Severe Tetanus Research Articles

Pharmacological management of tetanus: an evidence-based review.

Tetanus is becoming rarer in both industrialized and developing nations due to an effective vaccination program. In 2010, the World Health Organization estimated there was a 93% reduction in newborns dying from tetanus worldwide, compared to the situation in the late 1980s. Due to its rarity, many diagnostic delays occur as physicians may not consider the diagnosis until the manifestations become overt. Without timely diagnosis and proper treatment, severe tetanus is fatal (mortality is also influenced by the comorbidities of the patient). The principles of treating tetanus are: reducing muscle spasms, rigidity and autonomic instability (with ventilatory support when necessary); neutralization of tetanus toxin with human antitetanus immunoglobulin or equine antitetanus sera; wound debridement; and administration of antibiotics to eradicate locally proliferating bacteria at the wound site. It is difficult to conduct trials on different treatment modalities in tetanus due to both logistical and ethical reasons. However, it is imperative that physicians are aware of the best evidence-based treatment strategies currently available to improve the outcome of patients. This review concentrates on analyzing the current evidence on the pharmacological management of tetanus.

Dexmedetomidine in the management of severe tetanus

Sir, Although tetanus is a rare disease in the developed countries now, it remains a significant cause of death world-wide and is associated with a high rate of mortality. Components of severe tetanus management are supportive care with sedation, airway protection and controlled ventilation.[1] Dexmedetomidine is a high selective α-2-receptor agonist. It has combined analgesic and anti-sympathetic effect without respiratory system depression. There have been several studies describing its successful use in mechanically ventilated patients for short- (24 h) and long-term (up to 7 days) use in the intensive care unit (ICU).[2] Dexmedetomidine has been also used in the treatment of tetanus in six patients for 7 days.[3] We present a case of generalised tetanus complicated by uncontrolled sympathetic over activity (SOA) managed with dexmedetomidine infusion. A 53-year-old male patient presented with complaints of dyspnoea, upper lip twitching, difficulty in swallowing and a local abscess around his right foot. He had a medical history of penetrating wound in his right foot 11 days before. Antibiotics and human tetanus immunoglobulin were administered and the wound was surgically debrided. Because of respiratory failure with SOA, he was intubated and mechanically ventilated. SOA persisted despite midazolam and magnesium sulphate infusion. Dexmedetomidine infusion was started on day 5 and SOA could be controlled successfully. On day 10, severe bronchopneumonia developed and the patient died on day 12. The management of tetanus requires the prevention of tetanospasmin absorption, treatment of symptoms, stabilisation of autonomic instability, antibiotic therapy and control of the airway with assisted ventilation if indicated. Basal SOA is characterised by resting tachycardia and depression of bowel motility and bladder function, while severe SOA presents with fluctuating tachycardia, labile hypertension and sweating with and without stimulation.[4] Different methods to control SOA have been provided, including magnesium sulphate infusions, dantrolene infusions, intrathecal administration of baclofen, benzodiazepine, clonidine and dexmedetomidine.[5] Girgin et al.[3] reported use of dexmedetomidine in the management of tetanus for 7 days in six patients without any side-effects. According to the same author, its administration did not fully control the muscle spasm, but decreased their frequency and severity and reduced the use of sedative drugs to control muscle spasms and cardiovascular instability. In this case, we started dexmedetomidine infusion on the 5th day in the ICU, because midazolam and magnesium sulphate infusions did not efficiently control SOA. We observed that tachycardia (heart rate >110 beats/min) and hypertension (mean arterial blood pressure gt;100 mmHg) decreased to acceptable normal levels and need for sedative drugs was reduced after starting dexmedetomidine infusion. However, we were not able to fully avoid their use. We used dexmedetomidine for 4 days. Although hypotension and bradycardia are the most significant side-effects, we did not observe any of these and could control SOA during the first 3 days of the infusion. However, hypotension and bradycardia were observed on the 4th day of the infusion and hence we cut it off. The patient died because of nosocomial pneumonia despite multidrug antibiotherapy. Thus, dexemedetomidine can be a good alternative drug for resistant SOA during tetanus management.

Post-neonatal tetanus in University of Maiduguri Teaching Hospital, North-eastern Nigeria

Background: Tetanus is a public health problem in Nigeria. This study examines the demographic and clinical profile of postneonatal tetanus (PNT) seen in University of Maiduguri Teaching Hospital (UMTH), North- eastern Nigeria.Methods: This is a hospital-based prospective study of PNT. All childrenbeyond the neonatal period to 14 years of age admitted into the Paediatrics unit of UMTH, Maiduguri from June 2009 to July2011 with the diagnosis of PNT were studied.Results: A total of 39 cases of PNT were admitted over the period underreview. The male: female ratio was 2.3:1.0. Their ages at presentationranged between 16 months and 14 years, with mean +SD of 6.9+3.87 years. Over 90 percent of the children were either not immunizedagainst tetanus or their immunization status was unknown and onlytwo of the children were fully immunized. No booster immunizationwas received by any of the eligible children. The portal of entry of the infection was injury to the lower limbs and otogenic route in 53.9% and 33.3% respectively. Majority of patients were of low socioeconomicstatus. The duration of hospital stay ranged between 1-50 days with mean + SD (18.68+ 11.51).The mortality rate was (7)18 %.Conclusion: Tetanus still remains a major cause of childhood morbidityand mortality in Nigeria. Severe disease and the first one week of admission are the main variables identified to influence outcome.Therefore, there is need to strengthen routine immunization and booster doses of tetanus toxoid (TT) should be mandatory at primary and secondary school entry. Close monitoring of patients with severe tetanus during the critical period is imperative for successful management.

Animal-related injuries in a resource-limited setting: experiences from a Tertiary health institution in northwestern Tanzania

BackgroundAnimal related injuries are a major but neglected emerging public health problem and contribute significantly to high morbidity and mortality worldwide. No prospective studies have been done on animal related injuries in our setting. This study was conducted to determine the management patterns and outcome of animal related injuries and their social impact on public health policy in the region.MethodsThis was a descriptive prospective study of animal related injury patients that presented to Bugando Medical Centre between September 2007 and August 2011. Statistical data analysis was done using SPSS computer software version 17.0.ResultsA total of 452 (8.3%) animal-related injury patients were studied. The modal age group was 21-30 years. The male to female ratio was 2.1:1. Dog-bites (61.1%) were the most common injuries. Musculoskeletal (71.7%) region was the most frequent body region injured. Soft tissue injuries (92.5%) and fractures (49.1%) were the most common type of injuries sustained. Only 140 (31.0%) patients were hospitalized and most of them (97.1%) were treated surgically. Wound debridement was the most common procedure performed in 91.2% of patients. Postoperative complication rate was 15.9%, the commonest being surgical site infections (SSI) in 55.1% of patients. SSI was significantly associated with late presentation and open fractures (P < 0.001). The overall median duration of hospitalization was 16 days. Patients who had severe injuries, long bone fractures and those with hemiplegia stayed longer in the hospital (P < 0.001). Mortality rate was 10.2% and was significantly high in patients with severe injuries, severe head injury, tetanus and admission SBP < 90 mmHg (P < 0.001). The follow up of patients was poor.ConclusionAnimal related injuries constitute a major public health problem in our setting and commonly affect the young adult male in their economically productive age-group. Measures towards prevention and proper treatment and follow up are important in order to reduce morbidity and mortality resulting from this form of trauma

Safeguarding against FGM: everyone's issue

British Journal of Midwifery • June 2012 • Vol 20, No 6 In light of the recent press coverage on female genital mutilation (FGM) (Laville, 2012), earlier this month the Chief Medical Officer and the Director of Nursing asked all general practitioners, practice nurses, health visitors and school nurses to familiarise themselves with the actions they need to take where they have reason to believe that a girl has undergone, or is at risk of, FGM (Department of Health (DH), 2012). I wholeheartedly support this and am very passionate that FGM is eradicated. It is often looked on as a taboo subject as many health professionals do not want to interfere with what is seen as a cultural belief. It is not, it is child abuse. FGM is illegal in the UK. The law clearly states that it is an offence to excise, infibulate or mutilate the whole or any part of a girl or woman’s labia majora, minora or clitoris. It is also an offence to assist a girl to mutilate her own genitalia, and the UK FGM Act (2003) and the Scottish Act in 2005 also makes it illegal to remove a girl from the country to perform a mutilation. A person guilty of an offence under this Act is liable to a 14 year term. The prevalence of FGM in the UK has been notoriously difficult to calculate. FORWARD, the UK charity working to tackle FGM, estimated that 66 000 women with FGM are living in England and Wales (FORWARD, 2007) and that there are nearly 21 000 girls under the age of 15 at high risk of mutilation. However, this figure will only increase as the immigrant population in the UK from the western, eastern, and north-eastern regions of Africa, and from Asian and Middle Eastern countries increase. Therefore it is imperative that appropriate safeguarding is in place to stop this practice from going unnoticed. There are no health benefits to FGM. It can harm a woman both physically and psychologically. The immediate physical complications can include severe pain, shock, haemorrhage, tetanus or sepsis, urine retention, open sores in the genital region and injury to nearby genital tissue (WHO, 2012). However, the long-term psychological effects may scar a woman for life. FGM is performed sometime between infancy and the age of 15 and, as a result, may be the first memory the woman has. This memory may come back to haunt her when she is giving birth—having her legs held back may spark flash-backs of the procedure. It is important to be aware of this when delivering a baby from an FGM mother and to ensure that counselling is offered to the woman at booking. Midwives are often the first health professional to encounter women who have been subject to FGM, and are best placed to initiate safeguarding. In 2011, the DH issued multi-agency guidelines that advocated a multidisciplinary approach to safeguarding those at risk of FGM (DH, 2011). This aims to ensure that no women or child falls out of the system and appropriate actions can be taken. When a woman who has undergone FGM gives birth to a daughter, she should be provided with clear information that FGM is illegal in the UK and should not be performed on her daughter. This should be done in a sensitive manner as the woman may have been a victim of enforced FGM and may be distressed at the suggestion that she would do the same to her daughter (DH, 2011). It is upsetting that FGM still takes place but lets hope that by working together with general practitioners, practice nurses, health visitors and school nurses, we can put an end to this illegal practice. Please join us at our free study day in Belfast on Friday 12 October to find out more about FGM. BJM

TÉTANO GRAVE ASSOCIADO A CHOQUE SÉPTICO EM UMA PACIENTE IDOSA INTERNADA EM UNIDADE DE TERAPIA INTENSIVA

We report a case of severe tetanus associated with septic shock in a 61-year-old female admitted to the Intensive Care Unit (ICU) after perforating injury in the right foot. The patient presented with loss of muscle strength, paresis in the right lower limb and dysphagia. The patient’s conditions worsened, progressing to generalized muscle spasms, dyspnea, and respiratory failure. Intense spasm made the prolonged use of invasive mechanical ventilation, sedation, and neuromuscular blockers necessary. The favorable outcome in the present case is probably related to advances in ICU management and well-trained medical and nursing staff.

Tetanus in adults: Clinical presentation, treatment and predictors of mortality in a tertiary hospital in Ethiopia

BackgroundTetanus remains a major health problem in the developing world. The aim of this study was to evaluate the clinical presentation, risk factors, complications, treatment, outcome and predictors of death in patients with tetanus. MethodsPatients aged ≥13years admitted to Tikur Anbessa Hospital from June 2001 to May 2009 with the diagnosis of tetanus were included in this retrospective study. ResultsData from 68 patients were analyzed; majority (77.9%) were males, the mean age was 33.8years. None of them was vaccinated for tetanus. The types were: generalized (91.2%), cephalic (7.4%), localized (1.5%), severe (72.1%), moderate (19.1%) and mild (8.8%). One or more complication(s) occurred in 75%; dysautonomia (58.8%), pneumonia (44.1%) and hypoxemia (41.2%). Tracheostomy and mechanical ventilation was used in 45.6% and 11.8%, respectively. Case-fatality was 35.3%. Predictors of mortality were age ≥40years, duration of symptoms prior to presentation <4days, severe tetanus, incubation period <7days, period of onset <3days and dysautonomia. The cause of death was early acute respiratory failure due to uncontrolled spasms in 87.5%. ConclusionsMost tetanus patients were young males and there was high case fatality due to acute respiratory failure. Age ≥40years and dysautonomia were independent predictors of mortality. Preventing tetanus by vaccination and treating patients in a well equipped ICU is recommended.

Rehabilitative management of swallowing and oral-motor movements in patients with tetanus of a public service in Brazil

When looking at developing countries, the prolonged intensive medical and nursing care required by many patients places extra demands on an already stretched healthcare budget. The purpose of this study was to verify the effectiveness of a systematic rehabilitative program for swallowing and oral-motor movements in intensive care unit patients with the diagnosis of tetanus. Forty-five patients who were clinically diagnosed with tetanus were included in the study. Participants were divided in two groups: GI – consisted of 18 tetanus patients who were consecutively admitted to the infectious disease ICU from January 2002 to December 2005, prior to the existence of a systematic swallowing and oral-motor intervention; GII – consisted of 27 tetanus patients who were consecutively admitted to the infectious disease ICU from January 2006 to December 2009 and were submitted to a specific rehabilitative management of swallowing and of the oral-motor movements. Results indicate that the proposed rehabilitative program reduced by approximately 50% the time patients remained in the ICU. The significant improvement observed in patients with tetanus who were submitted to the rehabilitative program for swallowing and oral-motor movements occurred in conjunction with a reduction in the amount of time necessary to reintroduce oral feeding, to decannulate and to remove the feeding tubes. In conclusion, swallowing/muscle exercise, in patients with severe/very severe tetanus, seem to promote the remission of muscle tension and seem to maximize functional swallowing.

Successful Treatment Using Magnesium Sulphate for Severe Tetanus Suggested the Complication of Takotsubo Cardiomyopathy: A Case Report

Successful Treatment Using Magnesium Sulphate for Severe Tetanus Suggested the Complication of Takotsubo Cardiomyopathy: A Case Report

Semi-recumbent body position fails to prevent healthcare-associated pneumonia in Vietnamese patients with severe tetanus

Healthcare-associated pneumonia (HCAP) is a common complication in patients with severe tetanus. Nursing tetanus patients in a semi-recumbent body position could reduce the incidence of HCAP. In a randomised controlled trial we compared the occurrence of HCAP in patients with severe tetanus nursed in a semi-recumbent (30°) or supine position. A total of 229 adults and children (aged ≥1 year) with severe tetanus admitted to hospital in Vietnam, were randomly assigned to a supine (n = 112) or semi-recumbent (n = 117) position. For patients maintaining their assigned positions and in hospital for > 48 h there was no significant difference between the two groups in the frequency of clinically suspected pneumonia [22/106 (20.8%) vs 26/104 (25.0%); p = 0.464], pneumonia rate/1000 intensive care unit days (13.9 vs 14.6; p = 0.48) and pneumonia rate/1000 ventilated days (39.2 vs 38.1; p = 0.72). Mortality in the supine patients was 11/112 (9.8%) compared with 17/117 (14.5%) in the semi-recumbent patients (p = 0.277). The overall complication rate [57/112 (50.9%) vs 76/117 (65.0%); p = 0.03] and need for tracheostomy [51/112 (45.5%) vs 69/117 (58.9%); p = 0.04) was greater in semi-recumbent patients. Semi-recumbent body positioning did not prevent the occurrence of HCAP in severe tetanus patients. [Clinical Trials.gov Identifier: NCT01331252]

Magnesium sulfate as an adjunct therapy in the management of severe generalized tetanus in a dog

To describe the use of magnesium sulfate in a case of generalized tetanus in a dog. A 1.5-year-old golden retriever was presented for a digital wound on the right thoracic limb and clinical signs associated with generalized tetanus. Initial case management consisted of wound debridement, treatment with metronidazole, tetanus immunoglobulin, methocarbamol, airway management via tracheostomy, and nursing care. Sedation to control severe muscle spasms became insufficient despite increasing doses of benzodiazepine, methocarbamol, and barbiturate continuous rate infusions. A magnesium sulfate continuous rate infusion was instituted on day 7 and muscle rigidity improved within 16 hours allowing discontinuation of sedative infusions over the subsequent 2 days. Clinical improvement continued and the dog was discharged on day 14. This case demonstrates the use of supraphysiologic magnesium in the treatment of severe generalized tetanus with a positive outcome. No clinical signs associated with magnesium toxicity were noted during the course of therapy. Magnesium sulfate should be considered as a potential adjunct therapy in the management of spastic paralysis caused by severe tetanus in dogs.

Airway Management of Tetanus After the Haitian Earthquake

Two men developed severe tetanus after the 2010 Haitian earthquake. They were admitted to the United States Naval Ship Comfort, a hospital ship sent to provide humanitarian relief. Severe masseter and intercostal muscle spasm impaired airway access and ventilation. Propofol and sevoflurane relieved the tetany, allowing airway control and ventilation without intubation or neuromuscular blocking drugs during wound debridement. Presynaptic impairment of inhibitory neurotransmitter release by tetanospasmin toxin is countered by enhancement of spinal cord postsynaptic inhibitory receptor activity by general anesthetics. Avoidance of tracheal intubation and mechanical ventilation during anesthesia may be desirable in the settings of limited resources in which tetanus usually presents.

Study of enteral nutrition on patients with severe tetanus

Objective To study the effect of enteral nutrition on patients with severe tetanus. Methods The patients totaled 60 cases were divided into two groups with 30 cases in each. The patients in EN group were treated with enteral nutrition on basis of routine treatment, control group was treated with total parenteral nutrition (TPN). The indicators values of BMI, TSF, MAMC, TP, PAm, m, ALB and Hb were tested on the day before nutrition supports and after nutrition supports 10 days later in two groups. Adverse reaction and the treatment effect were observed simultaneously. Results With nutritional supports 10 days later, two groups had no obvious decline in BMI, TSF and MAMC. TP, PA, ALB and Hb of EN group were higher than those of control group (P＜0.05) . Complication rate of EN group was lower than that of control group, there was significant differences (P＜0.05) . Conclusions Early EN may improve protein metabo lism in patients with severe tetanus and nutritional status. Key words: Severe tetanus; Enteral nutrition; Total parenteral nutrition; Nutritional support

Autonomic Dysfunction Because of Severe Tetanus in an Unvaccinated Child

Tetanus is rare in a country with a national vaccination program. When it does occur, the associated autonomic dysfunction is a challenge for physicians. We report here a case of an unvaccinated 5-year-old boy who suffered from tetanus complicated by autonomic dysfunction, which was successfully controlled by the infusion of magnesium sulfate. This is the first case that demonstrated the therapeutic effect of magnesium sulfate in a child with tetanus. This case highlights the importance of implementing a vaccination program.

A case of successful circulation management using landiolol in severe tetanus complicated with nonclostridial gas gangrene

【背景】外傷による緊急四肢切断術後の早期合併症として最も多いのは創感染であり，その対策には多数の報告がある。我々は手関節，足関節より近位の緊急切断術では創の一次縫合を行っていたが，創感染が複数例生じたため，2008年から原則としてsecond-look surgeryを行う方針に変更した。今回，創感染率の比較により，この治療戦略変更の妥当性の検証を行った。【対象と方法】治療戦略として一次縫合を行い観察していた前期（11肢）とsecond-look surgeryを行うようになった後期（8肢）の創感染率を比較検討した。また切断部位（上肢，下肢）別も検討した。【結果】患者背景として年齢，性別，糖尿病の有無，ISS，MESSに差はなく，出血性ショックのみ後期のほうが多かった。全体の感染率は前期45%，後期0%（p=0.0395），上肢は前期17%，後期0%（p=0.6），下肢は前期80%，後期0%（p=0.0397）で全体の感染率および下肢の感染率に有意差が認められたが，上肢は有意差が認められなかった。また近位関節を超えての切断は前期後期とも1例ずつあり感染はなかった。【考察】切断肢において，重度四肢開放骨折の初期治療戦略に準じてsecond-look surgeryを導入したところ，感染率の有意な低下を認めた。高度で広範囲な軟部組織の挫滅のため，初回手術で挫滅組織が残存していたり，その後壊死が進行する可能性が高い場合，創感染の発生する頻度が高くなるため，原則としてsecond-look surgeryを行うことが望ましいと考える。ただし，上肢の切断と近位関節を超える切断は一次縫合のままでも感染は少なかったことから，second-look surgeryの適応は少ないと思われる。

Follow-up and treatment of a severe tetanus case in the intensive care unit

Tetanoz, Clostridium tetani tarafindan yara yerinden salinan tetanospazmin (ekzotoksin) isimli guclu bir norotoksin etkisiyle kontrol edilemeyen kas spazmlari ile seyreden bir hastaliktir. Tetanospazmin alfa motor noronlarin noromuskuler kavsagindan sinir sistemine girer. Toksin buradan retrograt transport ile noronal hucrelerin govdesine ulasir. Spinal kord veya beyin sapina gelen toksin, hucre disi bosluga ve buradan da presinaptik inhibitor hucrelere gecer. Bu hucreler transmitor olarak glisin ve GABA kullanmaktadir. Toksin tarafindan transmitor saliniminin engellenmeCiddi Bir Tetanoz Olgusunun Yogun Bakimda Takip ve Tedavisi Follow-up and Treatment of a Severe Tetanus Case in the Intensive Care Unit

Epidural infusion of midazolam in the management of a patient with severe tetanus

Epidural infusion of midazolam in the management of a patient with severe tetanus

Evaluation of oral-motor movements and speech in patients with tetanus of a public service in Brazil

The characterisation of oral-motor movements and speech of patients with tetanus were investigated to determine the existence of possible signs that are characteristic of this pathology. Thirteen patients clinically diagnosed with tetanus (10 with severe tetanus and three with very severe tetanus) and admitted to an intensive care unit underwent clinical evaluation of oral-motor movements and speech. Statistical analysis indicated significant between-group differences for speech motor functions, suggesting that individuals with very severe tetanus present rigidity as a characteristic interfering in articulatory precision (P = 0·035) and movement rate (P = 0·038). For lip closure, tongue movement, palatal elevation, gag reflex and voice quality, no between-group differences were identified for the specific abnormal characteristics. The observed abnormal results indicate that muscle strength and functional status of the oral-motor system presented by most of the participants of the study did not ensure the necessary integrity for satisfactory performance. The characterisation of the oral myofunctional aspects of patients with tetanus provides medical teams, patients and families with a wider and better description of the clinical situation, giving support to the diagnosis, prognostics and treatment.

Gastric myoelectrical activities in elderly severe tetanus: Useful marker to increase volume and calorie of nasogastric tube feeding

Summary Background & aims Early high nasogastric tube feeding (NTF) is effective for improving the nutritional status of critical illness. However, potential complications of NTF in tetanus include aspiration pneumonia because of dysphagia and gastrointestinal dysfunction induced by over-activity of autonomic nervous system. Methods We serially evaluated gastric myoelectrical activities using electrogastrogram (EGG) recorder in 4 elderly severe tetanus patients, and assessed its potential as a marker to increase volume and calorie of NTF. Results Although dominant frequencies of EGG in all patients (1.8 ± 0.6 cycle/min (cpm)) were lower than those in healthy volunteers (2.9 ± 0.2 cpm) at least until 12th hospital day, it tended to improve from 14–24th hospital day and reached the same levels in healthy volunteers at least until 28th hospital day. We transferred total NTF along their metabolic costs when the timing of dominant frequency tended to improve in each patient (17–24th hospital day). No aspiration pneumonia and malnutrition occurred in their hospital days. Conclusion EGG data may be a useful marker to know the level of over-activity of autonomic nervous system and to guess the best timing to increase volume and calorie of NTF especially in elderly severe tetanus.

A 4 year review of neonatal outcome at the University of Benin Teaching Hospital, Benin City.

Neonatal morbidity and mortality rates reflect a nation's socio-economic status, the efficiency and effectiveness of health care services. This important indicator is useful in planning for improved healthcare delivery. A four year review of neonatal outcome was therefore conducted in the special care baby Unit (SCBU) of University of Benin Teaching Hospital (UBTH). The study was done between 2003 and 2006 and sought to review the morbidity, mortality, salvage rate of low birth weight babies and outcome of all inborn and outborn babies admitted into the SCBU of UBTH. The biodata, birth weight, sex, APGAR scores and reasons for admissions and outcome were abstracted from case notes/admission records. A total of 3075 babies were admitted to the unit during the period under review. 2602 (84.6%) were inborn while 473 (15.4%) were out-born. There were more males 1676 (54.6%). There were 855 (27.8%) preterm babies of which 803 (26.1%) were low birth weight babies. Neonatal sepsis, severe birth asphyxia, pre-maturity and neonatal tetanus were the most common morbidities suffered by the neonates. Mortality was recorded amongst 625 (20.3%) babies. Mortality rate was significantly higher amongst the out-born than in born babies, P value < 0.0001. The neonatal mortality rate in this study is high. The morbidity profile observed in the study is attributable to preventable causes. Of note is the contribution ofNNT to morbidity and mortality. Strengthening of linkages in perinatal care, improving maternal emergency obstetric care and neonatal resuscitation skills are proposed measures to reduce neonatal mortality.