July, 1944]
TETANUS
NEONATORUM
IN THE TROPICS
:
ROGERS
297
rejected immunization against the disease. Moreover, in the Middle East troops, Boyd and Maclennan in 1942 reported a tetanus incidence
had
Original Articles
only 0.13 per 1,000 wounded among the immunized, compared with 1.6 per 1,000 among the unimmunized, or 12.8 times fewer than
of
TETANUS NEONATORUM IN THE TROPICS A
SUGGESTION FOR REDUCTION
Of the five cases that among the unimmunized. occurred among the immunized, 2 recovered; of
ITS
the three fatal cases 2 showed extensive necrosis and sepsis of the tissues of their wounds, so that had the essential adjunct to immunization, the London removal of the damaged tissues, been available, these patients might very probably also have about forty years ago I found that placing Calcutt been saved. There is thus very strong evidence a very small amount of the dust of now available regarding the protective value of streets under the skin of rats caused five out o active immunization against tetanus in the case six of them to die of tetanus. That disease of infected war wounds. was then very common among the surgical admisMethods of tetanus immunization?In recent sions into the Medical College Hospitals with years much research work has been carried out wounds contaminated with street dust, but my by British army investigators and others to advocacy of the administration of prophylactic doses of antitetanic serum on admission of sue 1 determine the immunological response in relation to the number and spacing of the doses of tetanus cases led to a great decrease in the post mortems toxoid. It is generally recognized that the first on tetanus cases. In an analysis of 1,600 post dose produces little or no antitoxin in the blood, mortems performed by me in Calcutta, recoicle in my Findlayson lectures of 1925, I showed but it appears to sensitize the reticuloendothelial that 2.05 per cent of the total deaths were due system over a period of about six weeks, at the to tetanus; compared with only 0.1 per cen , end of which time a second dose of 1 c.cm. of at a toxoid results in an out-pouring of tetanus antitwenty times less, in 1,000 post mortems vital toxin into the blood to reach 0.1 to 1 unit per London hospital. I also quoted Calcutta s statistics to show that 6.04 per cent of the tota c.cm. after the lapse of a further 10 to 12 days, deaths were due to tetanus, with 906 such deaths after which it declines very slowly. A third in 1921, 785 of which were in children up to five dose given six months later causes a remarkable years of age. The great majority of these are rise of the antitoxin titre to reach, as a rule, 2 well known to be cases of tetanus neonatorum to 10 units per c.cm. of the patient's serum, an due to Indian dais or midwives dressing the effective level in the case of wounded soldiers who severed umbilical cords of new-born infants with receive early and adequate surgical treatment. In the American army an additional ' boosting' cow-dung and other filthy applications. In China, tetanus neonatorum has been dose is given shortly before the men proceed on reported to be appallingly frequent, and a active service; in the British army it is now similar high incidence is likely to occur in the rule that an additional dose of toxoid is ?ther tropical countries with backward sanitary administered to all the wounded still further to is increase their resisting power against the very customs, such as New Guinea where tetanus also reported to be common. The treatment o dangerous tetanus infection. In 1941 Evans tetanus neonatorum cannot be expected to )e reported that the antitoxin level in the blood is successful in many of the cases, although substantially maintained for ten months after recoveries are on record. It is therefore w or the second injection; and that a third dose after While considering if anything can be done o that interval results in a rapid and large increase in the antitoxin level of the serum, which is lessen the present terribly high incidence oi disease among infants born in tropical countries, maintained substantially unchanged for a month. apart from the very slow progress of improve Marvell and Parish (1940) also reported that a third injection given at an interval of seven to social customs. Immunization against tetanus.?Active "J11 nine months after the second had a greater uization against tetanus by injections o } immunizing effect than when given at an earlier toxoids of Ramon has been compulsory mdate; this increase more than counteracted the o> waning effect of the immunity during the the French army since 1936. In 1938 i interval? to basis extended their use on a voluntary There is very general agreement that adults 1940 reported in and Perry army, do not show in their serum any material amount there had been no case of tetanus among to 90 per cent of about 850,000 men of theof naturally acquired tetanus antitoxin, as so British Expeditionary Force in France who haacommonly occurs in the case of diphtheria as accepted inoculation against the disease, m spi the result of sub-infective doses of diphtheria the circumstances of the fighting making^ bacilli gradually acquired through contact with carriers of the latter organism. Thus, Evans ^possible to administer antitoxic serum in tne w (1941) did not find as much as 0.01 international tetanus of cases Majority of the wounded; unit of tetanus antitoxin per c.cm. of the serum ?uly reported among the 10 to 20 per cent who By Sir LEONARD ROGERS, k.c.s.i., r.K.s., i.m.s. (Retd.)
m.d., f.r.c.p-,
?
.
.
l^ritish
-
298
THE INDIAN MEDICAL GAZETTE
of any of the 81 persons aged 15 to 60 years. Even in the case of those specially exposed to possible contact with the tetanus bacillus, Lahiri (1939) found no tetanus antitoxin. There is therefore no likelihood of new-born infants having even a slight degree of immunity to tetanus, such as is commonly met with in the case of diphtheria in infants during the first year of their lives. Can infants be 'protected against tetanus neonatorum by immunizing their mothers during their pregnancies ??In this' connection it is of interest, to note that Marvell and Parish in 1940 observed that women responded much better than men to tetanus toxoid injections. There seems good reason to expect that tetanus antitoxins developed in the blood of pregnant women by means of toxoid injections will be transmitted to the Thild she is carrying, as occurs in the case of diphtheria antitoxins, although I have not found any records of this having been experimentally tested. The object of this note is to suggest that this possibility should be investigated at the Calcutta School of Tropical Medicine with the help as regards clinical material of the Eden and Dufferin Hospitals by determining the tetanus antitoxin titre of the serum of the immunized mothers and of their newly-born infants. If this test should demonstrate that practically important amounts of tetanus antitoxin are transmitted to the infants, it will clearly be advisable to immunize as many mothers as possible during the prenatal period by means of two doses as early in the pregnancy as proves to be practicable, and to give an additional dose ten days before the expected date of delivery to provide the maximum protection of the babes against the frequent and deadly tetanus neonatorum of tropical countries. REFERENCES J. Roy. Army Med. Corps, 70, 289. Boyd, J. S. K., and Lancet, ii, 745. D. J. Maclennan,
Boyd, J. S. K. (1938)
..
(1942). Evans, D. G. (1941) Lahiiu, D. C. (1939) Marvell, D. M., and Parish, H. J. (1940). ..
..
Ibid., ii,
628.
Indian J. Med. Res., 27, 581. i Brit. Med. J., ii, 891.
[jULY)
1944
TETANUS
NEONATORUM
IN THE TROPICS
:
ROGERS
297
rejected immunization against the disease. Moreover, in the Middle East troops, Boyd and Maclennan in 1942 reported a tetanus incidence
had
Original Articles
only 0.13 per 1,000 wounded among the immunized, compared with 1.6 per 1,000 among the unimmunized, or 12.8 times fewer than
of
TETANUS NEONATORUM IN THE TROPICS A
SUGGESTION FOR REDUCTION
Of the five cases that among the unimmunized. occurred among the immunized, 2 recovered; of
ITS
the three fatal cases 2 showed extensive necrosis and sepsis of the tissues of their wounds, so that had the essential adjunct to immunization, the London removal of the damaged tissues, been available, these patients might very probably also have about forty years ago I found that placing Calcutt been saved. There is thus very strong evidence a very small amount of the dust of now available regarding the protective value of streets under the skin of rats caused five out o active immunization against tetanus in the case six of them to die of tetanus. That disease of infected war wounds. was then very common among the surgical admisMethods of tetanus immunization?In recent sions into the Medical College Hospitals with years much research work has been carried out wounds contaminated with street dust, but my by British army investigators and others to advocacy of the administration of prophylactic doses of antitetanic serum on admission of sue 1 determine the immunological response in relation to the number and spacing of the doses of tetanus cases led to a great decrease in the post mortems toxoid. It is generally recognized that the first on tetanus cases. In an analysis of 1,600 post dose produces little or no antitoxin in the blood, mortems performed by me in Calcutta, recoicle in my Findlayson lectures of 1925, I showed but it appears to sensitize the reticuloendothelial that 2.05 per cent of the total deaths were due system over a period of about six weeks, at the to tetanus; compared with only 0.1 per cen , end of which time a second dose of 1 c.cm. of at a toxoid results in an out-pouring of tetanus antitwenty times less, in 1,000 post mortems vital toxin into the blood to reach 0.1 to 1 unit per London hospital. I also quoted Calcutta s statistics to show that 6.04 per cent of the tota c.cm. after the lapse of a further 10 to 12 days, deaths were due to tetanus, with 906 such deaths after which it declines very slowly. A third in 1921, 785 of which were in children up to five dose given six months later causes a remarkable years of age. The great majority of these are rise of the antitoxin titre to reach, as a rule, 2 well known to be cases of tetanus neonatorum to 10 units per c.cm. of the patient's serum, an due to Indian dais or midwives dressing the effective level in the case of wounded soldiers who severed umbilical cords of new-born infants with receive early and adequate surgical treatment. In the American army an additional ' boosting' cow-dung and other filthy applications. In China, tetanus neonatorum has been dose is given shortly before the men proceed on reported to be appallingly frequent, and a active service; in the British army it is now similar high incidence is likely to occur in the rule that an additional dose of toxoid is ?ther tropical countries with backward sanitary administered to all the wounded still further to is increase their resisting power against the very customs, such as New Guinea where tetanus also reported to be common. The treatment o dangerous tetanus infection. In 1941 Evans tetanus neonatorum cannot be expected to )e reported that the antitoxin level in the blood is successful in many of the cases, although substantially maintained for ten months after recoveries are on record. It is therefore w or the second injection; and that a third dose after While considering if anything can be done o that interval results in a rapid and large increase in the antitoxin level of the serum, which is lessen the present terribly high incidence oi disease among infants born in tropical countries, maintained substantially unchanged for a month. apart from the very slow progress of improve Marvell and Parish (1940) also reported that a third injection given at an interval of seven to social customs. Immunization against tetanus.?Active "J11 nine months after the second had a greater uization against tetanus by injections o } immunizing effect than when given at an earlier toxoids of Ramon has been compulsory mdate; this increase more than counteracted the o> waning effect of the immunity during the the French army since 1936. In 1938 i interval? to basis extended their use on a voluntary There is very general agreement that adults 1940 reported in and Perry army, do not show in their serum any material amount there had been no case of tetanus among to 90 per cent of about 850,000 men of theof naturally acquired tetanus antitoxin, as so British Expeditionary Force in France who haacommonly occurs in the case of diphtheria as accepted inoculation against the disease, m spi the result of sub-infective doses of diphtheria the circumstances of the fighting making^ bacilli gradually acquired through contact with carriers of the latter organism. Thus, Evans ^possible to administer antitoxic serum in tne w (1941) did not find as much as 0.01 international tetanus of cases Majority of the wounded; unit of tetanus antitoxin per c.cm. of the serum ?uly reported among the 10 to 20 per cent who By Sir LEONARD ROGERS, k.c.s.i., r.K.s., i.m.s. (Retd.)
m.d., f.r.c.p-,
?
.
.
l^ritish
-
298
THE INDIAN MEDICAL GAZETTE
of any of the 81 persons aged 15 to 60 years. Even in the case of those specially exposed to possible contact with the tetanus bacillus, Lahiri (1939) found no tetanus antitoxin. There is therefore no likelihood of new-born infants having even a slight degree of immunity to tetanus, such as is commonly met with in the case of diphtheria in infants during the first year of their lives. Can infants be 'protected against tetanus neonatorum by immunizing their mothers during their pregnancies ??In this' connection it is of interest, to note that Marvell and Parish in 1940 observed that women responded much better than men to tetanus toxoid injections. There seems good reason to expect that tetanus antitoxins developed in the blood of pregnant women by means of toxoid injections will be transmitted to the Thild she is carrying, as occurs in the case of diphtheria antitoxins, although I have not found any records of this having been experimentally tested. The object of this note is to suggest that this possibility should be investigated at the Calcutta School of Tropical Medicine with the help as regards clinical material of the Eden and Dufferin Hospitals by determining the tetanus antitoxin titre of the serum of the immunized mothers and of their newly-born infants. If this test should demonstrate that practically important amounts of tetanus antitoxin are transmitted to the infants, it will clearly be advisable to immunize as many mothers as possible during the prenatal period by means of two doses as early in the pregnancy as proves to be practicable, and to give an additional dose ten days before the expected date of delivery to provide the maximum protection of the babes against the frequent and deadly tetanus neonatorum of tropical countries. REFERENCES J. Roy. Army Med. Corps, 70, 289. Boyd, J. S. K., and Lancet, ii, 745. D. J. Maclennan,
Boyd, J. S. K. (1938)
..
(1942). Evans, D. G. (1941) Lahiiu, D. C. (1939) Marvell, D. M., and Parish, H. J. (1940). ..
..
Ibid., ii,
628.
Indian J. Med. Res., 27, 581. i Brit. Med. J., ii, 891.
[jULY)
1944
