Progress Toward Maternal and Neonatal Tetanus Elimination — Worldwide, 2000–2018

Abstract

Maternal and neonatal tetanus* (MNT) remains a major public health problem, with an 80%–100% case-fatality rate among neonates, especially in areas with poor immunization coverage and limited access to clean deliveries (i.e., delivery in a health facility or assisted by medically trained attendants in sanitary conditions) and umbilical cord care ( 1 ). In 1989, the World Health Assembly endorsed the elimination † of neonatal tetanus (NT), and in 1999, the initiative was relaunched and renamed the MNT elimination § initiative, targeting 59 ¶ priority countries ( 1 ). Elimination strategies include 1) achieving ≥80% coverage with ≥2 doses of tetanus toxoid-containing vaccine (TTCV) among women of reproductive age through routine immunization of pregnant women and supplementary immunization activities (SIAs)** in high-risk areas and districts †† ; 2) achieving care at ≥70% of deliveries by a skilled birth attendant (SBA) §§ ; and 3) enhancing surveillance for NT cases ( 1 ). This report summarizes progress toward achieving MNT elimination during 2000–2018. Coverage with ≥2 doses of TTCV (2 doses of tetanus toxoid [TT2+] or 2 doses of tetanus-diphtheria toxoid [Td2+]) among women of reproductive age increased by 16%, from 62% in 2000 to 72% in 2018. By December 2018, 52 (88%) of 59 priority countries had conducted TTCV SIAs, vaccinating 154 million (77%) of 201 million targeted women of reproductive age with TT2+/Td2+. Globally, the percentage of deliveries assisted by SBAs increased from 62% during 2000–2005 to 81% during 2013–2018, and estimated neonatal tetanus deaths decreased by 85%, from 170,829 in 2000 to 25,000 in 2018. By December 2018, 45 (76%) of 59 priority countries were validated by WHO as having achieved MNT elimination. To achieve elimination in the remaining 14 countries and sustain elimination in countries that have achieved it, implementation of MNT elimination strategies needs to be maintained and strengthened, and TTCV booster doses need to be included in country immunization schedules as recommended by the World Health Organization (WHO) ( 2 ). In addition, integration of maternal, newborn, and child health services with vaccination services is needed, as well as innovative approaches to target hard-to-reach areas for tetanus vaccination and community engagement to strengthen surveillance. Immunization Activities To estimate TT2+/Td2+ vaccination coverage delivered through routine immunization services and the number of neonates protected at birth (PAB) ¶¶ from neonatal tetanus, WHO and the United Nations Children’s Fund (UNICEF) use data from administrative records and vaccination coverage surveys reported annually by member countries ( 3 ). WHO and UNICEF also receive summaries of the number of women of reproductive age receiving TTCV during SIAs ( 4 ). During 2000–2018, coverage worldwide of women of reproductive age with TT2+/Td2+ increased by 16%, from 62% to 72% ( 3 ). In 2018, 17 (29%) of 59 priority countries achieved TT2+/Td2+ coverage ≥80%; in 39 of 48 (81%) priority countries where data were available,*** TT2+/Td2+ coverage increased compared with that in 2000. In 2018, the percentage of infants who were PAB was ≥80% in 46 (78%) of 59 priority countries (Table). TABLE Estimated coverage with ≥2 doses of tetanus toxoid-containing vaccine (TTCV) among women of reproductive age (WRA) administered through routine immunization services, estimated percentage of newborns protected at birth (PAB), number of WRA vaccinated with TTCV during supplementary immunization activities (SIAs), percentage of deliveries attended by a skilled birth attendant (SBA), and number of reported neonatal tetanus cases — 59 priority countries, 2000–2018 MNT elimination priority countries WRA TT2+/Td2+ coverage (%) Newborns PAB (%) WRA vaccinated during TTCV SIAs* SBA attendance at delivery (%) No. of neonatal tetanus cases Year Change 2000–2018 (%) Year Change 2000–2018 (%) No. of TT2+/Td2+ doses received % vaccinated Year† Change 2000–2018 (%) Year Change 2000–2018 (%) 2000 2018 2000 2018 2000 2018 2000 2018 Validated for MNT elimination by end-2018 Bangladesh 89 97 9 89 98 10 1,438,374 47 12 68 467 376 84 −78 Benin 81 69 −15 87 85 −2 1,399,461 97 66 78 18 52 13 −75 Burkina Faso NA 92 NA 57 92 61 2,306,835 91 38 80 111 22 3 −86 Burma 81 89 10 79 90 14 8,170,763 87 57 60 5 41 22 −46 Burundi 28 90 221 51 90 76 679,222 55 25 85 240 16 0 −100 Cambodia 40 75 88 58 93 60 2,099,471 79 32 89 178 295 14 −95 Cameroon 40 66 65 54 85 57 2,687,461 85 56 65 16 279 27 −90 China NA NA NA NA NA NA NA NA 97 100 3 3230 83 −97 Comoros 40 78 95 57 85 49 160,767 55 62 NA NA NA 1 NA Congo 39 83 113 67 85 27 273,003 91 83 91 10 2 0 −100 Côte d'Ivoire 78 85 9 76 85 12 5,924,527 85 63 74 17 30 17 −43 Egypt 71 NA NA 80 86 7 2,518,802 87 61 92 51 321 2 −99 Equatorial Guinea 30 41 37 61 70 15 26,466 9 65 NA NA NA 6 NA Eritrea 25 65 160 80 99 24 NA NA 28 NA NA 4 0 −100 Ethiopia 32 87 172 54 93 72 13,210,107 84 6 16 167 20 14 −30 Gabon 16 50 213 39 85 118 79,343 90 86 NA NA 8 0 −100 Ghana 73 64 −12 69 89 29 1,666,666 87 47 78 66 80 9 −89 Guinea Bissau NA NA NA 49 83 69 312,669 98 32 45 41 NA 0 NA Haiti NA NA NA 41 81 98 2,785,588 88 24 42 75 40 3 −93 India 80 81 1 85 90 6 7,643,440 94 43 81 88 3287 129 −96 Indonesia 81 47 −42 82 85 4 1,442,264 50 66 94 42 466 14 −97 Iraq 55 49 −11 75 75 0 111,721 96 65 96 48 37 3 −92 Kenya 51 61 20 68 88 29 4,463,695 67 42 62 48 1278 NA NA Laos 45 37 −18 58 90 55 968,323 90 17 64 276 21 16 −24 Liberia 25 74 196 51 89 75 288,984 57 51 61 20 152 14 −91 Madagascar 40 51 28 58 78 34 2,705,588 72 47 44 −6 13 30 131 Malawi 61 67 10 84 89 6 NA NA 56 87 55 12 9 −25 Mauritania NA 31 NA 44 80 82 586,277 76 53 69 30 NA 0 NA Mozambique 61 85 39 75 86 15 605,640 79 48 73 52 42 160 281 Namibia 60 76 27 74 88 19 NA NA 76 88 16 10 0 −100 Nepal 60 75 25 67 89 33 4,537,864 86 12 58 383 134 2 −99 Niger 31 94 203 63 81 29 2,184,277 92 16 40 150 55 9 −84 Philippines 58 48 −17 55 90 64 1,034,080 78 58 84 45 281 54 −81 Rwanda NA 90 NA 81 95 17 NA NA 31 91 194 5 2 −60 Senegal 45 65 44 62 95 53 359,845 92 58 68 17 0 6 NA Sierra Leone 20 90 350 53 90 70 1,704,814 102 37 69 86 36 36 0 South Africa 65 NA NA 68 90 32 NA NA 91 97 7 11 0 −100 Tanzania 77 94 22 79 90 14 987,575 71 43 64 49 48 0 −100 Timor-Leste NA 68 NA NA 83 NA 24,141 53 18 57 217 NA 1 NA Togo 47 76 62 63 83 32 262,130 87 35 45 29 33 14 −58 Turkey 36 55 53 50 95 90 1,242,674 58 83 98 18 26 0 −100 Uganda 42 66 57 70 85 21 2,448,527 86 39 74 90 470 78 −83 Vietnam 90 88 −2 86 94 9 367,842 69 59 94 59 142 37 −74 Zambia 61 76 25 78 85 9 330,030 81 42 63 50 130 71 −45 Zimbabwe 60 75 25 76 87 14 NA NA NA 78 NA 16 0 −100 Not validated for MNT elimination by the end of 2018 Afghanistan 20 85 325 32 68 113 5,211,872 46 14 59 321 139 53 −62 Angola NA 66 NA 60 78 30 7,097,552 84 NA 47 NA 131 86 −34 Central African Republic 20 89 345 36 60 67 804,984 78 32 NA NA 37 39 5 Chad§ 12 69 475 39 78 100 3,222,840 84 14 20 43 142 189 33 Democratic Republic of the Congo§ 25 96 284 45 85 89 10,342,937 92 61 80 31 77 47 −39 Guinea 43 70 63 79 80 1 3,545,105 91 49 55 12 245 107 −56 Mali 62 60 −3 50 85 70 4,086,957 49 41 67 63 73 10 −86 Nigeria NA 62 NA 57 60 5 4,986,353 84 34 43 26 1643 130 −92 Pakistan 51 60 18 71 85 20 21,143,148 87 23 69 200 1380 0 −100 Papua New Guinea 10 30 200 24 70 192 450,739 15 39 NA NA 138 0 −100 Somalia 22 59 168 47 67 43 497,561 27 25 NA NA NA NA NA South Sudan NA 44 NA NA NA NA 5,223,306 65 NA NA NA NA NA NA Sudan 34 51 50 NA 80 NA 4,780,345 89 NA 78 NA 88 NA NA Yemen 31 22 −29 54 70 30 3,043,456 52 27 45 67 174 116 −33 All 59 priority countries — — — — — — 154,476,411 — — — — 16,754 1,760 — Abbreviations: MNT = maternal and neonatal tetanus; NA = not available; Td2+ = 2 or more doses of tetanus and diphtheria toxoid-containing vaccine; TT2+ = 2 or more doses of TTCV. * Includes first-year SIA conducted in Bangladesh in 1999 and first- and second-year SIAs conducted in Ethiopia in 1999. † Includes SBA attendance surveys conducted within 5 years for year 2000 and year 2018. § Validated for MNT elimination in 2019. By the end of 2018, 52 (88%) of 59 priority countries had conducted TTCV SIAs, and 154 million (77%) of the targeted 201 million women of reproductive age received at least 2 doses of TTCV ( 4 ). In 2018, 49 million women remain unreached by TTCV SIAs (Figure 1). Among the 52 countries that conducted TTCV SIAs, 29 (56%) vaccinated ≥80% of the targeted women with ≥2 doses of TTCV (Table). Among the 45 countries that achieved MNT elimination by the end of 2018, 38 (84%) had conducted TTCV SIAs. Among the seven countries that achieved elimination by the end of 2018 but did not conduct SIAs, six (China, Eritrea, Namibia, Rwanda, South Africa, and Zimbabwe) achieved MNT elimination through strengthening of routine immunization and reproductive health services; one country (Malawi) achieved elimination because women of reproductive age are targeted for vaccination during pregnancy, and 5 TTCV doses are provided in the routine vaccination schedule for children and adolescents. ††† FIGURE 1 Number of women of reproductive age protected by TTCV* received during SIAs, number targeted but not yet vaccinated, number not yet targeted, and number of priority countries achieving maternal and neonatal tetanus elimination — worldwide, 2000–2018 Abbreviations: SIAs = supplementary immunization activities; TTCV = tetanus toxoid–containing vaccine. * 2 doses of tetanus toxoid (TT) or 2 doses of tetanus and diphtheria toxoids (Td). The figure is a combination bar and line graph showing the number of women of reproductive age protected by TTCV received during SIAs, number targeted but not yet vaccinated, number not yet targeted, and number of priority countries worldwide achieving maternal and neonatal tetanus elimination during 2000–2018. Surveillance Activities Reported NT cases and incidence. WHO recommends nationwide case-based surveillance for NT, including zero-case reporting (submission of reports even if no NT cases are seen), active surveillance through regular site visits, and retrospective record review at major health facilities at least once a year ( 2 ). During 2000–2018, the number of reported NT cases worldwide (i.e., including nonpriority countries) decreased by 90% from 17,935 to 1,803 ( 3 ). In 2018, 13 (22%) of 59 priority countries reported zero NT cases (Table). The number of NT cases reported annually is likely to represent <11% of the actual number of NT cases occurring worldwide annually, because NT tends to occur in remote areas and cases might not be seen by health care workers ( 5 ). NT mortality estimates. Because most NT deaths occur in the community and are not reported to WHO, NT deaths are usually estimated using mathematical models ( 6 ). During 2000–2018, the estimated number of NT deaths decreased by 85% from 170,829 to 25,000 (Figure 2). In 2018, neonatal tetanus accounted for 1% of major causes of neonatal deaths, a significant decrease compared with a 7% contribution to all-cause neonatal mortality in 2000. §§§ FIGURE 2 Estimated number of neonatal tetanus (NT) deaths and estimated coverage with ≥2 doses of tetanus toxoid (TT) or tetanus and diphtheria toxoids (Td)–containing vaccine (TT2+/Td2+) among women of reproductive age — worldwide, 2000–2018 The figure is a combination bar and line graph showing the estimated number of neonatal tetanus deaths and estimated coverage with ≥2 doses of tetanus toxoid (TT) or tetanus and diphtheria toxoids (Td)–containing vaccine (TT2+/Td2+) among women worldwide of reproductive age, during 2000–2018. Deliveries Assisted by Skilled Birth Attendants WHO and UNICEF estimate the percentage of births attended by an SBA from health facility reports and coverage survey estimates shared by countries ( 7 ). During 2000–2018, the percentage of deliveries attended by an SBA increased by 31% from 62% during 2000–2005 to 81% during 2013–2018 ( 7 ). In 2018, among 51 priority countries with available data, ≥70% of deliveries were attended by an SBA in 24 (47%) countries (Table). Validation of Maternal and Neonatal Tetanus Elimination WHO recommends the validation of MNT elimination when countries complete the implementation of planned elimination activities ( 8 ). The validation process involves a review of district-level core indicators, including reported NT cases per 1,000 live births, percentage of deliveries by SBA, TT2+/Td2+ coverage, and supplementary indicators, including TTCV SIA coverage, antenatal care coverage, ¶¶¶ infant coverage with 3 doses of diphtheria-tetanus-pertussis vaccine, socioeconomic indices, urban versus rural status, field visits to assess the performance of the health system, validation surveys of districts with the most poorly performing MNT elimination indicators, and assessment of long-term plans for sustaining elimination ( 9 ). During 2000–2018, 45 (76%) of 59 priority countries were validated to have achieved MNT elimination, and 14**** remain to be validated (Table) (Figure 1). In addition, by 2018, three countries were validated to have achieved elimination in some regions: Pakistan (Punjab province), Mali (Southern regions), and Nigeria (South East zone). Discussion There has been significant progress globally to eliminate MNT, and approximately 75% of the 59 priority countries were validated to have achieved MNT elimination by the end of 2018. The intensive targeting of “high-risk areas and districts” reached an estimated 154 million women of reproductive age with at least 2 doses of TTCV through SIAs, resulting in an 85% decline in the number of NT deaths annually during 2000–2018. Critical factors contributing to success include improvement in women’s access to education, country commitment to the implementation of recommended elimination strategies, timely availability of resources, good planning for SIAs, community engagement in elimination activities, strong monitoring and supervision of MNT elimination activities, and integrated delivery of antenatal care and tetanus vaccination services. Once countries are validated to have achieved MNT elimination, efforts to sustain elimination and broader tetanus control should continue, because tetanus cannot be eradicated from the environment. MNT elimination validation assessments conducted in Cameroon and Timor-Leste, as well as Algeria and Djibouti (both validated before the 1999 relaunch of the initiative), showed that elimination was sustained; however, access to SBAs needed to be improved in Cameroon and Timor-Leste. Critical strategies for sustaining MNT elimination include strengthening routine immunization services for children and adolescents to receive a 3-dose primary TTCV series, and 3 TTCV booster doses at ages 12–23 months, 4–7 years, and 9–15 years to ensure long-term protection; antenatal screening of pregnant women for tetanus vaccination to ensure protection of neonates at birth; increased access to SBAs and clean delivery and cord care practices; strong tetanus surveillance; and periodic review of data to identify districts that are at risk for reemergence of MNT ( 2 ). The findings in this report are subject to at least two limitations. First, TT2+/Td2+ coverage can underestimate true protection from tetanus, especially in countries with well-established vaccination programs, because it excludes women who were unvaccinated during pregnancy but were already protected through previous vaccination or had undocumented previous doses ( 10 ). Therefore, the percentage of PAB needs to be assessed, especially in countries that have achieved MNT elimination. Second, the number of neonatal tetanus cases and deaths are an underestimate of the actual number of NT cases because the majority of deaths occur in communities in areas underserved by the health care system ( 5 ). Despite the progress made, the MNT elimination initiative still faces numerous challenges. Approximately 47 million women and their babies remain unprotected against tetanus, and 49 million women remain unreached by TTCV SIAs. Low TT2+/Td2+ coverage in these countries can be attributed to weak health systems, including conflict and security issues that limit access to vaccination services, competing priorities that limit the implementation of planned MNT elimination activities, and withdrawal of donor funding. Promoting institutional deliveries and ensuring the availability of clean delivery kits †††† for every home delivery would help MNT elimination and efforts to achieve the United Nations’ Sustainable Development Goal 3 to reduce maternal and neonatal mortality (https://www.un.org/sustainabledevelopment/health/). Innovative approaches to reach remote and unsafe areas could include the use of compact, prefilled autodisable devices; integration of reproductive, maternal, newborn, and child health services with vaccination services to optimize maternal immunization; and integration of TTCV SIAs with other SIAs, such as serogroup A meningococcal vaccine (MenA), measles-rubella, yellow fever, and polio campaigns. Efforts to strengthen NT surveillance through community engagement could serve as a platform for creating community-based surveillance systems for other diseases, and case-based surveillance for NT could be integrated with polio and measles case-based surveillance. §§§§ Summary What is already known about this topic? In 1999, the maternal and neonatal tetanus (MNT) elimination initiative was relaunched to focus on 59 priority countries that were still at risk for neonatal tetanus (NT). What is added by this report? During 2000–2018, 45 countries achieved MNT elimination, reported NT cases decreased 90%, and estimated deaths declined 85%. Despite this progress, some countries that achieved elimination are still struggling to sustain performance indicators; war and insecurity pose challenges in countries that have not achieved MNT elimination. What are the implications for public health practice? To maintain MNT elimination and to achieve it in remaining priority countries, sustained efforts are needed to enhance routine vaccination, embrace life-course vaccination, and develop innovative strategies for reaching underserved populations.