Tetanus Elimination: An Amazing Public Health Achievement

Neonatal tetanus is one form of a devastating illness with a very high mortality rate. The illness was recognized by Hippocrates as early as the 5th century BC. The causative bacterium and its exotoxin were identified in the late 1800s.

An effective toxoid vaccine was developed in 1924 and widely used during World War II to prevent tetanus induced by battle wounds. The illness itself is characterized by generalized rigidity and painful convulsive spasms of skeletal muscles.

The infectious agent, Clostridium tetani, is a spore-forming anaerobe found in the soil and in the gastrointestinal tract of animals. It generally enters the body through a break in the skin, such as a cut or a puncture wound with a contaminated object. The bacteria produce a potent biological toxin which is responsible for the clinical signs. The spores which cause tetanus are ubiquitous, so the only prevention is immunization.

Newborns typically receive passive immunity from their immunized mothers and are therefore protected. However, if mothers have not been immunized, not only are they at risk for developing tetanus but so are their unprotected babies. In many countries, deliveries take place in unhygienic circumstances putting both mothers and babies at risk for life-threatening infections.

Maternal and neonatal tetanus are among the most common lethal consequences of unclean (out of health care facilities and/or not assisted by medically trained assistants) deliveries.

In newborns, the site of infection is generally an unhealed umbilical cord stump, particularly when the cord is cut with a non-sterile instrument.
In 1988, the World Health Organization (WHO) estimated that 787,000 newborns died of neonatal tetanus.

The numbers are particularly staggering and alarming since deaths can be prevented by hygienic delivery and cord care practices and/or by immunizing mothers with tetanus vaccine that is both inexpensive and efficacious.

Subsequently, the WHO and partner organizations such as UNICEF and UNFPA initiated a public health campaign with the goal to eliminate maternal and neonatal tetanus. Tetanus cannot be eradicated such as polio and small pox due to the worldwide distribution of spores in the environment.

The goal, however, to eliminate the disease sets a target of less than 1 case/1000 live births. Persistent and painstaking efforts throughout all 6 WHO Regions to enhance vaccination of pregnant women and children as well as to increase skilled birth attendance and to educate regarding clean umbilical cord practices have achieved remarkable success.

As of 2013, the WHO estimated that 49,000 newborns died from neonatal tetanus, a 94% reduction from that of the late 1980s. As recently as May 2016, the WHO reported that the South-East Asia Region, an area comprising 25% of the global population, had successfully eliminated maternal and neonatal tetanus. India, a member nation of the South-East Asia Region had previously met the goal in 2015.

While progress continues to be made, by June 2016, 19 countries have not reached elimination status. Activities to achieve the goal are ongoing in these countries, with many likely to achieve maternal and neonatal tetanus elimination in the near future.

Despite the resounding success of the campaign, efforts can not cease and must continue to maintain and enhance high population immunity with tetanus vaccination during infancy, for women of childbearing age, and during adolescence through school immunization programs.

Additionally, achieving high coverage of skilled birth attendance and promoting appropriate umbilical cord care are essential goals necessary to maintain maternal and neonatal tetanus elimination.