---Of 124 tetanus cases reported in the United States between 1995 and 1997, only one was in a neonate.
ATLANTA - Montana health officials investigated a case of neonatal tetanus (NT) in a child whose mother had a philosophical objection to vaccination. The cause of the infection was probably unsterilized material used to hasten healing of the umbilical cord.
"Factors contributing to this case include the lack of maternal vaccination, the aerobic conditions and Clostridiumtetani contamination of the umbilical cord resulting from the application of a nonsterile clay, and the potential exposure to C. tetani spores from the nearby horse pasture," said the report by the Centers for Disease Control and Prevention (CDC).
Although NT, caused by a toxin of C. tetani accounts for more than 250,000 deaths worldwide, it is rare in the United States. Tetanus-associated deaths in U.S. infants declined from 64 per 100,000 people in 1900 to less than 0.01 per 1,000 live births in 1967. The decline is associated with improved birth practices and routine vaccination with tetanus toxoid. Of 124 tetanus cases reported in the United States between 1995 and 1997, only one was in a neonate.
"Since 1972, 31 cases of NT have been reported to CDC. Of these cases, only five (16%) mothers had a history of never having received tetanus toxoid, and only one was known to have received more than one dose," the CDC said in its report.
C. tetani is a ubiquitous, spore-forming bacterium concentrated in soil and animal excrement. NT is associated with nonsterile delivery or umbilical cord-care practices for newborns of mothers with antitoxin levels insufficient to transfer protective maternal antibodies. The 32-year-old mother in this case lived near a horse pasture. She had never been vaccinated because her family had a philosophic objection to vaccination. After the child was diagnosed, the mother did receive tetanus and diphtheria toxoids (Td).
In March 1998, the parents brought their 9-day-old newborn to a Montana hospital. The infant had difficulty opening her jaw and was unable to nurse. The newborn had trismus, increased general muscle tone, and was hyper responsive to external stimuli. The umbilical cord was covered with dried clay, which when retracted revealed a foul-smelling, yellow-green discharge. Culture from the umbilical cord grew anaerobic and aerobic bacteria.
The newborn was treated with tetanus immune globulin (500 units intramuscularly) and penicillin G (300,000 U/kg/day intravenously) for 10 days. Three days after being admitted, she required mechanical ventilation and remained ventilated for 12 days. She was discharged on April 10 with no apparent neurologic sequelae. At a follow-up examination at age 7 months, it appeared she was developing normally, but her mother still had not initiated her vaccination series because of concern about potential adverse effects.
The mother had an uncomplicated pregnancy, which was attended throughout by a "direct-entry" midwife. A direct-entry midwife is licensed to attend women during uncomplicated pregnancies, labor and postpartum periods. The newborn was delivered in a local hospital by caesarian section. While in the hospital, the infant received standard umbilical cord care with isopropyl alcohol and was discharged at 3 days of age.
For home umbilical cord care, the parents applied a "Health and Beauty Clay" powder provided by the midwife. This powder was applied to the umbilical cord up to three times daily with a clean cotton-tipped swab. The clay powder was made from bentonite clay, which was not sterilized during manufacturing. Local midwives recommended the clay for umbilical cord care because they believed it accelerated drying of the cord.
The county health department issued an advisory to more than 60 local health care providers emphasizing the importance of tetanus toxoid vaccination, particularly for pregnant women. Vaccination with tetanus toxoid during pregnancy is safe and effective in preventing NT, the CDC said.
In addition, the health department's advisory cautioned against using nonsterile products for umbilical cord care; the midwives stopped recommending the clay for umbilical cord care.
Since 1984, only two other cases of NT have been reported, both in infants of unvaccinated or inadequately vaccinated foreign-born mothers. Unless all women giving birth are vaccinated appropriately with tetanus toxoid, even hospital-born infants are at risk for developing NT, especially if unconventional practices of umbilical cord care are followed.
For your information:
- CDC. Neonatal tetanus - Montana, 1998. MMWR 1998;47:928-930
- Expanded Program on Immunization. WHO/EPI Information System. Geneva, Switzerland: WHO, September 1998; document no. WHO/EPl/GEN/98.10.
- Bardenheier B. Prevots DR, Khetsuriani N. Wharton M. Tetanus surveillance - United States, 19951997. In: CDC surveillance summaries (July). MMWR. 1998;47(no. SS-2~:1-13.
- Craig AS, Reed GW, Mohon RT, et al. Neonatal tetanus in the United States: a sentinel event in the foreign-born. Pediatr Infect Dis J. 1997;16:955-9.