TETANUS AND RABIES

SESSION 24
 LEARNING OBJECTIVES
• Define tetanus and rabies
• Describe epidemiology and Clinical features
of tetanus and rabies
• Explain diagnosis and management of tetanus
and rabies
• Describe prevention and control of tetanus
and rabies
 DEFINITION
• Tetanus (Greek ‘tetanus’ means ‘to contract’): A
neurological disorder /infection caused by bacteria
called Clostridium tetani.
• When the bacteria invade the body, they produce a
toxin that causes painful muscle contractions.
• Another name for tetanus is ’’lockjaw" because it often
causes a person's neck and jaw muscles to lock, making
it hard to open the mouth or swallow.
• Vaccines are recommended for infants, children, teens
and adults to prevent tetanus.
 Overview
• Tetanus is different from other vaccine-
preventable diseases because it does not spread
from person to person. The bacteria are usually
found in soil, dust and manure and enter the body
through breaks in the skin - usually cuts or
puncture wounds caused by contaminated objects.
• Today, tetanus is uncommon nearly all cases of
tetanus are among people who have never
received a tetanus vaccine.
 TRANSMISSION
Clostridium tetani are everywhere in the
environment, including soil, dust and
• .
manure
Transmission occur when ;-
• Bacteria get through broken skin,
usually through injuries from
contaminated objects. Others include:
• Wounds contaminated with dirt, poop
(feces), or spit (saliva)
• Wounds caused by an object puncturing
the skin, like a nail or needle (puncture
wounds)
• Burns
• Crush injuries
• Injuries with dead tissue
 EPIDEMIOLOGY
• Tetanus occurs sporadically all over Africa, Clostridium tetani
is a ubiquitous organism present in the soil and in human
and animal (cattle) faeces.
• Tetanus bacilli live in the bowel of animals and humans.
When the bacilli are passed out in faeces, they form spores
in order to survive the harsh conditions outside.
• Tetanus as a disease in humans occurs only when the spores
enter the body through a contaminated wound.
• Tetanus is an important disease because of its high case
fatality rate of 20 – 40 percent in adults and 60 – 89% of the
newborns even when the nursing care is excellent.
 EPIDEMIOLOGY CONT….
• Endogenous infection may occur when intestinal tetanus bacilli
are introduced into the tissues e.g. during bowel surgery.
• In 10-15% of tetanus cases, the site of entry remains undetected.
• In new born is called tetanus neonatorum and it is nearly always
fatal, even with the best treatment/management.
• The necrotic tissue in the umbilical stump is an ideal place for
tetanus bacilli to enter the body, especially if cow’s dung
containing tetanus bacilli is used for dressing the cord as it has
been the custom in some communities in Africa.
• The infection can also be introduced if unsterile instruments are
used for cutting the umbilical cord.
 Rare Ways……to be infected
• Tetanus has a link to clean superficial wounds, surgical
procedures, insect bites, dental infections, compound /open
fractures , chronic sores and infections, and intravenous (IV)
drug use.
• The incubation period is usually 3–21 days (average 10 days),
range from 1 day to several months, depending on the kind of
wound. Most cases occur within 14 days. In general, shorter
incubation periods are seen with more heavily contaminated
wounds, more severe disease, and a worse outcome of the
disease .
 Clinical features

 Headache
• Patient first notices increased tone in the jaw muscles, causing
trismus or lockjaw and resus sardonicus (devil’s sign)
• Painfull musle spasm all over the body
• Severe spasms are associated with pain and disturbances of
swallowing and respiration
• The spasms of the neck muscles resemble the neck stiffness of
meningitis but other neurological signs supporting meningitis
are negative
• Death usually occurs due to asphyxia and exhaustion
 CLINICAL FEATURES CONT…
Asphyxia may be due to:
• Spasm of glottis, thoracic muscles and diaphragm
• Chronic hypoventilation because of muscle stiffness
• Periods of apnoea
• Aspiration of food materials and respiratory secretions
and subsequent suffocation
• In the new born, the first sign of tetanus is inability to
suck by a baby who was doing well after delivery. Later
on, spasms appear accompanied by severe apnoea and
cyanosis.
 BACILLUS.
• Tetanus bacillusis a gram-positive rod forms
terminal spores giving it a characteristic ‘drum
stick’ appearance under the microscope.
• Tetanus bacillus is an obligate anaerobe i.e.
can only live and multiply in the absence of
oxygen.
 DIAGNOSIS
• Diagnosis;-
• The diagnosis of tetanus is clinical.i.e. Painless spasm of the
muscles of the jaw ‘Trismus’, difficulty in opening the
mouth ‘lock Jaw’, contraction of the muscles on the
forehead and mouth ‘risus sardonicus, and board-like
rigidity of the abdomen.
• There are no specific laboratory tests to determine the
diagnosis of tetanus
• Other tests may be used to rule out meningitis, rabies,
chemical poisoning ,OR other diseases with similar
symptoms and signs.
 MANAGEMENT
Antibiotics;-Metronidazole is the antibiotic of
choice, although penicillin is still widely used.
Antitoxin (Antitetanus Serum) - ATS, Adult and
children are given 10,000 units IM or IV once
after a test dose first while keeping adrenaline
at hand because allergic reactions are
common and dangerous.
Prevent muscle spasm – use diazepam
 MANAGEMENT CONT…
• Maintain sedation by giving the drugs every 3 hours
.Further doses of diazepam should be given depending on
the condition of the patient.
• Diazepam is usually very well tolerated and the maximum
dose is very high (500mg daily).
• There is a need of making sure that heavily sedated
patient’s airway is secured admit in Intensive Care Unit).
• Chloralhydrate, phenobarbitone or chlorpromazine will
sustain the effect of diazepam. Children are given
chloralhydrate and adults phenobarbitone 100mg 4 hourly.
 NURSING CARE….
• Nursing support, wound care, airway support, feeding
and sedation
• Tracheostomy with artificial respiration in specialized
centres
• Feeding of the patient via a nasogastric tube is important
• Respiratory support should be offered
• The patient should be kept in cool place also noise
should be minimized
• Observation chart on which medication, fluid input,
spasm and position change are recorded
 PREVENTION AND CONTROL
• Proper surgical treatment of wound, such as removal of foreign
bodies and excision of necrotic tissue will diminish the risk of tetanus.
• Active immunisation with tetanus toxoid gives adequate protection.
• First 3 immunisations should be given in childhood, together with
diphtheria, tetanus pertussis and hepatitis B (DPT-HB).
• Tetanus of the newborn can be prevented by active immunisation of
the mother during pregnancy.
• It is recommended for adults to be vaccinated every 10 years to
prevent tetanus.
• Advising the community about hospital delivery will reduce the
chance of acquiring infection.
•  
RABIES
 DEFINITION
Rabies is a preventable viral disease of
mammals most often transmitted through the
bite of a rabid animal.
The vast majority of rabies cases reported
each year occur in wild animals like raccoons,
skunks, bats, and foxes.
 TRANSMISSION
• Causes and Transmission
• Rabies is caused by rabies virus, a rhabdovirus of the genus Lyssavirus.
• The virus has preference for the salivary gland and nervous tissue, finally causing encephalitis and
resulting in death.
• The risk of rabies is present in all mainland African countries.
• The main animal reservoirs of the disease are wild animal such as jackals, mangooses and hyaenas.
• These animals usually do not live in close contact with humans, but they may infect domestic
animals such as dogs and cats.
• Cattle, horses and donkeys may also become infected.
• Man becomes infected when bitten by a rabid animal, usually a dog.
• Saliva left behind in the wound contains the virus which finds its way to the brain via the nerves.
• When no immediate action is taken after a bite by an infectious animal, the disease is invariably
fatal once the clinical signs have appeared (case fatality rate is 100%).
• Africa has a large reservoir of diseased wild animals and the transmission between them and
domestic animals is difficult to control under present conditions.
•  
 CLINICAL FEATURES
• In human, the incubation period ranges from 2 weeks to 1 year, with an
average of 2 -3 months depending on:
– Size of the bite
– Distance of wound from the brain
– Type of wound (abrasion, small wound, wound with extensive tissue damage)
– Dose of virus deposited in the wound.
• The earliest symptoms usually consist of increasing severe pain in the wound.
• Later, two different clinical pictures emerge i.e. furious and paralytic rabies.
• The first, experienced by about 80% of patients is furious rabies.
• This form of disease is characterized by periods of:
– Extreme anxiety
– Violet behaviour
– Seizures
– Hallucinations
 CLINICAL FEATURES
• This may then lead to paralytic rabies which manifests with:
– Depression
– Paralysis of the limbs
– Spasms of the pharyngeal muscles
– Hypersalivation
– Sweating
• This result in intense hydrophobia (fear of water) because of the
severe pain experienced when swallowing water.
• They may have a tightly feeling in the throat and jerky spasms of
the stenomastoids, diaphragm and other inspiratory muscles
leading to a generalized extension, sometimes with convulsions
and episthotonus
 CLINICAL FEATURES
• Coma eventually ensues, with flaccid paralysis.
• Survival for more than a week is unlikely and death
usually follows.
• In animal, abnormal behaviour is one of the earliest
things.
• The animal may bite at the slightest provocation or
without any provocation at all.
• Animals may also be depressed and curl up in a corner.
• Death usually ensues within 10 days of the onset of the
disease.
 DIAGNOSIS
• the presence of rabies virus antigens in brain tissue. In humans, several
tests are required.
• Rapid and accurate laboratory diagnosis of rabies in humans and other
animals is essential for timely administration of postexposure prophylaxis.
Within a few hours, a diagnostic laboratory can determine whether or not
an animal is rabid and inform the responsible medical personnel. The
laboratory results may save a patient from unnecessary physical and
psychological trauma, and financial burdens, if the animal is not rabid.
• In addition, laboratory identification of positive rabies cases may aid in
defining current epidemiologic patterns of disease and provide appropriate
information for the development of rabies control programs.
• The nature of rabies disease dictates that laboratory tests be standardized,
rapid, sensitive, specific, economical, and reliable.
 MANAGEMENT
• Management
• No cure available once the disease has actually developed
• Prevention is however possible before it has reached that
state
• Once a person has been bitten by a rabid animal the disease
can be prevented from developing by first-aid treatment of
the bite, followed by anti-rabies immunisation Counting the
first day of vaccine treatment as day 0, injections are
administered on days 0, 3, 7, 14, and 28
•  
 How to Handle a Case of Animal Bite
• If the animal is available and looks healthy, write down the name and address of the patient and
ask the person to come back for a check up after 10 days.
• Note the date of appointment in your diary.
• The animal must be observed for 10 days, if it remains health during this period, there is no
danger of rabies.
• If on the other hand, the animal shows signs of rabies, trace the patient immediately and refer
with a proper referral letter to the hospital for immunisation.
• If the dog has disappeared, refer the person for immunisations.
• If animal looks rabid and has been caught lock it up carefully inform the regional or district
medical officer of your suspicion of rabies and refer the patient for immunisation.
• If the dead animal is brought to your dispensary, burry it carefully (unless you make
arrangements for investigation of the dog with local Veterinary Department and they give you
detailed instructions on how and where to sent the infectious materials).
• Do not send heads of rabid dogs in plastic bag or wrapped in papers by bus or post to Veterinary
Department which does not have the equipments for laboratory confirmation of diagnosis. Refer
the patient to hospital for investigation.
•  
 PREVENTION AND CONTROL
• Rabies is a notifiable disease and its control is the full responsibility of
the Veterinary Department.
• You must however play your part by giving health education about
preventive measures such as regular immunisation of dogs and cats (at
least every 3 years) and killing of stray dogs.
• Because it is very expensive, routine pre-exposure immunization is
reserved only for those at higher risk of catching the disease e.g.
Veterinary officers.
• Action to be taken in cases of animal bites include;
– Give first aid – wound washing with water and soap (social toilet)
– Give tetanus toxoid as a prophylaxis
– Decide on immunisation – Antirabies vaccine
– Observe biting animal for 10 days if available