Working to eliminate maternal and neonatal tetanus (MNT)

François Gasse, M.D., Senior Project Officer, UNICEF Immunization

Q: Why is eliminating maternal and neonatal tetanus (MNT) a priority for UNICEF?

GASSE:  In some ways, it is an ethical issue. 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.

Secondly, elimination of MNT is something completely within our grasp. Tetanus is a completely preventable disease. Tetanus toxoid (TT) vaccine is extremely effective and has been around for 80 years. We also have more flexibility with the vaccine because it does not require such a rigid cold chain - we can travel a long distance with tetanus toxoid and it can stand greater fluctuations in temperature.

Q: What is the global impact of MNT?

GASSE:  In the early 1980s, there were 800,000 neonatal tetanus deaths and 70,000 maternal deaths from tetanus in 160 developing countries. In 2001, tetanus killed 200,000 newborns and 30,000 mothers. These numbers may be even higher because tetanus is an invisible killer: many deaths occur at home and go unreported.

Q: What role is UNICEF playing in the global effort to eliminate tetanus by 2005?

GASSE:  Tetanus will always be around, so you can never stop immunizing. Our efforts are aimed at finding a viable way to fund and deliver vaccines on a routine basis. UNICEF is very involved in the procurement and delivery of the vaccines. We guarantee the cold chain, educate health workers, and offer technical support. Routine immunization and improved hygiene during childbirth are critical to eliminating the disease.  I think all countries should be autonomous eventually, but for the time being, UNICEF is there to support them.

Q: What are the challenges?

GASSE:  For tetanus, one of the biggest challenges is creating demand – mobilizing communities to get immunizations. 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 casual relationship between birthing practices and the disease.

Some communities see the convulsions caused by tetanus and think the child is possessed. Or they blame it on something the family has done. In some parts of Sudan, they call tetanus the “black bird.” So many children were dying of tetanus in one area that they even had a special cemetery. After the immunizers came, the disease disappeared. Then the communities said, “The black bird has flown away.”

Q: How does UNICEF work to mobilize communities to immunize?

GASSE:  We have learned we must target key decision makers. Often it will be the religious leaders, the husband, or even the mother-in-law. We must get acceptance. This is particularly critical for maternal immunizations because we immunize women of childbearing age. Communities are often suspicious that women are going to be sterilized. Often we must first convince a community leader. For example, if the leader allows his unmarried daughter to be immunized, this can be very effective.

Q: How does UNICEF reach women and children in the most remote areas?

GASSE:  It can be very difficult with our current staffing. One of our biggest constraints is finding enough health workers, in terms of quantity and gender. In some countries, women refuse to be immunized by male health workers. Other women stay home and health staff must go to their homes. All supplemental TT campaigns conducted in high-risk areas to women of childbearing age are with auto-disable syringes (injection devices that block the plunger after a single use) or pre-fitted, single-dose injection devices, thus preventing re-use and any re-infection of blood-borne diseases.

We hope that pre-filled devices such as UniJect will allow us to increase the number of vaccinators. The UniJect is a little bubble of plastic with a small needle. It is much easier to administer than a traditional injection and we can train students and others to perform vaccinations.  The device can’t be used twice so there is no danger of spreading disease through reuse. It will also be helpful in overcoming resistance to vaccinations because of fear of needles. Some women tell us, “Oh, no, spiritually I cannot accept this vaccination.” However, the real reason is that they fear the injection.

Q: Where are the MNT trouble spots?

GASSE:  Basically countries with the lowest rate of immunization coverage have the biggest problem. Today, 54 countries are still problematic. Usually those most at risk are countries at war or those with civil unrest such as Afghanistan, Angola, Southern Sudan, Somalia, and the Democratic Republic of Congo. Due to conflict, these countries have little or no infrastructure and poor levels of literacy.

Q: What are the MNT success stories?
GASSE:  There are many countries that have achieved elimination with their own resources, most without being recognized for their achievement. It is a silent success against a silent killer. I have been amazed by the progress made in Indonesia, India and Bangladesh. In 1990, Indonesia ranked second in the world for tetanus. Today Indonesia has achieved elimination of 80 per cent in 360 districts. In 1987, Bangladesh had the third highest number of estimated tetanus cases/ and only seven per cent of the women received protection. Today that number is 85 per cent. It is a fantastic program, where workers from Bangladesh, paid only pennies, go out to very remote areas. There the immunization program has been called a miracle.