Progress Toward Achieving and Sustaining Maternal and Neonatal Tetanus Elimination — Worldwide, 2000–2020

Immunization Activities

To estimate TTCV vaccination coverage delivered through routine immunization services and the number of neonates protected at birth from tetanus, World Health Organization (WHO) and UNICEF use data from administrative records and vaccination coverage surveys reported annually by member countries (4). WHO and UNICEF receive summaries of the number of women of reproductive age receiving TTCV during SIAs (5). In 2020, 16 (27%) of 59 priority countries achieved ≥80% TTCV2+ coverage, with 34 countries increasing coverage since 2000 (Table). In 2020, among 58 priority countries with available data, 46 (79%) reported ≥80% of infants protected at birth. The global proportion of infants protected at birth increased from 74% (2000) to 86% (2020) (Table).

During 2000–2020, 52 priority countries conducted TTCV SIAs, and 168 million (67%) of the targeted 250 million women of reproductive age received TTCV2+ (Table) (Figure 1). In 2020, 59 million women targeted for protection by TTCV SIAs remained unreached, and TTCV SIA activities aiming to target an estimated 16 million women of reproductive age in five countries were postponed because of COVID-19–related disruptions in immunization services (Figure 1) (6).

Deliveries Assisted by Skilled Birth Attendants

WHO and UNICEF estimate the percentage of births assisted by a skilled birth attendant from health care facility reports and coverage survey estimates shared by countries (7). During 2000–2020, the percentage of deliveries assisted by a skilled birth attendant increased 30%, from 64% (2000–2006) to 83% (2014–2020) (7). In 2020, among 50 priority countries with available data, ≥70% of deliveries were assisted by a skilled birth attendant in 28 (58%) countries (Table).

Surveillance Activities

WHO recommends nationwide, case-based surveillance for neonatal tetanus, including zero-case reporting (submission of reports even if no neonatal tetanus cases are observed) and active surveillance through regular site visits (8). The number of reported neonatal tetanus cases worldwide decreased by 88% from 17,935 (2000) to 2,229 (2020).^¶¶¶ In 2020, among all 59 priority countries, 10 (17%) reported zero cases, whereas seven countries (Angola, Central African Republic, Chad, Congo, Ethiopia, Madagascar, and Mozambique) reported more cases in 2020 than in 2000 (Table).

Most neonatal tetanus deaths occur in remote communities, which leads to underreporting. Hence, mathematical models are used to better estimate the number of neonatal tetanus deaths (9). The estimated number of neonatal tetanus deaths decreased by 92% from 170,829 (2000) to 14,230 (2019) (Figure 2). In 2019, tetanus accounted for 0.4% of all neonatal deaths, a decrease from 7% in 2000.

Validation of Maternal and Neonatal Tetanus Elimination

When a country believes it has eliminated MNT, validation activities are implemented, consisting of review of district-level core indicators, including reported neonatal tetanus cases per 1,000 live births and review of the surveillance system, percentage of clean deliveries assisted by a skilled birth attendant, and TTCV2+ coverage among pregnant women (6); the country also uses supplementary indicators, including TTCV SIA coverage, antenatal care coverage,**** infant coverage with 3 doses of the diphtheria, tetanus, and pertussis (DTP) vaccine, socioeconomic indices, urban versus rural status, field visits to assess the performance of the health system, validation surveys of poorly performing districts, and assessment of long-term plans for sustaining elimination.^†††† During 2000–2020, 47 (80%) of 59 priority countries were validated to have achieved MNTE, and 12 remain to be validated (Table) (Figure 1). In addition, by 2020, three countries were partially validated to have achieved elimination in some regions: Mali (Southern regions), Nigeria (Southeast and Southwest zones), and Pakistan (Punjab province).^§§§§

Sustainability of Maternal and Neonatal Tetanus Elimination

Once countries are validated for MNTE, WHO recommends four strategies to sustain elimination: 1) providing 3 primary doses of DTP during infancy and 3 TTCV booster doses at ages 12–23 months, 4–7 years, and 9–15 years; 2) checking maternal tetanus vaccination status during antenatal care and providing TTCV2+ to pregnant women, if needed, to ensure that ≥70% of infants are protected at birth; 3) promoting ≥60% clean deliveries through increased access to a skilled birth attendant ; and 4) maintaining strong neonatal tetanus surveillance (6). After validation, WHO recommends that countries conduct annual neonatal tetanus risk analyses as part of an immunization desk review and complete postvalidation assessments every 5 years to identify whether elimination status is maintained and take corrective actions as needed (6). In 2020, 14 (30%) of the 47 priority countries validated for MNTE achieved ≥90%^¶¶¶¶ coverage with 3 doses of DTP; TTCV booster doses***** were provided to children aged 12–23 months in 11 (23%) of those countries, to children aged 4–7 years in 12 (26%) countries, and to children aged 9–15 years in nine (19%) countries. In 45 (96%) countries, ≥70% of infants were protected at birth against tetanus; and in 34 (72%), ≥60% of births were assisted by a skilled birth attendant.

Five countries (Algeria, Cameroon, Djibouti, Indonesia, and Timor-Leste) implemented postvalidation assessments for corrective actions and have met the sustainability indicators for infants protected at birth and the percentage of births with access to a skilled birth attendant. In addition, Cameroon conducted annual neonatal tetanus risk analyses and used assessment outcomes for corrective action by targeting women of reproductive age in high-risk districts with two rounds of TTCV SIAs to sustain MNTE.

Discussion

Substantial progress has been made toward global MNTE; 80% of the 59 priority countries were validated to have achieved MNTE by the end of 2020. Progress can be attributed to increases in TTCV2+ coverage among women of reproductive age in 34 (58%) of 59 priority countries, implementation of intensive SIAs in high-risk districts, and a 30% increase in deliveries with a skilled birth attendant. These efforts contributed to a 16% increase in infants protected against tetanus at birth and a 92% decline in estimated neonatal tetanus mortality since 2000.

Although progress has been made, countries that have not achieved MNTE still face several challenges. First, suboptimal health systems, evidenced by low vaccination coverage and low proportions of safe and clean deliveries assisted by a skilled birth attendant, make it difficult to adequately implement MNTE strategies. Second, conflict and political instability in some countries contribute to districts remaining inaccessible and at high risk for the incidence of maternal and neonatal tetanus. Lastly, country immunization programs might have competing priorities in addressing the overall incidence of vaccine preventable diseases (e.g., measles and polio) or responding to outbreaks (e.g., Ebola and COVID-19) that hinder their ability to achieve MNTE. During 2020, the COVID-19 pandemic affected TTCV SIAs planned in five countries.

Complete eradication of tetanus is not possible because tetanus spores are ubiquitous in the environment. Therefore, countries need to implement strategies to sustain MNTE. Only five of 47 countries validated for MNTE have conducted the recommended postvalidation assessments, and only 12 have introduced ≥1 TTCV booster doses in their routine immunization schedule. This low uptake could be attributed to competing priorities and the deprioritizing of MNTE once countries are validated, which put countries at risk for reemergence of MNT (6). Combining MNTE postvalidation assessments with review of immunization programs and integrating childhood and adolescent tetanus vaccination with other immunization activities (e.g., measles vaccination during second year of life, school vaccination programs, or human papillomavirus vaccination) promote better efficiency and use of resources and help sustain MNTE. Neonatal tetanus case-based surveillance could also be integrated into polio and measles case-based surveillance; community engagement might help raise awareness of neonatal tetanus and serve to strengthen community-based vaccine preventable disease surveillance systems (8).

The findings in this report are subject to at least three limitations. First, TTCV coverage among pregnant women can underestimate true tetanus protection because it excludes women who were unvaccinated during current pregnancy but protected through previous vaccination or those missing documentation of previous doses (6). Second, the percentage of infants protected at birth could be underestimated because of doses provided outside routine services (6). Finally, <10% of neonatal tetanus cases and deaths are estimated to be reported (2); although neonatal deaths are projected using mathematical models, cases and deaths might still be underestimated, especially in communities with suboptimal health systems.

The Immunization Agenda 2030,^{†††††} the global immunization strategy for the next decade, includes MNTE as an endorsed vaccine-preventable disease elimination target. To achieve and sustain MNTE, strong national commitment and integration are needed, including integrating MNTE activities with polio, measles, cholera, yellow fever, or other vaccine-preventable disease SIAs, using MNTE to promote equitable access to health services, such as clean deliveries, and promoting a life course approach to tetanus vaccination by integrating TTCV booster doses in school health programs and other life course immunization platforms (10).