Global progress in neonatal tetanus elimination from 2000 to 2022

National immunization activities worldwide should incorporate maternal and neonatal tetanus elimination strategies to achieve and sustain elimination, according to a recent report from the Centers for Disease Control and Prevention (CDC).

Tetanus is a significant concern of maternal and neonatal mortality. Maternal and neonatal tetanus elimination (MNTE) strategies include using tetanus toxoid–containing vaccines (TTCVs) to strengthen antenatal immunization among pregnant women and providing TTCV supplementary immunization activities (SIAs) to reproductive-aged women from high-risk districts.

The MNTE initiative targets 59 priority countries and includes optimizing access to skilled birth attendees and investigating suspected neonatal tetanus cases. Updated progress toward MNTE from 2000 to 2022 has been reported by the CDC.

Vaccination coverage survey data and administrative data was collected by the World Health Organization (WHO) and UNICEF to estimate TTCV coverage among pregnant women. The number of women receiving TTCV during SIAs was also reported to these organizations.

Country health facility reports and coverage survey estimates were assessed for the percentage of births assisted by skilled birth attendants. According to WHO, case-based neonatal tetanus surveillance should be implemented, and surveillance should remain active through regular visits to reporting sites.

Mathematical models using Bayesian and multinomial frameworks to project cause-specific neonatal mortality are used to avoid underreporting in neonatal tetanus deaths. The CDC stated this practice is consistent with applicable federal law and CDC policy.

Prevalidation assessments are recommended after a country’s national tetanus incidence has reached less than 1 case per 1000 live births. MNTE achievement is defined by under 1 national tetanus case per 1000 live births, at least 80% routine 2 or more doses of TTCV (TTCV2+) coverage among pregnant women, and at least 70% of deliveries involving skilled birth attendants.

Annual neonatal tetanus risk analyses should be included in immunization program reviews based on WHO recommendations. Every 5 years, a postvalidation assessment should also occur to determine whether elimination has been sustained.

Antenatal TTCV2+ coverage data was supplied by 85% of countries. Of these, TTCV2+ coverage of 80% or more was reported by 32%. TTCV SIAs were reported by 88% of priority countries between 2000 and 2022.

Forty-one countries had available data from 2000 and 2022, with 73% of these countries reporting increased TTCV2+ coverage. In 2022, 86% of infants worldwide were protected at birth, vs 74% in 2000. Additionally, the number of priority countries with MNTE increased from 2% to 80%.

TTCV2+ reached 70% of targeted women worldwide through SIAs. However, 68 million targeted women were unreached by the end of 2022. Of countries with available data, 55% reported the assistance of skilled birth attendants during births. Twelve countries reported a higher proportion of births with attendant assistance in 2022 vs 2020.

In 2022, 11 of 59 priority countries reported 0 neonatal tetanus cases and 7 reported more cases than in 2020. An 89% decrease of neonatal tetanus cases was observed worldwide, from 17,935 in 2000 to 1995 in 2021. During this period, neonatal tetanus deaths decreased by 84%, accounting for 2% of all-cause neonatal mortality in 2000 and 0.3% in 2021.

MNTE was achieved by 80% of priority countries in the 2000 to 2022 period. Of these countries, 32% had at least 90% coverage with 3 primary doses of TTCV. In 98%, at least 70% of infants were protected at birth. In 55%, at least 70% of births included assistance from a skilled birth attendant.

This data highlights the need for integration of MNTE activities with those of other vaccine-preventable diseases to improve progress toward MNTE. Authors recommended promotion of equitable health care access to achieve MNTE.

Reference

Jones CE, Yusuf N, Ahmed B, Kassogue M, Wasley A, Kanu FA. Progress toward achieving and sustaining maternal and neonatal tetanus elimination — worldwide, 2000–2022. MMWR Morb Mortal Wkly Rep. 2024;73:614–621. doi:10.15585/mmwr.mm7328a1.