Overview

Tetanus is an acute infectious disease caused by the bacterium Clostridium tetani. The spores are found everywhere in the environment, particularly in soil, ash, intestinal tracts/faeces of animals and humans, and on the surfaces of skin and rusty metal, including nails, needles and barbed wire. The spores are very resistant to heat and most antiseptics and can survive for years.

Tetanus is acquired through infection of a cut or wound with the spores of the bacterium. Most cases occur within 14 days of infection.

Vaccination can prevent tetanus. Recovered individuals do not acquire natural immunity and can be reinfected.

While anyone can get tetanus, neonatal tetanus is particularly common, and serious, in newborn babies within the first 28 days of life. The majority of cases are associated with childbirth, especially when the mother is unvaccinated.

Transmission

Tetanus, in general, is acquired through infection of a cut or wound with the spores of Clostridium tetani and most cases occur within 14 days of infection.

Neonatal tetanus occurs when nonsterile instruments are used to cut the umbilical cord or when contaminated material is used to cover the umbilical stump. Deliveries carried out by people with unclean hands or on contaminated surfaces are also risk factors.

Symptoms

The incubation period of neonatal tetanus varies between 3 to 28 days after infection, with the most common period being 6 days.

Neonatal tetanus symptoms:

a neonate with normal ability to suck and cry during the first 2 days but who, between 3 and 28 days of age, ceases to suck normally and becomes rigid or has spasms; and

muscle spasms – difficulty opening the mouth, facial muscle spasm, increased muscle tone and clenched hands – often preceded by the newborn’s inability to suck or breastfeed and excessive crying.

Symptoms commonly appear 4 to 14 days after birth, with an average onset of about 7 days.

Treatment and management

Diagnosis: Tetanus is diagnosed clinically rather than through laboratory tests.

Treatment: Tetanus is a medical emergency requiring:

hospital care;

immediate treatment with human tetanus immune globulin (an antibody used to prevent and treat tetanus by neutralizing the toxin produced by the bacteria);

aggressive wound care, including umbilical cord stump care;

drugs to control muscle spasms;

antibiotics; and

tetanus vaccination.

People who recover from tetanus do not have natural immunity and can be infected again and therefore need to be vaccinated.

Prevention

Vaccination: Neonatal tetanus can be prevented by immunizing women of reproductive age with tetanus toxoid-containing vaccines (vaccines that stimulate the body to produce immunity against the tetanus toxin) either during or outside pregnancy.

Robust medical practices, including clean delivery and cord care during childbirth, can also prevent tetanus.

Community-based preventive measures

Childbirth practices: Encourage the use of boiled then cooled tools for cutting umbilical cords and clean, boiled cloths for wrapping the newborn. Promote handwashing with soap for anyone involved in childbirth.

If sinks are not available in patient areas, Veronica buckets (portable handwashing stations) can be installed to provide water for hand hygiene close to the point of care. Alternatively, a handwashing basin, soap and a jug of clean water can be placed on a trolley used for ward rounds to encourage handwashing as often as needed between patient contacts.

When soap, clean water and alcohol-based hand rubs are unavailable, the following options can be considered:

Sodium hypochlorite may be added to water to achieve an end formulation of 0.05% sodium hypochlorite for use in dispenser containers for hand hygiene.

Sodium hypochlorite solution becomes inactive when exposed to air and organic materials. If this method is used during supply shortages, it is recommended that the solution be prepared in small batches daily and dispensed from closed containers.

Sodium hypochlorite added to water with a high saline content (seawater) is also an option, as long as an end formulation of 0.05% sodium hypochlorite is achieved. Other water sources, such as rainwater, may be considered.

Hand hygiene products that have antimicrobial properties, such as waterless no-rinse hand soaps.

Community engagement and health care support

Education and awareness: Conduct educational sessions to raise awareness about the dangers of neonatal tetanus and prevention measures, emphasizing the use of sterile instruments and post-delivery umbilical cord care.

Hygienic practices: Offer training sessions for midwives, traditional birth attendants and community health workers on safe delivery practices and umbilical cord care (e.g. using sterilized materials and clean surfaces for childbirth).

Safe wound management: Teach community members basic wound care such as cleaning wounds with boiled water and covering them with clean cloths to reduce tetanus infection risks.

Sources

Infection prevention and control and water, sanitation and hygiene measures in health-care settings and shelters/congregate settings in Gaza: technical note. Geneva: World Health Organization and United Nations Children’s Fund; 2024 (https://www.unicef.org/sop/media/3681/file/Infection%20prevention%20%20and%20control%20and%20water,%20%20sanitation%20and%20hygiene%20%20measures%20in%20health-care%20%20settings%20and%20shelters%20congregate%20settings%20in%20Gaza.pdf).

Neonatal tetanus: vaccine preventable diseases surveillance standards. Geneva: World Health Organization; 2018 (https://www.who.int/publications/m/item/vaccine-preventable-diseases-surveillance-standards-neonatal-tetanus).