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Q&A with Diana Chang Blanc, UNICEF EAPRO Regional Immunization Specialist, and Dr. Francois Gasse, head of UNICEF’s global Maternal and Neonatal Tetanus Elimination Initiative

A 14-day-old baby suffering neonatal tetanus before dying from severe spasms in a rural hospital in Cambodia. The mother was not fully immunized against tetanus and delivered at home without a skilled birth attendant.

December 2008

When a newborn baby arches backward and goes silent with lockjaw, most likely there is a tetanus poison invading the newborn’s nervous system. In most cases, if appropriate medical care cannot be found quickly, there follows unmerciful, violent and painful spasms until the child suffers death, as the infant can no longer be nursed or breastfed. It leaves a haunting and heart-breaking image.

Despite the wide availability of a vaccine to prevent tetanus, it remains a serious risk to infants in 46 countries, eight of which are in East Asia and the Pacific. In 2004, 128,000 neonatal deaths due to tetanus occurred globally – three-fourths of all tetanus deaths.

Tetanus also kills many mothers each year. Maternal tetanus is often the outcome of unsterile abortions or deliveries that are unsafe and occur under unsterile conditions. The symptoms can appear up to three weeks after an injury and are similar to those of neonatal tetanus, including the tight jaw, stiff neck and body muscles, difficulty swallowing and violent and painful spasms. Death is swift. Immunization, which saves the newborn, will also protect the mother. UNICEF estimates the disease could be eliminated in all countries by 2012. But reaching women – and babies – is not so easy.

Following a recent joint UNICEF/World Health Organization workshop with government officials on eliminating maternal and neonatal tetanus in the region by 2012, Diana Chang, EAPRO Regional Immunization Specialist, and Dr. Francois Gasse, head of UNICEF’s Maternal and Neonatal Tetanus Elimination Initiative discuss why this bacterial disease remains a problem in the region and how several countries are closing in on its demise.

Q. What actually is tetanus?
A. It is a disease caused by bacteria that is pervasive – the spores live in the soil, in animal dung and even on the human body. With a newborn child, they can enter the body if the umbilical cord is cut with dirty instruments, is manipulated by dirty hands or is covered with contaminated dressings or traditional substances containing tetanus spores.

Once inside the body, the bacteria produce an extremely potent toxin, or poison, that attacks the nervous system causing spasms and tightening of muscles in the jaw and neck and, later, in the back and abdomen. In a baby, the mouth gets so rigid it becomes ‘locked’ and the child can no longer breastfeed or, ultimately, breathe.

Q. How is it prevented?
A. If a woman is immunized with tetanus vaccine, then her future newborn children will also be protected against the disease. Without that protection and if a birth takes place in unhygienic conditions, the newborn child may get tetanus through infection of the umbilical cord stump. Immunizing women will protect their newborns against tetanus during the first two months of a baby’s life. Immunizing children against tetanus is the most effective tool available to controlling this disease.

The WHO recommends two doses of tetanus toxoid for pregnant women during their routine ante-natal care, followed by booster doses to maintain protection. Where women have limited access to health care services, often vaccination campaigns need to be organized, and then three doses of the vaccine is given to all women of childbearing age. Three doses will protect the women for at least up to five years. When the mother is immunized, she will pass on (through the placenta) her immunity to her newborns, who will be protected for the first two months of life.

The overall strategy for eliminating maternal and neonatal tetanus is to emphasize clean deliveries, appropriate immunization and good surveillance. UNICEF works with governments to better provide safe and preventive care to mothers and babies, including clean-delivery kits for midwives and other traditional birth attendants to use when a mother can’t reach a health facility.

A woman grimaces as her arm is swabbed by a health worker following a tetanus vaccination in a village in Aceh Province, Indonesia

Q. Where is maternal and neonatal tetanus [MNT] still considered endemic in the region of East Asia and the Pacific?
A. MNT remains a public health problem in 46 countries across the globe, and most of them can be found on the African continent. In this region, the disease still circulates at unacceptable levels in Cambodia, China, Indonesia, Lao PDR, Myanmar, Papua New Guinea, Philippines and Timor-Leste.

Maternal and neonatal tetanus was previously endemic in Viet Nam, but the country successfully eliminated it in 2005.

Q. What does it mean to eliminate it?
A. It means there is less than one case of neonatal tetanus occurring for every 1,000 live births in every single district of a country. We use this standard when we talk of eliminating both maternal and neonatal tetanus.

Q. Why is tetanus still a public health problem?
A. Maternal and neonatal tetanus is a disease of the poor. It afflicts those who cannot, or in some instances, will not access the health care system and most often appears in remote populations who do not reach health care centres. Difficulties with access can be due to financial constraints but can also be due to geographical, cultural or social barriers. For this reason, MNT is often referred to as the ‘silent killer’ – deaths that occur at home but remain unreported and therefore, unrecognized.

In this region, as in others, many pregnant women do not receive proper ante-natal care, the time during which they would be protected with two doses of tetanus vaccine.

If an unprotected woman delivers a child at home without the help of a skilled midwife or health worker, there is the risk that she or her newborn will be infected with tetanus.

Q. What are the challenges in this region?
A. Countries like Papua New Guinea or Indonesia have extraordinary terrain and geographical conditions that make the provision of routine immunization quite challenging. Many of those most vulnerable to tetanus live in extremely remote corners or hills and health workers must sometimes travel for days, by foot, boat or animal to reach them. This takes money and adequate staffing. Finding sufficient resources is one constraint.

In some countries, women refuse to be immunized or are afraid to be immunized. One country in the region struggled over a decade to quell unfounded rumours that the tetanus toxoid vaccine leaves young women sterilized. Social mobilization efforts to adequately inform the community and gain the trust of community leaders, religious leaders and local decision-makers are essential.

In some parts of countries, such as Cambodia and Lao PDR, home deliveries can exceed 80%. These births often are attended by untrained birth attendants. In societies where traditional practices remain strong, unconventional substances can be placed on the umbilical cord after birth: from ashes to cow dung, salt and pepper and even a wasp’s nest. Again, this highlights the importance of raising awareness among communities and educating mothers about the risk of these traditions.

Q. What are the success stories in this region?
A. As of 2005, Viet Nam eliminated tetanus as a public health problem. This came after the government had implemented tetanus vaccination campaigns in the highest-risk districts, which were largely in the mountainous north. In these areas routine immunization coverage of pregnant woman during ante-natal care visits was less than 80%. The Government launched multiple supplementary immunization campaigns from 1993 through 2004, immunizing 93% of the targeted 27.2 million women. In addition, UNICEF supported campaigns from 2002 to 2005, targeting over 500,000 women. The result was that all over Viet Nam, including in the most remote areas, almost all women became protected with at least two doses of tetanus toxoid.

The progress made in Indonesia has also been amazing. As of 1990, over 22,000 newborns died in Indonesia each year due to neonatal tetanus. By 1997, this burden was reduced by 70% to 6,400, but this still represented a rate of 1.4 neonatal deaths per 1,000 live births. Since then, campaigns in high-risk areas have been organized, and we hope to demonstrate over the next few years that it can be eliminated.

Cambodia is making progress through a creative incentive scheme – in addition to tetanus vaccination campaigns in high-risk areas. The Government offers health staff US$15 for every live birth that occurs at a health facility – the midwife receives most of the payment for delivering the baby at the clinic, but a portion goes to the community volunteer or traditional birth attendant for encouraging a pregnant mother to go to the facility. Some districts are even supporting the transportation costs of the mother. The result has been an increase in facility-based deliveries, which have a positive impact on maternal and newborn survival, including on reducing the number of MNT cases.

China is focusing on making delivery safe by motivating pregnant women to deliver in institutions, promoting clean delivery practices for home-births by providing delivery kits and improving the reach of ante-natal care. In poor regions, mothers are provided a subsidy of 300 RMB (approximately $40) to pay the cost of delivering in a hospital. Children are immunized with five doses of tetanus by the age of six years, providing protection for life – which means girls would already be protected against tetanus by the time they reached child-bearing age.

Q. UNICEF started its elimination campaign in 1989, why is it taking so long?
A. Because neonatal tetanus is a silent killer that disproportionally affects the most poor and marginalized rural populations. Very few neonatal cases reach health facilities, and most remain unreported. Tetanus is the only vaccine-preventable disease that is not contagious, and so it does not produce media-attracting outbreaks. The result is that this is a disease with a low priority for politicians and programme managers. In the 1980s, it took multiple community mortality surveys to convince politicians and development agencies of the neonatal tetanus disease burden. It is only after the World Health Assembly recognized the problem in 1989 and called for its elimination that the disease was given more attention and funding. But even so, it often does not get the attention it deserves when it comes to prioritizing health activities or funding allocations.

Because there are no visible outbreaks, if a country has no political will to eliminate the disease among women and babies, it does not get addressed as a priority. And it is hard to compete with other visible health priorities.

We have been making progress – from 800,000 deaths in the mid 1980s to 128,000 in 2004. And we went from 90 countries endemic in 1990 to 46 in 2008.

If money and political will were at hand, we estimate a global elimination would be possible by 2012.

Q. What strategies are working in the EAPRO region?
A. The strategies in this region are also global strategies. As Viet Nam has demonstrated, protecting mothers and thus achieving neonatal elimination requires a multi-pronged approach that must be well-planned and coordinated, adequately financed and properly implemented. It requires a combination of promoting clean deliveries through safe motherhood programmes, vaccinating more than 80% of pregnant women through routine immunization (during ante-natal care) and supplemental campaigns to vaccinate all women of child-bearing age in areas where access to health services is limited. It also includes strong surveillance to identify and respond to neonatal cases to identify the pockets of vulnerability.

And we have found that in dealing with MNT, we can really push the need for reaching pregnant women with health services early. Such a continuum of care greatly improves the chances of a child’s survival because healthy mothers tend to give birth to healthy babies. As we already know, 40% of deaths among children younger than 5 years occur during the first weeks of life. If the mother is already integrated into the health system through proper ante-natal care, an important opportunity exists to further promote simple, affordable interventions to reduce newborn deaths – safe delivery and post-partum visits, kangaroo care and breastfeeding, micronutrient supplementation, Hepatitis B birth dose for the child, or distribution of insecticide treated bed-nets.

Q. What happens after a country eliminates mother and neonatal tetanus?
A. A country can never stop immunizing its women and children against tetanus. After adequately controlling maternal and neonatal tetanus, often through the use of vaccination campaigns, a country can then begin to focus on how to protect all individuals, not only mothers and newborns, throughout life against tetanus. This can be done by further strengthening its routine immunization programme so that ideally, all individuals receive six doses of tetanus toxoid through the course of their life, from infancy into adulthood.

UNICEF’s priority, in partnership with WHO and others, is to provide countries the financial and technical assistance to achieve the goal of MNT elimination and ultimately to protect all people against tetanus. This means ensuring vaccine security, strengthening the cold chain and logistics systems, providing the proper information and education on the importance of immunization and clean delivery practices.

In addition to ministries of health, UNICEF works with many partners in the effort to eliminate maternal and neonatal tetanus – the World Health Organization, GAVI Alliance, the Gates Foundation, the United Nations Population Fund, the Program for Appropriate Technology in Health (PATH), Becton Dickinson, Basic Support for Institutionalizing Child Survival (BASICS)/United States Agency for International Development and Save the Children-US, among others. UNICEF also is partnering globally with Proctor & Gamble, which is donating US$.07 to the Maternal and Neonatal Tetanus Elimination Initiative, from every package of Pampers diapers sold.

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