I have reached the three month mark - I am now over a third of the way through my time on mission here in Pakistan. It is strange as it has gone so quickly, yet it feels like I have been here for years. Things that initially seemed so new are now very normal. From wearing my shalwar kameez and dupatta, to the routine of my day in the projects. It is definitely starting to feel like home.
But clinically, I am continually challenged as I am seeing and treating conditions that I have never seen back home. Previously, if someone mentioned the word Tetanus, the thing that would come to mind was the painful booster shot you need every few years. But now when I hear the word tetanus, it brings up completely different images…
Tetanus is now a rare disease in the developed world thanks to the success of tetanus immunization. But worldwide it kills up to 50,000 babies every year, and Pakistan is one of the handful of countries in the world who have not yet eliminated this terrible disease. Neonatal tetanus develops when the umbilical cord becomes contaminated with the tetanus bacteria and its spores as a result of unhygienic delivery or umbilical cord care practices after delivery. Tetanus is a highly fatal disease, almost 100% fatal if not treated, and even with optimal treatment, survival is often only 50%.
Here in Dera Murad Jamali, we see neonatal tetanus far too often, usually having at least one-two babies in the nursery at a time with this awful disease. Often these babies are brought in at a few days of life with the complaint of fevers and not feeding. They have a characteristic stiffened posture and are often unable to open their mouth (trismus or lockjaw). Their small bodies suffer from frequent painful spasms that can be triggered by any stimuli, even the lightest touch or softest noise. Seeing your baby so sick and in pain, and not being able to soothe them for fear of making it worse, is crippling. Sometimes these spasms affect the airway and can cause the baby to stop breathing – a very dangerous scenario here where we don’t have the option of mechanical ventilation to support their breathing.
Recently, after seeing so many babies coming into the nursery and suffering, the staff decided to build a tetanus room. This is a small room within the nursery where these babies can be nursed in a more calm and quiet environment, trying to minimize any noise or disturbance that could act as a trigger for the painful spasms – it has tinted windows and minimal lighting (just enough to allow the monitors to be seen from outside) and any entry into the room is kept to essential care only. Often they are in the nursery for many weeks while their little bodies try to fight against this deadly disease.
One such baby came in recently. She was rushed in to the nursery by her mother with the complaint of high fever and episodes of fits with lockjaw. The umbilical stump was dirty and tied with non-sterile thread. This baby had been born at home with the presence of a traditional birth attendant and the mother had not been vaccinated against tetanus. The baby was admitted to the nursery, and the staff promptly inserted an IV line and administered medications to stop the spasms. Human tetanus immunoglobulin was administered to try to neutralize the toxin, and antibiotics were commenced. The baby was kept under close observation in the tetanus room. A few days into the admission, the baby became worse with continuous fits and frequent apneas. Despite optimal treatment this continued for many days – if the baby stopped breathing, the bag-mask was used to breathe for the baby, hoping it would again start breathing on its own. But very gradually, day by day, improvement was seen - the apneas and fits became further apart, and after two weeks in hospital, there were no fits or apneas, and only occasional muscle spasms. Gradually the baby was able to start feeding again. And after a prolonged stay of almost 1 month in the nursery, this baby is almost ready to be discharged home.
And while we breathe a sigh of relief that this baby has done so well, three more babies with tetanus have been admitted in the last 24 hours - and we know that many are not so fortunate, so we are again apprehensive.
While the tetanus bacteria can’t be eliminated from the environment, the disease can be. With the simple interventions of hygienic delivery practices and immunization, this horrible disease is entirely preventable. While progress has been made, much more needs to be done to prevent any more babies from suffering like this. Back home we are faced more and more with people who choose not to vaccinate their children for risk of the side effects – most people having never seen the diseases these vaccines protect against. But when you look through the window into that Tetanus room and see these babies suffering, how can the importance of vaccination be questioned?