|Year : 2016 | Volume
| Issue : 3 | Page : 102-106
Incidence of neonatal tetanus in a Nigerian State Hospital, Benin, Nigeria
Florence O Adeyemo1, Tijani A Abioye2, Amiegheme Ehobhayi Felicia3, Agbontaen Usunobun4
1 Department of Nursing, College of Health Sciences, Ladoke Akintola University of Technology, Osogbo, Osun State, Nigeria
2 Department of Nursing Science, University of Ilorin, Ilorin, Nigeria
3 Department of Nursing Sciences, School of Basic Medical Sciences, University of Benin, Benin City, Edo State, Nigeria
4 Department of Nursing Science, School of Medical Sciences, University of Benin, Benin City, Edo State, Nigeria
|Date of Submission||07-Jul-2016|
|Date of Acceptance||10-Sep-2016|
|Date of Web Publication||2-Nov-2016|
Florence O Adeyemo
Department of Nursing, College of Health Sciences, Ladoke Akintola University of Technology, Osogbo, Osun State
Source of Support: None, Conflict of Interest: None
Aim: The study was aimed at determining the incidence of neonatal tetanus (NT) in Stella Obasanjo State Hospital, Benin City over a period of 5 years. Settings and Design: Retrospective design was used where past records were reviewed from January 2008 to June 2013 and analyzed. Materials and Methods: An observational checklist was developed for manual collection of secondary data from the case notes and the neonatal ward register (the admission and discharge records of patients). The checklist includes information on the following; age at birth, age at discharge, duration of hospitalization, date of manifestation of the disease, entry point of the disease, mother's immunization, place of birth, treatment modality, and outcome of treatment. Statistical Analysis: Descriptive statistics was used which involves the use of simple percentage and bar chart to analyze the data. Results and Conclusions: The result of findings shows that 5 cases were admitted in 2008 and 2010 and the age at manifestation of disease range from 3 to 15 days old while age at admission ranges from 5 to 17 days old. The highest number of days infants stayed in the hospital is 44 days while the least was 2 days whereas the age at discharge ranges between 7 and 52 days. The result further revealed that 60% of the cases were born in the hospital, 26.6% were born out of the hospital while 13.3% gave were born in traditional birth attendant quarters. Finally, this study showed that the percentage of unimmunized mothers outweighs that of immunized mothers. NT is a key cause of neonatal mortality even though it is preventable and it was recommended that all babies born on the floor, roadside, or in a motor vehicle due to precipitated labor should be given injection ATS 4 units/kg before the disease appears.
Keywords: Incidence, neonatal tetanus, neonates
|How to cite this article:|
Adeyemo FO, Abioye TA, Felicia AE, Usunobun A. Incidence of neonatal tetanus in a Nigerian State Hospital, Benin, Nigeria. J Health Res Rev 2016;3:102-6
|How to cite this URL:|
Adeyemo FO, Abioye TA, Felicia AE, Usunobun A. Incidence of neonatal tetanus in a Nigerian State Hospital, Benin, Nigeria. J Health Res Rev [serial online] 2016 [cited 2020 Sep 26];3:102-6. Available from: http://www.jhrr.org/text.asp?2016/3/3/102/193187
| Introduction|| |
Neonatal tetanus (NT) occurs in newborns within the first 28 days of life. Tetanus infection is as old as history itself. It is one of the six childhood killer diseases that the government of Nigeria has targeted for eradication or control through the implementation of National Programme of Immunization. It is the second leading cause of death from vaccine-preventable diseases among children worldwide caused by Clostridium tetani. Neonatal tetanus (NT) remains a public health problem in many developing countries. It is a highly debilitating disease, found commonly in wounds with small external opening such as needle pricks, nail, or fork piercing. The high mortality of NT remains a therapeutic challenge to health workers and requires continuous evaluation.
Contributing factors are the cultural diversity of hygienic childbirth practices and cord care, lack of skilled attendance with delivery, parent's illiteracy, lack of antenatal care, including low level of immunization against tetanus, seasonality, geographical location and climate, the prevalence of spores of C. tetani and rural agricultural settled populations. Lambo et al. explained that the determinants of mortality in NT are not well understood. The most common port of entry for the tetanus spores is the unhealed umbilical cord and 90% cases of NT develop symptoms during the first 3–14 days of life with the majority presenting at 6–8 days and mortality tends to be very high. In the absence of medical treatment, case fatality approaches 100%, with hospital care, 10–60% of NNT cases die, depending on the availability of intensive care facilities. It is more effective to prevent tetanus than case management even where intensive care is available.
NT is mostly associated with the poor, illiterates, and those in adverse environmental circumstances and it is being described as a social scourge., Mothers of affected babies are likely to have a low tetanus toxoid coverage rate, unlikely to attend antenatal care during pregnancy, likely to deliver outside a medical establishment, therefore, attended to by unskilled personnel and care of the cord after delivery may be unhygienic.
The estimated mortality rate of NT varies widely from one country to another. NT was responsible for almost 500,000 deaths globally in the early 1980s and about 130,000 deaths were recorded in the year 2004 from this very preventable disease. Quddus et al. stated that an estimated 248,000 neonatal deaths were caused by NT globally in the year 1997, and almost 11% (26,400) of these NT deaths were in Pakistan with an NT mortality rate of 5/1000 live births. NT has a high case fatality ratio (CFR) and community-based surveys in developing countries have reported CFRs approaching 80%–90% even with treatment. NT accounts for 18%–38% and 17%–22% of all neonatal and infant deaths respectively in Pakistan. Nigeria is one of the 27 countries which account for over 90% of the global burden of NT. Globally, 7% of neonatal deaths was as a result of tetanus, but the incidence is up to 20% in Nigeria. Out of 5 million babies born annually in Nigeria, 240,000 (4.8%) die within the first 4 weeks of life. The incidence of NT in Lagos state, Nigeria from 1982 to 1987 is between 4% and 8% of all birth. A study of NT in Ladoke Akintola University Teaching Hospital, Osogbo from January 2006 to December 2008 revealed that admissions were significantly higher in 2006 compared to 2007 and 2008 (2.3% vs. 0.2%). Another study in University of Benin Teaching Hospital (UBTH) and Modic Hospital, Benin City, Nigeria showed that the annual incidence of NT was 6.9% in UBTH and 5.3% in Modic Centre out of which 43.8% survived while 56.2% died among those admitted to both hospitals. It was further observed that many of the mothers were uninformed about immunization and some did not have knowledge about the relevance of antenatal care. Despite this, deaths have been reduced, however, recently there appears to be an increase in NT despite these interventions leading to increasing neonatal morbidity and mortality. The purpose of this study was to determine the incidence of NT over the past 6 years in Stella Obasanjo Maternal And Child Care Hospital, Benin City been the biggest hospital in the state.
Aims of the study
- To examine the incidence (admitted cases) of NT in Stella Obasanjo Hospital, Benin City, Edo State
- To determine the causes of NT in this cohort
- To examine the treatment modalities employed in the care of infants with NT
- To assess the treatment outcome of infants with NT
- To determine if the mothers of the infected neonates were immunized during pregnancy.
| Materials and Methods|| |
A retrospective descriptive design of patient records between January 2008 and June 2013 was reviewed. The study focuses on newborn babies admitted to Stella Obasanjo Hospital, Benin City, between 0 and 28 days old diagnosed with “NT.” A checklist was developed for the manual collection of data from the case notes of mothers and the neonatal ward register (the admission and discharge records of patients). The checklist included information on the following; age at birth, age at discharge, duration of hospitalization, date of manifestation of the disease, entry point of the disease, mother's immunization, place of birth, treatment modality, and outcome of treatment.
Records of all neonates managed for tetanus at the Neonatal Unit of Stella Obasanjo Maternal and Child Care Hospital, Benin City between January 2008 and June 2013 were identified in the Medical records department and reviewed by the researcher. Descriptive statistics were used which involved the use of simple percentage and bar chart to analyze the data. Neonates < 28 days old diagnosed with NT were included in this study, while neonates older than 28 days were excluded from the study.
Permission was granted by the Ethical Committee of the Hospital and the Head of Department of the Medical Records to access the patient's documents.
| Results|| |
To examine the incidence (admitted cases) of NT, a total of 21 (n = 21) cases were admitted during the period under study out of a total of 1690 births (1.2%) [Table 1]. Observing the trend, years 2008 and 2010 have the highest (n = 5) registered and admitted cases during the period under investigation. [Table 1] also shows that the age at manifestation of disease ranges from 3 to 15 days old whereas age at admission ranges from 5 to 17 days old. The maximum number of days any infant stayed in the hospital was 44 days while the least was 2 days whereas the age at discharge ranges between 7 and 52 days. Furthermore, the result in [Table 1] presents the frequency and percentages of NT admission over the period of investigation in Stella Obasanjo Hospital, Benin City, from January 2008 to June 2013. It was observed that the incidence of neonatal cases is undulating (rise and fall). Although in 2011 only one case was admitted to this hospital we conclude that the incidence of NT admission in Stella Obasanjo Hospital can be associated more by place of birth.
- To determine the causes of NT in this cohort among neonates admitted to Stella Obasanjo Hospital.
The result in [Table 2] shows the place of birth for the infants in the study area are: hospitals, home, and traditional birth attendant quarters. 57.0% (n = 21) of subjects with cases were delivered in the hospital, 28.6% (n = 21) of subjects with cases were delivered out of the hospital (i.e., parents home) while 14.3% (n = 21) of subjects with cases were delivered at traditional birth attendant quarters.
To examine entry point of the disease and the treatment modalities employed in the care of infants with NT.
The result in [Table 3] shows entry point of disease while [Table 4] sought to find out treatment modalities employed in the care of infants with NT infections. As it can be seen in the table, there is two entry point of this disease: umbilical and scarification. It can be observed from the table that umbilical cord is the major route of entry 90.47% (n = 19), followed by scarification 9.53% (n = 2). [Table 4] shows the results of pharmacological agents used for the treatment of the disease (NT).
- To assess the treatment outcome of infants with NT in Stella Obasanjo Hospital.
[Table 4] also shows the treatment outcome of NT among infants in Stella Obasanjo Hospital. The result reveals that more infants (patients) had successful treatment outcome as discharged cases were 10 (48%) percent as against 8 death cases (33%).
- Maternal immunization status during pregnancy.
[Table 4] also shows the immunization status of pregnant mothers. More than half of mothers whose wards were diagnosed with NT were not immunized during pregnancy (38.0%) while 29.0% were immunized during pregnancy. This could be the possible cause of NT since immunization given to mothers during pregnancy help to fight against and prevent this type of disease. Health workers must ensure that pregnant women are immunized before and after child delivery.
| Discussion of Results|| |
A retrospective descriptive design was used to review patient records between January 2008 and June 2013. Trends, entry point, place of birth, and treatment modalities were recorded. Results were analyzed using simple percentages and charts.
This study revealed that a total of 21 cases of NNT were admitted between 2008 and 2013. Thus, the incidence and the mortality rate of NT appear to be lower in Stella Obasanjo Maternal and Child Hospital as compared to other parts of Nigeria. This might be as a result of increased awareness and immunization of pregnant mothers and better obstetrics care, which is in line with the report of Grange  and Onalo et al. Although, Lambo et al. discuss a decline in the overall NT incidence below the elimination target observed through routine immunization of pregnant women with tetanus toxoid. There is also the global initiative plain by the WHO to immunize children and women of childbearing age with tetanus toxoid.
This study also revealed that the mean age of disease manifestation is 7.3 days which is not consistent with the findings of Grange  and Chugh. The mean age of admission is 8.9 days and 18.1 days for hospitalization which is consistent with the study of Onalo et al.
Our result also revealed that 57% of these cases were born in the hospital, 28.6% were born out of the hospital while 14.3% were born by traditional birth attendants. This result does not agree with that of many writers in developing countries  as the majority of the pregnant mothers gave birth in hospitals. It was observed in this study that from January 2008 to June 2013, the incidence of neonatal cases is undulating (rise and fall). This may be as a result of the treatment modalities and increasing awareness of the antenatal services that are readily available.
It can be observed from our study that umbilical cord is the major route of entry followed by scarification during the period under investigation which supports the findings of many writers in developing countries.,,, Our findings also showed that different treatment modalities were used per year, and these could be as a result of the availability of drugs or severity of symptoms.
Furthermore, our study showed that more infants had successful treatment outcome as 48% were discharged compared with 33% death cases. This could be due to changes in treatment modalities although the mortality rate of NT in other studies is higher compared to that of ours (2.32% in Loralai District, Pakistan; 4.9% in Maiduguri, Nigeria; 5.3% in Modic Centre Benin City, Nigeria). This result is similar to the findings of Peter et al. in Niger Delta University Teaching Hospital where discharged cases were 52.5% as against death cases of 47.5% and not in line with the findings of Omoigberale and Abiodun  which recorded higher death rate (56.2%) than survival rate (43.8%) in NT cases admitted in both UBTH and Modic Centre.
Finally, in this study, 38% of mothers were unimmunized during pregnancy, this is in line with the study of Quddus et al. stating that there was low immunization coverage with tetanus toxoid (5%). Omoigberale and Abiodun  in their study also revealed that many of the mothers were ignorant about immunization while some of them did not have knowledge about the relevance of antenatal care.
| Summary|| |
Recent data in Onalo et al.'s  studies revealed that Nigeria contributes 16% of global NT deaths, second only to India. Although NNT is still prevalent in Benin City, the incidence and mortality rate are reduced compared to those of previous studies from Benin. A total number of 21 NNT cases were admitted under the period of investigation out of which 48.0% were discharged home, and 33.0% died. Factors causing NNT include scarification and infection of the infant's umbilical cord by C. tetani. This study showed that only 29.0% of the mothers got immunized during pregnancy. It is observed that the incidence of NNT is undulating, but different treatment modalities were used which may be as a result of advancement in science for the cure of NT. This accounts for the success of the patient outcome.
| Conclusion|| |
NT still contributes considerably to neonatal mortality in developing countries and also one of the major health problems in Public health despite the fact that mortality rate seems to be low in Benin City. NT remains a major cause of neonatal mortality even though it could be prevented. Various programs and concerted efforts toward the elimination of NT, with readily available effective vaccine for disease elimination and further improvements in the quality of care, should be sustained. Therefore, government needs to explore research and development trend at improving access points of vaccination; this will undoubtedly improve compliance. The following recommendations which may lead to a reduction of NNT, such as increase awareness of toxoid vaccine, good obstetrics care, and adequate care of the umbilical stump. The government of Nigeria instituted a policy that all children between the ages of 0–5 years and women of childbearing age should be immunized against tetanus through the National immunization program. The focus of this policy is to improve healthcare delivery in the country even in the rural areas.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Quddus A, Luby S, Rahbar M, Pervaiz Y. Neonatal tetanus: Mortality rate and risk factors in Loralai district, Pakistan. Int J Epidemiol 2002;31:648-53.
Lambo JA, Memon MI, Khahro ZH, Lashari MI. Epidemiology of neonatal tetanus in rural Pakistan. J Pak Med Assoc 2011;61:1099-103.
Janice L, Kerry H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing. 11th
ed. India: Jaypee Brothers Medical Publishers Ltd.; 2003. p. 2115-8.
Blencowe H, Lawn J, Vandelaer J, Roper M, Cousens S. Tetanus toxoid immunization to reduce mortality from neonatal tetanus. Int J Epidemiol 2010;39 Suppl 1:i102-9.
Rodrigo C, Fernando D, Rajapakse S. Pharmacological management of tetanus: An evidence-based review. Crit Care 2014;18:217.
Oruamabo RS. Neonatal tetanus in Nigeria: Does it still pose a major threat to neonatal survival? Arch Dis Child 2007;92:9-10.
Nte AR, Ekanem EE, Gbaraba PV, Oruamabo RS. Social-environmental influences on the occurrence of neonatal tetanus in some riverine communities in Nigeria. Trop Doct 1997;27:234-5.
Whitman C, Belgharbi L, Gasse F, Torel C, Mattei V, Zoffmann H. Progress towards the global elimination of neonatal tetanus. World Health Stat Q 1992;45:248-56.
Orimadegun AE, Adepoju AA, Akinyinka OO. Prevalence and socio-demographic factors associated with non-protective immunity against tetanus among high school adolescents girls in Nigeria. Ital J Pediatr 2014;40:29.
Federal Ministry of Health Situation Analysis. National child health policy. Nigeria: Federal Ministry of Health; 2005.
Grange AO. Neonatal tetanus in Lagos metropolis. Niger J Paediatr 1999;18:12-22.
Oyedeji OA, Fadero F, Joel-Medewase V, Elemile P, Oyedeji GA. Trends in neonatal and post-neonatal tetanus admissions at a Nigerian teaching hospital. J Infect Dev Ctries 2012;6:847-53.
Omoigberale AI, Abiodun PO. Upsurge in neonatal tetanus in Benin City, Nigeria. East Afr Med J 2005;82:98-102.
Onalo R, Ishiaku HM, Ogala WN. Prevalence and outcome of neonatal tetanus in Zaria, Northwestern Nigeria. J Infect Dev Ctries 2011;5:255-9.
Chugh SN. Tetanus: Medicine for nurses. New Delhi, India: Jaypee Brothers Medical Publishers Ltd.; 2009. p. 58-60.
Peterside O, Duru C, George B. Neonatal Tetanus at the Niger Delta University Teaching Hospital; A 5 year retrospective study. Internet J Paediatr Neonatol 2012;14(2). Available from: http://ispub.com/IJPN/14/2/14427
. [Last accessed on May 2007-April 2012].
[Table 1], [Table 2], [Table 3], [Table 4]