More than three weeks after the massive earthquake and tsunami struck nations around the Indian Ocean, they are still bringing new misery.  Predicted epidemics of cholera, typhoid, and measles have not materialized, but now a more unexpected killer, tetanus, is starting to claim victims. 

Siti Sarifah, 24, survived the disaster that killed all her immediate family.  A stranger pulled her bruised and bleeding from the receding waters, but her escape was only temporary.  Today she lies in hospital in Banda Aceh fighting a more insidious killer: tetanus.

She is being treated by a team of medical volunteers from Singapore, who have flown in to assist Aceh's victims.  Dr. Anton Cheng is part of the team.

"You basically go into spasms,” he explained.  “It stops you breathing, it stops you drinking, it stops you eating.  They give you a high temperature.  The spasms can be localized, it can be generalized, you arch your back.  In fact, it looks like strychnine poisoning.  It is painful as hell."

Those planning post-disaster medical assistance were prepared for more predictable problems, such as outbreaks of cholera, malaria or measles, but the number of tetanus cases has caught them by surprise.

"I think there is a couple of factors that have contributed: partly that there was a generally low immunization coverage in the population, probably in the rage 20 and 40 percent for tetanus, and secondly that there was many crush injuries because of the vast, devastating effect of the tsunami," said Dr. Eigil Sorensen, the World Health Organization's special envoy to Indonesia.

So far at least 65 cases of tetanus have been positively identified in Indonesia and the number is growing.  Most are victims of cuts that became infected because the floodwaters were contaminated by sewage and other material.

If caught early, tetanus is relatively easy to treat with an injection.  But that was not an option for people like Siti Sarifah, and if a tetanus infection is allowed to fester, it is frequently fatal.  Textbooks say the mortality rate can be as high as 80 percent.  Four of Dr. Cheng's 20 patients have died.

Dr. Cheng and his colleagues are struggling with inadequate resources.  The main hospital in Banda Aceh, where Siti is being treated, was shattered. 

Under normal circumstances, Dr. Cheng says, he would like to temporarily paralyze the patients to rid them of their spasms, but that would involve putting them on ventilators in intensive care, and there is no intensive care ward, and few ventilators.

The World Health Organization says it has enough immunization doses, and sufficient medical staff to administer them.  Doctors can theoretically protect those now being exposed to the bacteria - for instance, those who receive cuts while digging through the rubble for bodies or possessions.  But immunization might be too late for many who were exposed three-weeks ago and are still incubating the infection.

Dr. Cheng says he hopes to prove wrong the textbooks and their predictions of 80 percent mortality.  Certainly Siti seems to be pulling through, but her nurses say she is also suffering trauma from the disaster, and is refusing to eat.