title: The burden of tetanus in Uganda.
abstract: BACKGROUND
  The successful scale-up of safe male circumcision (SMC) in Uganda has been hinged on client's safety and quality of services. However, after the recent three tetanus deaths after circumcision a review of all tetanus cases in one of the hospitals where the cases occurred was initiated. This was to ascertain the potential for an association between tetanus infection and circumcision. Routinely collected national data were also reviewed to determine the burden of tetanus in Uganda and contextualize these incidents.
  
  
  METHODS
  A review of medical charts of tetanus cases identified from the inpatients registry at Masafu hospital, Busia district for the period 2009/2010-2013/2014. Data were abstracted from the inpatients registries, charts and HMIS annual reports, and a key informant interview conducted with the in-charge of the ward that treats tetanus patients. All quantitative data were captured in an electronic database. Routine facility data from the National District health Information Software-2 (DHIS-2) for all the 112 districts were also used. Descriptive analysis and Poisson regression models were used for statistical analysis using STATA version 13.0.
  
  
  RESULTS
  Data from the routine DHIS-2 showed a high and increasing burden of tetanus from the emergency/out-patient department records over the 4 year period, highest among females aged 5+ years in all the regions. At the Masafa hospital, the chart review revealed a total of 25 tetanus cases and all were males. Nearly a third (32 %) was aged 7-15 years, with no evidence of circumcision apart from only one case. The rate of tetanus infection among male inpatients over the review period was 2-6 per 1000. The case fatality rate was nearly a half (47.4 %) with deaths occurring within 2 days after admission, and rates of patients' self-discharge against medical advice were high, 36.8 %. The most common tetanus entry wounds were due to road traffic accidents, followed by diabetic foot. Anti-tetanus serum was only not readily available.
  
  
  CONCLUSIONS
  The burden of tetanus is increasing, especially among females aged 5+ years. Tetanus entry wounds among the inpatients in Masafa hospital were mostly due to road traffic accidents, and young males. The tetanus case fatality was very high (47.4 %) and so was patient requested discharge. There is a need to do more to protect the population against tetanus infection, especially among females, and males who need either initial or booster tetanus immunization as SMC is scaled up.
authors.affiliation: Ministry of Health, Lourdel Road, P.O. Box 7272, Kampala, Uganda.
authors.forename: Barbara
authors.initials: B
authors.lastname: Nanteza
authors.affiliation: International Hospital Kampala, Lourdel Road, P.O. Box 8177, Namuwongo, Kampala, Uganda ; School of Medicine, College of Health Sciences, Makerere University, Mulago Hill Road, P.O. Box 7072, Kampala, Uganda.
authors.forename: Moses
authors.initials: M
authors.lastname: Galukande
authors.affiliation: Ministry of Health, Lourdel Road, P.O. Box 7272, Kampala, Uganda.
authors.forename: Jane
authors.initials: J
authors.lastname: Aceng
authors.affiliation: Ministry of Health, Lourdel Road, P.O. Box 7272, Kampala, Uganda.
authors.forename: Joshua
authors.initials: J
authors.lastname: Musinguzi
authors.affiliation: Ministry of Health, Lourdel Road, P.O. Box 7272, Kampala, Uganda.
authors.forename: Alex
authors.initials: A
authors.lastname: Opio
authors.affiliation: Ministry of Health, Lourdel Road, P.O. Box 7272, Kampala, Uganda.
authors.forename: Anthony K
authors.initials: AK
authors.lastname: Mbonye
authors.affiliation: Ministry of Health, Lourdel Road, P.O. Box 7272, Kampala, Uganda.
authors.forename: Eddie
authors.initials: E
authors.lastname: Mukooyo
authors.affiliation: Ministry of Health, Lourdel Road, P.O. Box 7272, Kampala, Uganda.
authors.forename: Prosper
authors.initials: P
authors.lastname: Behumize
authors.affiliation: School of Public Health, College of Health Sciences, Makerere University, Mulago Hill Road, P.O. Box 7072, Kampala, Uganda.
authors.forename: Fredrick
authors.initials: F
authors.lastname: Makumbi
keywords: Safe Male Circumcision; Tetanus; Uganda