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

Abstract

Maternal and neonatal tetanus (MNT)* remains a major cause of neonatal mortality with an 80%–100% case-fatality rate among insufficiently vaccinated mothers after unhygienic deliveries, especially in low-income countries ( 1 ). In 1989, the World Health Assembly endorsed elimination † of neonatal tetanus; the activity was relaunched in 1999 as the MNT elimination (MNTE) § initiative, targeting 59 ¶ priority countries. MNTE strategies include 1) achieving ≥80% coverage with ≥2 doses of tetanus toxoid–containing vaccine (TTCV2+)** among women of reproductive age through routine and supplementary immunization activities (SIAs) †† in high-risk districts, §§ 2) achieving ≥70% of deliveries by a skilled birth attendant, ¶¶ and 3) implementing neonatal tetanus case-based surveillance ( 2 ). This report summarizes progress toward achieving and sustaining MNTE during 2000–2020 and updates a previous report ( 3 ). By December 2020, 52 (88%) of 59 priority countries had conducted TTCV SIAs. Globally, infants protected at birth*** against tetanus increased from 74% (2000) to 86% (2020), and deliveries assisted by a skilled birth attendant increased from 64% (2000–2006) to 83% (2014–2020). Reported neonatal tetanus cases worldwide decreased by 88%, from 17,935 (2000) to 2,229 (2020), and estimated deaths decreased by 92%, from 170,829 (2000) to 14,230 (2019). ††† By December 2020, 47 (80%) of 59 priority countries were validated to have achieved MNTE, five of which conducted postvalidation assessments. §§§ To achieve elimination in the 12 remaining countries and sustain elimination, innovation is needed, including integrating SIAs to cover multiple vaccine preventable diseases and implementing TTCV life course vaccination. 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). TABLE Indicators of maternal and neonatal tetanus elimination — 59 priority countries, 2000–2020 Country ≥2 TTCV doses among women of reproductive age* (%) Newborns protected at birth (%) Women of reproductive age vaccinated during TTCV SIAs Skilled birth attendant at delivery† (%) No. of neonatal tetanus cases Year Change 2000–2020 (%) Year Change 2000–2020 (%) No. of TT2+/Td2+ doses received Vaccinated (%) Year Change 2000–2020 (%) Year Change 2000–2020 (%) 2000 2020 2000 2020 2000† 2020† 2000 2020 Validated for maternal and neonatal tetanus elimination by end of 2020 Bangladesh 89 94 6 89 98 10 1,438,374 47 12 59 388 376 41 −89 Benin 81 83 2 87 81 −7 1,399,461 97 66 78 19 52 27 −48 Burkina Faso§ NA 69 NA 57 95 67 2,306,835 91 38 80 111 22 5 −77 Burma 81 83 3 79 90 14 8,170,763 87 57 60 6 41 17 −59 Burundi 28 89 218 51 90 76 679,222 55 25 85 238 16 0 −100 Cambodia 40 77 92 58 95 64 2,099,471 79 32 89 180 295 7 −98 Cameroon 40 62 56 54 83 54 2,687,461 85 56 69 23 279 16 −94 Chad 12 74 520 39 78 100 3,222,840 84 14 24 77 142 251 77 China NA NA NA NA NA NA NA NA 97 100 3 3,230 32 −99 Comoros 40 78 95 57 83 46 160,767 55 62 NA NA NA 0 NA Congo 39 72 85 67 87 30 273,003 91 83 91 9 2 54 2,600¶ Côte d’Ivoire 78 75 −3 76 86 13 5,924,527 85 63 74 17 30 17 −43 Democratic Republic of the Congo 25 96 283 45 85 89 10,342,937 92 61 85 40 77 48 −38 Egypt 71 NA NA 80 86 8 2,518,802 87 61 92 50 321 2 −99 Equatorial Guinea 30 36 20 61 60 −2 26,466 9 65 NA NA NA 4 NA Eritrea 25 65 160 80 99 24 NA NA 28 NA NA 4 0 −100 Ethiopia 32 90 181 54 90 67 13,210,107 84 6 50 789 20 45 125 Gabon 16 43 171 39 83 113 79,343 90 86 NA NA 8 1 −88 Ghana 73 62 −15 69 90 30 1,666,666 87 47 79 68 80 0 −100 Guinea-Bissau NA 90 NA 49 83 69 312,669 98 32 54 69 NA 3 NA Haiti NA 44 NA 41 80 95 2,785,588 88 24 42 75 40 4 −90 India 80 78 −2 85 90 6 7,643,440 94 43 81 92 3,287 162 −95 Indonesia§ 81 54 −34 82 85 4 1,442,264 50 66 95 43 466 4 −99 Iraq 55 42 −24 75 73 −3 111,721 96 65 96 47 37 0 −100 Kenya 51 NA NA 68 88 29 4,463,695 67 43 70 65 1,278 0 −100 Laos 45 40 −12 58 93 60 968,323 90 17 64 286 21 12 −43 Liberia 25 20 −18 51 90 76 288,984 57 51 84 66 152 1 −99 Madagascar 40 52 30 58 75 29 2,705,588 72 47 46 −2 13 42 223 Malawi 61 70 15 84 90 7 NA NA 56 90 62 12 NA NA Mauritania NA 31 NA 44 83 89 586,277 76 53 69 30 NA 0 NA Mozambique§ 61 88 45 75 86 15 605,640 79 48 73 53 42 155 269 Namibia§ 60 96 60 74 90 22 NA NA 76 NA NA 10 NA NA Nepal 60 80 33 67 89 33 4,537,864 86 12 77 549 134 3 −98 Niger 31 79 155 63 83 32 2,184,277 92 16 39 149 55 1 −98 Philippines 58 39 −33 55 91 65 1,034,080 78 58 84 46 281 28 −90 Rwanda§ NA 70 NA 81 97 20 NA NA 31 94 201 5 0 −100 Senegal 45 68 51 62 95 53 359,845 92 58 75 29 0 0 NA Sierra Leone 20 95 377 53 93 75 1,704,814 102 37 87 134 36 7 −81 South Africa 65 NA NA 68 90 32 NA NA 91 97 6 11 3 −73 Tanzania 77 92 19 79 91 15 987,575 71 43 64 46 48 2 −96 Timor-Leste NA 69 NA NA 83 NA 24,141 53 24 57 136 NA 2 NA Togo 47 71 52 63 83 32 262,130 87 35 69 96 33 12 −64 Turkey 36 67 85 50 95 90 1,242,674 58 83 97 17 26 0 −100 Uganda 42 65 54 70 83 19 2,448,527 86 36 74 106 470 35 −93 Vietnam§ 90 88 −2 86 96 12 367,842 69 59 NA NA 142 41 −71 Zambia 61 NA NA 78 85 9 330,030 81 42 80 91 130 26 −80 Zimbabwe 60 62 4 76 87 14 NA NA NA 86 NA 16 1 −94 Not validated for maternal and neonatal tetanus elimination by end of 2020 Afghanistan 20 82 308 32 63 97 5,212,394 45 14 59 311 139 NA NA Angola NA 41 NA 60 70 17 7,097,552 84 NA 50 NA 131 156 19 Central African Republic 20 88 341 36 63 75 804,984 30 32 40 27 37 177 378 Guinea 43 84 95 79 83 5 4,773,787 55 49 55 14 245 63 −74 Mali 62 39 −37 50 87 74 4,158,201 49 41 67 66 73 8 −89 Nigeria NA 32 NA 57 65 14 9,365,295 66 35 43 23 1,643 55 −97 Pakistan 51 62 22 71 85 20 25,405,510 84 23 71 209 1,380 504 −63 Papua New Guinea 10 32 219 24 67 179 450,739 15 39 56 45 138 4 −97 Somalia 22 66 200 47 60 28 497,561 27 19 32 65 966 NA NA South Sudan NA 61 NA NA 65 NA 6,002,402 64 NA NA NA NA 3 NA Sudan 34 49 43 61 81 33 7,365,615 86 NA NA NA 88 34 −61 Yemen 31 22 −30 54 70 30 3,546,356 53 27 NA NA 174 91 −48 Sources: Neonatal tetanus data: WHO Global Health Observatory Data Repository (2000–2020), Protected at birth data: WHO/UNICEF Joint Reporting Form on Immunization (2000–2020), Skilled birth attendant data: WHO Global Health Observatory Data Repository (2000–2020), SIA data: WHO/UNICEF Maternal and Neonatal Tetanus Elimination Database, as of January 2022, TTCV data: WHO Global Health Observatory Data Repository (2000–2020). Abbreviations: NA = not available; SIA = supplementary immunization activity; TT2+/Td2+ = ≥2 doses of tetanus toxoid/tetanus-diphtheria toxoid; TTCV = tetanus toxoid–containing vaccine; WHO = World Health Organization. * Includes first-year SIA conducted in Bangladesh in 1999 and first- and second-year SIAs conducted in Ethiopia in 1999. † Includes skilled birth attendant surveys conducted within 5 years for year 2000 and year 2020. § Administrative data of TTCV coverage with ≥2 doses among women of reproductive age were used when official data were unavailable for select country. ¶ The increase in neonatal tetanus cases seen from 2000 to 2020 might be the result of improvement in surveillance. 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 ). FIGURE 1 Number of women of reproductive age protected by tetanus toxoid–containing vaccine* received during supplementary immunization activities, number targeted but not yet vaccinated, number not yet targeted, and number of priority countries achieving maternal and neonatal tetanus elimination — worldwide, 2000–2020 Source: WHO/UNICEF Maternal and Neonatal Tetanus Elimination Database, as of January 2022. Abbreviations: SIA = supplementary immunization activities; WHO = World Health Organization. * Protected with 2 doses of tetanus toxoid or 2 doses of tetanus and diphtheria toxoids. This figure consists of a bar graph indicating the number of women of reproductive age protected by a tetanus toxoid-containing vaccine during supplementary immunization activities, number targeted but not yet vaccinated, number not yet targeted, and a line graph indicating the number of priority countries achieving maternal and neonatal tetanus elimination worldwide during 2000–2020. 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. FIGURE 2 Estimated number of neonatal tetanus deaths* and estimated proportion of children protected at birth † against tetanus — worldwide, 2000–2020§ Sources: Neonatal tetanus data: WHO Global Health Observatory Data Repository (2000–2018) and the Global Health Data Exchange (2019), Protected at birth data: WHO/UNICEF Joint Reporting Form on Immunization (2000–2020). Abbreviations: TTCV = tetanus toxoid–containing vaccine; WHO = World Health Organization. * The number of deaths is estimated from mathematical models that compute the yearly incidence and mortality for each country using the baseline rate of neonatal tetanus before introduction of TTCVs and promotion of clean deliveries, with adjustment for the estimated proportion of women vaccinated with TTCV and deliveries assisted by trained personnel. † The status of an infant born to a mother who received 2 doses of TTCV during the last birth, ≥2 doses with the last dose received ≤3 years before the last delivery, ≥3 doses with the last dose received ≤5 years earlier, ≥4 doses with the last dose received ≤10 years earlier, or receipt of ≥5 previous doses. § Data on deaths for 2020 were not available. This figure consists of a bar graph indicating the estimated number of neonatal deaths and a line graph indicating the estimated proportion of children protected at birth against tetanus worldwide during 2000–2020. 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 ). Summary What is already known about this topic? In 1999, the maternal and neonatal tetanus (MNT) initiative was relaunched to focus on 59 priority countries still at risk for maternal and neonatal tetanus. What is added by this report? During 2000–2020, 47 countries achieved elimination of MNT, reported neonatal tetanus cases decreased 88%, and estimated deaths declined 92%. Despite progress, 12 countries have not achieved elimination and are challenged by conflict, insecurity, and competing priorities. Other countries are struggling to maintain elimination. What are the implications for public health practice? To achieve MNT elimination in remaining priority countries and to maintain it globally, efforts are needed to enhance routine vaccination, integrate tetanus activities with other health activities, and promote a life-course vaccination approach for tetanus protection.