Tetanus: The high risk [Archives:2006/948/Health]
May 22 2006
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Immunization Advisor – PHR plus (USAID/Yemen)
Neonatal tetanus (NNT) is the second leading cause of death from vaccine-preventable diseases among children worldwide (1).
“A case of maternal or neonatal tetanus represents a triple failure of public health in terms of routine immunizations, antenatal care and clean delivery/cord care services.”
NNT occurs as a result of unclean delivery practices, most commonly when tetanus spores contaminate the umbilical cord when it is cut or dressed following delivery. NNT symptoms usually appear the third day after birth. An apparently healthy baby will stop nursing, become progressively more rigid, develop an arching of the whole body and experience painful convulsions. It is a deadly newborn disease with a fatality rate of 70 to 100 percent(2).
Yemen is one of seven EMRO member states (Egypt, Iraq, Somalia, Sudan, Afghanistan and Pakistan) that have not reached the elimination target. The World Health Organization (WHO) estimates that more than 3,000 cases occur annually in Yemen, with the mortality rate per 1,000 live births at 2.9(2). Nevertheless, NNT causes 20.3 percent of all neonatal deaths and thus is a major cause of neonatal death in Yemen.
Although NNT surveillance in Yemen has improved since 1999 when 133 cases were reported in 12 districts, NNT remains seriously underreported, with many districts and governorates remaining silent despite low Tetanus Toxoid (TT) vaccination and clean delivery coverage. For this reason, Yemen's disease reporting system must be reinforced.
Yemeni TT immunization coverage remains low, lagging behind coverage achieved for childhood immunization antigens. Moreover, the overall immunization program has declined, with TT coverage appearing to be around 20 percent. TT vaccine is provided in Antenatal Care (ANC) clinics.
The level of antenatal care during pregnancy remains low, not exceeding 35 percent. More than 75 percent of childbirths occur at home and most are not attended by a trained or skilled birth attendant which, along with unhygienic practices during childbirth and umbilical cord care, further adds to Yemen's burden of NNT-related mortality.
Difficult topography, low accessibility to health services, lack of female health workers, lack of awareness, high illiteracy rate and false rumors are among the most commonly identified reasons for low coverage.
Reducing deaths from NNT is one of the simplest and most cost-effective means to reducing the neonatal mortality rate. NNT can be prevented if women are immunized with at least two doses of TT vaccine before childbirth and clean practices are used during delivery and in caring for the infant's umbilical cord.
The Expanded Program on Immunization (EPI) has developed an ambitious plan to reduce NNT incidence by implementing a high risk approach (HRA) to vaccinate women of child bearing age (WCBA) in identified high risk districts (HRD), and further by vaccinating female secondary school students and their teachers.
Using the HRA during the period 2000 to March 2005, TT vaccination rounds were implemented in 113 identified HRDs, targeting more than 1.6 million WCBA (43 percent of total WCBA). These TT rounds resulted in vaccinating approximately 1.32 million WCBA with at least two doses of TT vaccine (TT2 + coverage = 82.3 percent).
Results and impacts of implementing the HRA strategy in Yemen:
Protecting approximately 1.32 million women (and their future newborns) from tetanus.
More than 60 percent reduction in NNT cases since 2001.
Detecting and investigating most NNT cases admitted to hospitals through established sentinel surveillance sites in 2002.
(1) WHO, Weekly Epidemiology Record, Progress toward the global elimination of neonatal tetanus, 1990-1998. (March 12, 1999. 74th year).
(2) UNICEF, WHO, UNFPA. Maternal and neonatal tetanus elimination by the year 2005: Strategies for achieving and sustaining elimination. November 2000 (UNICEF publication).
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