Neonatal tetanus in the United States: a sentinel event in the foreign-born

Lack of immunization documentation in Minnesota refugees: challenges for refugee preventive health care

Children and adults immigrating to the United States without documentation of vaccinations or evidence of immunity should receive age-appropriate immunizations. To learn how often immunization documentation is lacking, we reviewed medical screening records of 1,389 primary refugees over 18 months of age who came Minnesota during 1998. Restricting our analysis to those age groups for whom specific immunizations are recommended, 81.1% of refugees lacked documentation of receiving three doses of diphtheria and tetanus vaccines; 78.8% lacked documentation of one dose of measles vaccine, and 63.8% lacked documentation of three doses of polio vaccine. Of refugees without a known positive test for hepatitis B antigen or antibody, 99.5% lacked documentation of receiving three doses of hepatitis B vaccine. Documentation rates decreased with increasing age, and were lowest for refugees from sub-Saharan Africa (p < 0.001). Refugees and other immigrants may face a number of barriers to receiving necessary immunizations. Health care providers seeing these new arrivals need to ensure that they do fail to receive recommended vaccinations and other preventive health care.

Philosophic objection to vaccination as a risk for tetanus among children younger than 15 years

OBJECTIVES

Although safe and effective vaccines are available to protect against tetanus in the United States and vaccination rates are high, cases of tetanus among children continue to occur. The objectives of this article are to describe reported cases of tetanus in children in the United States and to identify the reasons for lack of protection against tetanus.

METHODS

We reviewed all cases of tetanus in children <15 years of age that were reported to the National Notifiable Diseases Surveillance System from 1992 through 2000. Cases were defined by physician diagnosis. We verified the information in the case reports with state and local health departments.

RESULTS

From 1992 through 2000, 15 cases of tetanus in children <15 years of age were reported from 11 states. Twelve cases were in boys. Two cases were in neonates <10 days of age; the other 13 cases were in children who ranged in age from 3 to 14 years. The median length of hospitalization was 28 days; 8 children required mechanical ventilation. There were no deaths. Twelve (80%) children were unprotected because of lack of vaccination, including 1 neonate whose mother was not vaccinated. Among all unvaccinated cases, objection to vaccination, either religious or philosophic, was the reported reason for choosing not to vaccinate.

CONCLUSION

The majority of recent cases of tetanus among children in the United States were in unvaccinated children whose parents objected to vaccination. Parents who choose not to vaccinate their children should be advised of the seriousness of the disease and be informed that tetanus is not preventable by means other than vaccination.

Neonatal tetanus: a continuing challenge in the southeast of Turkey: risk factors, clinical features and prognostic factors

Neonatal tetanus (NT) still causes significant mortality in developing countries, although in 1989 WHO adopted the goal of eliminating the disease by 1995-2000. To characterize the regional characteristics, clinical charts of 55 neonates (42 males and 13 females) admitted to the Pediatric Infectious Diseases Ward of Dicle University Hospital, Diyarbakir, Turkey with the diagnosis of NT from 1991 to 1997 were reviewed. Mean age at admittance was 8.9+/-4.3 days with a range of 3-25 days. Mean period for the appearance of first symptoms was 5.8 days ranging between 1 and 21 days. Mean birth weight of the patients was 3369+/-560g. All patients were from rural areas and were delivered at home by untrained traditional birth attendants with no prior antenatal healthcare services. Razor blade (55%), scissors (27%), and knife (18%) were the instruments used to cut the cord in non-hygienic conditions. No mothers had prior vaccination with tetanus toxoid during their pregnancy. Spasticity (76%), lack of sucking (71%), trismus (60%), fever (49%), omphalitis (44%), irritability (24%), risus sardonicus (22%), and opithotonus (15%) were the most common presenting signs and symptoms. Age at admission < 7.5 days and symptoms of onset <4.9 days, risus sardonicus and opisthotonus were associated with fatal outcome. All patients were treated with human tetanus immunglobulin or equine tetanus antitoxin where available, antibiotic therapy by penicillin G (100.000 U/kg/day) and intravenous high dose diazepam (40 mg/kg/day). Overall mortality rate was 40% (22 cases), without any equipment for mechanical ventilation. Health education of mothers and birth attendants, promotion of hospital delivery and prenatal tetanus immunization of all pregnant women particularly in rural areas are recommended, if NT is to be prevented.

Infectious diseases in early life in industrialized countries

A specific group of pathogens is important in neonatal infections. An understanding of the epidemiology, pathogenesis and etiology of neonatal infections has led to interventions which have decreased the risk of transmission or acquisition of infection in the newborn period. The interventions span the spectrum of preventive medicine from infection control, to antibiotics, to antivirals and to vaccines. However, the individual case management of the expectant mother is as critical to the control of neonatal infections as broad public health policies.