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Maternal and neonatal tetanus elimination: from protecting women and newborns to protecting all

Friday, 22nd of April 2016

Maternal and neonatal tetanus elimination: from protecting women and newborns to protecting all

Authors Khan R, Vandelaer J, Yakubu A, Raza AA, Zulu F

Received 8 October 2014

Accepted for publication 20 November 2014

Published 3 February 2015 Volume 2015:7 Pages 171—180

DOI http://dx.doi.org/10.2147/IJWH.S50539

Checked for plagiarism Yes

Review by Single-blind

Peer reviewer comments 4

Editor who approved publication: Professor Elie Al-Chaer

Rownak Khan,¹ Jos Vandelaer,¹ Ahmadu Yakubu,² Azhar Abid Raza,¹ Flint Zulu<sup>1

1</sup>Health Section, Programme Division, UNICEF, New York, NY, USA; ²Family, Women and Children´s Health Cluster, World Health Organization, Geneva, Switzerland

Best viewed at https://www.dovepress.com/maternal-and-neonatal-tetanus-elimination-from-protecting-women-and-ne-peer-reviewed-fulltext-article-IJWH#

Abstract: A total of 35 of the 59 countries that had not eliminated maternal and neonatal tetanus (MNT) as a public health problem in 1999 have since achieved the MNT-elimination goal. Neonatal tetanus deaths have decreased globally from 200,000 in 2000 to 49,000 in 2013. This is the result of increased immunization coverage with tetanus toxoid-containing vaccines among pregnant women, improved access to skilled birth attendance during delivery, and targeted campaigns with these vaccines for women of reproductive age in high-risk areas. In the process, inequities have been reduced, private–public partnerships fostered, and innovations triggered. However, lack of funding, poor accessibility to some areas, suboptimal surveillance, and a perceived low priority for the disease are among the main obstacles. To ensure MNT elimination is sustained, countries must build and maintain strong routine programs that reach people with vaccination and with clean deliveries. This should also be an opportunity to shift programs into preventing tetanus among all people. Regular assessments, and where needed appropriate action, are key to prevent increases in MNT incidence over time, especially in areas that are at higher risk. The main objective of the paper is to provide a detailed update on the progress toward MNT elimination between 1999 and 2014. It elaborates on the challenges and opportunities, and discusses how MNT elimination can be sustained and to shift the program to protect wider populations against tetanus.

Background

Tetanus is a noncommunicable disease contracted through exposure to the spores of the bacteriaClostridium tetani. C. tetani exists worldwide in soil and in animal intestinal tracts, and as such can contaminate many surfaces and substances.¹ As a result of the ubiquity of the bacterium causing tetanus, the disease cannot be eradicated.^1,2 If a wound is contaminated with C. tetani, the neurotoxin produced in anaerobic conditions by the bacteria leads to tetanus.² Tetanus occurring during pregnancy or within 6 weeks of the end of pregnancy is called maternal tetanus. Neonatal tetanus (NT) is defined as tetanus in the first 28 days of life. Whereas tetanus can occur worldwide and in all age-groups, neonates, who acquire the infection through contamination of the umbilical stump, and their mothers are most at risk, particularly when childbirth takes place under unhygienic conditions, and the mothers have insufficient antitoxins due to no or suboptimal immunization to protect themselves and their newborn babies. The case-fatality rate from tetanus in resource-constrained settings can be close to 100%, but can be reduced to 50% if access to basic medical care with experienced staff is available.^1,2 In the 1980s, it was estimated that over 787,000 neonates died annually of tetanus.¹ In the early 1990s, 15,000–30,000 women died globally of maternal tetanus (5% of all maternal mortality).¹

There is no natural immunity against tetanus, but the disease is preventable through immunization. Recovery from tetanus does not confer immunity.² Tetanus vaccination at any age will prevent disease, and the duration of protection depends on the number and spacing of doses received.³Maternal immunization with tetanus toxoid-containing vaccines (TTCVs) protects both the mother and her newborn, and is therefore a cornerstone to prevent both maternal and NT (MNT), in addition to clean deliveries and clean cord-care practices.

In an effort to take advantage of the availability of existing and affordable vaccines, and to reduce the burden caused by NT, the World Health Assembly in 1989 and the World Summit for Children in 1990 called for NT elimination by 1995.⁴ NT elimination is defined as an incidence of less than one NT case per 1,000 live births in a district or similar administrative unit in a year.⁴ Later, the target date was extended to 2000 and again to 2005, and maternal tetanus elimination was added as a goal by the World Health Organization (WHO), the United Nations Children Fund (UNICEF), and the United Nations Population Fund (UNFPA) in 1999. In the absence of a definition for maternal tetanus elimination, NT elimination acts as a proxy for maternal tetanus elimination, as the predisposing conditions, risk factors, and prevention measures are the same for maternal tetanus.¹

In order to accelerate progress, the WHO, UNICEF, and UNFPA relaunched in 1999 the “Maternal and Neonatal Tetanus Elimination” initiative with a focus on 57 priority countries that had not yet eliminated MNT.⁴ Due to geopolitical divisions in 2002 and 2011, two more countries (Timor-Leste and South Sudan) were added to the list, thus totaling 59 priority countries.