Lima V M, Garcia M T, Resende M R, Nouer S A, Campos E O, Papaiordanou P M, da Silva L J
Núcleo de Vigilância Epidemiológica do Hospital das Clínicas, Universidade Estadual de Campinas (UNICAMP), SP-Brasil.
Rev Saude Publica. 1998 Apr;32(2):166-71. doi: 10.1590/s0034-89101998000200010.
Notwithstanding its substantial decline over the last two decades, acquired tetanus is still a serious health problem in most developing countries. Epidemiological transition is often cited as an explanation for this decline, the increase in vaccination coverage of children being the most obvious cause. Few studies have looked carefully at the current epidemiological patterns of acquired tetanus in developing countries.
A descriptive, retrospective (series of cases). An acute care 400 - bed university referral hospital situated in a densely populated and highly urbanized area in Southeastern Brazil (Campinas, SP). Patient records the data-base analysed were from the Epidemiological Surveillance Unit of the hospital.
In the 57 month period from January 1989 to March 1996 fifty-three patients were admitted with a diagnosis of acquired tetanus. Fifty patients had clinical confirmation, 3 were otherwise diagnosed. Thirty-two (64%) were male and 18 (36%) female. Fourteen (28%) were from rural areas and 36 (72%) from urban. Mean age was 47.6 years, with a median of 49.5. Of the rural patients, 42.85% were under 30 years and 21.42% were over 50, mean age was 36.21 with a median of 34.5. Fewer urban patients were under 30 (13.88%) than over 50 (58.33%), mean age was 52.19 with a median of 54.5. Trismus was the most frequent (92.0%) clinical sign on admittance, followed by abdominal muscular rigidity (84.0%). Treatment measures were uniform and included tetanus immune globulin, antibiotics, surgical debridement of the wound when feasible, diazepan or curare depending on the intensity of spasms. In the second half of the study period, penicillin was replaced by metronidazol. Overall case fatality rate was 20%, in patients that had to receive curare, it was 60%. Hospitalization exceeded 21 days in 56% (28) of the cases, only 10% (5) had a hospital stay of less than 7 days.
A high proportion of patients were from rural areas, despite an urbanization rate of more than 90%. In the Campinas region there are two different epidemiological patterns of acquired tetanus: a rural pattern, with a higher proportion of younger patients, determined by an inadequate immunization rate and an urban pattern, similar to that found in industrialized countries, with a higher proportion of older patients.
There is an obvious need to immunize older individuals in urban areas and young adults in rural areas. The elimination of acquired tetanus will only be achieved with a wider and more intensive adult vaccination program.
尽管在过去二十年中发病率大幅下降，但在大多数发展中国家，获得性破伤风仍然是一个严重的健康问题。流行病学转变常被引用来解释这种下降，儿童疫苗接种覆盖率的提高是最明显的原因。很少有研究仔细观察发展中国家目前获得性破伤风的流行病学模式。
一项描述性回顾性（病例系列）研究。研究对象为位于巴西东南部人口密集且高度城市化地区（圣保罗州坎皮纳斯）的一家拥有400张床位的大学急症转诊医院。分析的患者记录数据库来自该医院的流行病学监测部门。
在1989年1月至1996年3月的57个月期间，有53例患者因获得性破伤风诊断入院。50例经临床确诊，3例经其他方式诊断。32例（64%）为男性，18例（36%）为女性。14例（28%）来自农村地区，36例（72%）来自城市。平均年龄为47.6岁，中位数为49.5岁。农村患者中，42.85%年龄在30岁以下，21.42%年龄在50岁以上，平均年龄为36.21岁，中位数为34.5岁。城市患者中年龄在30岁以下的（13.88%）少于50岁以上的（58.33%），平均年龄为52.19岁，中位数为54.5岁。牙关紧闭是入院时最常见的临床体征（92.0%），其次是腹部肌肉僵硬（84.0%）。治疗措施一致，包括破伤风免疫球蛋白、抗生素、伤口可行时的外科清创，根据痉挛强度使用地西泮或箭毒。在研究后半期，青霉素被甲硝唑取代。总体病死率为20%，必须使用箭毒的患者病死率为60%。56%（28例）的病例住院时间超过21天，只有10%（5例）住院时间少于7天。
尽管城市化率超过90%，但仍有很大比例的患者来自农村地区。在坎皮纳斯地区，获得性破伤风存在两种不同的流行病学模式：农村模式，年轻患者比例较高，这是由免疫接种率不足导致的；城市模式，与工业化国家相似，老年患者比例较高。
显然需要对城市地区的老年人和农村地区的年轻人进行免疫接种。只有通过更广泛、更密集的成人疫苗接种计划才能实现消除获得性破伤风的目标。
