Neonatal and postneonatal tetanus at a referral hospital in Kamsar, Guinea: a retrospective audit of paediatric records (2014-2018)

  • International health, Volume 14, No. 5, Year 2022

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Study Justification:
– The study aimed to determine the incidence of neonatal tetanus (NNT) and postneonatal tetanus (PNNT) at Kamsar Hospital in Guinea.
– Tetanus is a vaccine-preventable disease caused by the bacterium Clostridium tetani.
– Guinea was considered at risk for tetanus in 2018, and the country is currently in the elimination phase.
– Understanding the incidence and factors contributing to tetanus cases can help inform vaccination strategies and improve maternal and neonatal healthcare.
Study Highlights:
– The study covered a 5-year period from January 2014 to December 2018.
– Out of 5,670 admissions, 39 cases (0.7%) were due to tetanus (22 NNT and 17 PNNT).
– The primary entry sites for NNT were the umbilical cord and circumcision wounds, while PNNT had various entry sites including surface wounds and limb fractures.
– The majority of patients (92.3%) were born to unvaccinated or inadequately vaccinated mothers.
– The overall case fatality rate was high, with 53.8% of children dying within 7 days of admission.
Study Recommendations:
– Strengthen vaccination programs: Increase vaccination coverage among pregnant women to prevent NNT and PNNT cases.
– Improve antenatal care: Enhance education and awareness about the importance of tetanus vaccination during pregnancy.
– Enhance infection prevention practices: Promote proper umbilical cord care and safe circumcision procedures to reduce the risk of tetanus.
– Strengthen healthcare infrastructure: Ensure access to well-equipped hospitals with adequate neonatal and pediatric units to provide timely and appropriate care for tetanus cases.
Key Role Players:
– Ministry of Health: Responsible for implementing vaccination programs and coordinating healthcare services.
– Healthcare providers: Including pediatricians, general physicians, nurses, and supporting staff who provide care at Kamsar Hospital.
– Community health workers: Involved in educating and raising awareness about tetanus vaccination and infection prevention practices.
– Non-governmental organizations (NGOs): Collaborate with the government to support vaccination campaigns and healthcare infrastructure development.
Cost Items for Planning Recommendations:
– Vaccination supplies: Including tetanus vaccines for pregnant women and infants.
– Training and education: Conducting workshops and training sessions for healthcare providers and community health workers.
– Healthcare infrastructure development: Upgrading and expanding neonatal and pediatric units at Kamsar Hospital.
– Awareness campaigns: Designing and implementing campaigns to educate the community about tetanus prevention and the importance of vaccination.
Please note that the provided cost items are general categories and not actual cost estimates. Actual cost planning would require a detailed budget analysis.

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong. The study provides a 5-year audit of admissions to the neonatal and general pediatric units of Kamsar Hospital, which helps establish the incidence of neonatal and postneonatal tetanus. The study also identifies risk factors and outcomes associated with the disease. However, the abstract lacks specific details on the methodology used, such as sample size and data collection methods. To improve the strength of the evidence, the authors could provide more information on the study design, sample size calculation, and data collection procedures.

BACKGROUND: Tetanus is a vaccine-preventable disease caused by the bacterium Clostridium tetani. In 2018, all of Guinea was considered to be at risk of the disease and the country is currently in the elimination phase. METHODS: A 5-y audit (1 January 2014-31 December 2018) of all admissions to the neonatal and general paediatric units of Kamsar Hospital (Western Guinea) was undertaken to identify cases of neonatal tetanus (NNT) and postneonatal tetanus (PNNT). RESULTS: There were 5670 admissions during the study period, of which 39 (0.7%) were due to tetanus (22 NNT and 17 PNNT). Among NNT patients, the bacterial entry site was the umbilical cord (n=20) or wound following circumcision (n=2). For PNNT, the entry site was surface wound (n=12), limb fracture (n=1) or could not be established (n=4). A majority of the patients (36/39, 92.3%) were born to unvaccinated mothers or those who received suboptimal vaccination during pregnancy. Overall, 21 (53.8%) children died within 7 d of admission with a higher mortality observed among neonates (16/22, 72.7%) compared with postneonates (5/17, 29.4%). CONCLUSIONS: Tetanus was a rare cause of admission at Kamsar Hospital with a very high case fatality rate. The disease primarily occurred among children born to mothers who were unvaccinated/inadequately vaccinated during pregnancy.

This is a retrospective audit of all admissions to the neonatal and general paediatric units of Kamsar Hospital from 1 January 2014 up to and including 31 December 2018. The aim of this study was to determine the incidence of NNT and PNNT among those admitted to the neonatal and general paediatric units of Kamsar Hospital. This study was conducted at Kamsar Hospital, which is located in the Boke region of Western Guinea. The port city of Kamsar lies ∼250 km north of the capital Conakry. In 2014, according to the population census, Kamsar had a population of 133 350, of whom 32% were children aged <10 y.15 Bauxite was discovered in the region in 1963 and this led to the development of Kamsar as a major mining city. The city has permanent access to electricity, running water and health services, including the well-equipped Kamsar Hospital. Kamsar Hospital is a major referral hospital in the region and admits patients from the entire Boké region, which has a population of just over a million. The hospital has an outpatient ward dedicated to consultation and an inpatient ward for hospitalisation along with intensive care units (ICUs). The hospital provides a dedicated paediatric service along with a general paediatric unit and a specialised neonatal unit. The paediatric ward has a capacity of 50 beds, including 12 beds for neonatal care. As of 2019, there were five paediatricians and several general physicians, as well as nurses and supporting staff providing care. The case definitions of NNT and PNNT were based on the WHO protocol.16 The Dakar prognostic scoring system was used to grade the severity of cases: mild (Dakar scores from 0 to 2), moderate (scores equal to 3) and severe (scores from 4 to 6).1 On admission, metronidazole and diazepam were administered to all patients. Tetanus immunoglobulin antitoxin was administered intramuscularly, and the following drugs were administered based on the judgement of treating clinicians: phenobarbital, electrolyte supplements and penicillin G. For severe cases, intensive care support was provided and the patients were kept on a ventilator with an oxygen extractor and a nasogastric tube for hydration, feeding and administration of oral medications. The following patient characteristics were extracted: age, gender, body temperature, place of delivery of the newborn (home or hospital), suspected port of entry of the bacterium, incubation and onset period, complications encountered, requirement of nasogastric intubation support upon admission and the treatment regimen administered. Maternal characteristics such as education level, place of residence (rural/urban), number of antenatal care visits and vaccination against tetanus, including the number of doses received, were extracted. Information on clinical outcomes after treatment was extracted, including the length of hospital stay and mortality outcome. The descriptive characteristics of the included patients are presented. Survival probability was calculated using the Kaplan–Meier method. Univariable and multivariable Cox regression models were used to estimate the relative hazards of mortality within 7 d of admission. The results were reported following the RECORD (Reporting of studies Conducted using Observational Routinely collected Data) statement.17

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Based on the provided information, here are some potential recommendations to improve access to maternal health:

1. Strengthen maternal vaccination programs: Increase efforts to ensure that pregnant women receive adequate tetanus vaccinations during pregnancy to prevent neonatal and postneonatal tetanus.

2. Improve antenatal care services: Enhance access to antenatal care for pregnant women, including regular check-ups, education on maternal health, and tetanus vaccination.

3. Enhance health education and awareness: Implement community-based health education programs to raise awareness about the importance of maternal vaccination, hygiene practices, and wound care to prevent tetanus.

4. Strengthen healthcare infrastructure: Invest in improving healthcare facilities, particularly in rural areas, to provide better access to quality maternal healthcare services, including vaccination, wound care, and emergency obstetric care.

5. Train healthcare providers: Provide training and capacity-building programs for healthcare providers to improve their knowledge and skills in maternal health, including tetanus prevention, early detection, and management.

6. Implement surveillance systems: Establish robust surveillance systems to monitor the incidence of tetanus cases and identify areas with low vaccination coverage or inadequate access to maternal healthcare.

7. Promote community engagement: Engage communities in maternal health initiatives, encouraging active participation and ownership in promoting vaccination, wound care, and overall maternal health.

8. Strengthen collaboration and partnerships: Foster collaboration between healthcare providers, government agencies, non-governmental organizations, and other stakeholders to coordinate efforts and resources towards improving access to maternal health services.

These recommendations aim to address the specific challenges identified in the retrospective audit and contribute to reducing the incidence of neonatal and postneonatal tetanus, ultimately improving maternal and child health outcomes.
AI Innovations Description
Based on the information provided, the recommendation to improve access to maternal health and prevent cases of neonatal and postneonatal tetanus could be to implement a comprehensive tetanus vaccination program for pregnant women in the region served by Kamsar Hospital. This program should focus on ensuring that all pregnant women receive adequate vaccination against tetanus during pregnancy.

Specific actions that can be taken to implement this recommendation include:

1. Strengthening antenatal care services: Ensure that all pregnant women have access to regular antenatal care visits where they can receive tetanus vaccinations and other necessary healthcare services.

2. Education and awareness campaigns: Conduct community-based education and awareness campaigns to inform pregnant women and their families about the importance of tetanus vaccination during pregnancy and the risks associated with inadequate vaccination.

3. Training healthcare providers: Provide training to healthcare providers at Kamsar Hospital and other healthcare facilities in the region on the administration of tetanus vaccinations during pregnancy and the importance of promoting vaccination to pregnant women.

4. Vaccine supply and distribution: Ensure a consistent supply of tetanus vaccines and establish an effective distribution system to ensure that healthcare facilities have an adequate stock of vaccines at all times.

5. Monitoring and evaluation: Implement a system to monitor the vaccination coverage among pregnant women in the region and evaluate the impact of the vaccination program on reducing cases of neonatal and postneonatal tetanus.

By implementing these recommendations, it is expected that the incidence of neonatal and postneonatal tetanus will decrease, leading to improved maternal and child health outcomes in the region served by Kamsar Hospital.
AI Innovations Methodology
Based on the provided information, here are some potential recommendations to improve access to maternal health:

1. Strengthen maternal vaccination programs: Increase efforts to ensure that pregnant women receive adequate tetanus vaccinations during pregnancy. This can be achieved through targeted vaccination campaigns, education programs, and improved access to healthcare facilities.

2. Enhance antenatal care services: Improve access to antenatal care services, particularly in rural areas, to ensure that pregnant women receive regular check-ups, education on maternal health, and appropriate vaccinations.

3. Promote safe delivery practices: Implement programs to educate and promote safe delivery practices, including proper umbilical cord care and circumcision wound care, to reduce the risk of neonatal tetanus.

4. Improve healthcare infrastructure: Invest in improving healthcare infrastructure, particularly in referral hospitals and rural areas, to ensure that adequate facilities and resources are available for maternal and neonatal care.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Data collection: Gather data on the current state of maternal health access, including vaccination rates, antenatal care utilization, and incidence of neonatal and postneonatal tetanus cases.

2. Define indicators: Identify key indicators to measure the impact of the recommendations, such as vaccination coverage, antenatal care attendance, and reduction in tetanus cases.

3. Baseline assessment: Establish a baseline by analyzing the current situation and determining the existing levels of access to maternal health services.

4. Modeling and simulation: Use mathematical modeling techniques to simulate the potential impact of the recommendations on improving access to maternal health. This could involve creating scenarios and running simulations to estimate the expected changes in vaccination rates, antenatal care utilization, and reduction in tetanus cases.

5. Evaluation and analysis: Analyze the simulation results to assess the potential impact of the recommendations. This could include comparing the projected outcomes with the baseline assessment to determine the effectiveness of the proposed interventions.

6. Recommendations and implementation: Based on the simulation results, provide recommendations for implementing the identified interventions to improve access to maternal health. These recommendations should be supported by the evidence generated from the simulation.

7. Monitoring and evaluation: Continuously monitor and evaluate the implementation of the recommendations to assess their actual impact on improving access to maternal health. This could involve tracking vaccination rates, antenatal care attendance, and monitoring the incidence of neonatal and postneonatal tetanus cases over time.

By following this methodology, policymakers and healthcare providers can make informed decisions and take appropriate actions to improve access to maternal health services and reduce the incidence of tetanus cases.


Identifiers:
DOI: 10.1093/inthealth/ihab021
Research Areas:
Environmental, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants
Study Countries:
Guinea
Study Design:
Cohort Study, Cross Sectional Study
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