- Scores of survivors of the tsunami are dying of tetanus,
a rare but often deadly disease whose outbreak has caught health officials
completely off guard. Deaths have been reported in Banda Aceh and Meulaboh,
at either end of the Indonesian disaster zone in Sumatra. They are almost
certainly being replicated in the cut-off towns and villages along the
coast in between, say experts.
- Tetanus, once better known as lockjaw, has been almost
wiped out in the West through childhood immunization and is now uncommon
even in disaster areas. One doctor said this was the worst outbreak the
world had seen in years. "I might have expected to see 1 case in my
career," said Dr Charles Chan Johnson, from Singapore, who is working
in Banda Aceh's general hospital, Zainal Abidin. "Now I have 20 patients
in a single ward." Most had symptoms too far advanced to be treatable.
"I am afraid nearly all these patients will die," he said.
- Immunization is regarded as the most important means
of prevention because once symptoms appear the mortality rate is high.
But in Sumatra primary health care was limited even before the tsunami
which killed more than 100 000 Indonesians.
- Medical workers say the disaster provided perfect conditions
for tetanus. Many people were injured by the debris the waves picked up,
even if only with minor cuts, and ended up lying in the dirty water. Nevertheless,
the number arriving at hospitals and field clinics with the classic "smile"
of lockjaw has taken them by surprise. [The "smile" referred
to is "risus sardonicus", a characteristic expression with a
fixed grin and elevated eyebrows caused by spasm of the facial muscles
produced most often by tetanus - Mod.LL] Workers had been on the lookout
for cholera, dysentery and malaria, classic refugee-camp sicknesses, rather
- There have been 40 confirmed cases and 20 deaths in Banda
Aceh, and 7 cases and 5 deaths in Meulaboh. But patients were still arriving
at Zainal Abidin last night, and Meulaboh hospital is seeing several suspected
cases every day.
- Officials have still not assessed the scale of the outbreak
along the coast, where hundreds of thousands of survivors have fled. But
workers there may not even know why people are falling sick, said Dr Tony
Stewart, a consultant epidemiologist to WHO in Banda Aceh. "This is
totally unprecedented," he added. "This is now a really rare
- He had imported to Indonesia Australia's entire stock
of specific tetanus immunoglobulin. It amounted to 15 vials, a sign of
how few cases the West now suffers. Dr Johnson's ward is 1 of 3 which reopened
on Tue, 11 Jan 2005, in the hospital, which was inundated by mud during
- Date: Tue 11 Jan 2005
- From: Simon Mardel
- Although none of these reports (see: Wound infections,
tsunami-related - Asia 20050110.0079) mentions the wounds being surgically
closed (such as by suturing), this factor should be specifically asked
for in reports of severe wound infections, including tetanus and gas gangrene,
- 1. In large scale emergencies, there is often immense
pressure from staff, patients, and their families to deal with wounds in
one single surgical procedure, avoiding the need for planning a follow-up
surgical procedure of delayed primary or secondary closure.
- 2. Unfortunately, suturing wounds that are contaminated
during one single procedure will inevitably lead to more severe infection,
often with life or limb threatening consequences.
- 3. Knowledge of adequacy of wound surgery allows better
interpretation of bacteriological results from such wounds.
- 4. Education regarding wound infection and wound healing
directed toward staff operating in the field encourages good (and often
simple) tetanus cover and surgical technique (such as debridement and wound
cleaning), and encourages leaving the wound open, allowing it to drain
and covering it with an appropriate dressing, to be closed at a later stage
if infection is not present.
- Reassuringly, some of the reports specifically mention
debridement, which together with wound cleaning and irrigation is the correct
initial management of these potentially contaminated wounds, which may
include devitalized tissue. However, wound management experience from most
disasters and wars in many countries suggests that this basic principle
has to be relearned again and again, often regardless of technical levels
of skill or facilities available. In this respect, some of the affected
countries will already have considerable wound management expertise that
can be shared.
- Dr Simon Mardel
- Locum Consultant in Accident & Emergency, UK
- Date: Mon 10 Jan 2005
- From: ProMED-mail
- Source: Bordermail.com.au
- Infection Control Put To One Side
- After arriving in Indonesia's tsunami-shattered province
of Aceh, the Australian surgeons did what they had been taught never to
do. In a building with no running water and under hand-held lights powered
by faltering generators, they picked up their instruments, unsure about
whether they were sterile, and began to operate.
- "We just had to lower our standards and deal with
what we had to deal with," Dr Annette Holian said on 9 Jan 2005, as
she and her colleagues returned home after becoming the 1st emergency team
to leave Australia for the provincial capital Banda Aceh. "We had
to accept that the infection that patients were already suffering was much
worse than anything we were about to put on if our instruments weren't
- After landing in Sydney, the team of 28 doctors, nurses,
firefighters and ambulance officers told of the death, destruction and
desperation that greeted them when they reached Aceh.
- "You were confronted with an overwhelming and vast
area of destruction, cars on their sides, buses still with the remains
of deceased in them, and mud," team leader and medical director of
the NSW Ambulance Service Dr Michael Flynn said, "and lots and lots
of deceased initially in the streets, and there were large numbers of deceased
in the river. It was one of the most austere environments that I've ever
worked in, and it was a tribute to my team that they went through that,
and they still performed in an exemplary manner."
- Dr Holian said the ability to improvise had been crucial,
as the team struggled under unsanitary conditions and were hit by frequent
blackouts when operations were under way. "Once we were in there trying
to operate, we had very little to actually work with," she said. "With
our 1st patients, we were really just tipping water into wounds to wash
out the infection."
- About 240 patients came to the hospital's emergency ward
each day, infectious diseases physician Dr James Branley said. Many of
them had huge lacerations from corrugated iron and other debris ripped
from buildings when the tsunami struck. "You've seen some of the footage
of black, oily stuff flowing through the streets, and that was all washed
through these patients' lacerations," Dr Branley said, "People
had been bathed in a mixture of salt water and what could only be described
as open drain fluid. Many of them died." Dr Branley said conditions
on the ground would hasten the spread of disease in refugee camps.
- ProMED-mail thanks Dr Mardel for his comments regarding
the management of
- wounds in a mass-causality situation. The conditions
contributing to the
- amount and variety of wound infections is illustrated
by the 2nd part of
- the posting. - Mod.LL
- Patricia A. Doyle, PhD
- Please visit my "Emerging Diseases" message
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- Go with God and in Good Health