Maternal and Neonatal Tetanus Elimination

Once MNT elimination has been achieved, maintaining elimination will require continued strengthening of routine immunization activities for both pregnant women and children, maintaining and increasing access to clean deliveries, reliable NT surveillance, and introduction of school-based immunization with TTCV.

Achieving MNT elimination

Immunization against tetanus is routinely given to pregnant women

In many countries, immunization against tetanus is routinely given to pregnant women, usually during antenatal care contacts. For women who have never received Td vaccine, or have no documentation of such immunization, a total of five properly-spaced doses is recommended: 2 doses given one month apart in the first pregnancy, the 3rd dose is given at-least 6 months later, then 1 dose in each subsequent pregnancy (or intervals of at least 1 year), to a total of five doses. For recommended schedules, see the summary table on page 207 in the WHO Position Paper on Tetanus in the links below. Routine immunization with TTCV is reported as Td2+ (two doses or more of tetanus - diphtheria toxoid vaccine)**; countries report achieved coverage annually to WHO and UNICEF.

The "high-risk approach"

In areas where routine immunization fails to reach a substantial proportion of pregnant women, TTCV SIAs may be required. This is known as the "high-risk approach". All women of reproductive age living in high-risk districts (HRDs) are targeted with 3 properly spaced doses of TTCV through specially organized supplementary immunization activities (SIAs). This approach focuses on providing Td vaccination in districts where women have limited or no access to routine vaccination. HRDs are identified by systematic analysis of routinely reported district data, survey data when available and local knowledge.

Clean deliveries

Clean deliveries (deliveries in health facilities and/or assisted by medically trained attendants) effectively reduce MNT and other causes of maternal and neonatal mortality. Health workers who provide Td vaccination to women with limited access to routine services should encourage the use of trained health providers for obstetric care and also provide information about how to reach such services. If obstetric services are not available, or if women prefer to deliver at home without trained attendants, extra efforts should be made to teach pregnant women how to ensure a clean delivery at home, the importance of not using harmful traditional substances for cord care, and when and where to seek care for complications.

Surveillance

Surveillance for neonatal tetanus is poorly developed in most developing countries. It is estimated that less than 10% of NT cases and deaths are actually reported. It is necessary to integrate NT surveillance into the existing active AFP and measles surveillance to have active integrated disease surveillance for vaccine preventable diseases. This should be tied to NT case investigation and response as appropriate.

Maintaining MNT elimination

Complete eradication of tetanus is not possible because tetanus spores are found throughout the world in soil and the stool of people and animals - that is exposure to the bacteria causing tetanus cannot be completely prevented.

Countries that have succeeded in eliminating MNT must:

• Antenatal screening of pregnant women for tetanus vaccination to ensure tetanus protection at birth (PAB) and vaccination, where required; 
• Ensure that the majority of pregnant women are immunized against tetanus (at least >80%; see above);
• Ensure high coverage with tetanus toxoid-containing vaccines in infancy (such as DTP/Penta), and consider introducing three childhood and early adolescence booster doses along life course during the second year of life along with second dose of measles-containing vaccines (MCV) and other interventions delivered during this period of life, at 4 – 7 years during school entry and in early adolescence at 9 - 15 years. The second year-of-life delivery platform, school-based immunization can be an efficient and effective strategy to deliver booster doses of TTCV (and other vaccines); integrating TTCV booster dose during early adolescence with Human Papilloma Virus (HPV) vaccine;   
• Ensure access to and use of clean delivery practices;
• Maintain and improve MNT surveillance to monitor continued elimination and identify areas where MNT is still occurring. Good NT surveillance permits effective targeting of interventions when necessary. Because most neonatal deaths occur at home, often where neither births nor deaths are reported, NT surveillance can be quite challenging, It is nonetheless a key component of MNT elimination and serves as a valuable indicator of immunization and maternal and child health (MCH) system performance;
• The MNTE Technical Working Group (TWG) of the WHO Strategic Advisory Group of Experts (SAGE) recommends that all countries that have been validated for MNTE should conduct post-validation assessments at least every five to assess elimination status and take remedial actions.
  

** WHO recommended that countries shift from the use of single-antigen TT to combinations containing diphtheria toxoid (Td) and as of December 2023, nearly all countries have made the shift.