A ten-year review of neonatal tetanus cases managed at a tertiary health facility in a resource poor setting: The trend, management challenges and outcome

Background Neonatal Tetanus (NNT) is a vaccine preventable disease of public health importance. It is still being encountered in clinical practice largely in developing countries including Nigeria. NNT results from unhygienic delivery practices and some harmful traditional cord care practices. The easiest, quickest and most cost-effective preventive measure against NNT is vaccination of the pregnant women with the tetanus toxoid (TT) vaccine. The case-fatality rate from tetanus in resource-constrained settings can be close to 100% but can be reduced to 50% if access to basic medical care with adequate number of experienced staff is available. Materials and methods This retrospective study reviewed the admissions into the Special Care Baby Unit (SCBU) of the Ekiti State University Teaching Hospital, Ado-Ekiti from January 2011 to December 2020. The folders were retrieved from the records department of the hospital; Information obtained from folders were entered into a designed proforma for the study. Results During the study period, NNT constituted 0.34% of all neonatal admissions with case fatality rate of 52.6%. Seven [36.8%] of the babies were delivered at Mission home/Traditional Birth Attendant’s place while 5 [26.3%] were delivered in private hospitals. Cord care was with hot water compress in most of these babies16 [48.5%] while only 9% of the mothers cleaned the cord with methylated spirit. Age at presentation of less than one week was significantly associated with mortality, same with presence of autonomic dysfunction. Low family socioeconomic class 5 was significantly associated with poor outcome, so also maternal age above 24 years. Conclusion This study revealed that neonatal tetanus is still being seen in our clinical practice with poor outcome and the risk factors are the same as of old. Increased public health campaign, promotion of clean deliveries, safe cord care prac-tices, affordable and accessible health care provision are recommended to combat NNT scourge. Ethical approval for the study was given by the Research and Ethics committee of the Ekiti State University Teaching Hospital, Ado-Ekiti, Ekiti State with approval number EKSUTH/A67/2021/06/004. Formal verbal consent was obtained from the Parents/Guardians of the study participants. This retrospective study reviewed the admissions into the Special Care Baby Unit [SCBU] of the Ekiti State University Teaching Hospital (EKSUTH), Ado-Ekiti from January 2011 to December 2020. The EKSUTH is a tertiary public health facility providing health care to citizens of Ekiti State. It serves as a referral center to other hospitals within the state and other adjoining states like Osun, Ondo, Kwara, and Kogi that share borders with Ekiti State. The hospital is in Ado Ekiti which doubles as both the headquarters of Ado Local Government Area and the state capital. The city is mainly populated by the Yorubas of the southwestern part of Nigeria and has a population of approximately 313,690 inhabitants [20]. Agriculture is the main occupation of the people of Ekiti, and it is the major source of income for many in the state, while the women engage in trading. Agriculture provides income and employment for 75% of the population of Ekiti State. There are also civil servants, artisans, and small-business owners in Ekiti, and the minimum wage for the civil servants is like that of other states in Nigeria [21,22]. The hospital is a tertiary health facility, with a 16-bedded neonatal unit; 12 beds serve the inborn section while the outborn section has 4 beds. The SCBU is run by one consultant paediatrician, a senior registrar, one registrar, two house officers and fourteen nurses. The SCBU has facilities for neonatal resuscitation, phototherapy, and incubators. Neonates are admitted to the unit directly from the labour ward or the labour ward theatre as inborn patients while patients delivered outside the hospital are admitted into the outborn section. All cases of neonatal tetanus admitted into the SCBU of Ekiti State University Teaching Hospital (EKSUTH) during the ten-year period, from January 2011 to December 2020, were reviewed. The case note numbers of the patients were retrieved from the admission and discharge register on the ward. The folders were retrieved from the records department of the hospital. Information obtained from folders were entered into a designed proforma for the study. The information obtained included: the patient’s personal data, pregnancy and birth history, mother’s antenatal care and immunization history, place of delivery, cord care practices, age at admission, age at onset of first symptom, period of onset, interval between first symptom and presentation at the hospital, mother’s level of formal education, socio-economic class of the family, home treatment offered, duration of admission and outcome. Appropriate cord care was defined as the use of methylated only or use of chlorhexidine gel. The period of onset was defined as the interval in days between cessation of sucking and occurrence of spasms. Socioeconomic class was defined by the criteria described by Oyedeji et al [23]. Diagnosis of tetanus was made clinically according to the WHO diagnostic criteria [24] with all 3 of the following: Diagnosis of associated Sepsis was made by positive blood culture result and or use of the World Health Organization (WHO) identified clinical signs suggestive of sepsis [25] difficulty feeding, convulsions, movement only when stimulated, respiratory rate >60 per min, severe chest in-drawing and axillary temperature >37.5°C or <35.5°C. Diagnosis of autonomic dysfunction was made based on presence of tachycardia or bradycardia, arrhythmias, hyperpyrexia, and sweating. All cases of tetanus are admitted into the quiet section of the neonatal ward to reduce external stimuli. They all receive intravenous anti-tetanus serum at 10,000 IU within the first 24 to 48 hours of admission and intravenous metronidazole as the antibiotic of choice. Spasms are controlled with a combination of chlorpromazine, phenobarbitone and diazepam initially via intravenous route but this is later changed to oral medications via a nasogastric tube. The combination of the sedatives/muscle relaxants is dependent on the severity of the symptoms. The babies are fed with expressed breast milk via a nasogastric tube. A spasm chart is kept, vital signs are monitored before administration of sedatives and the doses of the sedatives adjusted accordingly depending on whether the spasms are increasing or reducing. The patients are worked up for sepsis which include blood culture, umbilical wound swab for microscopy, culture and sensitivity, complete blood count and urine microscopy culture and sensitivity are done for patients appropriately. Wound care is usually by wound debridement, application of hydrogen peroxide and subsequent cleaning with methylated spirit. Outcome of managed cases are classified as discharged, discharged against medical advice (DAMA) and death. The data obtained were analyzed using IBM SPSS version 25. The results were cross tabulated as frequency tables; means, standard deviations, percentages, and ranges was used as appropriate to describe continuous variables. Test of associations were assessed using Chi-square, and a p-value of 0.05 or less was considered significant.