Adult Tetanus Is Not Gone Yet, but Could Be Ready to Leave: A Case-Series from Central India

Abstract

Introduction Adult tetanus is a neurotoxin mediated infectious disease, that continues to be seen despite availability of a highly efficacious vaccine. In India population-based burden estimates for adult tetanus are not available. Elimination of neonatal and maternal tetanus from India was achieved in 2015 with DPT (diphtheria, pertusis, and tetanus) vaccine during childhood and tetanus toxoid (TT) during antenatal care. Vaccine coverage in adults is uneven. While pregnant women receive the vaccine as part of ante-natal care, booster dose coverage in all other non-pregnant women and men is poor. Case report We describe four cases of adult tetanus that presented to our tertiary care hospital in central India. Out of four cases, two were homemakers, one was a farmer, another was a student. Three of them were not aware regarding primary tetanus vaccination and none of the four received any booster dosages of tetanus vaccine. Conclusions These cases highlight complexity of disease management and reinforce the need for adult booster immunization against tetanus.

Introduction

Tetanus is a neurotoxin mediated infectious disease which continues to be seen in adults despite availability of a highly efficacious vaccine for about a century now [1]. The same vaccine could achieve elimination of maternal and neonatal tetanus [2] from India in 2015, yet sporadic occurrence of adult tetanus continues to burden intensive care facilities across the developing world. Some recent studies have reported the annual burden of adult tetanus from tertiary care hospitals to be 5 cases in Korea [3], 10 in Sudan [4] and Uganda [5], 12 in Afghanistan [6], 80 in Bangladesh [7], and 144 in Vietnam [8]. No population-based burden estimates for adult-tetanus are available in India [1]. We describe four cases of adult-tetanus that presented to our tertiary care hospital in central India between June and December 2021. According to the World Health Organization in the entire year 2021 a total of 1240 cases of tetanus were reported in India; of them 81 were neonatal and 1159 were non neonatal. While our cases represent a small fraction of the total (0.003%), they underscore the complexity of intensive care and need for adult booster immunizations.

Tetanus vaccination in India is a part of the national immunization regimen. The regimen is DPT (diphtheria, pertussis and tetanus) at 6, 10, 14 weeks for infants and DPT booster-1 at 16-24 months, DPT booster-2 at 5-6 years and TT (tetanus toxoid) at 10 years and 16 years. DPT at 6, 10, 14 weeks are replaced by pentavalent vaccine (hepatitis B, diphtheria, pertussis, tetanus and Haemophilus influenzae b). TT-1 in early pregnancy and TT-2, 4 weeks after TT-1 are also part of the national immunization schedule. However, adult tetanus vaccination is not part of the national immunization schedule.

Case reports

Case 1

A 35-year-old farmer presented with a six-day history of neck-pain, difficulty in swallowing, and difficulty in opening the mouth. About a week prior to these symptoms, he had sustained a small lacerated injury over his right toe, which was treated by a practitioner at a village dispensary by cleaning the wound and primary closure by suturing. He had no history of getting vaccinated for tetanus prior to this injury. The local practitioner also administered him a dose of tetanus-toxoid without subsequent plan of vaccination. On examination at our hospital, he had trismus, risus sardonicus, opisthotonos and board-like rigidity of the abdomen. As he developed tonic spasms on the day of admission, we intubated and mechanically ventilated him. We initiated him on intravenous diazepam (20 mg every 4 hours for 15 days followed by tapering and discontinuation at day 26), metronidazole (500 mg intravenous every eight hours for 10 days), and also administered 500 units of tetanus-immunoglobulin intramuscularly as single dose. His local wound was cleaned and dressed. Anticipating prolonged need for mechanical ventilation, we performed tracheostomy on the second day of hospital admission. Over the next three weeks, he required mechanical ventilation, and he continued to receive intravenous infusions of midazolam (2 to 7 mg/hour for 8 days) and intravenous boluses of atracurium (5 mg every 20 minutes when required). He had episodes of autonomic dysfunction (sweating, tachycardia, fluctuating blood pressure) and ventilator associated pneumonia during this period, which were managed with magnesium sulphate (intravenously, 1 g/hour for 2 days), beta-blockers (intravenous labetalol 30 mg/hour for 2 days), and intravenous antibiotics. He could be weaned off mechanical ventilation after tapering off muscle relaxants on day 26, and mobilized on day 30. He was discharged on day 33, free of spasms, swallowing or autonomic dysfunction. Following discharge no functional disability was left at 3 months (Figure 1).

Case 2

A 20-year-old female presented with generalized body stiffness, inability to chew and swallow food for 8 days. These symptoms started initially as pain over both jaws, followed by difficulty in chewing solid food, restricted mouth opening and intermittent extensor posturing. There was no history of preceding injury, vaginal discharge or any instrumentation. She had had her menstrual periods about two weeks previously, which were normal. She had received primary immunization with DPT at 6, 10, 14 weeks and DPT booster-1 at 2 years of age, DPT booster-2 at the age of 5 years but she had received no booster doses of tetanus-toxoid after the age of five years. She was administered tetanus toxoid (0.5 mL intramuscularly) and tetanus immunoglobulin (500 units intramuscular) on admission, and was initiated on intravenous diazepam (20 mg every 4 hours for 4 days) and metronidazole (500 mg intravenous eight hourly for 7 days), intubated and mechanically ventilated. On the third day she developed intermittent tachyarrhythmia, which was controlled with intravenous magnesium sulphate (2 g in 100 mL 5% dextrose over 20 minutes followed by 1 g/hour infusion for 48 hours). A tracheostomy was done, and as spasms increased, we shifted her from diazepam to intravenous midazolam 2 to 4 mg/hour for 12 days. She continued to be mechanically ventilated for the next two weeks. She was weaned off from mechanical ventilation on day 18 of admission and ambulation was initiated. She was discharged on day 24 of hospitalization. Muscle wasting was present at 3 months follow-up.

Case 3

A 50-year-old homemaker presented with generalized spasms and hyperextension of the neck for the past five days. There was a preceding history of severe backache for about three days. There was no history of injury, medical procedures, or instrumentation. She had had her menstrual periods about ten days previously, which were normal. She had had the last childbirth two decades previously, and did not remember ever receiving a tetanus vaccine. She was intubated, mechanically ventilated, and initiated on intravenous metronidazole (500 mg eight hourly for 10 days) and diazepam (30 mg intravenous every 4 hours as needed). She received the first dose of tetanus toxoid (0.5 mL intramuscularly) and tetanus immunoglobulin (500 units intramuscularly) on the day of admission and the second dose of tetanus toxoid four weeks later. We performed tracheostomy on day 4 of hospital admission. She developed autonomic storms on day 12 characterized by tachycardia, hypertension, diaphoresis and agitation with persistence of intermittent spasms. We initiated her on intravenous infusions of midazolam (2-4 mg/hour for 10 days) and magnesium sulphate (100 mL 5% dextrose over 15 minutes followed by 1 g/hour infusion for 48 hours). She could be weaned off mechanical ventilation on day 34, but her swallowing dysfunction persisted for another ten days and she could be fed only through nasogastric tube. On day 46 we could shift her on oral baclofen and oral lorazepam. As her mobilization was poor, she remained in the hospital until day 60. During discharge, muscle wasting and irritability and sleep disturbance were present and at 3 months of follow-up she was still feeling light-headedness and "swimminess" on sudden change of posture, particularly on standing after sitting.

Case 4

A 21-year-old homemaker presented with generalized body stiffness, fever and difficulty in mouth opening 10 days after having a spontaneous abortion. There was a history of instrumentation after abortion at a local clinic. She did not recall ever receiving a tetanus vaccine. On presentation she was in distress with hyperextended neck, stiffened lower extremities and a localized edematous area over right labia minora. She was admitted and initiated on intravenous metronidazole (500 mg eight hourly for 10 days), diazepam (20 mg intravenous 4 hourly for 13 days) and thrice daily intravenous 500 mg paracetamol for 5 days. We also administered the first dose of the tetanus vaccine (0.5 mL intramuscularly) and human tetanus immunoglobulin (500 units intramuscularly). She was intubated on the second day of hospital admission, and had tracheostomy done on day 5. She also developed secondary bloodstream infection (Escherichia coli, sensitive to carbapenems, piperacillin-tazobactam) during the hospital stay, which was treated with intravenous meropenem 1g eight hourly for 14 days. She was weaned off mechanical ventilator on day 32, and tracheostomy was closed on day 40. She was mobilized; swallowing restored, and she was discharged on day 44. During discharge irritability and muscle weakness was present and at 3 months follow-up the patient resumed her work.

Discussion

All these patients had long hospital stays between one and two months. In-hospital management of generalized adult tetanus is complex, and success depends on early tracheostomy, good supportive care, perseverance of the treating team and caregivers. Long hospital stays lead to loss of wages and are an additional economic burden on the caregivers. Occurrence of adult tetanus can be prevented by booster doses as part of adult immunization. The COVID-19 epidemic has taught us that it is possible to achieve universal adult immunization and the same zeal and enthusiasm can be extended to the 100% efficacious tetanus vaccine. Previous reports from India have confirmed poor coverage of tetanus boosters, and low antibody levels.9,10

Conclusions

This case series highlights the need for adult booster immunizations for tetanus. Success of maternal and neonatal tetanus needs to be extended to adults as well.