BQ Journal Vol 47 - Q2 2022 - 22

Morbidity and Mortality Weekly Report
Progress Toward Achieving and Sustaining Maternal and Neonatal
Tetanus Elimination - Worldwide, 2000-2020
Florence A. Kanu, PhD1; Nasir Yusuf, MD2; Modibo Kassogue, MD3; Bilal Ahmed, MBBS3; Rania A. Tohme, MD1
Maternal and neonatal tetanus (MNT)* remains a major
cause of neonatal mortality with an 80%-100% case-fatality
rate among insufficiently vaccinated mothers after unhygienic
deliveries, especially in low-income countries (1). In 1989, the
World Health Assembly endorsed elimination† of neonatal
tetanus; the activity was relaunched in 1999 as the MNT elimination
(MNTE)§ initiative, targeting 59¶ priority countries.
MNTE strategies include 1) achieving ≥80% coverage with
≥2 doses of tetanus toxoid-containing vaccine (TTCV2+)**
among women of reproductive age through routine and
supplementary immunization activities (SIAs)†† in highrisk
districts,§§ 2) achieving ≥70% of deliveries by a skilled
birth attendant,¶¶ and 3) implementing neonatal tetanus
case-based surveillance (2). This report summarizes progress
toward achieving and sustaining MNTE during 2000-2020
and updates a previous report (3). By December 2020, 52
(88%) of 59 priority countries had conducted TTCV SIAs.
Globally, infants protected at birth*** against tetanus increased
from 74% (2000) to 86% (2020), and deliveries assisted by a
skilled birth attendant increased from 64% (2000-2006) to
83% (2014-2020). Reported neonatal tetanus cases worldwide
* Tetanus occurring during pregnancy or within 6 weeks of the end of
pregnancy; maternal tetanus infection occurs during abortion, miscarriages,
or birth with unhygienic delivery. Neonatal tetanus occurs during the first
28 days of life, either following the cutting of the umbilical cord under
nonsterile conditions or applying nonsterile traditional remedies to the
umbilical stump in an infant without passively (transplacentally) acquired
maternal antibodies.
† The occurrence of less than one neonatal tetanus case per 1,000 live births
per year in every district in every country.
§ Neonatal tetanus elimination is considered a proxy for maternal tetanus
elimination; the same strategies for elimination are shared.
¶ Initially, the total number of priority countries was 57. The creation of
Timor-Leste in 2002 and South Sudan in 2011 increased the number of
priority countries to 59.
** Tetanus toxoid (TT2+) or tetanus-diphtheria toxoid (Td2+).
†† Mass vaccination campaigns that aim to administer doses of tetanus toxoid-
containing vaccines to women of reproductive age.
§§ Districts considered at high risk because the estimated neonatal tetanus case
rate exceeds one per 1,000 live births, clean delivery coverage is <70%, and
coverage with 3 tetanus toxoid-containing vaccine doses among pregnant
women is <80% during the past 5 years.
¶¶ A doctor, nurse, midwife, or health worker trained in providing lifesaving
obstetric care, including giving necessary supervision, care, and advice to
women during pregnancy, childbirth, and the postpartum period.
*** The status of an infant born to a mother who received 2 doses of TTCV
during the last birth, ≥2 doses with the last dose received ≤3 years before the
last delivery, ≥3 doses with the last dose received ≤5 years earlier, ≥4 doses
with the last dose received ≤10 years earlier, or receipt of ≥5 previous doses.
decreased by 88%, from 17,935 (2000) to 2,229 (2020), and
estimated deaths decreased by 92%, from 170,829 (2000) to
14,230 (2019).††† By December 2020, 47 (80%) of 59 priority
countries were validated to have achieved MNTE, five of
which conducted postvalidation assessments.§§§ To achieve
elimination in the 12 remaining countries and sustain elimination,
innovation is needed, including integrating SIAs to
cover multiple vaccine preventable diseases and implementing
TTCV life course vaccination.
Immunization Activities
To estimate TTCV vaccination coverage delivered through
routine immunization services and the number of neonates
protected at birth from tetanus, World Health Organization
(WHO) and UNICEF use data from administrative records
and vaccination coverage surveys reported annually by member
countries (4). WHO and UNICEF receive summaries of the
number of women of reproductive age receiving TTCV during
SIAs (5). In 2020, 16 (27%) of 59 priority countries achieved
≥80% TTCV2+ coverage, with 34 countries increasing coverage
since 2000 (Table). In 2020, among 58 priority countries
with available data, 46 (79%) reported ≥80% of infants
protected at birth. The global proportion of infants protected
at birth increased from 74% (2000) to 86% (2020) (Table).
During 2000-2020, 52 priority countries conducted
TTCV SIAs, and 168 million (67%) of the targeted 250 million
women of reproductive age received TTCV2+ (Table)
(Figure 1). In 2020, 59 million women targeted for protection
by TTCV SIAs remained unreached, and TTCV SIA
activities aiming to target an estimated 16 million women
of reproductive age in five countries were postponed because
of COVID-19-related disruptions in immunization services
(Figure 1) (6).
††† Neonatal mortality data were unavailable for 2020. http://ghdx.healthdata.
org/gbd-results-tool
§§§ A postvalidation assessment comprises a review of data to determine whether
MNTE indicator standards are being maintained and to identify districts
potentially at risk of not sustaining MNTE. Postvalidation assessments
include field visits and interviews at both the facility and community level,
cross checking the reported coverage of tetanus toxoid-containing vaccines,
antenatal care, and skilled birth delivery. The assessment also includes
bottleneck analysis and development of a work plan and time frame for
implementing corrective actions, if needed.
406
MMWR / March 18, 2022 / Vol. 71 / No. 11
US Department of Health and Human Services/Centers for Disease Control and Prevention
Diagnostics I Pharmaceuticals I DxRx Solutions I Continuing Education I News
22
A Henry Schein Publication

https://ghdx.healthdata.org/ https://ghdx.healthdata.org/

BQ Journal Vol 47 - Q2 2022

Table of Contents for the Digital Edition of BQ Journal Vol 47 - Q2 2022