Non-accidental broom sticks injury as a cause of post-neonatal tetanus

Non-accidental broom sticks injury as a cause of post-neonatal tetanus

Eyong Komomo^1,&, Torty Chimaeze¹, Ekanem Emmanuel¹, Asindi Asindi¹

 

¹Department of Paediatrics, University of Calabar Teaching Hospital, Calabar, Nigeria

 

 

^&Corresponding author
Eyong Komomo, Department of Paediatrics, University of Calabar Teaching Hospital, Calabar, Nigeria

 

 

 

 

Non-accidental injury results from a complex pathological interaction between the individual and the community [1]. It is a leading cause of death among children and young adults [2]. Over 875 000 children ≤ 18 years of age die annually in the world as a result of injuries, mostly in low- and middle-income countries (LMIC), where injuries account for 13% of the total burden of morbidity among children ≤ 15 years of age [3,4]. Non-accidental or intentional childhood injury includes injuries sustained by a child as result of deliberate self-harm or injuries deliberately inflicted by parents or caregivers for disciplinary, traditional and therapeutic interventions purposes [4,5]. These injuries may lead to physical, emotional and psychological harm to the child[4,5]. The practice of inflicting injuries on children intentionally is common in the developing world but a complex interplay of factors continues to downplay its recognition and reportage[4-6]. Post neonatal tetanus is a non-communicable disease of major public health concern in Nigeria and other developing countries[7]. The incidence has remained unacceptably high in developing countries despite being a vaccine-preventable disease[8,9] with the existence of the childhood immunization programs for over four decades [10]. The contributory factors to this continued high incidence of tetanus include lack of, or incomplete immunization among other reasons[2]. Previous studies have shown that most cases of post neonatal tetanus are due to accidental injuries occurring in non-immunized individual but we are presenting in this study, post neonatal tetanus from non-accidental broom stick and other injuries inflicted on children by parents or caregivers.

 

 

The study was a retrospective study of all children admitted into the Children’s ward of the University of Calabar Teaching Hospital with diagnosis of post neonatal tetanus between September 2008 and October 2017. The demographic characteristics of the children including the age, sex, ethnic group and religion. Social class of the children using the Oyedeji classification[11] which utilizes the educational background and occupation of parents. Possible portal of entry of the Clostridium tetanus and outcome status were documented. Data analysis was done using Microsoft Excel statistical package supplemented with Statistical Package for Social Sciences (SPSS) version 22. Mean, standard deviation and other parameters were generated as necessary for continuous data. Means of continuous variables were compared using the Student t- test and categorical variables using Chi-square test. Level of significance set at p< 0.05.

 

 

Forty-four children with post neonatal tetanus were seen in our facility within the period under review. Of these number, thirty-one (70.5%) were males while thirteen (29.5%) were female giving a male female ratio of 2.5:1). The age group 5-10 has the highest of children (22; 14 males and 8 females) with post neonatal tetanus; this is closely followed by the age group 11-15 years (18; 13 males and 5 females). The least incidence was amongst children aged 5 years and above 15 years with two cases each Forty (90.9%) of the children in the study are from the low social class while the other four are from the middle social class Accidental injuries accounted for 21 (47.7%), this is closely followed by non-accidental injuries in 20 children representing 45.5% (Table 1). Broom stick injuries accounted for 60% of tetanus from non-accidental injuries. Of the 44 children seen with post neonatal tetanus in the study, only 9 (20.5%) received complete immunization against tetanus. Twenty (45.5%) of the children had incomplete immunization while 15(34.1%) of them had no immunization. Thirty-four (77.3%) of the 44 children with post neonatal tetanus in the study survived. Of the 10 children who died from the disease eight were not immunized. There is a significant relationship between immunization against tetanus and survival (P<0.05) (Table 2).

 

 

Non-accidental childhood injuries sustained as a result of deliberate self-harm or inflicted by parents or caregivers for disciplinary, traditional and therapeutic interventions purposes may lead to physical, emotional and psychological harm to the child [4-6]. In this 12 year review of post neonatal tetanus cases in the University of Calabar Teaching Hospital Nigeria, twenty (45.5%) of the children developed tetanus as a result of injuries inflicted on them by either care gives or parents as disciplinary measures. It is important to note that 60% of tetanus from non- accidental injuries in this study were due to broom stick injuries. This confirms the results of earlier studies in Nigeria that broom stick constitute a significant cause of post neonatal tetanus [12-15].. Broom sticks are used in most homes in Nigeria to sweep the floor which is the natural habitat of clostridium tetanus and therefore at risk of harbouring the organism. The practice of flogging children with broom by parents or care givers and teachers in schools as a form of corporal punishment for erring pupils[16] exist with attendant risk of penetrating injuries to the child that may lead to tetanus.

 

Immunization is key in preventing post neonatal tetanus infection as evidence abounds in literature that lack or incomplete immunization is the major risk factor for tetanus infection [17-20]. In this study, approximately 80% of children who had tetanus had inadequate or no immunization. The DPT3 completion rate in Nigeria within the period under review ranged between 40-60% [21] implying a large number of Nigerian children are either inadequately or not immunized against tetanus or therefore prone to post neonatal tetanus. The dominance of school age children with post neonatal tetanus in the study shows the need to administer booster doses of tetanus toxoid to all children as part of the national immunization programme since immunity is known to wane during school age years in those who previously received the vaccine at infancy without follow up booster doses [22]. Studies in parts of South Eastern Africa show that tetanus seroprotection was lower among children 5-14 years when compared to those aged 1-4 years demonstrating waning immunity with age [22].

 

This study demonstrated that the social class of parents plays an important role in the likelihood of having tetanus; over 90% of the children in this study were from the low social class. Expectedly, no child from the high social class had post neonatal tetanus. Children in the low social class are the less likely to have complete immunization and are more likely involved in high risk behaviours that makes them vulnerable to tetanus infection. It would appear that corporal punishment is also more common among this group.

 

 

Non accidental injuries inflicted on children by care gives or parents as disciplinary measures accounted for about half of children with post neonatal tetanus. Broom stick injury was a major contributory factor. Incomplete or no immunization and low social class still remains major risk factors for post neonatal tetanus. There need for sustained campaign against physical abuse of children and complete immunization of every child to prevent post neonatal tetanus.

 

 

The authors declare no competing interests.

 

 

All authors were involved in the development and implementation of this scientific work. They read and approved the final version of the manuscript before submission.

 

 

Table 1: aetiopathogenesis of post neonatal tetanus

Table 2: comparison of immunization status and out come

 

 

1. Mulpuri K, Slobogean BL, Tredwell S j. The epidemiology of non-accidental trauma in children. Clin Orthop Relat Res. 2011; 469(3): 759-767. Google Scholar


2. Krug EG, Sharma GK, Lozano R. The global burden of injuries. Am J Public Health. 2000; 90(4): 523-6. PubMed | Google Scholar


3. Murray CJ, Lopez AD. Alternative projections of mortality and disability by cause, 1990-2020: global burden of disease study. Lancet. 1997; 349(9064): 1498-504. PubMed | Google Scholar


4. Anochie I, Graham-Douglas IB. Non-accidental injuries associated with convulsions in Port Harcourt, Nigeria. Anil Aggrawal’s Int J Forens Med Toxicol. 2000;1(2):9. Google Scholar


5. Famuyiwa O O. Child abuse and neglect in sub-Saharan Africa. Psychiatr Bull. 1997; 21:336-38. Google Scholar


6. Olatunya OS, Oseni S, Oginni L. Multiple injuries in a 3-year-old Nigerian girl: an extreme form of physical abuse. Paediatr Inter Child Health. 2013; 33:334-6. PubMed | Google Scholar


7. Oshinaike OO, Ojelabi OO, Ogbera AO, Ojo OO, Ajose FA, Okubadejo NU et al. Improving case fatality rate of adult tetanus in urban Nigeria: focus on better facilities of care. Trop Doct. 2012 Oct;42(4):208-10. PubMed | Google Scholar


8. Odusanya OO, Alufohai EF, Meurice FP, Ahonkhai VI. Determinants of vaccination coverage in rural Nigeria. BMC Public Health. 2008;8:381. PubMed | Google Scholar


9. Fatunde OJ, Familusi JB. Post-neonatal tetanus in Nigeria: the need for booster doses of Tetanus toxoid. Nig J Paediatr. 2001;28(2):35-38. Google Scholar


10. Babaniyi OA. A 10-year review of morbidity from childhood preventable diseases in Nigeria: how successful is the expanded programme on immunization (EPI)? an update. J Trop Pediatr. 1990;36(6):306-13. PubMed | Google Scholar


11. Oyedeji GA. Socio-economic and cultural background of hospitalized children in Ilesa. Niger J Paediatr. 1985;12(14):111-7. Google Scholar


12. Ide LEY, Uchenwa-Onyenegecha TA. Post neonatal tetanus: 20 years experience as seen at the University of Port Harcourt Teaching Hospital. British Journal of Medicine & Medical Research. 2016; 12(2): 1-5. Google Scholar


13. Ejike O, Chapp J, Onyire B, Amadi AN. Pattern and outcome of childhood Tetanus in Aba. Journal of Med Inves and Pract.2003;4:19-22. Google Scholar


14. Eberechukwu YIL, Angela B-ON. The socio-economic challenges in post neonatal tetanus. Modern Economy. 2015;(6):1327-1332. Google Scholar


15. Echey I, Fadekemi M. Post-neonatal tetanus from broomstick injuries: a word of caution for caregivers. Int J Med Res Rev. 2017;5(07):644-648.


16. Mahmoud AO, Ayanniyi AA, Salman MF. Observations of teachers in llorin, Nigeria on their practices of corporal punishment that are potentially injurious to their pupils' eyes. Annals of African Medicine. 2011;10(2):150-154. PubMed | Google Scholar


17. Akuhwa RT, Alhaji MA, Bello MA, Bulus SG. Post-neonatal tetanus in Nguru, Yobe State, Northeastern Nigeria. Nig Med Pract. 2010; 51(3): 40-42. Google Scholar


18. Alhaji MA, Mustapha MG, Ashir GM, Akuhwa RT, Bello MA, Farouk AG et al. Recurrent generalised tetanus: a case report. Trop Doct. 2011; 41: 127-128.


19. Nte AR, Mayuku A, Oruamobo RS. Neonatal and post neonatal tetanus: the time to act is now. Nig J Paediatr. 2002; 29: 85.


20. Gbadegesin RA, Adeyemo AA, Osinusi K. Childhood postneonatal tetanus. Nig J Paediatr. 1996; 23(1): 11-15.


21. WHO and UNICEF. WHO and UNICEF estimates of national immunization coverage: method and processes. 2017 revision. Access 10/10/2019


22. Heather Scobie M, Minal Patel, Diana Martin, Harran Mkocha, Sammy Njenga M, Maurice Odiere R et al. Tetanus immunity gaps in children 5-14 years and men ≥ 15 years of age revealed by integrated disease serosurveillance in Kenya, Tanzania, and Mozambique. Am J Trop Med Hyg. 2017; 96(2): 415-420. Google Scholar