Historical background and past knowledge: After Hippocrates’ primeval description of tetanus in medical literature, no significant advancement in understanding occurred till the early 19th century [2]. The causative agent of tetanus was identified by Rossenbach [3] but isolation of Clostridium tetani is credited to Kitasato in 1889 [4]. This gram-positive, spore-forming, motile, anaerobic bacillus constitutes the normal intestinal flora of animals. As the spores are ubiquitous and persist for long time in the soil, these can easily contaminate wounds. Thus, any non- or partially-vaccinated individual is vulnerable to develop tetanus. In 1897, Edmond Nocard established the role of tetanus anti-toxin in inducing passive immunity in humans. Nearly three decades later, tetanus toxoid – developed by Descombey in 1924 – was widely used during World War II. The use of tetanus toxoid as a combined vaccine in the form of DPT (Diphtheria, Pertussis and Tetanus) was licensed in 1949. In the pre-vaccination era, the true burden of tetanus was largely unknown as most neonatal births and deaths occured at home without an account of the either event.

Although DPT was introduced in 1950s, it became part of Expanded Program of Immunization (EPI) only in 1974. In the meanwhile, tetanus remained widely prevalent. In 1980’s, a significant proportion of global under-five mortality was attributed to tetanus (more than 1 million deaths every year), two-third of this being contributed by neonatal tetanus [5]. With effective implementation of the immunization program, the incidence of tetanus in the developed countries declined sharply during the last three decades, though it remained endemic in developing countries, particularly in Asia and Africa. The incidence in these nations is inversely related to the tetanus toxoid coverage of the population, and has direct relationship with poor hygiene, child-care practices, and wound management. By the end of 20th century, though there was a substantial decline in number of tetanus cases in India with improved vaccination coverage [6], it still constituted a significant burden on the health infrastructure, especially as the case fatality rate continued to be high [7].

During 2000-2013, the global mortality rates for tetanus declined by more than 30% with an impressive annual rate reduction of 8.9% for neonatal tetanus [8]. India has also witnessed reduced death rates from post-neonatal tetanus within last 5 years due to improvement in management strategies, especially supportive care provided to these patients [9]. In May 2015, India achieved the landmark of elimination of neonatal and maternal tetanus [10], certification of which requires incidence of less than 1 case per 1000 live births in all districts of the country for two consecutive years. This has been possible due to the sustained and diligent efforts in improving the vaccination coverage in pregnancy, rate of institutional deliveries, and promoting clean delivery and cord-care practices.

The risk factors associated with poor outcome in tetanus have largely remained unchanged in last 50 years [7,9]. There exists an inverse relationship between severity of disease and short incubation period and the interval between onset of first symptom and development of spasms. The autonomic dysfunction that usually appears in the second week of illness, and other complications like aspiration pneumonia and sepsis encountered frequently in individuals with prolonged hospital stay or in those who are mechanically ventilated, also contribute to mortality.

The use of ATS to neutralize the unfixed toxin has been phased out and replaced by Tetanus Immunoglobulin (TIG). The current recommendation is to use TIG early in course of illness as a single injection (500-2000 U) intramuscularly. Its use via intrathecal route has not been shown to provide any additional benefit [11]. The earlier recommendation to use penicillin has been criticized as it may inhibit the release of GABA, similar to the action of tetanospasmin [12]. Currently, metronidazole has become the drug of choice, to be given intravenously (30 mg/kg/day) every 6 hours for 10-14 days. Benzodiazepines (diazepam and lorazepam) in view of the potent anticonvulsant, sedative and hypnotic properties, continue as the preferred drugs for treatment of the spasms in tetanus since last half a decade [13], while use of barbiturates, phenothiazines, and meprobamate is no longer recommended in view of their serious side effects. Magnesium sulphate has emerged as an adjunctive drug in recent past with an additional benefit of controlling the autonomic symptoms [14]. Its use has been shown to reduce the dose requirement of benzodiazepines and neuromuscular blocking drugs, as well as the need of mechanical ventilation. Use of neuromuscular blocking agents is recommended in experienced hands after securing the airway in an intensive care set up if the above drugs fail to control spasms.

1. Saxena O, Saxena S. Tetanus in infancy and childhood. Indian Pediatr. 1965; 2:363-70.

2. Hippocrates. Tetanus. In: Major HH, editor. Classic Descriptions of Disease. 2nd ed. Springfield, IL, Charles C Thomas, 1939. p. 148-9.

3. Rosenbach AF. ZurAetiologie des Wundestarrkrampfes. Vorgetyrangen am. Sitzungslage des XV Congresses der Deutschen f. Chirurgiezu Berlin 7 April 1986. Arch Klin Chir.1887;34:306.

4. Kitasato S. Uber den tetanus Bacillus. Z. Hyg. Infektkr.1889;7:225-34.

5. Stanfield JP, Galazka A. Neonatal tetanus in the world today. Bull World Health Organ. 1984;62:647-9.

6. World Health Organization. WHO Vaccine Preventable Diseases Monitoring System 2015 Global Summary. Available from: http://apps.who.int/immunization_monitor ing/en/globalsummary/countryprofileselect.cfm　Accessed September 3, 2015.

7. Tullu MS, Deshmukh CT, Kamat JR. Experience of pediatric tetanus cases from Mumbai. Indian Pediatr. 2000;37:765-71.

8. Liu L, Oza S, Hogan D, et al. Global, regional, and national causes of child mortality in 2000–13, with projections to inform post-2015 priorities: An updated systematic analysis. Lancet. 2015;385:430-40.

9. Mishra K, Basu S, Kumar D, Dutta AK, Kumar P, Rath B. Tetanus-still a scourge in the 21st century: A pediatric hospital-based study in India. Trop Doct. 2012;42:157-9.

10. India declared free of maternal and neonatal tetanus. BMJ. 2015;350:h2975.

11. Abrutyn E, Berlin JA. Intrathecal therapy in tetanus: A meta-analysis. JAMA. 1991; 266: 2262-7.

12. Wassilak SGF, Roper MH, Murphy TV, et al. Tetanus toxoid. In: Plotkin SA, Mortimer EA, editors. Vaccines. 4th ed. Philadelphia: WB Saunders, 2004. p. 745-81.

13. Okoromah CN, Lesi FE. Diazepam for treating tetanus. Cochrane Database Syst. Rev. 2004;1:CD003954.