It takes a community to eliminate tetanus
By Karen Emmons
Late morning in quaint Solana municipality, a vaccination team finds two young women in their early 20s drenched in sweat in a hut where they have been hiding behind sacks of rice “from the needle”. But just a few kilometres across the fertile fields of Cagayan province in the far northern Philippines where water buffalo are as common as bushes and public transport includes horse-drawn wooden carts, another vaccination team finds ten young women in a corner of Iraga village who can’t wait to be jabbed.
A needle jab to these women is nothing compared to the horrible death the young mother described after she returned from two days in the hospital. With her she carried the lifeless body of her week-old baby who had been born at home, within earshot of the ten women.
Triggered by bacteria that are commonly found in soil, tetanus infection is considered one of the cruellest of diseases because it causes people who are afflicted to suffer through rhythmic muscle spasms that make breathing periodically impossible, contractions of the jaw and stomach, stiffness in the neck, difficulty swallowing and which often leads to death. Immunization with two doses of tetanus toxoid is the only way to prevent contracting the disease.
Neonatal and maternal tetanus is a vaccine-preventable disease that has been eliminated in all but 40 countries globally. An attempt to eradicate it in the Philippines in the mid 1990s was interrupted in many areas for 11 years because several influential religious leaders were erroneously convinced that the vaccine was an abortion agent and prevented girls and women from being immunized and thus protected.
In that 11-year period alone, countless Filipino babies and many mothers likely died from the disease, which primarily afflicts the poor and those living in remote areas with limited access to health services. For this reason, maternal and neonatal is often referred to as a ‘silent’ disease because the tetanus deaths go unreported.
My baby was turning blue
“She stopped feeding. Then my baby was turning blue,” recalls Maricel Busalin, now 28, the Iraga mother whose baby was the last known case of neonatal tetanus in Solana. Tetanus toxoid immunization was never banned in Solana, but uneven immunization coverage of the population has left pockets unprotected. Although Solana does not have the highest incidence of tetanus in the country, the 18 cases since 2000 are considered alarming.
“She was jerking. She was squeezing up, going stiff,” Ms. Busalin demonstrates. “As much as possible I wanted it to be me instead of my child suffering.” The mother of four had never been vaccinated because she feared the needles too much, she says.
In addition to lack of immunization, maternal and neonatal tetanus results from the use of unclean instruments during a delivery or the practice of applying ash, garlic or even a wasps’ nest on a baby’s cut umbilical cord, a healing ritual often favoured by the traditional birth attendants who assist women in home births.
Ms. Busalin’s baby girl was born suddenly one morning, without the mother suffering any labour pains. Her husband ran 50 meters for the hilot, as the Filipino traditional birth attendants are called, because there was no choice. But it was the same woman who had delivered their other four babies and they had no money to pay anyone else. The hilot used sterilized scissors to snip the umbilical cord but smeared coconut oil on the cut.
In Solana, 90 per cent of births are delivered at home, many of them with a hilot, who were trained by another hilot. In 2008, the Philippine Department of Health officially prohibited the use of hilots, promoting facility births as much as possible and midwife attendants for home deliveries to lower the country’s high incidence of maternal deaths due to childbirth-related complications, such as haemorrhaging, hypertension and eclampsia.
Ms. Busalin says everyone she knew relied on a hilot when it was time to give birth. The municipal health officer, Rebecca Battung, says hilots give additional service by staying with the mother for days, massaging and feeding her and helping her feed the baby. Midwives, whose services are free, cover a large population but sometimes are not easily available. As well, the cost of transport for many families makes travelling even 10 kilometres to a clinic prohibitive.
Vaccinating every female
With consistent advocacy from UNICEF and other partners, the remaining opposition to the tetanus toxoid vaccination by a religious group was lifted in 2006. Philippine health authorities now are determined to eliminate the incidence of neonatal tetanus as well as maternal tetanus from the nine high-risk areas in the country, beginning with Solana. To achieve tetanus ‘elimination’ status, the country must decrease the disease burden to less than 1 neonatal case per 1,000 live births per district.
To achieve that status, the health authorities are using Solana to pilot a door-to-door campaign that involves giving every female aged 15–40 – the ones most likely to have a baby in the future – three rounds of the tetanus toxoid vaccination. The three doses offer women additional opportunities to boost protection beyond routine injections received solely during pregnancy. That immunity shield will then be passed on temporarily to any baby born of a protected mother.
The pilot campaign began with methodical preparation. All households where the targeted females reside were mapped, and village meetings were arranged to educate these women as well as family members about the importance of vaccination. Raising such community awareness is critical before health workers show up with the intimidating syringes. Because fear of the needle is almost universal, and to mitigate any other possible threat to the campaign’s success, focus group discussions guided the marketing messaging, resulting in the huge posters that ask, “Are you ready?” A confident young woman exposing her arm is shown beaming, “Me, I am ready!”
To cover the targeted 15,260 females, 13 teams, each entailing a midwife and two vaccinators, were assembled and also consulted during the preparatory period. Their expressed need for transport allowance helped build their enthusiasm for conducting the three rounds.
Local politician requests help
The success of the approach relied on the backing of key local government officials and religious and village leaders. In fact, Solana became the pilot site because Mayor Meynard Carag asked public health officials for help in removing what he saw as a negative blight and unnecessary suffering.
“As a parent, I feel what they feel. As their leader, it’s my primary goal to look out for their safety,” says the young mayor who has visions of greater prosperity for his constituency. “I believe if you have healthy people, it will progress the town,” he adds.
With Mr. Carag’s instruction, the word went out that everyone in the path of the campaign was to provide whatever help was needed. The mayor provided transport for each team and his enthusiasm proved infectious; the men in official barangay positions below him deployed equal support, supplying food for the vaccination teams and warm cajoling to the reluctant vaccinees.
The president of the Association of Barangay Captains (village chiefs) sent reminders through radio and telephone messages before each round of vaccination visits. Mimicking the practice, many barangay captains checked with other village officers through text messages on the progress and any problems during each visit.
After being informed of the impending campaign by the regional public health officers, the nuns at the local Catholic school instructed teenaged female students not to fear the three jabs. The head of the civic Catholic Women’s League says she told her members in meetings that all eligible family members needed to be immunized.
“It was a true community effort,” says Marisa Ricardo, a health specialist with UNICEF in Manila, which covered a portion of the campaign expenses.
Whether they drove or walked into a village, the vaccination teams, assisted with a village health worker, often found women waiting for them under a tree at the main road. One mother rode the family water buffalo to bring her daughter to the team. They wanted to protect their future babies as well as themselves.
To reach the others, the team followed their maps and the village health workers or even a barangay captain to each targeted house. The few women who refused were counselled, though not always successfully. The midwives kept track of women who were not at home and returned repeatedly to ensure these women had an equal opportunity to protect themselves and their future babies.
The community commitment made a difference, helping the municipal public health team ultimately reach around 80 per cent of the 15,260 teenage girls and women targeted with at least two doses (the midwives are still following up recipients of the third dose) of protection. With a smiling grimace, Ms. Busalin took her injection. “To be safe from tetanus,” she says, “I can’t be scared any more.”