Eliminating Tetanus in Mothers and Newborns: 47 of 59 Countries There by 2022, and the Pandemic Setback

Tetanus still kills mothers who are not fully vaccinated, and their babies, after births that are not hygienic — above all in low-income countries. A global campaign to eliminate it has made large gains: by the end of 2022, 47 of 59 priority countries had been validated as having eliminated maternal and neonatal tetanus. But the COVID-19 pandemic's disruption of routine immunization stalled progress, and cases are rising again in some countries that had already reached the goal.

Headline numbers

What tetanus does, and why it can't be wiped out

Tetanus is an infection with Clostridium tetani, a bacterium that makes a powerful toxin.

• Maternal tetanus strikes during pregnancy or within 6 weeks of its end, and can follow an abortion, a miscarriage or an unhygienic birth.
• Neonatal tetanus strikes in the first 28 days of life, after the umbilical cord is cut in unsterile conditions or unsterile traditional remedies are put on the stump — in a baby without antibodies passed on from a mother who is immune.

Tetanus spores cannot be removed from the environment, and surviving tetanus does not make a person immune. So elimination — defined as fewer than 1 newborn case per 1,000 live births a year in every district of every country — depends on continuous vaccination with a tetanus toxoid–containing vaccine (TTCV). Women of reproductive age (usually 15–49) should have at least 2 doses; a pregnant woman who is not fully vaccinated should be vaccinated early in the third trimester. Eliminating the newborn disease is treated as a stand-in for eliminating the maternal one, since the strategies are the same.

The campaign

The World Health Assembly endorsed eliminating newborn tetanus in 1989; the effort was relaunched in 1999 as the maternal and neonatal tetanus elimination (MNTE) initiative, covering 59 priority countries (57 at first, with Timor-Leste added in 2002 and South Sudan in 2011). It has four strategies:

1. Vaccinate pregnant women with at least 2 doses of TTCV during antenatal care.
2. Run vaccination campaigns — three rounds, three doses — for women of reproductive age in high-risk districts: those where estimated newborn tetanus exceeds 1 case per 1,000 live births, fewer than 70% of deliveries are clean, and coverage of pregnant women with 3 doses was under 80% over the previous 5 years.
3. Make births clean, through access to skilled birth attendants — a doctor, nurse, midwife or health worker trained in lifesaving obstetric care.
4. Find and investigate suspected newborn cases with reliable surveillance.

What a country must show

A baby counts as protected at birth if the mother had 2 doses during her previous pregnancy; 2 or more with the last within 3 years of the delivery; 3 or more with the last within 5 years; 4 or more with the last within 10 years; or 5 or more at any time.

Progress, 2000–2022

Estimated newborn tetanus deaths and infants protected at birth, worldwide, 2000–2022. Deaths are modelled; 2022 death data were not available. CDC, from Child and Adolescent Cause of Death Estimation Group and WHO/UNICEF data.

Vaccinating pregnant women. In 2022, 50 of the 59 countries (85%) reported antenatal coverage; 16 of those 50 (32%) reached 80% or more. Of 41 countries with figures for both 2000 and 2022, coverage rose in 30 (73%).

Campaigns. 52 countries (88%) ran TTCV campaigns during 2000–2022, reaching 177 million (70%) of the 252 million women targeted. In 2021–2022, seven countries that had not yet eliminated tetanus ran campaigns, reaching 13 million women (42%) with at least 2 doses and contributing to a 16% rise in the number of infants protected at birth. At the end of 2022, 68 million targeted women had still not been reached.

Skilled birth attendants. In 2022, 26 of the 47 countries with data (55%) reported that at least 70% of births had a skilled attendant. Compared with 2020, the share was higher in 12 countries: Afghanistan, Burkina Faso, Cambodia, Chad, Côte d'Ivoire, Egypt, India, Kenya, Malawi, Mauritania, Niger and Nigeria.

Cases. In 2022, 11 priority countries (19%) reported no newborn tetanus at all — but seven reported more cases than in 2000.

Validation. No country was validated during 2020–2022; Mali was validated in 2023. By 2022, four of Nigeria's six geopolitical zones, and Pakistan's Punjab province, had also been validated.

Women protected by campaign doses, targeted but not yet vaccinated, and in high-risk districts not yet targeted (mainly for programmatic reasons), with the number of countries that had eliminated maternal and neonatal tetanus, 2000–2022. WHO/UNICEF MNTE database, March 2024.

Holding on to elimination

Among the 47 validated countries in 2022:

Since 2020, newborn tetanus cases have risen in 18 priority countries (31%) — 13 of them already validated. That could mean surveillance is detecting more cases. It could also mean babies are going unprotected and antenatal vaccination needs strengthening. In 12 validated countries, fewer than 70% of births had a skilled attendant, and fewer than a third of validated countries had added even one TTCV booster to their routine schedule. That slow uptake may reflect MNTE slipping down the list of priorities after validation, for lack of funds — leaving countries open to tetanus returning.

Many countries yet to be validated have fragile health systems. Political instability and conflict make more areas hard to reach, which compounds the difficulty of vaccinating, delivering babies safely, and detecting and responding to cases. Some countries' immunization programs have struggled to recover, and seen other vaccine-preventable diseases rise, after the pandemic.

What the authors recommend

• Fold MNTE into post-pandemic immunization recovery in the priority countries; MNTE is an endorsed elimination target in WHO's Immunization Agenda 2030.
• Combine work to save resources: run post-validation assessments alongside immunization program reviews, and give TTCV boosters alongside other vaccinations — in school programs, for example, as part of vaccination across the life course.
• Merge surveillance: track newborn tetanus case by case within surveillance for other vaccine-preventable diseases such as polio and measles, and engage the public to strengthen community-based surveillance.
• Widen fair access to health services, including clean deliveries.

Caveats

• Antenatal coverage figures can understate protection: they miss women vaccinated in an earlier pregnancy but not in the current one.
• Validation works district by district, but the coverage figures here are national, and can hide differences between districts.
• Newborn tetanus deaths are modelled, so the estimates rest on the models' assumptions.

Sources

Based on Jones CE, Yusuf N, Ahmed B, Kassogue M, Wasley A, Kanu FA, "Progress Toward Achieving and Sustaining Maternal and Neonatal Tetanus Elimination — Worldwide, 2000–2022," MMWR volume 73, number 28, Centers for Disease Control and Prevention, with authors from CDC, the World Health Organization and UNICEF; a work of the United States government in the public domain. The report gives the 2000 and latest case counts once as 2000–2021 and once as 2000–2022; the 2021 dating used in its abstract and results is kept here. Its statement that "one third of 43" validated countries sustained 80% antenatal coverage does not match its count of 47 validated countries and is left out.