By Ethan Covey
There have been significant global declines in neonatal tetanus cases and deaths since 2000, due to efforts of the WHO Maternal and Neonatal Tetanus Elimination (MNTE) initiative. However, disruptions caused by the COVID-19 pandemic have impeded MNTE progress (MMWR Morb Mortal Wkly Rep 2024;73[28]:614-621).
“Maternal and neonatal tetanus remains a major cause of neonatal mortality among undervaccinated mothers and their infants after unhygienic deliveries, especially in low-income countries,” said Camille E. Jones, PhD, a CDC Epidemic Intelligence Service officer, Global Immunization Division, Center for Global Health. “Although cases are almost always fatal, neonatal tetanus can be prevented through adequate maternal vaccination during pregnancy and access to clean and safe deliveries.”
From 2000 to 2022, 47 of 59 priority countries were validated to have achieved MNTE. The number of infants protected at birth against tetanus increased from 74% to 86%, and by December 2022, 177 million of the targeted 252 million women of reproductive age in 59 priority countries received at least two doses of tetanus toxoid-containing vaccine (TTCV2+). Neonatal tetanus cases declined by 89%, and neonatal tetanus deaths dropped by 84%.
As of June 2024, 10 countries remain to be validated for elimination of maternal and neonatal tetanus.
“The countries not yet validated for achieving elimination are challenged by conflict, insecurity and competing priorities,” Dr. Jones said. “To achieve and sustain elimination, countries will need to strengthen routine tetanus vaccination including booster doses across the life course, increase access to skilled birth attendants and hygienic delivery settings, and strengthen neonatal tetanus case-based surveillance.”
Although these efforts since 2000 have produced impressive results, the global disruption of routine immunizations caused by the COVID-19 pandemic has threatened to erase some of the gains, experts said.
Since 2020, reported neonatal tetanus cases have increased in 31% of priority countries.
“The COVID-19 pandemic interrupted health services worldwide, including routine immunization systems,” Dr. Jones said. “As we continue to move on from the pandemic, it is imperative that pregnant women continue to receive at least two doses of TTCV2+ vaccine prior to delivery and have access to a skilled birth attendant at delivery to ensure their newborn is protected against tetanus at birth. Since tetanus spores are ever present in the environment and infection does not result in immunity, it is also important for health systems to include strong and reliable neonatal tetanus case-based surveillance.”
Other non–pandemic-related challenges remain. By 2022, only one-third of 43 MNTE-validated countries sustained at least 80% TTCV2+ coverage, and in 12 MNTE-validated countries, less than 70% of births were assisted by skilled birth attendants. Additionally, less than one-third of validated countries had introduced at least one TTCV booster dose into their routine immunization schedule.
Dr. Jones stressed that while substantial progress has been made toward achieving global elimination of maternal and neonatal tetanus, with elimination validated in 80% of priority countries, more attention is needed to ensure that elimination in those countries is sustained.
“Future directions of the MNTE initiative should include continued support of introduction of TTCV booster doses into routine immunization schedules and integration of neonatal tetanus case-based surveillance into polio and measles case-based surveillance,” she said. “Research on integrated VPD [vaccine-preventable disease] case-based surveillance systems could provide countries with best practices and a framework for developing and implementing a well-performing surveillance system.”
