Children's Doctor

Global Health - Fall / Winter 2010

Tetanus

Neil Uspal, MD, David Chao, MD, Rakesh Mistry, MD, Fred Henretig, MD, RR, DSS

TG is a 10-year-old girl who presents to a Haitian hospital 1 week after surviving a severe earthquake. She had been trapped under rubble and suffered a deep, open wound to her right foot, extending to her ankle. Her father attempted to manage her injuries in their temporary tent shelter; however, she developed persistent swelling and pain. T.G. was admitted to a pediatric inpatient tent “ward,” staffed by a team from The Children’s Hospital of Philadelphia, for treatment of a wound infection and stable foot fracture.

While on call, the team was called to the bedside, because the patient’s father felt that TG was in significant pain. Upon assessment, she was in obvious distress, exhibiting paroxysmal rhythmic spasms of her torso and extremities. She was tachycardic and tachypneic; however, the lack of a blood pressure cuff or thermometer made it impossible to obtain other vital signs. She was conscious and oriented during the event. The neurologic exam was notable for trismus and the absence of a gag reflex; the remainder of her cranial nerve and overall neurologic exams were normal.

Discussion: Tetanus is a disease that causes significant morbidity and mortality in the developing world. Tetanus is rare in the United States, with an incidence of 0.16 cases/ million population, with adults older than 60 years being at greatest risk for infection. Tetanus carries a high mortality rate worldwide, especially among the pediatric population: deaths from tetanus in 2001 were estimated to be 281,000, with 201,000 in children younger than 5 years.

Clinical disease from tetanus is due primarily to a toxin known as tetanospasmin, elaborated by Clostridium tetani, a gram-positive, spore-forming, obligate anaerobic bacillus. Tetanospasmin’s primary activity is inhibition of neurotransmitter release at spinal cord inhibitory synapses. The toxin causes spasms and increased sympathetic activity, but has no effect on cognition or mental status.

tetanus-chart

C. tetani is ubiquitous in nature, often found as hardy spores that are highly resistant to moisture, disinfectants, or changes in temperature. The spores find optimum conditions for growth in contaminated wounds possessing low oxygen tension, where they become activated and begin to produce toxins. The incubation period for tetanus is generally 1-2 weeks.

There are several clinical manifestations of tetanus, the most common being generalized tetanus. Onset of clinical disease is usually insidious, often with trismus being the presenting symptom. Gradually, stiffness in the back, neck, and abdominal muscles develops, followed by development of risus sardonicus (sarcastic smile), which is characteristic of tetanus. As symptoms worsen, paroxysmal spasms develop, causing the opisthotonus observed in our patient. These events may be confused with seizures, however, the patient remains entirely conscious. Untreated patients may develop potentially fatal respiratory failure from laryngeal obstruction or decreased chest wall compliance. Autonomic instability may cause blood pressure lability, diaphoresis, fevers, and cardiac dysrhythmias. 

Other manifestations of tetanus include localized tetanus, which presents as muscle rigidity of the area close to the inoculation site; and neonatal tetanus. This form develops in infants born to inadequately immunized mothers. The disease is first manifest by weakness, developing into spasms and rigidity, and mortality is greater than 90%.

Diagnosis of tetanus is usually made based on the clinical picture. Blood counts and CSF studies are typically normal. Wound cultures are positive for C. tetani in only 30% of cases, and even if positive do not confirm if the bacteria are toxin-producing.

Treatment of tetanus involves supportive care and eradication of the causative pathogen. Patients with suspected tetanus should be transferred to an intensive care unit. Stimuli should be minimized, as slight triggers may result in paroxysms of spasms and autonomic lability. Wounds infected with tetanus should be thoroughly cleaned and debrided. Specific therapy consists of human tetanus immune globulin (TIG). The dosing is 3000 to 6000 units intramuscularly, with at least part given at the site of infection. In countries where TIG is not available, equine tetanus antitoxin is a potential alternative. Metronidazole should be given for 10-14 days.

Supportive care includes sedation and muscle relaxation for spasms, typically using diazepam. Treatment of hypertension and tachyarrhythmias is often accomplished with propranolol.

Our patient was diagnosed with generalized tetanus and received antibiotics, TIG and diazepam. During the medical team’s stay in Haiti, the patient improved significantly; at the time of the CHOP team’s departure her rigidity had significantly decreased and she was not experiencing paroxysmal spasms. Unfortunately, as a consequence of Haiti’s low pre-earthquake immunization rate of 50% , her illness was not unique among earthquake survivors, with widespread reports of tetanus and other preventable diseases Since the earthquake, more than 1 million internally displaced persons have been immunized against tetanus and other diseases.

Suggested Reading:
Rhee P, Nunley MK, Demetriades D, Velmahos G, Doucet JJ. Tetanus and trauma: a review and recommendations. J Trauma. 2005; 58:1082-8.
Brook I. Tetanus in children. Pediatr Emerg Care. 2004; 20:48-53.

Pediatric Global Health: The Impact Back Home

Rodney R. Finalle, MD

Dr. Finalle is director of CHOP’s Global Health Department and International Patient Services.

What does the Global Health Department at The Children’s Hospital of Philadelphia have to do with helping patients and families who are treated in Philadelphia and throughout the CHOP Care Network?

I believe that broadening CHOP’s mission to include caring for some of the poorest and most vulnerable children in the world has created a heightened sensitivity to the cultural differences of our domestic patients, and made us better care providers as a result.

Global Health gives CHOP clinicians, trainees, and staff the opportunity to spend time caring for patients in our partner
communities of Consuelo, Dominican Republic, and in Botswana.

Our Global Health programs encourage active participation by CHOP attending physicians, nurses, and other trainees in Consuelo, where they collaborate with clinical partners and provide hands-on care to children and their families who have limited access to healthcare. Often, our clinicians must practice without labs and high-tech equipment, and sometimes even without electricity or running water. By necessity, they sharpen their diagnostic skills relying on what they see and hear, and they learn from local experts in partner communities.

Visiting CHOP professionals also assist in building local capacity by providing training sessions for community health workers, local men and women who live in the communities where our programs are active, to teach families about the importance of nutrition, clean water, sanitation, breast-feeding, and much more. In the give-and-take of the ensuing relationships, CHOP practitioners learn of the overwhelming challenges families struggle with daily, and help partners on the ground develop strategies to mitigate them. Well-trained community health workers multiply the effort’s impact while collaborating in the development of educational materials to help CHOP staff improve their presentation and teaching skills.

The focus of our efforts in Botswana tends to be more on partnership at the new University of Botswana School of Medicine and its Department of Paediatrics. Specialists from infection control, adolescent medicine, and nutrition, for example, have worked with professional colleagues in Africa to share their expertise and develop relationships with their Botswana counterparts. This important work is done in conjunction with the Botswana-UPenn Partnership at the University of Pennsylvania School of Medicine. Our clinicians stay in touch with colleagues from Botswana through e-mail and Skype, continuing to provide support, guidance, and resources.

Through the David N. Pincus Global Health Fellowship, Children’s Hospital has 2 physicians living in our partner communities full-time, working alongside local care providers and undertaking research and scholarly activities. (See previous pages for their stories.) They also serve as resources for Global Health initiatives and guides for CHOP residents who complete Global Health electives at one of our collaborative sites.

The clinical professional who has traveled to one of our partner communities returns with a changed perspective and with a renewed sense of appreciation for the facilities, equipment, and expertise we have access to within CHOP. I often hear stories of how these CHOP clinicians are now able to interact in a more meaningful way with patients and families, especially those from a culture different from their own. Participants in the Global Health programs work intensively in challenging scenarios, including the use of interpreters, appreciating the unique needs of immigrants, and crossing through cultural barriers that affect children’s health. As the clinicians develop skills in these areas, they also build their confidence as they care for children in their Philadelphia-based practices. Philadelphia has an increasingly diverse population of immigrants and non-English speaking families, and our Global Health efforts can be put directly to use in our local efforts as well.

Global Health is increasingly local health. And a vibrant, engaging Global Health program—partnered with motivated and passionate teachers and learners—benefits not only the professional participants, but also the global and local pediatric population CHOP serves.

References and Suggested Readings
To learn more about our Global Health programs, visit us on the Web at: www.chop.edu/globalhealth.

Education Around the Globe

Stephen Ludwig, MD

As I was preparing to write about the international education program we share with the American Austrian Foundation (AAF),
I received an e-mail from Zsolt Matrai, MD. As it turns out, telling Dr Matrai's story tells it all.

Dr Matrai is a pediatrician from a small, rural town in Hungary. He was selected by the AAF to attend a 1995 seminar in Salzburg, Austria, where I was leading a group from The Children's Hospital of Philadelphia to teach a Pediatric Emergencies course. The AAF, through funding in part from the Austrian government and the Soros Foundation, had established a program for adult medical education subjects, and we were selected to initiate a program for pediatric education topics. The students came from all over Eastern Europe, some from traditional European countries and some from the emerging new countries that gained independence after the Soviet Union's dissolution. Five instructors and 30 students spent a week living together, having family-style meals, and most importantly, learning about how to improve medical care for children in the students' home communities. Dr Matrai was a physician "student" in this class.

The teaching was eye-opening for many students. There were, of course, interesting new concepts, medical facts, and patient management protocols. But more than the information, most students marveled at teaching techniques that were informal, case-based, and interactive. Most had been trained in a system where the professor came to class and gave a lecture, often without soliciting questions or discussion. Our teaching techniques seemed to be unheard of in that part of the world, and they benefited the students and made a difference in the material they were able to master in the course.

Dr Matrai was an avid student, and we quickly struck up a collegial relationship. We remained in communication, and he has since visited CHOP on 4 occasions, attending our Annual Pediatric Emergency Medicine CME Course in Philadelphia, where he also had an opportunity to observe in the ED, hear lectures and participate in skill stations and workshops. In 1997, he edited and published a small pamphlet for his patients' parents entitled, What to Do in Emergency Situations in Childhood. In 2001, he published a handbook for pre-hospital pediatric emergency care. He has taught in several life-support courses in Hungary and published 3 articles in Hungarian medical journals. He also has become a strong advocate for children's emergency services. It is astounding and gratifying to see that Dr Matrai, and others like him, are taking the knowledge from these CHOP-led seminars and putting it directly to work to improve pediatric care in their own corners of the world.

This is the nature of the AAF Project. Now CHOP sends teams 6 times a year to teach a variety of pediatric topics. Our courses are multidisciplinary and involve all the departments of the medical staff. The students are always appreciative, and we give them electronic copies of our lectures so they can share the information with their colleagues at their home institutions. I always complete these seminars with new contacts, new learning that I glean from the students, and a real sense that this is a kind of foreign diplomacy in which CHOP can take pride.

The AAF has also sponsored physicians coming to CHOP for periods of study, and it is now branching into other parts of the world. It has been a productive and important partnership for CHOP—though the true beneficiaries are countless children throughout the world. Dr Matrai's e-mails continue, and we plan to meet again somewhere, sometime soon.

Global Health Research

David N. Pincus, a Philadelphia philanthropist, has generously endowed a 2-year global health fellowship program for CHOP physicians working in the Dominican Republic and southern Africa. Henry Welch, MD, and Lara Antkowiak, MD, are the inaugural David N. Pincus Global Health Fellows. Here, they describe some of their research and daily work.

Full Disclosure

Henry Welch, MD

long-hair-doc“This person is strong because he’s taking his medicines and the bad guy goes to sleep.”

This is the response of a 7-year-old girl sitting at a table in rural South Africa, looking at a cartoon drawing of 2 figures fighting. “This person is sick because she doesn’t take her medicines and the bad guy attacks the soldier cells.”

She could be describing a battle between police officers and criminals in her home village. But in fact, she is describing a fight of a different nature—this child has HIV and is sitting in a clinic, where her doctor is showing her a cartoon that depicts the human body fighting off the virus that causes AIDS.

I work at Sparrow Village near Johannesburg. It is an HIV orphanage and hospice, an inspirational place that cares for more than 250 children living with or orphaned by HIV. Explaining a chronic illness, such as HIV, to a child is challenging in any setting, particularly when the patient is an orphan. Communicating an HIV diagnosis means discussing a stigmatized, potentially life-threatening illness. Many caregivers are reluctant to disclose the diagnosis to young patients for fear of causing significant distress for the child.

hiv-prevalency

The child examining the cartoon drawings is an example of my research exploring how best to ensure children are informed, in an age-appropriate manner, about their HIV status. Most children are told by a physician or nurse. When first learning of their illness, many children think they are going to die. Many are scared, uncertain, and angry. Some are relieved finally to know why they constantly must take medicines and get blood drawn. The majority had known nothing about HIV before being told of their diagnosis, and almost all wished they had known more before.

This is where the “bad guy/good guy” cartoons come in. While the 7-year-old may not truly comprehend what a soldier cell—or CD4 cell—does, or understand that the “bad guy” is HIV, the drawings and discussion give her a better grasp of her illness. This is important as she gets older: Clinical reports have indicated positive outcomes with disclosure to chronically ill children, including trust, improved adherence, open family communication, and better long-term health and emotional well-being.

Overcoming Cultural Taboos

Lara Antkowiak, MD, M Ed

breastfeedingThe mother came to our clinic for help, an alert 4-month-old on her lap. “I can’t afford formula for my baby,” she told me in a lilting Haitian Kreyol accent. I explained that our program, Niños Primeros en Salud, in Consuelo, Dominican Republic, was a clinic where her child could receive all pediatric care, medicines and lab tests free. But we did not give out formula.

“Why aren’t you breast-feeding?”  I asked.

“Breast-feeding!” she laughed. She looked at her friend, another mother in our program who laughed back. “I lost too much weight breast-feeding!” she said. “You want me to look like a stick?”

I looked at her slim figure, thinking how much I would love to be her size. But beauty is relative, and most Haitian women I know prefer curves.

I told the mother that breast milk is the best food for her baby, and that letting the baby suck is the way to increase milk production. The second mother looked at me unhappily. Her child was 2 months old, and she was not breast-feeding either.  Like many Dominican women, she began feeding her baby solid foods at 6 weeks of age. She fed her formula, tea, pasta, and mashed-up foods.

“I wanted to breast-feed,” she told me. “But I didn’t have enough milk.”

“Why do you think you didn’t have enough milk?”  I asked her.

“The baby was always crying,” she told me. “I didn’t have enough to satisfy him. And I couldn’t afford to buy oatmeal or chocolate.”

I explained again that the best way to make more milk is to let a baby suck, that sucking leads to the production of milk. Many Dominicans believe that certain foods—oatmeal, chocolate, codfish—increase the production of breast milk, so if you can’t afford them you are in trouble. I told both women that they were capable of breast-feeding and that we could help them.

“You can breast-feed the next baby,” I reassured them. They looked at me skeptically. This is going to take some work, I thought.

Since I brought my breast-feeding daughter home to the Dominican Republic 9 months ago, I have confronted myths every day. Dominicans’ cultural beliefs about breast-feeding are strong.

People have come up to me in restaurants and asked me to stop breast-feeding while eating, as it could harm the child. Much of it seemed harmless until I began to encounter babies in my pediatric practice with severe malnutrition who were not breast-feeding. Their mothers mixed extra water with formula to make it last longer, and often the water carried infection. These children returned to clinic repeatedly with diarrhea and malnutrition.

breastfeeding-exclusive

I spoke to our colleagues here at the Divine Providence Health Center in Consuelo, and we decided to spearhead a new project. Research shows that breast-feeding lowers childhood mortality rates, diarrhea, ear infections, respiratory infections, and malnutrition. The prevalence of exclusive breast-feeding through the first 6 months of age in the Dominican Republic is abysmally low, at 9%. In contrast, the 6-month exclusive breast-feeding rate in neighboring Haiti is 41%, according to UNICEF data. We hope to find out the reason for the disparity, and work to remedy it.

Many cultural beliefs and practices undermine breast-feeding in our community. Yet mothers are receptive to education, especially when it comes from their peers. In each of the barrios that we serve there is a community health worker (CHW), whose role is to act as a liaison between the poor, urban neighborhood and the clinic.

Using materials from experts like La Leche League, we plan to train the CHWs to act as breast-feeding educators for the community. They will make regular home visits to all pregnant mothers, before and after their children are born, to offer ongoing breast-feeding education. They will visit them in the hospital immediately after their child’s birth to offer first-hand guidance. And together with the breast-feeding mothers, they will lead support groups in the barrios, offering help woman-to-woman.

It’s not going to be easy, but I am hopeful. My daughter’s nanny was once the most skeptical critic of my exclusive breast-feeding. Now she is pregnant and tells me that she wants to breast-feed, too. It is possible to make a change, one mother at a time.
 

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