Peshawar: Wearing a traditional shalwar kameez, visibly threadbare from washing, Nasib Nawaz stands anxiously outside Sifwat Ghayur Children Hospital of Infectious Diseases, where his son is admitted due to a severe infection.
Nasib’s son was at home in Bannu, a town 170 km south of Peshawar, when he suddenly had a fit and fell unconscious. Doctors in Bannu diagnosed the boy had tetanus. Since they had no vaccine to treat the disease, nor was any available in other hospitals of Bannu, they referred him to a hospital in Peshawar.
Buying vaccine to the save the life of his only son has been a huge drain on resources of Nasib Nawaz, a fruit and vegetable vendor who earns a meager Rs. 500 rupees daily.
“I have spent more than Rs. 25,000 on purchasing vaccines for the treatment of my son,” Nawaz told News Lens outside the hospital. “I had put together the money by selling my wife’s jewelry. Now I am penniless.”
As Nawaz wonders where to find money for medicine, the prognosis whether his son will survive the tetanus infection looks grim. The deadly disease is caused by Clostridium Tetani, a kind of bacteria that produces neurotoxins on entering the body through a wound, affecting the brain and nervous system.
“The infection can cause severe muscle spasms, serious breathing difficulties, and can be ultimately fatal,” says Dr. Amir Muhammad, a physician at the Lady Reading Hospital in Peshawar.
Since the toxin leads to stiffness in the jaw muscles, tetanus infection often goes by the name “lockjaw”.
The Clostridium Tetani spores are commonly found in soil, dust and manure, but could exist virtually anywhere. Since children play out in the open and in places that may not be clean, say health experts, often cutting and bruising themselves, they are more exposed to tetanus than elders.
Also susceptible to the disease are mothers who have to be vaccinated against tetanus at the time of childbirth when they are exposed to infections due to wounds. According to Dr Muhammad, the bacteria usually get deposited in a wound, producing neurotoxins that interfere with nerves that control muscle movement.
“The graph of maternal mortality for local hospitals is high because of unavailability of the Anti-Tetanus Serum (ATS) vaccines,” says Musharaf Khan, a physician at the Peshawar Children Hospital, the only facility dedicated to treatment of tetanus in Peshawar.
Health experts say tetanus symptoms usually emerge about 10 days after the initial infection. However, this can vary between 4 days to about 3 weeks and in some cases may even take months.
The infection manifests itself in muscle spasms that spread to the neck and throat, causing dysphagia (difficulty in swallowing). Patients usually go on to have spasms in their facial muscles. In severe cases the spine will arch backwards as the back muscles are affected. This is more common when children are infected.
Most patients with tetanus will also have bloody stools (feces), diarrhea, fever and headache, sensitivity to touch, sore throat and sweating. If a patient does not receive treatment, the risk of life-threatening complications is higher. Mortality rates for tetanus vary from 40 percent to 78 percent.
Tetanus infections may also develop in case of animal bites, skin burns, abrasions and lacerations and injecting drugs with unsterilized needles. Tetanus infection may occur in case of clean superficial wounds when only the topmost layer of skin is scraped off, surgical procedures, insect bites, dental infections, compound fractures when a broken bone is exposed, chronic sores and infections, and intravenous (IV) drug use.
According to the South Asian Association for Regional Cooperation Medical Association, an estimated 25,000 infants die of tetanus every year in Pakistan.
The situation is alarming in the districts where tertiary healthcare facilities often do not exist and primary healthcare units do not have the medical supplies to treat patients. When his son got infected with tetanus, Nawaz had taken him to three different health facilities in his village for treatment. When his condition did not improve, Nawaz took him to a hospital in city of Bannu where doctors referred him to Peshawar because the hospitals there were not equipped to treat the infection.
Even as the family arrived at the Hayatabad Medical Complex (HMC), a leading tertiary healthcare facility in Peshawar, the doctors could do little to help the boy recover. After two days of treatment at the HMC, the doctors referred him to the Peshawar Children Hospital, located in the Haji Camp neighbourhood of Peshawar.
Even when children with infection do make it to a proper healthcare facility, their prognosis remains grim because they are at an advanced stage of disease. According to Dr. Khan at the Peshawar Children Hospital, there is little awareness among people about the disease that could kill patients within days.
The hospital record shows that 24 children admitted with advanced symptoms of tetanus died in the first two months of 2016. In January, 28 children with neonatal tetanus were admitted to the hospital. Of these, 10 died and 18 recovered due to getting timely treatment. In February 2016, 32 children with neonatal tetanus were admitted to the hospital. Among these, 14 babies died whereas 17 were saved.
According to Dr. Khan, the government has recently removed Tetanus Immune Globulin (TIG), a “life-saving” anti-tetanus drug, from the list of medical supplies due to its high price, increasing the mortality ratio of tetanus patients in hospitals. The cost of TIG vaccine per patients falls between Rs. 25,000 to 30,000. The hospital that collects donations from individuals and pharmaceutical companies to run the day-to-day affairs cannot afford to get its own supplies of TIG.
Most patients at the hospital come from poor families, says Umaira, a female nurse at the hospital. Some patients admitted in the tetanus ward cannot even afford the cost of travel, leave alone TIG.
“The worst sufferers are poor patients of tetanus who cannot afford ATS injections, anti-biotics and drips, let alone TIG which is much expensive,” she said.
She said the babies infected with tetanus were mainly those delivered at home by untrained midwives. “Their umbilical cords were severed by a variety of unsterilized instruments, leading to tetanus infection.”
Pakistan has one of the highest maternal mortality rates in the world, with widely prevalent maternal and neonatal tetanus, according to Dr. Khan. Among reasons for wide prevalence of tetanus, says Dr. Khan, are use of unsterilized instruments, lack of training and conservative views on immunizations where people refuse them due to conspiracy theories.
Dr. Khan said that according to WHO recommendations, a three-dose anti-tetanus vaccine provided protection against the disease for five years. Five doses of the vaccine safeguarded women throughout the child-bearing age but due to lack of awareness, women often don’t get vaccinated.
“Despite advice from gynecologists, uneducated women in villages do not take the complete course of tetanus vaccine during pregnancy,” said Dr. Khan.
Similarly, wounded patients going to hospitals do not get vaccinated against tetanus even when doctors prescribe it.
According to Dr. Khan, primary treatment for tetanus is prevention – avoiding delivery at the hands of untrained midwives, use of unsterilized instruments during delivery or surgery, ensuring immunization during pregnancy. The secondary prevention after infection is TIG.
Back in the tetanus ward, nervous mothers sit in darkness, watching over their sick children. A death like silence prevailed inside. Tetanus patients are kept in isolation and darkness, in complete silence. They have come from different parts of Khyber Pakhtunkhwa due to unavailability of treatment in their hometowns.
Nawaz’ wife has dark circles under her eyes because she hasn’t slept for several nights. She did not know what had happened to her son. “He had sudden fits,” is all she says.