Eliminating MNT

GOAL: Eliminate maternal and neonatal tetanus (MNT) by 2005.

The Challenge

Maternal and neonatal tetanus (MNT) is a swift and painful killer that killed 200,000 newborns and 3“Those affected by tetanus are often populations in remote places in the poorest countries. It costs more to go to the end of the world. Thus, these people are still not reached by routine immunization and often have little access to health care services. They are the least important populations for politicians and often the official policy is to deny the problem.” – UNICEF Senior Project Officer, Immunization, Dr. François Gasse. 0,000 mothers in 2001 alone due to unhygienic and unsafe childbirth delivery practices. Tetanus bacteria are pervasive – they live in the soil, in animal dung and in feces – and can enter the infant at birth if the umbilical cord is cut with dirty instruments or if the incision is treated with contaminated dressings.

Once inside the body, the bacteria produce an extremely potent toxin, or poison, which attacks the nervous system causing spasms and tightening of muscles in the newborn’s jaw and neck and later, in the back and abdomen. The baby’s mouth grows so rigid that it becomes “locked” (thus the name lockjaw given to tetanus) and the child will no longer be able to breastfeed, or ultimately, breathe. The fatality rate is high – between 70 and 100 per cent. The true extent of the tetanus death toll is not known as many newborns and mothers die at home and neither the birth nor the death is reported.  For this reason, tetanus is often called the “silent killer.”

Eight countries account for about 73 per cent of neonatal tetanus deaths: Bangladesh, China, the Democratic Republic of the Congo (DRC), Ethiopia, India, Nigeria, Pakistan and Somalia.

The majority of mothers and newborns dying of tetanus live in Africa and Southern and East Asia, generally in areas where women are poor, have little access to health care and have little information about safe delivery practices. At the time of the World Health Assembly in 1989, when the goal of eliminating MNT was called for, 104 of 161 developing countries had eliminated MNT as a major public health problem.  In 1999, the goal to eliminate MNT was reinvigorated and the target date of elimination in the remaining 57 countries was set for 2005. Since that time, four countries (Malawi, Namibia, South Africa and Zimbabwe) have been provisionally declared as having eliminated MNT. During the same period, other countries have initiated Supplemental Immunization Activities (SIAs) to eliminate the disease.

The Solution

Maternal and neonatal tetanus (MNT) is easily preventable through immunization and hygienic birth practices.

The World Health Organization (WHO) recommends two doses of tetanus toxoid (TT) for pregnant women during routine Ante Natal Care (ANC) and three TT doses to all women of childbearing age in high-risk areas during SIAs. Three doses will protect the women for up to 15 years and will pass on their immunity to their newborns for the first few months of life.

UNICEF works with many partners in the Initiative to Eliminate Maternal and Neonatal Tetanus – WHO, the United Nations Population Fund (UNPFA), the Program for Appropriate Technology in Health (PATH), the US Fund for UNICEF, Becton Dickinson (BD), the Gates Foundation, Basic Support for Institutionalizing Child Survival (BASICS)/United States Agency for International Development and Save the Children-US, ministries of health and others. The initiative is focussed on finding viable means to fund and deliver vaccines on a routine basis to the remaining 53 nations where MNT remains a major public health problem.

The role of UNICEF in this global effort is to procure and deliver vaccines, maintain the cold chain, educate health workers, and offer technical support to immunization programmes. To ensure that the disease is eliminated and elimination is sustained, UNICEF is also engaged in teaching and promoting clean birthing practices.

One of the constraints UNICEF faces in the field is finding enough health workers. Many of those most vulnerable to tetanus live in extremely remote locales and vaccinators some times must travel for days, by foot, boat, or camel to reach them. In some countries, women refuse to be immunized by male health workers or they won’t leave their homes  and health staff must make house calls.

“We can go to a village with vaccines and nobody will come. We are often dealing with populations who are illiterate or uninformed about tetanus. There is also a very deep mystical association with tetanus that can make it difficult for communities to appreciate the causal relationship between birthing practices and the disease.” – UNICEF Senior Project Officer, Immunization, Dr. François Gasse.

New pre-filled, single-use injection devices, such as Uniject, may help alleviate cultural, geographical and social constraints. They are easy to use and can be administered by non-professional health workers such as traditional birth attendants and teachers, they can be taken out of the cold-chain for up to 3 months at ambient temperatures, and they have smaller needles, which may reduce fears of injection, which often led to women refusing vaccination.

Another hurdle is convincing communities to vaccinate young women against tetanus because they may be uninformed about tetanus or reluctant to allow contact with strangers. Therefore, social mobilization efforts to inform and gain the acceptance of all community leaders, such as religious leaders and traditional healers, are critical for successful immunization activities.

Progress

• In 2001, 15,000 newborns were saved from neonatal tetanus – the number of deaths declined from 215,000 in 1999  to 200,000.
• Neonatal tetanus has been eliminated in 104 of 161 developing nations. Four additional countries – Malawi, Namibia, South Africa and Zimbabwe – have provisionally eliminated the disease and 19 more countries are close to elimination.
• Approximately 40 million women of child-bearing age have been targeted with at least one of the three required doses of TT since the launch of the initiative in 1999.
• Since 1999, the beginning of the initiative, 32.7 million women at risk have been protected against tetanus by a two-dose course.