Neonatal tetanus in Pakistan
Every second many neonates die worldwide due to several infections. These infections are more prevalent in the developing countries of the world. Studies reveal that the average neonatal mortality rate (NMR) in the developing countries is 34 per 1000 live births, which is seven times higher than in the developed countries (Paul & Singh, 2004). This NMR is increased due to many reasons of which neonatal tetanus (NNT) is the most common one. Specifically, Pakistan is one of the eight high burden countries which account for 73% of deaths from NNT (Nisar, Aziz & Mumtaz, 2010). A recent study conducted at a tertiary care hospital in Lahore also reported 100% mortality among premature neonates and 44% mortality in full term neonates with tetanus (Wasay, Khatri & Salahuddin, 2008). The elimination criterion of NNT is the achievement of less than one case of NNT per 1000 live births in every district of every country. But in countries of Asia like Pakistan, it still strikes babies who have minute or no access to health facilities (SPARC, 2007; Kiwanis & UNICEF, 2011). Thus, this health problem has become one of the greatest concerns in Pakistan and more resources are needed to help all mothers and neonates in need. But, we still need to understand the disease in depth and work on its solutions. Ultimately, these reasons compelled us to produce this issue into a paper. Therefore, this paper is an attempt to discuss the cause and risk factors, solutions and recommendations for neonatal tetanus.
According to Ghosh and Sharma (2011) “Neonatal tetanus is defined as tetanus occurring in a newborn between the 3rd and 28th day after birth” (p.2). It is a preventable and non-communicable infectious disease caused by a neurotoxin produced by a gram-positive anaerobic bacterium known as Clostridium tetani. This organism produces hard spores which are present in soil and the gastrointestinal tract of human beings and animals. So, in a neonate, infection begins when tetanus spores are introduced through damaged tissue of umbilicus or circumcised area. (Roper, Vandelaer & Gasse, 2007). These spores incubate between 3 and 21 days and results in major clinical features such as poor sucking, convulsions, locked jaw (trismus), and muscle rigidity. (Haddad & Assi, 2007; Wasay et al., 2008). Though, the direct cause of the disease is the organism but there are several risk factors associated with it. A recent case trial was conducted in a Malaysian hospital in which five cases of NNT were seen during the study period. It was found that all five babies were delivered at home by TBAs, four mothers were unsure whether clean instruments were used during delivery or not and only one mother attended antenatal clinic but still did not receive any immunization (Lum & Chew, 2009). This study and several others show that the primary risk factors related with NNT are inadequate immunization, lack of clean delivery services and improper postpartum cord care. (Ghosh & Sharma, 2011). Firstly, the major risk factor of NNT is the lack of immunization in mothers. In a research conducted at Lahore, it was shown that 80% of the neonates were home delivered with 88% mothers not being vaccinated against tetanus (Wasay et al., 2008). Thus, if mothers are not immunized with tetanus toxoid then the neonate has a high chance of acquiring NNT. Secondly, most of the mothers do not have privileges of delivering a baby at proper health care facilities which in turn puts their babies on a danger for attaining NNT due to high risk of non-sterility. In rural areas of Pakistan, due to cultural limitations and lack of access to quality health care services, home deliveries are preferred over hospital deliveries. Also, more than 83% of deliveries take place at home with the help of TBAs or mother in laws. (Ismail, Sarmad & Akram, 2007; Hirani, 2008). But the question arises that are these TBAs competent enough to conduct safe deliveries? In this regard, a study reported that in Bakkar district of Pakistan, no significant differences were found between the level of trained and untrained TBAs (Ismail et al., 2007). This shows that unhygienic delivery practices prevail which can be a risk factor for the development of NNT. Finally, cord clamping and care practices also play a vital role in the progress of NNT. In Pakistan, as a traditional practice, a baby’s cord is cut with unclean blades or knives, and many a times cow dung or ash is applied for the healing purpose. (Hirani, 2008). These practices are very harmful and can result in NNT. Besides these, several other risk factors that can lead to NNT are lack of antenatal visits, poverty, ignorance, lack of paternal and maternal education, young maternal age and cultural restrictions. (Demicheli, Barale, Rivetti, 2007; Roper et al.,2007).
Treating NNT is a complex task that requires both primary and secondary interventions. On one hand, secondary treatment is mostly symptomatic which comprises of wound debridement, administration of tetanus immunoglobulin, muscle relaxants, analgesics and anti-infective drugs (Edlich et al., 2003). But on the other hand, optimal control of NNT requires certain measures at primary level that could help in resolving this health issue. First of all, the key strategy to prevent NNT is the provision of passive immunity to neonates through prior immunization of their mothers with tetanus toxoid. A recent study has estimated that mortality from NNT can be decreased by 94% with the immunization of pregnant women and women of childbearing age with at least 2 doses of tetanus toxoid vaccine (Ganatra & Zaidi, 2010). In Pakistan, this measure is being carried out through Expanded Immunization Programme in all districts where lady health workers are motivating and referring women for immunization (Ismail et al., 2007). However, the percentage of women getting two doses of TT vaccination was 56% in 2002, 57% in 2003, 45% in 2004 and 53% in 2006 (Nisar et al., 2010). But why most of the women are deprived of this intervention? Illiteracy and ignorance are the core reasons behind this lacking. In a study, the most common reason for inadequate TT vaccination reported by Pakistani women was that they did not know the importance of TT vaccination (Nisar et al., 2010). Moreover, due to lack of motivation from self and family they do not approach for immunization. Secondly, safe obstetric care can ensure less risk of NNT. This includes educating health professionals like doctors, nurses and TBAs about safe and clean delivery methods. It can be achieved by providing them sterile equipments, hygienic environments and proper instructions for cord cutting and clamping (Sibley & Sipe, 2004). Though, health care providers are educated but still women lack access to avail these safe facilities. The poor women of our country face three delays to acquire these facilities. These are the lack of availability of services, lack of access of services and lack of referral transport system (Paul & Singh, 2004). Ultimately, deliveries are performed at home. Therefore, EmOC services should be well established and monitored (Jafarey et al., 2008). Another interesting strategy for this is the introduction of a community-based delivery kit which contains necessary materials for achieving clean delivery. This kit should remain in the mother’s home and explanations on its use should be given to the family by health care workers through pictures. (Roper et al.,2007). Finally, proper cord care is also a significant solution to prevent NNT .It involves practices like proper hand washing before and after the contact with cord and keeping the cord dry and exposed to air or loosely covered with clean clothes (WHO, 1998). Moreover, TBAs, mothers and other family members should be instructed to avoid applying cow dung, ash or ghee on the umbilical cord or circumcised wound. Instead of this, they should be advised to use topical antimicrobial agents such as povidone iodine, chlorhexidine and ethanol. (WHO, 1998; Ganatra & Zaidi, 2010). Among which, chlorhexidine is the most preferred by WHO due to broad spectrum activity, high effectivity and low cost. A case control study in rural Pakistan, reported decreased risk of NNT when above mentioned antibitoics were used for wound care (Ganatra & Zaidi, 2010). If we consider the greatest barrier in this intervention then we’ll come to know that the cultural beliefs of our people are so strong that they are not ready to accept and apply these measures. Therefore, it is necessary to explore their value belief systems and make them aware of the negative consequences of these practices (Hirani, 2008). For example, help people to understand the phenomenon of bacterial contamination of the cord stump by unwashed hands, unclean blades, cow dung etc. using easy terminologies (WHO, 1998).These strategies were also implemented through a community trial in the Hala district of Pakistan by three community mobilizers of AKU who provided community education and advocacy for facility births (Bhutta et al., 2011).
Various steps should be taken to promote immunization, clean delivery practices and proper cord care at individual, family, community and government level. At individual level, the mothers and health care workers should implement appropriate practices and adhere to provided guidelines. At the family level, along with mothers, fathers and other family members should be provided knowledge and encouraged to take part in care giving. (Hirani, 2008). Families should cater the nutritional needs of a mother and provide her opportunity to have antenatal visits. (Demicheli et al., 2007; Edlich et al., 2003). At community level, the ‘high risk approach’ is recommended to all childbearing and pregnant women (Griffiths et al.,2004). In this, campaigns should be launched to provide immunization to women who are unable to access routine tetanus immunization, antenatal care and quality obstetric services. Also, public awareness programs should be run on regular basis. These programs should invite all mothers with their families and give them a platform to discuss their concerns. Sessions for pregnant women should also include the important component of antenatal immunization dates and the females themselves should take the initiative to remember them and go as per schedule (PAHO, 2005). Community health services should assess the families for unsafe practices and also establish tetanus surveillance system to record the cases and non-cases separately. Then, all suspected cases should be investigated by an epidemiologist or other trained staff to confirm the diagnosis and to detect possible sources of infection (PAHO, 2005). They should also circulate informative brochures according to the level of understanding of community members. According to WHO (1998) there should be a written policy for immunization, cleanliness for birth and cord care that is routinely communicated to all staff. Community health workers should also incorporate general antenatal plan for all the females to have a tetanus shot when attending the antenatal clinic. At the same time, it should be ascertained that women are keeping a permanent immunization record. They could also introduce simpler injection techniques which can be used by lay personnel. As we have observed the use of insulin pens which could be administered even at homes. Similarly, it could be applied for tetanus vaccines with proper instructions. (UNICEF, 2005). At government level, a voucher system for vaccination which was previously introduced in Gujarat could also be introduced in Pakistan to reduce the risk of NNT. (Jafarey et al., 2008). Furthermore, financial support should be provided to the communities with low resources. Also, district management information system (DMIS) should be incorporated to plan for interventions (Jafarey et al., 2008). The government should collaborate with the non-governmental organizations in order to plan for effective maternal and child health services. In addition, it can cooperate with media authorities to promote mass awareness among public regarding this issue (Wasay et al.,2008).
Researches have been conducted for the NNT but still more work needs to be done. Studies are required in exploring the effects of community health care utilization in order to compare and contrast different communities for the variations in health care. (Ghosh & Sharma, 2011). Also, hospital and community-based studies could be done to compare the risk of cord infection with and without antibiotic application (WHO, 1998). Moreover, researches should be directed to establish the pharmacological properties of traditional substances such as herbs, leaves and colostrum so that instead of applying harmful substances they could utilize easily available material (WHO, 1998).
In conclusion, neonatal tetanus which is caused by Clostridium tetani, is a major reason of neonatal mortality in Pakistan. Three major risk factors associated with this disease are low immunization status, poor delivery conditions and unsafe cord cleaning practices. But there are also several other risk factors related to NNT. Therefore, many strategies have already been implemented to minimize the magnitude of this disease. However, with further recommendations and researches, more efforts could be made to eliminate this disease and assure a safe and quality life to neonates who are truly the assets of our country.