Scores Of Tsunami Survivors
Dying Of Tetanus, Infections

From Patricia Doyle, PhD
From ProMED-mail
By Richard Spencer
The Telegraph - UK
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 than tetanus.
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 disease."
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 the disaster.
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, since:
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
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 sterile."
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
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