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
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?
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?
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.
Q. Where is maternal and neonatal tetanus [MNT] still considered endemic in the region of East Asia and the Pacific?
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?
Q. Why is tetanus still a public health problem?
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?
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?
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?
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?
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?
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.