Tetanus is an infectious, non-contagious disease caused by Clostridium tetani, also known as Nicolaier's bacillus. It is a ubiquitous anaerobic telluric bacillus that produces toxins: tetanolysin and tetanospasmin. Tetanospasmine is a potent neurotropic exotoxin and once it reaches the anterior horns of the spinal cord and cerebellum, it causes an increase in muscle tone.

Tetanus is a fatal but completely preventable disease through vaccination and the administration of anti-tetanus serum as post-exposure prophylaxis [1]. In developed countries, this condition has become increasingly rare. The number of confirmed cases of tetanus identified since 2006 has ranged from 49 to 167 per year, with a downward trend. In 2014, the total incidence reported in the European Union was 0.01 cases per 100,000 inhabitants [2].

In Madagascar, tetanus is still prevalent despite the efforts of the state-supported by its partners, particularly in mass vaccination campaigns. The tetanus vaccination coverage rate was 73% in 2009 [3]. Efforts and the program to combat this disease are concentrated on the fight against neonatal tetanus and on prophylaxis for pregnant women, which fall within the scope of the Expanded Program on Immunization (EPI). In recent years, several Malagasy researchers have been interested in monitoring the epidemiological trend of neonatal tetanus [4].

Moreover, few studies have focused on the evaluation of juvenile tetanus, even though this disease does not spare children. It is in this context that the current study carried out this study whose objectives were to describe the epidemiological profile, clinical manifestations, treatments and evolution of infantile tetanus in the pediatric resuscitation unit of the University Hospital Centre of Tamatave (UHCT).

Study framework: The present study took place in the university hospital of Analankinina, a reference hospital of the first resort located in the city of Tamatave, in the eastern region of Madagascar. A city whose population has been estimated at 300, 813 inhabitants in 2014. Our service receives children aged 0 to 15 years old coming from all the districts of the eastern part of Madagascar.

Fig-1: Distribution of patients according to the age.

In terms of immunization status, the notion of tetanus vaccine third dose before the age of 1 year was reported in only 41% of cases. None of the children over 11 years of age received a tenth-year booster vaccination. Wound staining after chewing flea removal was the most common cause (76%) (Table 1).

Table-1: Entrance ways of infantile tetanus

Tetanus was generalized from the outset in 81.5% of cases, of which 44.4% had respiratory distress due to glottic spasm and/or diaphragmatic contracture. All of these cases were treated with long-term manual ventilation after intubation with diazepam and/or pancuronium. Isolated trismus was observed in 18.5% of cases (Table 2).

Fig-2: Distribution of patients according to the temperature at admission.

Table-2: Clinical signs of infantile tetanus

As a result, very little work has been done on tetanus [5].

In Madagascar, few studies are devoted to infant tetanus, where surveillance is concentrated on maternal and neonatal tetanus as in African countries [6].

This study shows that morbidity related to childhood tetanus accounts for 2.6% of all hospitalized tetanus cases. In Dakar Soumaré M. reported a prevalence twice as high (5.3%) as that of the present study [7], while an even higher prevalence was found in Conakry Guinea, reaching 8.28% [8]. Although this prevalence was lower than that found in Dakar, it is not reassuring because our hospital data does not reflect the reality on the ground because of the underestimation of this figure. Thus, as in all developing countries, many cases occur outside the health system and are not reported [2].

Tetanus is most prevalent in unimmunized or unboosted vaccine recipients [9]. It is the only vaccine-preventable and non-contagious disease. In the series studied by Sbai H, none of the patients were vaccinated [10]. Tetanus was preceded by unbooster vaccination in 2.64% of cases in the series studied by Patel JC [9]. Soumaré M. and his team in Dakar reported that none of these patients had been properly vaccinated against tetanus [7]. In our series, only 41% of cases were vaccinated before the age of one year, and none of the children over 11 years of age received a tenth-grade booster. In children, 39.2% of non-neonatal tetanus cases occur before the age of 10 years old [9]. In our series, three cases were recorded under 10 years of age (11.1%). This can be explained by the fact that the tetanus vaccination coverage rate before the age of 1 year in Madagascar is 73% [3].

Entrance door: According to some authors, the portal of entry remains identifiable in 89% of cases and not found in 11%, dominated by cutaneous wounds in 46.3%, operative wounds in 22.2%, open fractures in 3.7% and abscesses in 3.7% [11]. In Senegal, the study by Attinsounon CA and al reported that the portal of entry was dominated mainly by the integument, reaching 82.1% of cases [12]. This figure was not far from our series, wound staining after chewing flea removal was the most frequent cause (21 cases, 77.8%). This frequency can be explained by the tropism of chewing fleas always in the toes, an area exposed to the ground and objects possibly infested by Clostridium tetani as described in Africa [13].

risk of glottic spasm and was limited only to the administration of crystalloids.

Evolution: Depending on the early diagnosis and treatment, the evolution can be good (18%), fatal (60-82%), sequelae, or full of serious complications, such as nosocomial infections (respiratory in 60% and urinary in 20%), thromboembolism (10%), cardiovascular dysautonomia, pressure ulcers (30%), and decompensation of a pre-existing defect [10,18].

In our series, nosocomial pneumonitis occurred in 29.6% (8 cases), urinary tract infections in 2 cases (7.4%), superinfected bedsores in 1 case (3.7%), and thromboembolism in 1 case (3.7%). The aggravation of malnutrition in the 7 cases was mainly due to swallowing problems, while a feeding tube stimulated a glottic spasm in them and became impossible.

The duration of hospitalization is long and heavy, on average 19 days ranging from 5 to 42 days, which is generally reported in the literature [10,18], whereas, in our series, hospitalization lasted on average 12.7 days (5 to 25 days).

Mortality: In our work, mortality was 22.2%, while some authors such as Barry MC and al and Sbai H and al recorded high mortality of 60% and 80%. Hounkpè PC and al in their study showed that the determining factors for poor prognosis are mainly the length of hospitalization, but gender did not influence the prognosis [23].

Three main points emerge from this study.

Clinically: as trismus is not constant during a Clostridium tetani infection, any hyperthermia in children must be checked for a recent wound soiled by the soil, and the tetanus vaccination status must be checked.

Given the seriousness of this disease and the heavy burden of management, it is essential to prevent this serious and fatal disease in children, so the Expanded Programme on Immunization must also target older children over ten years of age. The improvement of case management in the present study center requires the supply of a complete parenteral feeding kit and equipment for the technical platform.