Neonatal tetanus in Serbia from 1968 through 1997.

Abstract

To The Editors: Within the former Yugoslavia the highest incidence rate of tetanus infection in the Republic of Serbia was registered in 1952 (8.4/100 000). The effect of obligatory vaccination since 1951 led to a continuous decline in the disease with 27 cases registered in 1997 (0.3/100 000). From 1951 through 1969, the annual average of neonatal tetanus was 157 cases: the most in 1954 (204 cases); and the least in 1969 (106 cases). We have evaluated the frequency and case fatality ratio from disease in the Republic of Serbia for the period 1968 to 1997. The data in this paper are based on the official material from the Institute of Statistics and the Institute for Health Care in Serbia. 1, 2 They comprise numbers of liveborn children and the annual reports of notifiable infections including tetanus in the Republic of Serbia from 1968 through 1997. Data after 1997 were not evaluated because of political circumstances in Kosovo. In the Republic of Serbia 696 cases of tetanus were registered in newborn children during 1968 to 1997: 235 cases (34%) in central Serbia; 396 cases (57%) in the territory of Kosovo; and 65 cases (9%) in Vojvodina. The disease was registered continually in all areas of Serbia until 1977, mostly in Kosovo (268) and the least in Vojvodina (61), and in central Serbia (213 cases). In Vojvodina from 1978 to 1997, 4 cases were recorded in total, 2 in 1979 and 1 each in 1988 and 1994. In central Serbia neonatal tetanus was registered with continuous drop in frequency every year until 1982; from 1983 through 1997, 5 cases in total were recorded. In Kosovo neonatal tetanus appeared during the entire time that records were kept, except in 1988 and 1990, with an obvious decrease of cases. Since 1985 there have been <10 cases per year. Frequency of tetanus in newborns per 10 000 liveborn children in the Republic of Serbia and its provinces is shown in Table 1. In all observed 5-year intervals the frequency of neonatal tetanus was the highest in Kosovo (average, 2.7/10 000 liveborns), which was 2.5 to 3.5 times higher rate than in central Serbia (1.0/10 000) and Vojvodina (0.8/10 000). In all areas of Serbia, the risk for disease in newborn children was also noticed.TABLE 1: Neonatal tetanus per 10 000 newborns in 5-year intervals in the Republic of SerbiaThe case fatality rate for tetanus in newborn children indicated the serious nature of the disease. From 1968 to 1997, almost every second case in central Serbia (44%) and Vojvodina (46%) and every third in Kosovo (32%) ended in death. In Vojvodina all fatal cases from neonatal tetanus occurred before 1978. Frequency of tetanus in newborn children correlates with undeveloped health service and unhygienic conditions in which the deliveries are done without obstetric help, often with old, deep-rooted customs and prejudices. Cutting of the umbilical cord with unsterile objects, knives, scissors, sometimes even with a sickle, especially in male children, are the basic cause of neonatal tetanus. More than 50% of cases in Vojvodina were of gypsy origin. No mother of diseased children had medical examination during the pregnancy, and all deliveries were done without the help of health services. The rare occurrence of neonatal tetanus in Vojvodina and central Serbia during the last years and the small number of cases that have been registered in Kosovo are the consequences of significant increase of vaccine coverage against tetanus and the increased number of deliveries with medical assistance. The percentage of deliveries in Vojvodina with professional help during the observation period was 96%, and since 1978 it has been >99%. The observation that in Vojvodina from 1978 and in central Serbia from 1983 through 1997, only four cases in Vojvodina and five cases in central Serbia were registered indicates that the greatest part of the Republic of Serbia, according to the WHO criteria, 3 is about to eliminate neonatal tetanus. Mirjana Jarebinski, M.D., Ph.D. Tatjana Pekmezovic, M.D., Ph.D. Milen Pavlovic, M.D., M.Sc. Vesna Pantovic, M.D., Ph.D. Aleksandra Acimovic, M.D.