Tetanus : Faktor-faktor risiko

mortalitas,
(Apa yang perlu diketahui..?)

Nur Farhanah
Div. Peny Tropik dan Infeksi FK Undip/RSUP Dr Kariadi
SPEED-6, 2019
 Pendahuluan
• Data/informasi kejadian dan mortalitas tetanus
terbatas.
• WHO : kejadian tetanus 1 juta orang/tahun dan
> 715.000 kematian/tahun
• CFR 20-50%
• Negara maju mortalitas usia ±60 th.
• Negara berkembang mortalitas tetanus
neonatorum
• Pelayanan ruang intensive yang modern
kematian ± 20% .
Pendahuluan

Europe & Central Asia

Institute of Health Metrics and Evaluation (IHME), Global Burden of Disease

(GBD) from 1990 onwards
Pendahuluan

indonesia

Institute of Health Metrics and Evaluation (IHME), Global Burden of Disease

(GBD) from 1990 onwards
 Pendahuluan
• Tetanus : Preventable disease
• Rekomendasi WHO vaksin tetanus toksoid
 3 primer, 3 booster usia 2 th ,4-7 th dan
9-15 th, booster tiap 10 th.
• WHO
- Eliminasi MNT Maternal-Neonatal
Tetanus,2015 (Indonesia, 2016)
• Data cakupan vaksin (booster) data
terbatas
• Mortalitas secara umum dipengaruhi :
- Usia
- Masa inkubasi
- Tipe luka
- Tanda klinis
- Keterlambatan pengelolaan/profilaksis
Tetanus. World Health Organization 2018
N. Saltoglu., et al. Clin Microbiol Infect 2004; 10: 229–233
Kyu et al. BMC Public Health (2017) 17:179
 Diagnosis
Anamnesis

Pemeriksaan Fisik/Tanda Klinis

Pemeriksaan lab tidak spesifik

Phillips
Sistem Skor
Dakar
Mortalitas derajat :
Ablett Ringan <10%
Sedang 10-20%
Tetanus Derajat berat/Risiko kematian Pasien Berat 20-40%
Severity Score Tetanus Sangat berat >50%
 Factors Score
Incubation Time <48 hours 5
2-5 day 4
5-10 days 3
10-14 days 2
Phillips Score >14 day 1
Site of infection Umbilical 5
Head, neck 4
Peripheral proximal 3
Peripheral distal 2
Unknown 1
skor ≥19 derajat berat
skor 9-19 derajat sedang Protection none 10
skor <9 derajat ringan. Maternal immunization (0-8)
Compicating factors (2-10)
Sens 80%;spes 51%
ASA grade 1 0
Total Score
 Factor Score 1 Score 0
Incubation <7 days ≥7 day or unknown
Period
<2 days ≥2 days
Period of Onset
Umbilicus, burn, All others plus unknown
Entry Site
Dakkar Score uterine,open fracture,
≥3 : berat
Surgical wound,IM
injection

Spasms Present
Absent
Fever >38,4°C
<38,4°C
Tachycardia Adult >120 beats/min
Adult<120 beats/min
Total Score

Sens 25%; spes 96%

 Kriteria Ablett
Grade Clinical Features
I (mild) Mild trismus, general spasticity, no respiratory
embarrassment, no spasms, no dysphagia

Moderate trismus, rigidity, short spasms, mild dysphagia,

II (moderate)
moderate respiratory involvement, RR >30, mild
dysphagia
III (severe)
Severe trismus, generalized spasticity, prolonged spasms,
RR>40, severe dysphagia, apneic spells, pulse >30

IV (very severe) Grade 3 plus severe autonomic disturbances involving

the cardiovascular system
 Factors
Age (year)

Time from first symptom to admission (days)

Tetanus Severity
Difficulty breathing on admission
Score
Co-existing medical conditions

Entry Site

Highest systolic blood pressure recorded during first day

inhospital (mmHg)

Highest heart rate recorded during first day in hospital (bpm/

Lowest heart rate recorded during first day in hospital (bpm)

Highest temperature recorded during first day in hospital (0C)

Skor ≥8 : buruk
Sens 65%; Spes 91%
25 RS
N = 117 pasien tetanus
Kasus tetanus di RSUP Dr. Kariadi Semarang
Januari 2010 – Maret 2016 (n = 131)

Danawan R, Farhanah N. 2017

 Jumlah Kasus dan Kematian Tetanus
Tahun Jumlah Kasus Meninggal Hidup Angka Kematian (%)
n % n % n %
2010 17 15,4 3 7,8 14 19,4 17,6
2011 25 22,7 10 26,3 15 20,8 40
2012 12 10,9 6 15,8 6 8,3 50
2013 21 19,1 6 15,8 15 20,8 28,5
2014 16 14,5 7 18,4 9 12,5 43,75
2015 10 9,1 3 7,9 7 9,7 30
2016* 9 8,1 3 7,9 6 8,3 33,3
Total 110 100 38 100 72 100
 Site of injury
Jumlah Penderita Meninggal Hidup Angka
Lokasi
n % n % n % Kematian (% )
Paha – mata kaki 55 50 20 52,6 35 48,6 36,3
Telapak kaki 3 2,7 2 5,2 1 1,3 66,7
Jari kaki 9 8,1 1 2,6 8 11,1 11,1
Lengan 12 10,9 4 10,4 8 11,1 33,3
Telapak tangan 1 0,9 0 0 1 1,3 0
Jari tangan 4 3,6 1 2,6 3 4,1 25
Abdomen 3 2,7 2 5,2 1 1,3 66,7
Dada 1 0,9 0 0 1 1,3 0
Gigi/gusi 12 10,9 3 7,8 9 12,3 25
Telinga 3 2,7 1 2,6 2 2,6 33,3
Wajah 5 4,5 4 10,4 1 1,3 80
Lidah 1 0,9 0 0 1 1,3 0
Anus 1 0,9 0 0 1 1,3 0
Total 110 100 38 100 72 100
 Status Keluar RS
Variabel Meninggal Hidup Total (n = 110) Nilai pa
(n = 38) (n = 72)
Usia 0,004*
<70 tahun 29 (76,4%) 69 (95,8%) 98 (89,1%)
71 – 80 tahun 6 (15,8%) 3 (4,2%) 9 (9,2%)
>80 tahun 3 (7,8%) 0 3 (2,7%)
Entry site 0,258
Internal/Injection 37 (97,4%) 65 (90,3%) 102 (92,7%)
Others/Unk nown 1 (2,6%) 7 (9,7%) 8 (7,2%)
Waktu gejala pertama
<0,0001*
sampai masuk RS
<3 hari 26 (68,4%) 18 (25%) 44 (40%)
3 – 5 hari 10 (26,3%) 48 (66,7%) 58 (52,7%)
>5 hari 2 (5,3%) 6 (8,3%) 8 (7,3%)
Co-existing Medical
<0,0001*
Condition (ASA 1963)
Fit and well 0 0 0
Minor illness/injury 0 1 (1,4%) 1 (0,9%)
Moderately severe
3 (7,9%) 26 (36,1%) 29 (26,3%)
illness
Severe illness not
immediately life 7 (18,4%) 33 (45,8%) 40 (36,4%)
threatening
Immediately life
28 (73,7%) 12 (16,7%) 40 (36,4%)
threatening illness
Sulit bernapas saat
<0,0001*
masuk RS
Ya 27 (71,1%) 16 (22,2%) 43 (39,1%)
Tidak 11 (28,9%) 56 (77,8%) 67 (60,9%)
analisis multivariat menggunakan uji regresi logistik,
didapatkan :
 usia (p = 0,004; OR = 6,908; IK 95% = 1,578 – 30,244),
 kesulitan bernapas saat masuk Rumah Sakit (p = 0,021;
OR = 4,196; IK 95% = 1,246 – 14,127),
 co-existing medical conditions (p = 0,002; OR = 0,233; IK
95% = 0,094 – 0,580) dan
 HR tertinggi hari pertama di RS (p < 0,0001; OR = 5,023;
IK 95% = 2,106 – 11,976)
faktor risiko yang berpengaruh pada kematian pasien
tetanus di RSUP Dr. Kariadi Semarang periode Januari
2010 – Maret 2016.
 Kesimpulan
• Sistem skor tetanus bermanfaat menilai
Derajat berat
stratifikasi risiko/prognosis/mortalitas
• Mengambil keputusan secara cepat
• Mengelola pasien tetanus
• Menurunkan mortalitas yang masih
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