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International Notes Progress Toward the Global Elimination of Neonatal Tetanus, 1989- 1993

Neonatal tetanus (NT) is a leading cause of neonatal mortality in many parts of the world. During the 1980s, NT accounted for half of all neonatal deaths and one fourth of all infant mortality in some countries (1). In addition, in 1993, an estimated 515,000 neonatal deaths were caused by NT * (2) for a global mortality rate of 4.1 per 1000 live births. In 1989, the World Health Organization (WHO) adopted a resolution to eliminate NT worldwide (3), and in 1990, the World Summit for Children issued a declaration for global elimination of NT by the end of 1995 (4). In 1993, WHO's goal was defined as the elimination of NT as a public health problem by reducing its incidence to less than one case per 1000 live births for each health district (2) (baseline: in 1988, a total of 32,454 NT cases were reported to WHO and an estimated 787,000 NT deaths occurred; the global NT mortality rate was 6.5 cases per 1000 live births {5}) ** . To achieve and maintain NT elimination, 80% or more of infants need to be protected at birth through vaccination of their mothers with at least two doses of tetanus toxoid (TT2+) or through clean delivery and cord-care practices (2). In addition, effective surveillance systems must be developed to detect NT cases and enable timely investigation of them. This report, which is based on data from WHO, presents reported coverage with TT2+ in developing countries *** only and reported number of NT cases and estimated number of NT deaths in all countries, and summarizes progress toward the global elimination of NT during 1989-1993 (WHO, unpublished data, 1994).

Global. From 1989 to 1993, vaccination coverage with TT2+ among pregnant women increased from 27% to 45% Figure_1. During the same period, the number of NT cases reported to WHO decreased from 29,494 in 1989 to 14,232 in 1993. However, only 2%-5% of all NT cases were reported (2). Of the estimated 515,000 deaths worldwide, approximately 80% occurred in 12 countries Table_1. Most deaths (34.2%) occurred in the Southeast Asian Region Table_2. Overall, an estimated 724,300 deaths attributable to NT were prevented **** in 1993 by vaccination with tetanus toxoid. Of the 156 countries reporting NT incidence to WHO in 1993, a total of 79 (51%) reported zero cases. In 1993, a total of 66% of live births occurred in areas with NT surveillance, compared with 39% in 1985 and 73% in 1989.

African Region. Coverage with TT2+ increased from 25% in 1989 to 40% in 1993. In 1993, a total of 3461 cases (24% of the global total) were reported, compared with 7299 cases in 1989. Of the 47 countries in the region, 36 (77%) reported NT incidence to WHO for 1993; of these, four reported zero cases.

Region of the Americas. From 1989 through 1993, TT2+ coverage increased from 29% to 40% in the Region of the Americas, where major efforts were undertaken to vaccinate women of childbearing age in high-risk areas. Reported cases decreased from 1430 in 1989 to 708 (5% of the global total) in 1993; Brazil reported 216 cases (31% of the regional total for 1993). Of the 47 countries in the region, 40 (85%) reported NT incidence to WHO for 1993; of these, 25 reported zero cases.

Eastern Mediterranean Region. Coverage with TT2+ increased from 31% in 1989 to 50% in 1993. The number of reported cases decreased from 6314 in 1989 to 3350 (24% of the global total) in 1993. Of the 23 countries in the region, 21 (91%) reported NT incidence to WHO for 1993; of these, 10 reported zero cases.

European Region. In 1993, TT2+ coverage levels of 16% were reported in the European Region, where only Turkey routinely reports tetanus toxoid coverage to WHO. During 1989-1992, 63-67 cases were reported annually. In 1993, a total of 48 NT cases were reported in the region -- 46 from Turkey. Of the 50 countries in the region, 30 (60%) reported NT incidence to WHO for 1993; of these, 27 reported zero cases.

Southeast Asian Region. In 1993, TT2+ coverage was reported to be 74%. The number of reported cases decreased from 14,102 (48% of the global total) in 1989 to 5809 (40% of the global total) in 1993. Three countries accounted for 97% of all NT cases reported in the region: India (4339 {75%} cases), Bangladesh (720 {12%}), and Indonesia (566 {10%}). Of the 11 countries in the region, 10 (91%) reported NT incidence to WHO for 1993; of these, two reported zero cases.

Western Pacific Region. In 1993, TT2+ coverage was 13% in the Western Pacific Region (including China, which began administering tetanus toxoid in selected areas in 1992). The number of cases reported to WHO increased from 282 in 1989 to 856 (6% of the global total) in 1993. Two countries reported 79% of the total cases for the region: Vietnam (333 cases) and the Philippines (343 cases). Of the 35 countries in the region, 18 (51%) reported NT incidence to WHO for 1993; of these, 11 reported zero cases. Reported by: Expanded Program on Immunization, Global Program for Vaccines and Immunization, World Health Organization, Geneva. International Health Program Office; National Immunization Program, CDC.

Editorial Note

Editorial Note: NT results from the effect of a neurotoxin elaborated by the anaerobic organism Clostridium tetani (6). Infection occurs when the umbilical cord becomes contaminated as a result of unclean childbirth or cord-care practices. Access to clean birth practices is ultimately the long-term goal for prevention; however, most infants in developing countries continue to be born at home under unsanitary conditions. Although global tetanus toxoid coverage levels nearly doubled to 45% during 1989- 1993 in countries that administer the vaccine, reported coverage levels are underestimated because annual estimates do not include doses administered during previous years. In addition, many women do not maintain vaccination records, making verification of vaccination status difficult (7). WHO now recommends that women receive and maintain life-long vaccination records and that tetanus toxoid coverage be monitored nationally by determining the proportion of children protected at birth when they seek their first diphtheria and tetanus toxoids and pertussis vaccine dose.

The findings in this report are subject to at least two limitations. First, because NT cases are grossly underreported, NT incidence is underestimated. Second, the numbers of NT deaths and prevented deaths are based on projections from national data (which often are estimated) or data extrapolated from other countries.

As of August 1, 1994, the estimated NT case rate was less than one per 1000 live births nationwide (i.e., not by district) in 83 countries. In addition, in 57 countries, the estimated rate of NT was one to five cases per 1000 nationwide, while in 25 countries the estimated rate was higher than five cases per 1000. Although progress has been made toward eliminating NT as a public health problem, present resources and commitments must be increased and activities greatly accelerated if the 1995 goal is to be achieved by all countries (8). In 1993, the Global Advisory Group of WHO's Expanded Program on Immunization identified four constraints to NT elimination (2): 1) insufficient funds to purchase tetanus toxoid in selected high-risk countries; 2) lack of adequate health-care infrastructure in many countries, resulting in limited tetanus toxoid vaccination activities and poor access to clean birth practices; 3) civil unrest in some high-risk countries; and 4) high levels of NT underreporting.

To reach the global elimination goal for NT, efforts must be accelerated, especially in the 12 countries from which 80% of NT cases were reported in 1993 and in countries where the incidence rate is higher than five per 1000 live births. Each country must identify areas where the incidence rate is higher than one per 1000 live births, coverage levels are low, or there is limited access to clean deliveries or trained birth attendants. These high-risk areas must be targeted for intensified vaccination efforts, including the use of mass vaccination campaigns. In addition, surveillance activities in all areas must be strengthened. Finally, because NT is not a communicable disease, and C. tetani cannot be eradicated from the environment, ensuring long-term elimination of NT will require the development of adequate health-care delivery systems to reach those at greatest risk -- infants of poor women residing in rural areas in developing countries.

References

  1. World Health Organization. Neonatal tetanus elimination. Tokyo: World Health Organization, Expanded Program on Immunization, Global Advisory Group, October 16-20, 1989; publication no. WHO/EPI/GAG/89/WP.9.

  2. Global Advisory Group, Expanded Program on Immunization, World Health Organization. Achieving the major disease control goals. Wkly Epidemiol Rec 1994;69:29-31,34-5.

  3. World Health Assembly. Expanded Program on Immunization. Geneva: World Health Organization, May 19, 1989. (Resolution WHA42.32).

  4. World Health Organization. Revised plan of action for neonatal tetanus elimination. Geneva: World Health Organization, Expanded Program on Immunization, 1993; publication no. WHO/EPI/GEN/93.13.

  5. World Health Organization. The global elimination of neonatal tetanus: progress to date. Bull World Health Organ 1994;72:155-64.

  6. Galazka AM. Tetanus: the immunologic basis for immunization. Geneva: World Health Organization, Expanded Program on Immunization, 1993; publication no. WHO/EPI/GEN/93.13.

  7. Deming MS. Monitoring tetanus toxoid immunization coverage. Geneva: World Health Organization, Expanded Program on Immunization, 1990; document no. EPI/NNT/90/WP.3/Rev1.

  8. World Health Organization. Global programme for vaccines and immunization: proceedings of the Meeting of the Scientific Advisory Group of Experts. Geneva: World Health Organization, October 17-19, 1994.

* Estimates of NT deaths are derived from national mortality data, NT mortality rates from NT surveys, or in the absence of surveys, by assuming that rates are similar for countries with similar socioeconomic conditions and from tetanus toxoid coverage levels. 

** Because the case-fatality rate for NT is high (100% in some countries), WHO estimates only the number of deaths for NT, not number of cases. 

*** Countries are categorized as developing based on criteria developed by the United Nations and used by WHO for analytic purposes only. 

**** The number of NT deaths prevented was calculated for each country using the number of live births, NT mortality rate, and tetanus toxoid coverage and efficacy.



Figure_1

Figure_1
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Table_1
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TABLE 1. Number of reported cases of neonatal tetanus (NT), estimated number of
NT deaths * and NT deaths that were prevented + , and percentage of pregnant women
who had received two or more doses of tetanus toxoid (TT2+) among the 12
countries that represent 80% of NT deaths worldwide, 1993
===================================================================================

                                                           TT2+ coverage (%)
              No. reported   Estimated     Estimated no.        among
Country           Cases      no deaths   prevented deaths    pregnant women
-----------------------------------------------------------------------------------
India             4,339       101,000        289,700              78
China                NA &      98,000          1,900               2
Pakistan          1,685        44,000         34,000              46
Nigeria           1,984        39,000         17,700              33
Bangladesh          720        30,000        144,700              73
Indonesia           566        28,000         49,200              67
Ethiopia             NA        23,000          3,300              13
Zaire                90        13,000          4,900              29
Nepal                20        10,000          1,300              12
Somalia              NA        10,000            500               5
Sudan                71         9,000            800               9
Ghana                 8         6,000            900              14
-----------------------------------------------------------------------------------
* Estimates of NT deaths are derived from national mortality data, NT mortality
  rates from NT surveys, or in the absence of surveys, by assuming that rates are
  similar for countries with similar socioeconomic conditions and from tetanus
  toxoid coverage levels.
+ The number of prevented NT deaths was calculated for each country using number
  of live births, NT mortality rate, and tetanus toxoid coverage and efficacy.
& Not available.

Source: Global Program for Vaccines and Immunization, World Health Organization,
1994.
===================================================================================

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Table_2
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TABLE 2. Estimated number of deaths * attributable to neonatal tetanus (NT),
by region -- worldwide, 1993
============================================================================
                        Estimated no.
Region                     deaths          (%) +
----------------------------------------------------------------------------
Southeast Asian            176,000      ( 34.2%)
African                    145,000      ( 28.2%)
Western Pacific &          110,000      ( 21.4%)
Eastern Mediterranean       80,700      ( 15.7%)
Region of the Americas       2,000      (  0.4%)
European @                   1,300      (  0.3%)

Total                      515,000      (100.0%)
----------------------------------------------------------------------------
* Estimates of NT deaths are derived from national mortality data, NT
  mortality rates from NT surveys, or in the absence of surveys, by assuming
  that rates are similar for countries with similar socioeconomic conditions
  and from tetanus toxoid coverage levels.
+ Percentages may not total 100 because of rounding.
& Includes China, which began administering tetanus toxoid in selected areas
  in 1992.
@ In this region, only Turkey routinely administers tetanus toxoid coverage
  to WHO.

Source:  Global Program for Vaccines and Immunization, World Health
Organization, 1994.
============================================================================

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