Eliminating Maternal and Newborn Tetanus Worldwide, 2000–2018

This page summarizes progress through 2018, as reported by CDC, WHO and UNICEF in 2020.

Maternal and neonatal tetanus (MNT) remains a major public health problem. Neonatal tetanus kills 80% to 100% of the newborns it strikes, especially where vaccination coverage is low and few births take place in clean conditions with trained attendants. Newborns are infected when the umbilical cord is cut with unsterile instruments or unsterile traditional remedies are applied to the cord stump, in babies who did not receive protective antibodies from their mothers; mothers can be infected through unhygienic deliveries, miscarriages or abortions.

In 1989 the World Health Assembly endorsed eliminating neonatal tetanus, defined as fewer than one case per 1,000 live births per year in every district of every country. In 1999 the effort was relaunched as the MNT elimination initiative, focused on 59 priority countries still at risk.

The strategy

• Vaccinate women: reach at least 80% coverage with 2 or more doses of tetanus toxoid-containing vaccine among women of reproductive age, through routine vaccination of pregnant women and mass vaccination campaigns in high-risk districts.
• Make births safer: have at least 70% of deliveries attended by a skilled birth attendant (a midwife, trained nurse, doctor, or health extension or community health worker).
• Strengthen surveillance for neonatal tetanus cases.

Progress, 2000–2018

Vaccination. In 2018, 17 of the 59 priority countries reached 80% coverage with 2 or more doses, and coverage rose in 39 of the 48 with data for both years. In 46 countries (78%), at least 80% of infants were protected at birth because their mothers had been vaccinated. By the end of 2018, 52 priority countries had run vaccination campaigns, reaching 154 million of the 201 million women targeted with at least 2 doses; 49 million remained unreached. Of the 45 countries that achieved elimination, 38 used campaigns. Six others (China, Eritrea, Namibia, Rwanda, South Africa and Zimbabwe) did it by strengthening routine immunization and reproductive health services, and Malawi by vaccinating women during pregnancy and giving 5 doses of tetanus vaccine to children and adolescents.

Surveillance. WHO recommends nationwide case-based surveillance, including reporting zero cases, regular site visits and yearly reviews of hospital records. In 2018, 13 priority countries reported no cases. Reported cases probably represent less than 11% of the true number, since neonatal tetanus strikes mostly in remote areas and many cases are never seen by health workers; deaths are estimated with models for the same reason. Neonatal tetanus fell from 7% of newborn deaths in 2000 to 1% in 2018.

Safer births. Among 51 priority countries with data in 2018, 24 had skilled attendants at 70% or more of deliveries.

Validation. WHO validates elimination after reviewing district-level indicators such as case rates, attended births and vaccination coverage, along with field visits and surveys of the poorest-performing districts. By 2018, 45 priority countries had been validated, and Pakistan (Punjab province), Mali (southern regions) and Nigeria (South East zone) had been validated in part. Chad and the Democratic Republic of the Congo followed in 2019, leaving 12 countries not validated by December 2019.

What worked, and what remains

Keys to success included better access to education for women, national commitment, timely resources, well-planned campaigns, community engagement, strong monitoring, and delivering antenatal care and tetanus vaccination together. Because tetanus lives in the environment and cannot be eradicated, elimination has to be sustained. Reviews in Cameroon, Timor-Leste, Algeria and Djibouti found it had held, though Cameroon and Timor-Leste needed more skilled birth attendants.

To sustain and extend elimination, the authors recommend:

• a 3-dose primary series of tetanus vaccine in childhood plus boosters at 12–23 months, 4–7 years and 9–15 years, as WHO recommends
• screening pregnant women to ensure newborns are protected
• more skilled attendants, and clean delivery kits for every home birth
• strong surveillance and regular review of data to spot districts at risk of a resurgence
• innovations for remote and unsafe areas: compact prefilled auto-disable injection devices, combining maternal and child health services with vaccination, and pairing tetanus campaigns with serogroup A meningococcal, measles-rubella, yellow fever and polio campaigns

Conflict and insecurity, weak health systems, competing priorities and withdrawn donor funding remain obstacles in the countries still at risk.

Limitations: coverage with 2 doses may understate true protection where women were already protected by earlier doses, and reported cases and deaths are underestimates because most occur in communities the health system does not reach.

Sources

• Njuguna HN, Yusuf N, Raza AA, Ahmed B, Tohme RA. "Progress Toward Maternal and Neonatal Tetanus Elimination — Worldwide, 2000–2018." MMWR 69(17). https://www.cdc.gov/mmwr/volumes/69/wr/mm6917a2.htm
• The report's map and chart are not reproduced here because it was prepared jointly with WHO and UNICEF.