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

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).

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.^†††

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.^§§§

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.^§§§§