ELIMINATION OF TETANUS - STRATEGIES AND WAY FORWARD

DR R KANNAN,

MAHATMA GANDHI MEDICAL COLLEGE AND RESEARCH INSTITUTE, PUDUCHERRY

CHAIR, ACADEMY OF MEDICAL SPECIALITIES, IMA TNSB

STORY TO TELL

• The scorching dry heat was palpable as the sun sizzled at 44 degrees…….
• The temperature inside the barely 10X 10 feet room was, however, several notches lower……..
• It was bustling with a bevy of new mothers with their babies and their elderly female family members.
• The room houses the anganwadi [child and mother care center] of Basantpur Sainthali village, located off National Highway 58. near Ghaziabad

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• On pre-designated immunization days, the anganwadi turns into a make-shift health facility to provide vaccination services to expectant mothers, newborns and children below 5 years of age.
• “The heat does not make a difference as long as the temperature inside this box is maintained,” remarks Prasanna Kumari, an experienced health worker, pointing to the grey coloured plastic box, which keeps life-saving vaccines at the right temperature using ice packs inside.

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• Zainab is the one of innumerable mothers in the country who have a similar experience to share, and who are key participants in India’s journey of achieving Maternal and Neonatal Tetanus Elimination (MNTE).

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INTRODUCTION

• Tetanus - acute potentially fatal disease caused by Clostridium tetani
• Neonatal tetanus contributes to 5 – 7% of neonatal mortality worldwide
• Several thousand mothers are also estimated to die annually of maternal tetanus

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• MNT Cases are clustered in poor remote communities due to unhygienic obstetric and postnatal practices prevail and access to maternal tetanus toxoid immnisation is poor
• 1980s – 1 million deaths every year were due to tetanus
• In 1990s the death has been reduced to 30000 around ie 5% of maternal mortality rates
• Only 10 percent of cases are being reported
• As the day passes by the number of NT cases in India is about not more than 5% of the total cases reported all over India

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• There is no immunity against tetanus but it is preventable through immunisation
• Maternal immunisation with tetanus toxoid containing vaccines protects both mother and the newborn

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FACTORS FOR INCREASED INCIDENCE OF TETANUS IN CHILDREN - BEFORE

• Hand washing techniques
• Delivery practices
• Traditional birth customs such as application of cow dung over umbilical stump
• Interest toward immunization
• Predominant livestock raising regions

HOW TO PREVENT MNT�

1. avoidance of unsafe delivery, abortion and umbilical cord care practices
2. promotion of maternal tetanus immunisation
3. hygiene of puerperal amd umbilical stumo has a significant impact on prevention of NT

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CONTROL AND ELIMINATION STRATEGIES�

1. TT vaccination of pregnant women to prevent NT in the Immunisation program since 1970s
2. WHO NT elimination program had helped a lot where they wanted to reach a goal of less than 1 case per 1000 live births in every district
3. UNICEF / WHO launched initiative - Maternal and Neonatal Tetanus Elimination Initiative - in high risk districts along with routine immunisation schemes, there is a supplemental immunisation activities to vaccinate more than 80% all women of childbearing age

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Maternal and Neonatal Tetanus Elimination Initiative

SUSTAINING THE MNT ELIMINATION�

1. Routine TT coverage for pregnant women
2. Routine DPT coverage of children
3. Womens access and to use clean delivery services

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DELVIERY BY SKILLED BIRTH ATTENDANTS TO ENSURE CLEAN DELVIERY PRACTICES�

• Their presence will ensure there is clean delivery practices, clean hands and clean cutting of cord are applied during delivery.
• It helps the mother to understand the importance of clean cord care as it is vital to avoid unclean practice
• The ratio of SBA has increased from 56 to 75% in developed countries and less number in developing countries suggest that it is poor among the poor SE status

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CLEAN DELIVERIES

• Clean deliveries (deliveries in health facilities and/or assisted by medically trained attendants) effectively reduce MNT and other causes of maternal and neonatal mortality.
• Health workers who provide TT vaccination to women with limited access to routine services should encourage the use of trained health providers for obstetric care and also provide information about how to reach such services.

IMMUNISATION OF WOMEN DRUIGN PREGNANCY�

1. Administration of properly spaced does of vaccine during the antenatal period can reduce the incidence of NT by 88%
2. The dosage depends upon the previous vaccination schedule of the women

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TETANUS SCHEDULE

• For women who have never received TT vaccine, or have no documentation of such immunization,
• a total of five properly-spaced doses is recommended:
• 2 doses given one month apart in the first pregnancy,
• the 3rd dose is given at-least 6 months later,
• then 1 dose in each subsequent pregnancy (or intervals of at least 1 year) - to a total of five doses

IMMUNISATION OF WOMEN OF REPRODUCTIVE AGE GROUP WITH TTCV �

• High risk districts with increased MNT where the basic facilities are not avaible then it can be planned to have 3 doses of TTCV are given to women of age group 15 – 45 years
• There would be community involvement through interpersonal communication and focus group discussion before and during the campaign
• This approach focuses on providing TT vaccination in districts where women have limited or no access to routine vaccination

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NEONATAL TETANUS SURVEILLENCE

• Surveillance for neonatal tetanus is poorly developed in most developing countries.
• It is estimated that less than 10% of NT cases and deaths are actually reported.
• It is necessary to integrate NT surveillance into the existing active AFP and measles surveillance to have active integrated disease surveillance for vaccine preventable diseases.
• This should be tied to NT case investigation and response as appropriate.

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NT SURVEILLENCE �

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• Effective surveillance is important to identify areas that are high risk for MNT and to monitor the impact of interventions and maintenance of elimination status
• In some areas the NT reporting can be passive and many reported cases are not investigated
• There has to be community based surveillance that integrates vaccine preventable diseases such as polio and vital events registration include neonatal deaths also

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MAINTAINENCE OF MNT ELIMINATION

• Continued strengthening of routine immunization activities for both pregnant women and children
• Maintaining and increasing access to clean deliveries
• Reliable NT surveillance
• Introduction of school-based immunization with TTCV.

INDIA’S STAND

1. Training of auxillary mid wives to conduct clean deliveries
2. Trained birth attendants at the village level
3. High political commitment
4. Effective village level promotional material on vaccination
5. Village level registration
6. TT vaccination to the pregnant mothers
7. Cash payments to families to cover costs associated with institutional deliveries
8. Promotion of institutional deliveries through cash incentives,
9. Availability of delivery kit for safe umbilical cord practices
10. Training of auxiliary nurse midwife, and local dais for safe delivery practices under the National Health Mission.

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WAY FORWARD

• Ensure that the majority of pregnant women are immunized against tetanus (at least >80%)�
• Ensure high coverage with tetanus toxoid-containing vaccines in infancy (such as DTP/Penta), and consider introducing child booster doses.
• School-based immunization can be an efficient and effective strategy to deliver booster doses of TTCV (and other vaccines);
• Ensure access to and use of clean delivery practices;

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• Maintain and improve MNT surveillance to monitor continued elimination and identify areas where MNT is still occurring.
• Good NT surveillance permits effective targeting of interventions when necessary.
• Because most neonatal deaths occur at home, often where neither births nor deaths are reported, NT surveillance can be quite challenging,
• It is nonetheless a key component of MNT elimination and serves as a valuable indicator of immunization and maternal and child health (MCH) system performance.

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