Validation of Maternal and Neonatal Tetanus Elimination in the Philippines, 2015

A mother holds her infant daughter in rural Philippines while being interviewed about maternal and neonatal tetanus in her family.

In many countries, deliveries take place in unhygienic circumstances, putting mothers and their newborn babies at risk for a variety of life-threatening infections.

Maternal and neonatal tetanus (MNT) have been among the most common lethal consequences of unclean deliveries and umbilical cord care practices. When tetanus develops, mortality rates are extremely high, especially when appropriate medical care is not available.

The MNT Elimination Initiative aims to reduce MNT cases to such low levels that the disease is no longer a major public health problem. Unlike polio and smallpox, tetanus cannot be eradicated (tetanus spores are present in the environment worldwide), but through immunization of pregnant women and other women of reproductive age (WRA) and promotion of more hygienic deliveries (especially health facility deliveries) and clean cord care practices, MNT can be eliminated (defined as less than one case of neonatal tetanus per 1000 live births in every district).

WHO estimates that in 2013 (the latest year for which estimates are available), 49,000 newborns died from NT, a 94% reduction from the situation in the late 1980s. While progress continues to be made, by February 2015, there were still 24 countries that had not reached MNT elimination status. Activities to achieve the goal are on-going in these countries, with many likely to achieve MNT elimination in the near future.

Validation of MNT elimination is recommended once countries believe that they have achieved elimination. CDC assisted the Philippines Department of Health and partners, such as UNICEF and WHO, with this documentation process in a remote part of the Philippines, Mindoro Occidental Province. Dr. Minal Patel from the Global Immunization Division shared these photos from the project.

Survey staff conduct household level logistics planning for the day’s data collection.

When you first visit a village selected for the survey, you have to figure out the boundaries of the villages and identify the center of the village. From the center, you count houses and choose a random house to visit. This is where the survey starts.

Survey interviewer asks a mother questions while she holds her baby at her home.

Vincent, a Department of Health staff member, knocked on doors until he found a household which contained women of reproductive age. He then interviewed those women to find out if they had been pregnant in the past two years, and the outcome of the pregnancy, including if it was a stillbirth, miscarriage, or live birth.

He asked if they were vaccinated with tetanus toxoid vaccine, and if the baby was born at a health facility or at home. Then he asked if the umbilical cord was cut with a non-sterile instrument, and if any non-medical substance was applied to the umbilical cord (as these are risk factors for tetanus). Finally, Vincent asked if the baby had died within one month of birth. If the baby had died, the mother was asked questions about the pregnancy, delivery, and post-delivery period to determine the cause of death of the baby. Specifically, the team was looking to see if any baby had died of tetanus.

The interviewer marks the house with numbers and letters to let others know that this house has been interviewed.

After the interview, Vincent marked the house with chalk to let other surveyors know that the family inside had been interviewed.

A small house in the middle of a tropical forest.

Houses in Mindoro Occidental are quite far apart and there aren’t many paved roads. Survey teams made their way from house to house trekking through the forest.

A rustic bridge made mainly of bamboo.

Going from house to house also required crossing some tenuous-looking bridges.

Rice paddies in the Philippines.

The goal of these surveys is to document that there are one or less newborn tetanus cases per 1000 live births in the areas with the least access to health facilities and care. Mindoro Occidental was chosen as the poorest performing area where national and international survey staff could safely travel.

Rural communities such as the one seen here are at the highest risk of tetanus infections and deaths because they have the poorest access to health facilities to have a safe delivery and are at risk for not receiving adequate tetanus vaccination.

Rice Paddies

In addition to having to walk through forests to get to households, large rice paddies made accessing houses challenging. Additionally, some families were not at home and were working in the rice paddies, so some interviews were done in the rice fields.

surveyors advised mothers who were under-vaccinated to get their booster doses of tetanus vaccine

Families were very willing to answer questions about the difficult topics, and surveyors advised mothers who were under-vaccinated to get their booster doses of tetanus vaccine.

Survey interviewer giving thumbs-up at the end of a long day.

After visiting 100 households, Vincent had found the 12 eligible live births in the village he needed to complete the survey, just as the sun was setting over the Philippines Sea.

In the end, over 13,000 households were visited in the span of one week, and family members of 1,755 babies were interviewed. Zero cases of neonatal tetanus were identified!

Page last reviewed: April 17, 2015
Content source: Global Immunization