Tetanus complicating snakebite in northern Nigeria: clinical presentation and public health implications.

BACKGROUND There is inequality in vaccination coverage, and adult farmers in tropical rural communities could have missed tetanus toxoid as campaigns target children. Snakebite is not uncommon and partly because of lack of effective antivenom, management in inaccessible areas could be complicated with tetanus in unimmunized victims. PATIENTS AND RESULTS Four snakebite victims who developed tetanus were seen in northern Nigeria. Three were bitten while farming and patients took 10-25 days before presenting to hospital. All patients had incised bite sites and applied local medicinal herbs and in one case, a black 'snake' stone. Bites were by the cobra (Naja nigricollis) and carpet viper (Echis ocellatus) in the extremities and victims had swollen limbs and bleeding with incoagulable blood. Three of the patients were given anti-tetanus serum (ATS) after development of tetanus symptoms in a primary facility and only one recalled receipt of one dose of tetanus toxoid prior to bite. Patients had trismus, rigidity, backache, spasms and one had autonomic dysfunction and was managed with antispasmodics, ATS, wound care, antibiotics and supportive measures. Two patients with envenoming and severe tetanus received antivenom, but died. One of the two surviving patients developed osteomyelitis with prolonged hospital stay, while the other recovered with residual disability. CONCLUSION Tetanus could follow snakebite in inaccessible rural agricultural communities with inadequate health care provision. Clinical presentation is typical but late and is confounded by snakebite complications leading to considerable morbidity and mortality. The cases highlight the triple problems of inadequacy, inaccessibility and inequality in health care and calls for measures aimed at improvement.