|Year : 2021 | Volume
| Issue : 1 | Page : 47-52
Maternal & Neonatal Tetanus Elimination
Angela A. Okolo
Professor, Department of Pediatrics, Federal Medical Center, Asaba At the 21st Biennial conference of MWAN, Asaba 2019, Nigeria
|Date of Web Publication||30-Jun-2021|
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Okolo AA. Maternal & Neonatal Tetanus Elimination. J Med Womens Assoc Niger 2021;6:47-52
| Outline|| |
- Burden of Disease
- Management / Prevention strategies
- Key Challenges
- Lessons from successes
- Solutions / Proposed solutions
| Definition|| |
Tetanus is a disease caused by the Clostridium tetany bacterium. Clostridium tetany spores are able to survive for a long time outside of the body. They are most commonly found in animal manure and contaminated soil, but may exist virtually anywhere.
It is a potentially lethal disease which has no cure but is largely preventable and it is acquired through exposure of open wound to the spores or penetration injury of the spores into the body. When Clostridium tetany spores are deposited in a wound, neurotoxin is released and these interfere with nerves that control muscle movement.
| Burden of Disease|| |
Tetanus is a serious disease that has no cure and it is caused by a bacterial toxin that affects nervous system, leading to painful muscle contractions. Worldwide, tetanus kills an estimated 180,000 neonates (about 7% of all neonatal deaths and up to 30 000 women (about 5% of all maternal deaths) each year. If the mother is not immunized with the correct number of doses of tetanus toxoid vaccine, neither she nor her newborn infant is protected against tetanus at delivery.
| Epidemiology|| |
The reduction of NT cases to less than 1 per 1000 live births in every district of every country is called Elimination.
Nigeria is one of the 27 countries which account for over 90% of the global burden of NT with an incidence of up to 20% in Nigeria.
Of 5 million annual births in Nigeria, 240,000 (4.8%) die within the first 4 weeks of life. Nigeria is one of the high burden neonatal mortality countries and ranks 13th in order of highest Neonatal death. Elimination of neonatal tetanus is a key area of priority to achievement of the SDGs of ending preventable child deaths by 2030.
Tetanus is acquired when the bacterium Clostridium Tentany enters into the body through a wound or breach in the skin.
Neonatal tetanus usually occurs because of umbilical stump infections. In the presence of anaerobic conditions, the spores germinate. The bacteria produce very potent toxins, most of which the blood stream and lymphatic system disseminate through the body. Toxins act at several sites within the central nervous system, including peripheral motor end plates, spinal cord, and brain, as well as in the sympathetic nervous system. Tetanus toxin causes the typical clinical manifestations of tetanus by interfering with the release of neurotransmitters and blocking inhibitor impulses. This leads to unopposed muscle contraction and spasm. Seizures may occur, and the autonomic nervous system may also be affected.
Who is at risk of Tetanus Infection?
Tetanus infection is not age bound and it affects those persons who have never received a tetanus vaccine or did not stay up to date on their 10-year booster shots.
Disasters like earthquakes, hurricanes, floods, and tsunamis does not increase the risk of been affected by tetanus. However, to minimize the risk of tetanus among disaster survivors and emergency responders, routine vaccination and proper wound care are recommended.
Occupation may predispose some persons to the risk of been infected with tetanus, just like a study in the US from 2009-2017, >60% of the 264 reported cases were among people 20 years through 64 years of age. In addition, 25% of these were among people 65 years old or older. The risk of death from tetanus is highest among people 65 years old or older.
In the US study, 'these are the' risk groups that can be affected with tetatanus infection:
Diabetes, a history of immunosuppression, and intravenous drug use may be risk factors for tetanus. From 2009 through 2017, persons with diabetes was associated with 13% of all reported tetanus cases, and a quarter of all tetanus deaths.
Intravenous drug users accounted for 7% of cases from 2009 through 2017.
Risk group in Nigeria
In the move towards elimination of maternal and Neonatal Tetanus in Nigeria, attention should be given to Pregnant women from early pregnancy and special categories of women should be identified.
Special Groups to be targeted for special attention include: women with viral diseases and endocrine dysfunction in pregnancy.
Target Communities especially the hard to reach because of the low utilization of the Health system utilization, it is important to increase coverage of activities for the prevention strategies & to reach out to the communities through community outreach activities.
Clinical Forms of Tetanus
There are three clinical forms of tetanus: Generalized, Localized & Cephalic
Generalized Tetanus: This is the most common form, accounting for more than 80% of cases. Its clinical course is variable, because it depends on the degree of prior immunity; Amount of toxin present; age and general health of the patient
Even with modern intensive care, generalized tetanus is associated with death rates of 10% to 20%.
Localized Tetanus: This is an unusual form of the disease consisting of muscle spasms in a confined area close to the site of the injury. Although localized tetanus often occurs in people with partial immunity and is usually mild, progression to generalized tetanus can occur.
Cephalic Tetanus: It's the rarest form, and it's associated with lesions of the head or face and may also be associated with otitis media. The incubation period is short, usually 1 to 2 days.
Unlike generalized and localized tetanus, cephalic tetanus results in flaccid cranial nerve palsies rather than spasm. Spasm of the jaw muscles may also be present and can progress to the generalized form.
Given that Tetanus has no cure, treatment is mainly symptomatic to alleviate the spasms. Main stay of treatment is Preventive Approach using the 5 levels of prevention;
Targets Primary prevention
In this approach we shall explore the situation that has been used so far in the elimination of the disease globally, and examine the situation in Nigeria. Since people cannot naturally acquire immunity to tetanus, the best way to prevent tetanus is to vaccinate the populace. WHO/CDC recommends tetanus vaccines for all infants and children, preteens and adolescents, and adults.
Booster doses are needed when the risks for diseases present.
An effective monitoring and evaluation mechanism in place ensures availability of suffcient information for surveillance.
Health education activities to increase community awareness of the importance of tetanus immunization should be carried out is essential for sustaining vaccine acceptance.
Cord Care and Clean Delivery Practices- Key for Tetanus Prevention In Neonates.
Skilled & careful wound Management (crucial for tetanus prevention).
Risk of tetanus disease in the mothers and their babies, depends on the methods of clean delivery practices and mode of cord care provided, the immune status of the parturient is of key importance.
In Nigeria the EPI immunization mainly covers infants - most children above the age of 12- 24 months are not usually targeted. The older age groups of children are not on the regular immunization schedule- an area of GAP. So the adult pregnant mothers are vulnerable groups as most of them might not have received or completed the 3- Dose Primary Tetanus vaccination series and they do not utilize the health system for delivery services. Skilled attendance at delivery rate is low.
Key Ideas for Tetanus Prevention
It is known that Persons, who have completed a 3-dose primary tetanus vaccination series and have not received a tetanus toxoid-containing vaccine for 5 or more years earlier, would need to receive a booster dose of an age-appropriate tetanus toxoid-containing vaccine. Hence there is the need to ensure that the pregnant women also receive their full 5 doses of tetatnus toxoid as recommended by WHO.
However, rarely has cases of tetanus occurred in persons with a documented primary series of tetanus toxoid.
| Management of Cases|| |
Assess need for administering TIG for prophylaxis.
In the management of Maternal & Neonatal tetanus, TIG prophylaxis is needed alongside the efforts targeting Tetanus toxoid immunization
TIG: provides temporary immunity, helps remove unbound tetanus toxin but cannot neutralize toxin that is already bound to nerve endings.
- Persons with contaminated and dirty wounds and are either unvaccinated or have not received a primary series of tetanus toxoid-containing vaccines should receive TIG for prophylaxis at 250 IU IM.
- Persons with HIV infection or severe immunodeficiency who have contaminated wounds (including minor wounds) should also receive TIG, regardless of their history of tetanus immunizations.
Do not use antibiotics for prophylaxis against tetanus.
Medical experts do not recommend antibiotic prophylaxis against tetanus. However, clinicians should observe wounds for signs of infection and promptly treat if they detect signs of infection.
| Challenges|| |
Maternal and neonatal tetanus persist as public health problems in 13 countries, mainly in Africa and Asia. More recently India has succeeded in elimination of maternal and Neonatal Tetanus.
In 2018, an estimated 19.4 million infants worldwide were not reached with routine immunization services such as 3 doses of DTP vaccine.
Around 60% of these children live in 10 countries: Angola, Brazil, the Democratic Republic of the Congo, Ethiopia, India, Indonesia, Nigeria, Pakistan, the Philippines and Viet Nam. Because tetanus spores are ubiquitous in the environment, eradication is not biologically feasible.
High immunization coverage of pregnant women, clean delivery and the identification and implementation of corrective action in high-risk areas are the three primary strategies for eliminating MNT.
Developing countries have achieved elimination of MNT over time.
Achievements in other Countries
India has achieved a public health feat by the elimination of maternal and neonatal tetanus. Maternal and neonatal tetanus is reduced to less than one case per 1000 live births in their entire country.
Maternal and Neonatal Tetanus has decreased in countries that follow strict immunization schedules. Immunization coverage depends on several factors;
Utilization of the services which is influenced by many factors such as availability, accessibility of services, socio economic status and cultural practices of family, education of mother etc.
In fact, knowledge of the mothers of children on protective role of vaccines is the important factor to improvement of immunization coverage and also for successful introduction of new vaccines in the program.
Global Immunization Coverage Rates
Coverage of a third dose of vaccine protecting against diphtheria, tetanus, and pertussis (DTPcv-3) remains at 86% in 2018, leaving 19.4 million children vulnerable to vaccine preventable diseases.
The key goal of the Immunization Agenda 2030 is to make vaccination available to everyone, everywhere, by 2030. While immunization is probably the most successful public health intervention, reaching 86% of infants is not enough. The upward trend in coverage has increased by only 5% in the past decade and has plateaued.
Global vaccination coverage; the proportion of the world's children who receive recommended vaccines has remained the same over the past few years.
In 2018, about 86% of infant's worldwide (116.3 million infants) received 3 doses of diphtheria-tetanus-pertussis (DTP3) vaccine, protecting them against infectious diseases that can cause serious illness and disability or be fatal. By 2018, 129 countries had reached at least 90% coverage of DTP3 vaccine.
The gap between the best performer, the European Region, and the lowest performer, the African Region, is 18 %. The Western Pacific Region and especially the Region of the Americas experience drops in coverage. The biggest gains have been made by the African Region (over a 20 year period), and the South East Asian Region (over a ten year period).
Countries with most unprotected children:
10 countries account for 11.7 of the 19.4 million under and un vaccinated children in the world (60%). This list includes some countries with moderate coverage and very large birth cohorts, other countries with very large birth cohorts substantially lower coverage. Nigeria (3.0M), India(2.6), Pakistan(1.4M), Indonesia(1M), Ethiopia(960K), Philippines(750), DRC(620K),Brazil(490K), Angola(480K), Vietnam(390K).
Un & Under vaccinated children disproportionately live in fragile countries.
Of the 19.4 million infants who are not fully vaccinated with DTPcv-3, 8.6 million (44%) live in 16 countries that are polio endemic, fragile or affected by conflict*.About 4.8 million of them (25%) live in just three countries - Afghanistan, Nigeria and Pakistan - where access to routine immunization services is critical to achieving and sustaining polio eradication.
Current immunization coverage is low even when the various vaccines are examined.
The BCG coverage is low, yet this is provided at birth to babies born in the hospital before discharge home or during scheduled visits for the purpose.
We should be mindful of the fact that there is underutilization of the health system for maternity and delivery service- Only about 45% have access to skilled attendants at birth
The Gaps - Challenges
The fact that more children are been born in countries with weaker health systems and lower coverage also acts as a brake on global coverage improvements.
11 countries, where DTP3 coverage was below 60% in 2018 include: Angola, Chad, the Central African Republic, Equatorial Guinea, Guinea, Nigeria, Samoa, Somalia, South Sudan, the Syrian Arab Republic, and Ukraine. Of these 11 countries, 10 are projected to have more babies born each year through 2030, making the challenges of vaccine coverage even greater. Average coverage at national level hides geographical and socio-economic inequalities, even in high and middle income countries.
| Factors That Improve Immunization Coverage Rate|| |
Information to the community members particularly to mothers is important to immunization success.
Such is the experience in South America where in Nicaragua Health workers at local health centers across Nicaragua are integral to the implementation of the large-scale immunization campaign in the country. In Nicaragua, anyone can receive immunization services throughout the year for free at local health centers, but the Ministry of Health launches a large-scale campaign in April of every year-as part of Vaccination Week in the Americas. To date, more than 720 million people have been vaccinated as part of the yearly campaign.
Studies from Nigeria have also shown the role of awareness programs and role of maternal education in increasing vaccine Coverage. Hence Tagbo et al in their study demonstrated that predictors to high immunization coverage rate, were: High maternal education as well as being a government employee and delivery of a child in a government hospital, knowledge of the age at which a child should start and complete routine vaccinations were the independent predictors of the high vaccination coverage.
Effective Community Communication Strategy / Mechanism is key to improvement of immunization coverage.
How to Achieve High Immunization Coverage:
In achieving high immunization coverage, 95% target of immunization coverage is necessary for sustained control of vaccine preventable diseases.
The 2017 endorsed resolution of the GAVI Alliance for vaccines which has been endorsed by 194 countries has called on countries to expand immunization services beyond infancy, mobilize domestic financing, and strengthen international cooperation to achieve GVAP goals.
Antenatal services provide a convenient opportunity for vaccinating pregnant women. Where ANC coverage is inadequate, mass immunization of women of childbearing age could be an alternative though more costly option . About US$ 1.20 is needed to protect a woman with three doses of TT/Td using the high-risk approach.
Reminding patients, tracking and outreach activities are effective in increasing immunization coverage. Immunize the patient with- Provided TT & TIG to a tetanus prone wound, women who have had an unsafe abortion, particularly when the patient is considered not protected to ensure that she is no longer at risk in the future. In addition, prophylaxis with tetanus immunoglobulin's may be required if the wound is large and possibly infected with soil or instruments contaminated with animal excreta.
Effective surveillance is crucial to monitoring progress, and is possible even where resources are scarce.
| Solution|| |
Improving immunization coverage to cover All Ages is the potential means to elimination of Maternal and Neonatal Tetanus.
To reach everyone, everywhere, it is necessary to identify and focus on under-served populations (including rural remote, urban slums, the poor and uneducated).
While the immunization program efforts has successfully focused on reaching infants, for the full benefits of vaccines to be realized, strong program for other age groups need to be built. Programs for the Preschool child, child at school entry, adolescent at secondary school entry are also needed. Pregnant women should be given special focus and attention.
Providing Information to the community members particularly to mothers is key to immunization success. Such is the experience in South America where in Nicaragua Health workers at local health centers across Nicaragua are integral to the implementation of the large-scale immunization campaign in the country.
Vaccine refusal could be mitigated by advance provision of information on the efficacy of vaccines in the prevention of diseases.
Proposal for MWAN's Involvement:
Specific area for MWAN involvement in the elimination of maternal & neonatal Tetanus in Nigeria is to engage in wide spread of the prevention strategies to ensure high coverage and spread of the primary prevention strategies.
The MWAN can contribute in reaching the unreached or hard to reach communities by;
- Ensuring delivery of effective community communication strategy for improvement of immunization coverage
- Provision of Education to the community members particularly to mothers on the protective role of immunization
- Improving vaccine coverage to cover all ages - attain 95% target of immunization coverage
- Support for mass immunization of women of childbearing age for TT coverage?
Can the MWAN include the agenda in the WOTHY campaign as part of information to the women?
| Conclusion|| |
Maternal & Neonatal Tetanus is currently a challenge in Nigeria! Given its contribution to high mortality indicators; MWAN should join efforts (as part of the all capable hands that should go on deck) to provide the possible solutions so as to contribute to attainment of the SDGs by Nigeria.
| References|| |
Liang J. L, Tiwari T, Moro P, et al. Prevention of Pertusis , Tetanus & Diphtheria in the united States: Recommendations of the advisory committee on immunization practices (ACIP). MMWR Morb Mortal Wkly Rep. 2018;67(2):1-44.
American Academy of Pediatrics. Tetanus External. In: Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book®: 2018-2021 Report of the Committee on Infectious Diseases. American Academy of Pediatrics; 2018; 793-8.
Pink Book's Chapter on Tetanus. Epidemiology & Prevention of Vaccine-Preventable Diseases
Dr. M. Siva Durga Prasad Nayak1 , Dr. S Appala Naidu2 , Dr. B Devi Madhavi3 , Dr. Sunita Sreegiri. Assessment of immunization coverage among children of 12-23 months age group in the field practice area of Andhra Medical College Visakhapatnam, Andhra Pradesh.
WHO Fact sheets April 2018
Tagbo, B.N., Eke, C.B., Omotowo, B.I., Onwuasigwe, C.N., Onyeka, E.B. and Mildred, U.O. (2014)Vaccination Coverage and Its Determinants in Children Aged 11 - 23 Months in an Urban District of Nigeria. World Journalof Vaccines.Vaccination Coverage and Its Determinants in Children Aged 11 - 23 Months in an Urban District of Nigeria.