a
58.0
70. 9
0.0
45.0
288
36.1a
69.3
63.9
3548
146
46
32.3a
34.5a
69.9
63
49.3
60.8
51
9.0b
54
31.4
757
40
8.8a
75.0
8.0
30
36.0a
70.0
26.7
349
29.8a
66.0
37.0
4 123
440
20.0a
70.7
22.0
(continues. . .)
Bull World Health Organ 2016;94:613621| doi: http://dx.doi.org/10.2471/BLT.15.166777
617
(. . .continued)
Reference
Country
United Republic
of Tanzania
Cte dIvoire
Ghana
Study period
JanDec 2004
19851998
19942001
Population
Tetanus admissions
All tetanus admissions
All tetanus admissions
Total no.
of hospital
admissions
Average
age,a,b
years
Male,
%
Case
fatality
rate, %
22
91.0
72.7
62313
1870
158
28.0b
32.7a
71.0
76.6
31.9
50.0
Acknowledgements
Dedicated to the memory of Dr Martha
H Roper whose public health career
contributed to preventing illness and
deaths from tetanus.
Funding: This work was supported by the
United States Centers for Disease Control
and Prevention.
Competing interests: None declared.
.2014 2003
.
98% 65%
.2013 14
10.7% 0.3%
. 71%
.
.
618
.
14 2007
13 .) HIV(
2016 ) WHO(
.
11
.
2007 14
(HIV)
2016 3 (WHO)
13
1,100
2003-2014
(WHO)
100
201314
65%98%
0.3-10.7%
71%
Rsum
Les cas de ttanos et de dcs lis au ttanos dans la population masculine rvlent la ncessit de la vaccination
Avec lorientation des efforts sur llimination du ttanos maternel
et nonatal, une moindre attention a t porte sur lincidence et la
mortalit du ttanos dans la population masculine. Depuis 2007, la
circoncision mdicale masculine volontaire sest intensifie dans 14 pays
dAfrique subsaharienne, en tant quintervention efficace pour rduire
le risque dacquisition du virus de limmunodficience humaine (VIH)
chez les hommes. Dans le cadre dune analyse des effets indsirables
de ces programmes, nous avons identifi 13 cas de ttanos, dans
cinq pays, qui ont t notifis lOrganisation mondiale de la Sant
(OMS) jusqu mars 2016. Huit patients sont dcds et un seul patient
avait un antcdent connu de vaccination antittanique. Sur plus de
11millions de procdures ralises, les infections ttaniques suite une
circoncision mdicale masculine volontaire ont t rares. Nanmoins,
ces cas dinfection nous ont pousss mener une tude des donnes
disponibles sur la couverture antittanique et sur la notification des cas
en Afrique subsaharienne, complte par une revue de la littrature sur
,
. 2007 14
,
,
() .
, ,
13 ,
()
2016. ,
.
11 ,
,
.
.
,
( )
2003 2014.
( )
-
.
, 65 98%
14 2013.
, ,
( )
0,310,7%
71%.
,
.
.
619
Resumen
La enfermedad del ttanos y las muertes en hombres revelan la necesidad de vacunacin
Dado que se han concentrado los esfuerzos en la eliminacin del ttanos
materno y neonatal, se ha prestado menos atencin a la incidencia y
mortalidad del ttanos en los hombres. Desde 2007, ha aumentado la
circuncisin mdica masculina voluntaria en 14 pases subsaharianos,
puesto que se trata de una intervencin efectiva para reducir el riesgo de
contagio del virus de la inmunodeficiencia humana (VIH) en los hombres.
Como parte de una revisin de los fenmenos adversos derivados de
estos programas, se identificaron 13 casos de ttanos de cinco pases
notificados a la Organizacin Mundial de la Salud (OMS) hasta marzo
de 2016. Ocho pacientes murieron y solo uno estaba vacunado contra
el ttanos. Tras practicar la circuncisin mdica masculina voluntaria, el
ttanos era poco frecuente entre ms de 11 millones de intervenciones
realizadas. No obstante, los casos dieron lugar a una revisin de la prueba
de la cobertura de vacunas contra el ttanos y las notificaciones de los
casos en el frica subsahariana, junto con una revisin documental del
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