Tetanus: Scientists want vaccination target, schedule revisited

Bukirwa, a resident of Zana in Wakiso District, says the nine-year-old boy contracted tetanus around October 2021. 

“He was brought back home and they told me he was injured but his wound was healing. He could even jump around yet tetanus bacteria were in his body,” she continues.

Later, he started experiencing pain and soon he could not even bend his legs. He could not breathe well and he had a serious fever, the mother reveals. “His chest appeared to come outside and he was like a lame person,” Bukirwa recalls.

Signs

Tetanus is a vaccine-preventable infectious bacterial disease that manifests with painful uncontrollable contraction of muscles and this can interfere with the ability to breathe, eventually causing death.

Bukirwa says: “When his condition deteriorated, we rushed him to St Francis Hospital, Nsambya, where we spent three days. From there, we were referred to TMR International Hospital in Naalya, where he was admitted to the Intensive Care Unit (ICU).”

Muwonge, the mother reveals, successfully underwent treatment at TMR Hospital and has recovered from the disease. But she says this experience of seeing her son in excruciating pain and trying to get him the best care caused a lot of emotional and financial stress to the family. 

Bukirwa says the family lost a lot of property and entered a fundraising drive to clear the more than Shs200m medical bill. She says this was accrued after Muwonge spent 60 days in the Intensive Care Unit (ICU) of the private hospital since they could not get space at Mulago National Referral Hospital during the second wave of the Covid-19 pandemic. Public facilities are considered more affordable. 

Prevalence

Muwonge is not the only person affected by tetanus. According to information from the Ministry of Health, around 4,000 cases of tetanus, a disease that costs a lot of money to treat, are registered in Uganda annually. 

In a recent research report by Joyce Nguna and colleagues from the Uganda National Institute of Public Health (UNIPH) of the Health Ministry, up to 17,903 cases of tetanus were reported between 2012 and 2016, with 56 percent being males, according to the report.

The infectious bacterial disease has also remained a big cause of death in Uganda with the death rate among infected people ranging from 11 to 49 percent, according to separate research reports by Ugandan researchers Andrew Kazibwe and Nguna.

The researcher from UNIPH notes that in the 2012 to 2016 period studied, specifically, “from 2015 to 2016” there was a “sharp increase” in cases with those aged five to 59 years contributing 84 percent of the cases amid a lack of prioritisation in immunisation programme for the above age group.

"Although Uganda validated maternal and neonatal tetanus elimination target in 2011, the country reports one of the highest rates of non-neonatal tetanus globally," Nguna states.

“The government needs to refocus and scale up tetanus toxoid (TT) vaccination for adult males and females. Additionally, there is need for community-wide health education on the importance and benefits of TT for pregnant mothers in order to increase its acceptability and utilisation,” Nguna writes in the report.

The researcher also notes that a three-dose primary series pentavalent vaccine containing TT is provided to infants through routine immunisation services at 6, 10, and 14 weeks of age.

“Uganda does not provide the three World Health Organisation (WHO) recommended booster doses of TT containing vaccine (TTCV) at ages 12-23 months, four to seven years, and nine to 15 years. To prevent and maintain maternal and neonatal tetanus elimination, up to five doses of TTCV are provided to women of reproductive age,” the researcher further notes in the report.

In children

Dr Hellen Aanyu, the head of paediatrics department at Mulago National Referral Hospital, explains that even for young children who are vaccinated while still infants, the protection lasts around seven years.

“That means they need to get a booster at least every 10 years (for their immunity to remain effective). Usually, once you get an injury, they can inject you with the vaccine but if you got the injury and the tetanus bacteria at the same time, the vaccine may not help you because immunity builds up with time,” she notes.

Signs and symptoms

Dr Aanyu says the most obvious symptoms of tetanus are abnormal movement of the muscles, which is referred to as spasms and fever.

“For one to get tetanus, the germ should enter the body and it is through an opening onto the skin such as a wound, prick, or umbilical cord,” she says, adding that tetanus affects the jaw area, causing stiffness and inability for the patient to open their mouth. There is also stiffening of different parts of the body as a result of the abnormal movement of the muscles,” she adds.

According to information from the World Health Organisation (WHO), the incubation period of tetanus varies between three and 21 days after infection. Most cases occur within 14 days.

The WHO also states that symptoms can include: “jaw cramping or the inability to open the mouth, muscle spasms often in the back, abdomen and extremities, sudden painful muscle spasms often triggered by sudden noises, trouble swallowing, seizures, headache, fever and sweating, changes in blood pressure or fast heart rate.”

“In neonatal tetanus, symptoms include muscle spasms, which are often preceded by the newborn’s inability to suck or breastfeed, and excessive crying. Tetanus is diagnosed on the basis of clinical features and does not require laboratory confirmation,” the WHO states.

The global health agency also notes that tetanus is a medical emergency requiring care in the hospital with “immediate treatment with medicine called human tetanus immune globulin (TIG).”

The other care that is provided includes aggressive wound care, drugs to control muscle spasms, antibiotics, tetanus vaccination. “People who recover from tetanus do not have natural immunity and can be infected again, and, therefore, need to be immunised,” the WHO further reveals. 

Cost of treatment

Dr Sabrina Kitaka, a paediatrician at Mulago National Referral Hospital, says a significant number of cases of tetanus is among males who were not targeted by the Ministry’s initial campaign.

“The MoH has put a lot of emphasis on the prevention of neonatal tetanus so they vaccinate the girls and the women who are pregnant. But what about the men? The men also get tetanus. A lot of the children that come to our wards are boys,” she says.

Victoria Nabiteeko, a Kampala resident whose son Jovan Mulondo survived tetanus in 2020, says she paid at least Shs165 million for treatment. This is, however, lower than Shs235 million which Bukirwa says she was charged for treatment.

Nabiteeko says what was even more concerning was that at first, even doctors in some hospitals she went to did not know what was wrong with her son or how to treat him.

“He (my son) had a problem before; he had stepped in hot ash so we were doing corrective surgery on his foot. So, tetanus bacteria entered his body through the surgery wound,” she narrates.

She continues: “We went to TMR International Hospital [in Kampala] where he was treated. He was in coma for 40 days and we were not sure what would happen. It was the worst experience. But he is now fine.”

Like Bukirwa, Nabiteeko says she had to sell some of her property and rely on fundraising to clear the medical bill.

Kenneth Mwehonge, the executive director of HEPS Uganda, an NGO, says families are losing loved ones because of tetanus. 

“On July 27, 2022, a mother lost two children aged 13 and 15 to tetanus at Kibuli hospital. The two stepped on broken glass while playing,” he says.

He adds: “Due to less awareness about tetanus and the required booster jabs, the family members first suspected witchcraft when symptoms started manifesting. By the time they took them to the hospital, it was too late and the second child died minutes after the burial of his sibling.”

Pregnant women

Dr Nicholas Mugagga, an obstetrician and gynaecologist, says pregnant mothers should always get the tetanus shots during every pregnancy since protection from the shots wanes off over time.

He is also concerned that the tetanus vaccine is being administered to pregnant women too early. He says there is a need for revisiting the schedules in that the first shot should be given at around 27 weeks of pregnancy.

“Right now, a mother comes in at eight weeks [of pregnancy] and then you give them a shot. Remember the placenta that transfers nutrients and antibodies from the mother to the baby will not do any transfer around 17 weeks of pregnancy, so giving the vaccine before this time is equivalent to wasting the vaccine because the purpose is to protect the [unborn] baby,” he reasons.

Health officials speak

Dr Michael Baganizi, the deputy manager for Uganda National Expanded Programme on Immunisation (UNEPI), says plans are underway to reach out to more people, adult males and females included, for tetanus immunisation.
 
“Tetanus is one of the diseases you do not want to handle at the hospital because it is difficult to rescue the patient. There is alo too much suffering by the patient and a lot of pain which causes demoralisation,” he says.
  
Dr Allan Muruta, the commissioner for epidemics at the MoH, says the ministry has approved booster doses to minimise the risk of getting the disease. He also calls for addressing hygiene gaps that make people contract the bacteria. 

“There are practices where we put soil and cow dung in the umbilical cord and yet the soil and cow dung store the bacteria,” he says.