Definition

Tetanus is a disease of the nervous system caused by a neurotoxin called tetanospasmin. This toxin is the result of a bacterial infection. Tetanospasmin inhibits the neural signals of GABA and glycine, disrupting muscle reflex activity. This results in muscle stiffness, either locally (around the infected area) or generally (affecting muscles in the head, limbs, and torso). The resulting stiffness and tension can be painful and potentially fatal.

Causes

The bacterium Clostridium tetani is the cause of tetanus. This bacterium is commonly found in soil, dust, or animal waste such as that from horses and cows. The bacteria can survive in the environment for a long time and enter the body through open wounds. Once inside the body, the bacteria multiply rapidly and produce a toxin that attacks the nerves. The bacteria can enter the body through:

• Contaminated wounds from soil, dirt, or saliva containing the bacteria.
• Puncture wounds from nails or needles.
• Burns.
• Traffic accidents.
• Animal bites, such as from rats.

Additionally, tetanus bacteria can infect the body through skin wounds from insect bites, dental infections, unsterile surgical procedures, fractures, intravenous drug use, and intramuscular injections.

Tetanus can also occur in newborns due to unsterile instruments used during delivery and mothers who did not receive complete tetanus immunization. This condition is known as neonatal tetanus.

Risk factor

A person is more susceptible to tetanus infection if they have the following risk factors:

• Incomplete or no tetanus vaccination history.
• Weakened immune system due to certain diseases or medications.
• The presence of foreign objects causes wounds, such as a rusty nail.
• Poorly cleaned wounds.

Symptoms

Tetanus infection takes about 3-21 days (with an average of 10 days) from exposure to the bacteria until symptoms appear. However, this duration can vary, even extending to several months, depending on the type of wound.

Common signs and symptoms include:

• Stiffness in the jaw muscles (lockjaw), makes it difficult to open the mouth.
• Pain and stiffness in the muscles, make breathing and swallowing difficult.
• Fever.
• Excessive sweating.
• Rapid heartbeat.

There are four general forms of tetanus based on the affected area:

1. Local tetanus: Symptoms include persistent stiffness tension and pain in the muscles around the wound. This type can develop into generalized tetanus.
2. Cephalic tetanus: This form affects the face with an incubation period of about 1-2 days, usually caused by a wound on the head or ear infection. Symptoms include jaw stiffness (trismus), difficulty swallowing, and facial nerve disorders. Although rare, this form can develop into generalized tetanus and more often leads to death.
3. Generalized tetanus: This occurs if there is a deep wound prone to tetanus or deterioration from other forms. Symptoms include jaw muscle stiffness, neck stiffness, difficulty swallowing, chest and abdominal stiffness (opisthotonus), severe pain and anxiety, and seizures, especially triggered by light, sound, and touch. However, in tetanus, seizures occur while the patient remains conscious.
4. Neonatal tetanus: This form occurs in newborns due to infections in the umbilical cord and unclean procedures. Symptoms include inability to breastfeed, weakness, and muscle stiffness and tension.

Diagnosis

Doctors diagnose tetanus through medical history and physical examination. They will inquire about current symptoms experienced by the patient or family if the patient is in poor condition. Tetanus vaccination status is also important to know.

A physical examination will assess the severity of tetanus. No specific supplementary tests are generally required for diagnosis, but doctors may recommend blood lab tests to check for other signs and symptoms indicating severity.

Management

Tetanus treatment may include:

• Wound care: Cleaning the wound and removing dead tissue. Recommendations for injury-related wound care are:
• All wounds must be cleaned, and deeper cleaning (debridement) may be needed.
• Tetanus immunization history must be obtained by the doctor.
• Tetanus antitoxin injection: Aims to neutralize the toxin.
• If the last booster vaccine was more than 10 years ago or unknown, tetanus antitoxin or Tetanus Toxoid (TT) needs to be given.
• If the last immunization was more than 10 years ago, Tetanus Immunoglobulin (TIg) must also be provided.
• Antibiotics: To kill tetanus bacteria.
• Oxygen or breathing assistance: May be considered if the toxin affects respiratory muscles. Tetanus treatment may require a long time, such as 2-4 months. Hospitalized tetanus patients also need isolation to avoid external stimuli like sound and light, making the isolation room dim and quiet. Currently, there is no specific cure for the disease, only medication to neutralize the toxin that has not affected the nerves. Thus, it is important to prevent this disease through tetanus vaccination.

Complications

Tetanus is a dangerous disease that can cause death. It can lead to several complications, such as:

• Respiratory issues due to tense respiratory muscles.
• Brain damage due to lack of oxygen supply.
• Bone fractures due to stiff and tense muscles.
• Heart rhythm disturbances.
• Tongue injuries from seizures.
• Back injuries from lying in one position for too long.
• Other infections from prolonged hospital care.

Prevention

Tetanus vaccination is one preventive measure. This vaccine is mandatory in Indonesia and is given three times to children before the age of 1 year. It is combined with other vaccines, namely diphtheria and pertussis/whooping cough (DPT vaccine). The Indonesian Medical Association in 2020 recommended a DPT booster at 5-7 years old. Additionally, at 10-18 years old, the Td vaccine can be given. The vaccine needs to be repeated every 10 years.

The Indonesian government also requires women to get tetanus vaccination before marriage and during pregnancy to prevent neonatal tetanus. This can be done at health centers, posyandu, clinics, or hospitals. During the first pregnancy, pregnant women should receive at least two tetanus vaccine injections 4 weeks apart. If previous vaccination status is unknown, pregnant women should receive three injections: the first and second 4 weeks apart, and the second and third 6 months apart.

In addition to vaccination, proper wound care is essential since one of the entry points for tetanus bacteria is through deep and unclean wounds. If possible, clean wounds with running water and soap. If the wound is deep and wide or hard to clean, seek medical attention immediately.

When to see a doctor?

If you or someone around you experiences tetanus symptoms, especially generalized tetanus, seek medical attention immediately. Early treatment is necessary to prevent worsening and further complications. Some conditions require immediate medical attention, including:

• No improvement after initial treatment.
• Complications such as respiratory issues.

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