Neonatal tetanus.

Neonatal tetanus* 1. Brief description of the condition/disease Neonatal tetanus (NT) results from Closit idiitm tetanii infection of the umbilical stump at or following deliverv of a child born to a mother without suffi- cient circulating antibodies to protect the infant pas- sively by transplacental transfer. Contamination of the umbilical stump at or following delivery is espe- cially likely in an unattended delivery or a delivery attended by an untrained midwife. In sormc areas ot the world. the cord is cut with ani unclean object or the umbilical stump is traditionally covered with contaminated material. In addition. traditional sur- geries (e.g. circumcision. uvulectoiniy) are associated with increased risk. as are mothers witl) a historv of a previously delivered infant with NT. The average incubation period is 6 days (range: 3-28 days). NT is clharactcrized by generalized stiff- niess with spasms or convulsions. The case-fatality ratio is %80%. 2. Current global burden and rating within the overall burden of disease NT is a leadiiig cause of childlhood mortalitv in de- veloping countiics and is second only to measles among the vaccine-preventable diseases as a cause of childhood nmortality. In some developinig coun- tries, NT accounts tor one fourth of inifant mortality and half of neonatal mortality in unimmunized populations. In 1997. an estimated 277376 neonatal deaths were attnbuted to NT, with an estimated glo- bal mortality rate of 2.1 per 1000 live births. 3. Feasibility (biological) of elimination/eradication Because tetanus spores are ubiquitous in the envi- ronment, eradication is not biologically feasible. "Elimination" (achieving rates <I per I 000 Il e births) is fcasible only it high lcvels of coverage with appropriate strategies are achieved (sec below). Contributed by D Rebecca Prevots, Centers for Disease Con- trol and Prevention, Atlanta, GA, USA 4. Estimated costs and benefits of elimination Tetanus prevention througuh vaccination is highly cost-effective. The median estimated cost- effectiveness of tetanus toxoid (TT) vaccination programmes is US$ 89 (range, USS 27-205) per case prevented tor routine strategies. and USS 0.21 (range, US$ 0.55-1.71) for the cosL pei dose of TT administered during mass campaign strategies. These costs do not include (he need for certification as part of an elimination strategy. 5. Key strategies to accomplish the objective The following are key stiategies: achieving and maintaininig hirgh vaccination covcrage levels for at least two doses of potent 1T among reproductive- aged women in higli-nsk areas: promoting clean delivery, cord-care practices, a-nd other surgical pro- cedures perfornmed on neonates (including tllc fol- lowing practices shown to rcduce risk: handwashing by the delivery attendant. delivery on a clean sur- face, use ot a sterile or clean cutting tool, and appli- cation of a topical antimicrobial Lo the umbilical stump wound); and targeting women with a history of NT in previous infants 6. Research and evaluation needs Studies are needed to determine the following: opti- mum vaccination schedules tor hiigh, long-lasting immunity levels; optimum topical antimicrobial practices: operational approachcs to monitor the ficld effectiveness of TT using data on population coverage and maternal vaccination levels among NT cases; satety of iodinc as a topical antimicrobial in newborns and tvpe of iodine to be uscd; safety and effectiveness of sustained-release TI: duration of proLeCtion amnong girls vaccinatcd durLtio child- lhood through EPI: arnd mechanisms tor sensiti,e sunI eillance. 7. Status of elimination efforts to date An eliminiation goal (dcfined as <1 case per 1000 live birtlhs for all districts) has been established. Bulletin of the Wodd Health Organzatnon, 1998, 76 (Suppl 2) 135-136 135 Neonatal tetanus During 1980-95. the number of developing countries that have eliminated NT increased from 38 to 97. 8. Principal challenges to elimination Challenges to elimination mclude the following in- sufficient resources: coordination of efforts by EPI/ MCH to achievc all strategies proposed m Section 5 above: acblevement of hlih coverage levels with two or more doses of potent TI amono prcgnant women; achievement of high coverage levels with two or more doses of potent TT among women of child- bearing age; ensuring that doses of TT meet produc- lion and quality requirements: development and de- livery of culturally appropriate programmes for promotmg vaccination of girls and women and clean- cord and post-surgi%al care in neonates. develop- ment of operational approaches to reach and vaccinate, on a priority basis. women with a hustory of a previouts child with NT,; lack of effective surveil- lance and insufficient political will. Addendum In June 1998 the Scientific Advisory Group of Ex- perts (SAGE) for WHO recommended that TI' bc replaced with tetanus-diphthesla Td vaccine. 16WHO Bulletin OMS Vol 76, Suppl 2 1998136