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Intensive therapy in neonatal tetanus

Ganendran A

Anaesthesia, 1974 May;29(3):356-62.
PMID: 4599155
Matched MeSH terms: Tetanus/drug therapy; Tetanus/etiology; Tetanus/epidemiology; Tetanus/therapy*; Tetanus Antitoxin/therapeutic use
Fulltext Economic impact of switching from partially combined vaccine "Pentaxim® and hepatitis B" to fully combined vaccine "Hexaxim®" in the Malaysian National Immunization Program

Aljunid SM, Al Bashir L, Ismail AB, Aizuddin AN, Rashid SAZA, Nur AM

BMC Health Serv Res, 2022 Jan 05;22(1):34.
PMID: 34986870 DOI: 10.1186/s12913-021-07428-7

BACKGROUND: The decision to implement new vaccines should be supported by public health and economic evaluations. Therefore, this study was primarily designed to evaluate the economic impact of switching from partially combined vaccine (Pentaxim® plus hepatitis B) to fully combined vaccine (Hexaxim®) in the Malaysian National Immunization Program (NIP) and to investigate healthcare professionals (HCPs)' and parents'/caregivers' perceptions.
METHODS: In this economic evaluation study, 22 primary healthcare centers were randomly selected in Malaysia between December 2019 and July 2020. The baseline immunization schedule includes switching from Pentaxim® (four doses) and hepatitis B (three doses) to Hexaxim® (four doses), whereas the alternative scheme includes switching from Pentaxim® (four doses) and hepatitis B (three doses) to Hexaxim® (four doses) and hepatitis B (one dose) administered at birth. Direct medical costs were extracted using a costing questionnaire and an observational time and motion chart. Direct non-medical (cost for transportation) and indirect costs (loss of productivity) were derived from parents'/caregivers' questionnaire. Also, HCPs' and parent's/caregivers' perceptions were investigated using structured questionnaires.
RESULTS: The cost per dose of Pentaxim® plus hepatitis B vs. Hexaxim® for the baseline scheme was Malaysian ringgit (RM) 31.90 (7.7 United States dollar [USD]) vs. 17.10 (4.1 USD) for direct medical cost, RM 54.40 (13.1 USD) vs. RM 27.20 (6.6 USD) for direct non-medical cost, RM 221.33 (53.3 USD) vs. RM 110.66 (26.7 USD) for indirect cost, and RM 307.63 (74.2 USD) vs. RM 155.00 (37.4 USD) for societal (total) cost. A similar trend was observed for the alternative scheme. Compared with Pentaxim® plus hepatitis B, total cost savings per dose of Hexaxim® were RM 137.20 (33.1 USD) and RM 104.70 (25.2 USD) in the baseline and alternative scheme, respectively. Eighty-four percent of physicians and 95% of nurses supported the use of Hexaxim® in the NIP. The majority of parents/caregivers had a positive perception regarding Hexaxim® vaccine in various aspects.
CONCLUSIONS: Incorporation of Hexaxim® within Malaysian NIP is highly recommended because the use of Hexaxim® has demonstrated substantial direct and indirect cost savings for healthcare providers and parents/caregivers with a high percentage of positive perceptions, compared with Pentaxim® plus hepatitis B.
TRIAL REGISTRATION: Not applicable.

Matched MeSH terms: Diphtheria-Tetanus-Pertussis Vaccine*
Total paralysis regime in severe tetanus

Alhady SMA, Bowler DP, Reid HA, Scott LT

Br Med J, 1960;1:540-545.

Tetanus may be mild, moderate, severe, or inevitably fatal. Our clinical experience suggests it may be classified as severe (or, maybe, inevitably fatal) when a tetanic spasm stops respiration. Ten patients with severe tetanus were treated by the total paralysis regime (T.P.R.), consisting of tracheostomy, curarization, and intermittent positiveor positive/negative-pressure respiration. Two of the patients were saved by T.P.R. and therefore only limited effectiveness can be claimed for the regime. In inevitably fatal cases survival can be prolonged by T.P.R. so that further effects of tetanus toxin emerge. Of these, the most important appears to be direct damage to the myocardium.

Matched MeSH terms: Tetanus
Fulltext Supplementation with natural forms of vitamin E augments antigen-specific TH1-type immune response to tetanus toxoid

Radhakrishnan AK, Mahalingam D, Selvaduray KR, Nesaretnam K

Biomed Res Int, 2013;2013:782067.
PMID: 23936847 DOI: 10.1155/2013/782067

This study compared the ability of three forms of vitamin E [tocotrienol-rich fraction (TRF), alpha-tocopherol (α-T), and delta-tocotrienol (δ-T3)] to enhance immune response to tetanus toxoid (TT) immunisation in a mouse model. Twenty BALB/c mice were divided into four groups of five mice each. The mice were fed with the different forms of vitamin E (1 mg) or vehicle daily for two weeks before they were given the TT vaccine [4 Lf] intramuscularly (i.m.). Booster vaccinations were given on days 28 and 42. Serum was collected (days 0, 28, and 56) to quantify anti-TT levels. At autopsy, splenocytes harvested were cultured with TT or mitogens. The production of anti-TT antibodies was augmented (P < 0.05) in mice that were fed with δ-T3 or TRF compared to controls. The production of IFN-γ and IL-4 by splenocytes from the vitamin E treated mice was significantly (P < 0.05) higher than that from controls. The IFN-γ production was the highest in animals supplemented with δ-T3 followed by TRF and finally α-T. Production of TNF-α was suppressed in the vitamin E treated group compared to vehicle-supplemented controls. Supplementation with δ-T3 or TRF can enhance immune response to TT immunisation and production of cytokines that promote cell-mediated (TH1) immune response.

Matched MeSH terms: Tetanus Toxoid/administration & dosage*
Fulltext Timing of antenatal tetanus immunization for effective protection of the neonate

Chen ST, Edsall G, Peel MM, Sinnathuray TA

Bull World Health Organ, 1983;61(1):159-65.
PMID: 6601539

The relationship between the timing of maternal tetanus toxoid immunization and the presence of protective antitoxin in placental cord blood was investigated among women admitted to the obstetrical service of the University Hospital in Kuala Lumpur, Malaysia. The 1st dose was given between 13-39 weeks of gestation, with a median of 29 weeks. The 2nd dose was given an average of 4 weeks later. Protection was conferred on 80% or more of newborns whose mothers received their 1st tetanus toxoid injection 60 days or more before delivery. Protective levels were seen in all cord blood samples from infants whose mothers had received their 1st injection 90 days before delivery. Similarly,protective titers were found in 100% of cord blood samples when the 2nd maternal injection was give 60 days or more before delivery. There was no significant degree of protection when immunization was carried out less than 20 days before delivery. A single-dose schedule provided no protection when less than 70 days before delivery. Cord and maternal antiotoxin titers differed by no more than 1 2-fold dilution for almost all of the individual paired sera. A cord: maternal antitoxin ratio of 2 was more likely to occur with increasing time between the 2nd injection and delivery. Overall, these findings indicate that the 1st injection of a 2-dose maternal tetanus toxoid schedule should be given at least 60 days and preferably 90 days before delivery.

Matched MeSH terms: Tetanus/prevention & control*; Tetanus Antitoxin/analysis; Tetanus Toxoid/administration & dosage*
Effects of supplementation with tocotrienol-rich fraction on immune response to tetanus toxoid immunization in normal healthy volunteers

Mahalingam D, Radhakrishnan AK, Amom Z, Ibrahim N, Nesaretnam K

Eur J Clin Nutr, 2011 Jan;65(1):63-9.
PMID: 20859299 DOI: 10.1038/ejcn.2010.184

Vitamin E is an essential fat-soluble vitamin that has been shown to induce favorable effects on animal and human immune systems. The objective of this study was to assess the effects of tocotrienol-rich fraction (TRF) supplementation on immune response following tetanus toxoid (TT) vaccine challenge in healthy female volunteers.

Matched MeSH terms: Tetanus Toxoid/administration & dosage; Tetanus Toxoid/immunology*
Fulltext Parents' and healthcare professionals' perception toward the introduction of a new fully liquid hexavalent vaccine in the Malaysian national immunization program: a cross-sectional study instrument development and its application

Al Bashir L, Ismail A, Aljunid SM

Front Immunol, 2023;14:1052450.
PMID: 37180162 DOI: 10.3389/fimmu.2023.1052450

A newly developed fully liquid hexavalent vaccine that comprises six antigens for Diphtheria, Tetanus, acellular Pertussis, Inactivated Poliomyelitis, Haemophilus Influenza type b., and Hepatitis B, is proposed to be introduced in the Malaysian national immunization program, instead of the non-fully liquid pentavalent vaccine and monovalent Hepatitis B vaccine that is currently employed in the immunization schedule. Although the introduction of new vaccines is a necessary intervention, it still needs to be accepted by parents and healthcare professionals. Hence, this study aimed to develop three structured questionnaires and to investigate the participants' perception and acceptability toward the incorporation of the new fully liquid hexavalent vaccine. A cross-sectional study was conducted among a sample of 346 parents, 100 nurses, and 50 physicians attending twenty-two primary health care centers in the states of Selangor and the Federal Territory of Kuala Lumpur and Putrajaya during 2019-2020. The study found that Cronbach's alpha coefficients for the study instruments ranged from 0.825 to 0.918. Principal components analysis produced a good fit with KMO>0.6. For the parents' perception questionnaire, the only extracted factor explained 73.9 % of the total variance; for the nurses' perception toward a non-fully and fully liquid combined vaccine, there was a sole extracted factor that explained 65.2 % and 79.2% of the total variance, respectively. Whereas for the physicians' perception, there was one factor extracted that explains 71.8 % of the total variance. The median score for all the questionnaire items ranged from 4 to 5 (Q1 and Q3 vary between 3-5). Parents' ethnicity was significantly associated (P-value ≤ 0.05) with the perception that the new hexavalent vaccine would reduce their transportation expenses. Moreover, a significant association (P-value ≤ 0.05) was found between physicians' age and the perception of the hexavalent vaccine's ability to decrease patient overcrowding in primary healthcare centers. The instruments used in this study were valid and reliable. Parents of Malay ethnicity were the most concerned about transportation expenses since they have the lowest income and are more concentrated in rural areas compared to other races. Younger physicians were concerned about reducing patient crowding and hence reducing their workload and burnout.

Matched MeSH terms: Diphtheria-Tetanus-Pertussis Vaccine*
Fulltext Re-Emergence of Tetanus in a District Referral Hospital

Ariff HH, Verghese A, Brian CMK

International Medical Journal Malaysia, 2017;16(1):127-130.
MyJurnal

Tetanus is an acute, potentially fatal disease caused by Clostridium tetani. It is characterized by generalized, painful spasms and rigidity of skeletal muscles. We present two fatal cases and discuss the potential causes that lead to mortality in cases of tetanus infection

Matched MeSH terms: Tetanus
Influence of immunization schedule on immunization coverage

Chen ST

J Trop Med Hyg, 1989 Dec;92(6):386-90.
PMID: 2607571

The infant immunization coverage for triple antigen (DPT) from 1968 and trivalent oral polio vaccine (TOPV) from 1972 to 1985 for Peninsular Malaysia are presented. It shows that immunization coverage improved when the recommended age for first dose of DPT was changed from the fourth to the second month of life in 1972 and declined when the recommended age for the first dose of DPT and TOPV was revised again from the second to the third month of life in 1980. The advantages of immunizing children early in life are discussed.

Matched MeSH terms: Diphtheria-Tetanus-Pertussis Vaccine/administration & dosage*
Tetanus neonatorum in West Malaysia

Chen ST

J Trop Med Hyg, 1974 Sep;77(9):204-7.
PMID: 4416077
Matched MeSH terms: Tetanus/mortality; Tetanus/epidemiology*; Tetanus Toxoid/administration & dosage
Effect of Spirulina (Arthrospira) supplementation on the immune response to tetanus toxoid vaccination in a mouse model

Chu WL, Quynh le V, Radhakrishnan AK

J Diet Suppl, 2013 Sep;10(3):229-40.
PMID: 23927690 DOI: 10.3109/19390211.2013.822452

The aim of this study was to investigate whether Spirulina (Arthrospira) supplementation could enhance the immune response to tetanus toxoid (TT) vaccine in a mouse model. Vaccination of TT was performed on day 7 and 21 in mice fed daily with Spirulina (50 and 150 mg/kg body weight). Both Spirulina supplementation and TT vaccination did not significantly affect body weight gain of the mice. Supplementation of Spirulina significantly enhanced IgG level (p = .01) after the first but not after the second TT vaccination. The anti-TT IgG levels of the groups that received low dose and high dose of Spirulina were not significantly different. Spirulina supplementation did not show significant effects on in vitro splenocyte proliferation and cytokine (IFN-γ and IL-4) production induced by Con A and TT. This study showed that Spirulina supplementation could enhance primary immune response in terms of antibody production, but not secondary immune response following TT vaccination in a mouse model.

Matched MeSH terms: Tetanus Toxoid/immunology; Tetanus Toxoid/pharmacology*
Case of traumatic tetanus cured by inhalation of ether

Smith GH

Lancet, 1849;54:667-668.
DOI: 10.1016/S0140-6736(02)71261-0
Matched MeSH terms: Tetanus
The "built-in failure-rate" of immunisation at infant-health clinics

Dugdale AE

Lancet, 1969 Feb 22;1(7591):409-11.
PMID: 4179241 DOI: 10.1016/S0140-6736(69)91371-3
Matched MeSH terms: Tetanus/prevention & control
Notes on a case of tetanus

Gupta M

Malayan Medical Journal, 1927;2:164-5.

Matched MeSH terms: Tetanus
Record of interesting cases

Davies EC

Malayan Medical Journal, 1927;2:80.

Matched MeSH terms: Tetanus
Universal child immunization coverage in Kuala Lumpur

Sinniah, D., Rajeswari, B., Koh, S., George, J., Sundari, J., Sosapillai, J.N., et al.

Malaysian Journal of Child Health, 1991;3(1):23-28.
MyJurnal

To verify the actual immunisation coverage in Kuala Lumpur, City Hall Health Department and the Malaysian Paediatric Association (NGO ) carried out a survey. The survey revealed that the immunisation coverage determined at the child's first birthday for BCG was 95%, DPT 3 94%, OPV 3 94%, and measles = 27% (59% at 2 years). These figures correspond closer to City Hall's estimated coverage rather than the rates projected by the Ministry of Health. The main reasons for immunisation failure were, child ill 31.8% (not brought = 20.1%, brought but not given vaccine 11.7%), lack of information 28.6%, lack of motivation 9.1%, mother too busy 9.1%. Measles immunisation coverage at 1 year was low because of wrong information on schedules. Tetanus toxoid immunisation coverage of pregnant women was low. Only 27% of children were protected against neonatal tetanus although 97% of pregnant women received antenatal care and 50% had attended other health facilities as well during pregnancy. Private medical practitioners were responsible for more than 40% of all immunisations but were not submitting returns to the Health Department. Recommendations to improve immunisation coverage include education and motivation of the public and also doctors and health personnel on prevention of missed opportunities, contraindictions to immunisation and correct schedules. (Copied from article).

Matched MeSH terms: Tetanus; Tetanus Toxoid
Control of vitamin a deficiency for reducing morbidity and mortality in children

Muhilal

Malaysian Journal of Child Health, 1997;9(1):49-52.
MyJurnal

Various studies conducted in Indonesia have shown that administration of Vitamin A to pre-school children had decreased the mortality and morbidity rates among them. In the first study conducted in the province of Acheh in North Sumatra, a twice yearly high dose of vitamin A led to a 34% decrease in mortality. In a second study in Bogor, conducted by fortifying the nutritional additive MSG with vitamin A and distributing the product in a designated area, the mortality rate among preschool children was 45% less than in a control area. In the third study also conducted in Bogor, where vitamin A was given to lactating women 2 weeks after giving birth and then directly to the infants themselves after 5 months of age, the mortality rate was 38% lower. The prevalences of respiratory and diarrhoeal infections were statistically lower than in the control gorups. Another study on preschool children showed a two-fold increase of anti TT IgG on primary immunisation against tetanus when compared to a control group and a four-fold increase with a secondary immunisation. Other studies conducted in Bogor and other parts of the world have showed that smaller doses given more often are more effective than bigger doses given less often.

Matched MeSH terms: Tetanus; Tetanus Toxoid
Current trends in morbidity and mortality of children in Malaysia

Lin, Hai Peng, Mohd Sham Kasim

Malaysian Journal of Child Health, 1997;9(2):104-132.
MyJurnal

Malaysia is a rapidly developing country with a very young population, about 36% of which are below the age of 15 years. The standard of child health has improved greatly. However, there are great changes in the morbidity and mortality patterns of childhood diseases relating mainly to an improved standard of living; availability of safe water supply and adequate sanitary latrines; a higher literacy rate; rapid industrialisation and urban migration. The infant mortality rate has droppedfrom 50.1 per 1,000 livebirths in 1986 to 10.4 in 1995, and similar trends apply also to neonatal, perinatal and toddler mortality rates. Nevertheless, current major child health problems are those relating to events in the perinatal period and to infections. Despite improvements in the standard of neonatal care with the use ofhigh technology, the commonest cause of certified deaths still occur in the neonatal period. A rapid and inexpensive screening test for G6PD deficiency, a disease present in 2-3% of the population, is now widely available and, together with the use of phototherapy is largely responsible for the declining incidence of kernicterus in the country. Infections remain an important cause of morbidity and mortality although their patterns have changed. The very high (>95%) WHO-EPI-vaccines coverage rate is linked to the great reduction in the incidence of diphtheria, pertussis, tetanus, poliomyelitis and measles. Childhood tuberculosis is less common now, with about 250 - 300 reported cases per year and TB meningitis is rare with about 30-40 reported cases/year. The hepatitis B carrier rate is high (5%) and the introduction of routine newborn hepatitis B vaccination in 1989 is expected to have a positive impact as is the immunisation of young girls against rubella introduced in 1985 in reducing the incidence of congenital rubella syndrome. The incidence of malaria has declined but remains prevalent in the interiors of PeninsularMalaysia and in Sabah and Sarawak. Filariasis is largely under control. Unfortunately, despite great efforts at mosquito control, dengue virus infection remains a major problem with thousands of cases reported every year. Children are most susceptible to dengue haemorrhagic fever with many dying from the shock syndrome. The incidence of acute gastroenteritis has also dropped with most cases being due to a viral aetiology. Acute respiratory infections, mostly viral in origin, account for most attendances at paediatric outpatient services. Although staphylococcal and streptococcal impetigo and pneumonia are common, the incidence of streptococcal related diseases like rheumatic fever and acute glomendonephritis is rapidly declining. The nutritional status of children has improved in tandem with the rise in the standard of living, but subclinical malnutrition is prevalent, particularly among urban squatters and the rural poor. There is a disturbing decline in breastfeeding among urban working mothers. Poor weaning practices and food habits are responsible for the common occurrence of nutritional anaemia (5%) among infants and young children. Greater prosperity, rapid industrialisation and urbanisation have resulted in changes in the childhood disease pattern where non-communicable diseases assume greater importance as the problems of malnutrition and infection are gradually overcome. Road traffic accidents are a major killer and home accidents, largely preventable, are an important cause of morbidity and mortality. Childhood cancer, with about 550 new cases a year, is an important cause of death beyond infancy. Major congenital malformations, with a 1% prevalence rate, cause much ill-health. Thalassaemia is a particularly common genetic disease with fl thalassaemia gene frequency of about 5%. The prevalence of asthma is increasing, with a rate of 13.9% in the Kiang Valley but the prevalence of asthma-related symptoms is much higher. Physical, sexual child abuse and neglect, abandoned babies, substance abuse are but signs of stress of modern city living and peoples inability to cope with it. Although the general standard of child health has greatly improved, there are several states where it is still not satisfactory. In Sabah where there is a large illegal immigrant population, the infant mortality and infection rates are relatively high. In Kelantan and Trengganu, it is common for parents to refuse permission for a lumbar puncture required to treat meningitis. Other still deeply entrenched, culturally-related adverse health practices include : a fatalistic attitude to illness; a preference for traditional practitioners of medicine resulting in late treatment; and 'doctor-hopping' with unrealistic expectations of 'instant cure'. Childhood illnesses that are uncommon in Malaysia include: cystic fibrosis, coeliac disease, ulcerative colitis, Crohns disease, Sudden Infant Death Syndrome, Encopresis, enuresis and epiglottitis due to Haemophilus Influen:ae.

Matched MeSH terms: Tetanus; Tetanus Toxoid
Fulltext Diphtheria anti-toxoid antibody levels among pre-clinical students and staff in an institute of higher learning in Malaysia: are they protected?

Hamat, R.A., Malina, O., Chua, Y.J., Seng, K.L., Zubaidah, M., Norhanim, K., et al.

Malaysian Journal of Medicine and Health Sciences, 2011;7(1):-.
MyJurnal

Little is known about the sero-prevalence of diphtheria anti-toxoid antibody levels among medical students in Malaysia. They too, just like other health care workers (HCWs) are at risk of contracting and transmitting diphtheria. Fortunately, this can be prevented by giving a specific vaccine: the diphtheria, tetanus and pertussis (DTP) vaccine. Nonetheless, data from local or regional surveys are needed before any decision is made by the respective authorities. General objective: We studied the epidemiology of diphtheria anti-toxoid antibody levels and vaccination history amongst medical students and staff in Faculty of Medicine and Health Sciences, Universiti Putra Malaysia. Specific objectives: We determined the level of diphtheria anti-toxoid antibodies amongst pre-clinical students and staff. Methodology: A total of 152 sera were collected from subjects aged 19 to 63, and diphtheria anti-toxoid levels were measured by an enzyme-linked immunosorbent assay. Results: One hundred and fifty-two (94.4%) blood samples out of 161 participants were successfully withdrawn, which comprised 105 (69.1%) and 47 (30.9%) medical students and staff, respectively. A total of 77.6% and the other 22.4% of the subjects had full and basic protection, respectively. Higher levels were predominant amongst males and they were 1.3 times more protected than females in 20-29 year-old group (85.1% vs 66.2%; odd ratios 1.25 [95% CI 1.03-1.50]; P=0.03). No significant difference in the levels of immunity among subjects for ethnicity and academic position (P>0.05). Recommendations: Level of full protection against diphtheria toxin should be clearly defined by broad population based studies using several comparable detection methods. Medical students and staff with basic protection should be closely monitored or should be given a booster dose for those who are at high risk of acquiring the disease. Thus, a standard degree of coverage should be clearly determined for health workers to prevent a potential outbreak. Conclusion: Students and staff possess immunity towards diptheria toxin however the level of full protective antibody is yet to be determined in future.

Matched MeSH terms: Tetanus; Tetanus Toxoid
Vaccine update: the association between measles-mumps-rubella vaccination (MMR) and onset of autism and inflammatory bowel disease

Lee, E.L.

Malaysian Journal of Paediatrics and Child Health, 2001;13(1):1-12.
MyJurnal

Vaccines, used appropriately and efficiently, have changed the landscape of infectious diseases. Poliomyelitis is almost completely eliminated globally. In many industrialised countries, there has been over 99 percent reduction in incidence of diphtheria, tetanus, measles, mumps, rubella, Haemophilus in-fluenzae b meningitis and over 97 percent reduction in whooping cough.',2Unlike anti-biotics, most vaccines have remained equally effective despite years of continuous usage.

Matched MeSH terms: Tetanus; Tetanus Toxoid

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