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Final Issue: Volume 16 Number 51
Published on: 21 December 2006
Final Issue in PDF
Last updated: Volume 15, No.19 (PDF file, 858 KB)
Tetanus is a severe disease that is vaccine preventable, and is reportable by law, and under enhanced surveillance. Despite this, tetanus is under-reported and its surveillance needs improving. In a review of cases in England and Wales between 1984 and 2000, 23% of cases had not been notified and no follow-up information was available for 19% of cases (1).
Under-reporting of tetanus takes two forms: either a case is unknown to the Health Protection Agency (HPA), or else clinicians fail to provide the detail required following a preliminary report. Several cases unknown to local Health Protection Units (HPUs) have only been identified because specimens were referred to a national reference laboratory which passed on information to national public health colleagues. Of more concern are two recent incidents. In the first, a case was identified because a clinician unconnected with the care of the patient with tetanus, contacted the HPA Centre for Infections (CfI) for advice on immunisation after the patient had recovered. In the second, another case was discovered when it appeared as a case report in a peer-reviewed journal (2). This suggests that there are other cases that are probably never reported.
In the United Kingdom (UK), tetanus is a rare disease with which clinicians are often unfamiliar (3). Rapid reporting of tetanus cases to HPUs can be very helpful to clinicians for a number of reasons which they may not appreciate:
In addition to giving access to immediate public health advice, reporting is also important as an integral part of the national tetanus vaccination programme – for evaluating its effectiveness, and to inform the development of policy. Completeness of ascertainment and information about cases (including vaccination status) is a particular necessity for vaccine preventable diseases. Small changes in the epidemiology of a vaccine preventable disease need to be detected immediately as they may have large implications for national vaccination policy.
The evaluation of the outbreak of tetanus in injecting drug users (IDUs) which started in 2003 (5) led to improved advice on tetanus immunisation of IDUs (6). The outbreak was initially identified in 2003 by astute microbiologists, and case reporting was subsequently triggered by alerts to public health departments, infectious disease clinicians, accident and emergency (A&E) departments, and regular reports in the CDR Weekly. This experience demonstrates the importance of raising awareness and having good multidisciplinary networks of communication for infectious disease surveillance. Good surveillance rests on constructive relationships between clinicians, microbiologists, HPUs, and the CfI.
Reporting by clinicians of great importance, and maintaining reporting in an ever changing healthcare sector is essential for health protection. Tetanus prevention is a great public health achievement, and needs continuing support.
Emma Savage (firstname.lastname@example.org), Joanne White (email@example.com) and Natasha Crowcroft (Natasha.firstname.lastname@example.org) are the public health epidemiology contacts for tetanus reporting at the Centre for Infection.
1.Rushdy AA White JM, Ramsay ME, Crowcroft NS. Tetanus in England and Wales 1984-2000. Epidemiol Infect 2003; 130:71-7.
2.Padmakumar B, Date AR. Tetanus in an unvaccinated child in the United Kingdom: case report. J Public Health (Oxf) 2005;(1):118-9. [online] 2004 Nov 25.
3.Beeching NJ, Crowcroft NS. Tetanus in injecting drug users. BMJ 2005; 330(7485): 208-9.
4.Health Protection Agency [online]. Tetanus. London: HPA, [undated]. Available at <http://www.hpa.org.uk/infections/topics_az/tetanus/menu.htm>.
5.Cluster of cases of tetanus in injecting drug users in England: European alert. Eurosurveillance Weekly [serial online] 2003 [cited 1 May 2003]; 7(47). Available at: <http://www.eurosurveillance.org/ew/2003/031120.asp>.
6.Department of Health. Tetanus. Notifiable. London: Department of Health, [undated]. Available at <http://www.dh.gov.uk/assetRoot/04/08/73/89/04087389.pdf>.
Between 29 March and 10 May 2005, 214 cases of meningococcal disease, including 16 deaths, were reported in Delhi, northern India by the World Health Organization (WHO) Regional office for South East Asia (SEARO) (1).
The majority of cases have occurred in the walled city of Old Delhi and Shahdara, the most congested part of the capital, and in young adults between 16 and 30 years of age. Recent press reports have suggested that the outbreak may now be spreading to other parts of the city (2). Cerebrospinal fluid samples collected from seven cases, tested positive for Neisseria meningitidis serogroup A.
WHO is providing technical support to the national health authorities by assisting with epidemiological investigations and by producing guidelines and tools; they are continuously monitoring the situation. Chemoprophylaxis of close contacts and vaccination of high-risk population groups is ongoing.
Meningococcal disease is endemic in India and sporadic cases have been known to occur in the Delhi area in previous years, but this is the first outbreak to be recorded in the area since 1985, when 6133 cases, including 799 deaths, were reported. Isolates from this outbreak were also confirmed as N. meningitidis serogroup A.
Transmission of meningococcal disease occurs via the respiratory route from coughing and sneezing and is often associated with overcrowded conditions.
The National Travel Health Network and Centre (NaTHNaC) has recommended that until further information becomes available, and in view of the increased number of cases, travellers to Delhi who will be visiting friends and family, or will be working or living in close contact with the local population, should consider vaccination with the quadrivalent meningococcal meningitis ACW135Y vaccine (3). As more information becomes available, this advice will be updated on the NaTHNaC website <http://www.nathnac.org>.
General information about meningococcal disease can be found on the HPA website at <http://www.hpa.org.uk/infections/topics_az/meningo/menu.htm>.
1.World Health Organization Regional Office for South East Asia. Meningococcal disease in Delhi. [online] [cited 12 May 2005]. New Delhi: SEARO, 11 May 2005. Available at <http://w3.whosea.org/EN/Section10/Section1973.htm>.
2.New Delhi: Meningococcal disease - India (New Delhi) (03). Archive number 20050509.1273. In Promed Mail [online]. Boston US: International Society for Infectious Diseases, 9 May 2005 [cited 10 May 2005]. Available at <http://www.promedmail.org>.
3.National Travel Health Network and Centre. Clinical update [online]. Meningococcal disease in India [cited 10 May 2005]. London: NaTHNaC, 10 May 2005 Available at<http://www.nathnac.org/pro/clinical_updates/MeningococcaldiseaseIndiaMay2005.htm>.