Maternal and neonatal tetanus* (MNT) remains a major public health problem, with an 80%-100% case-fatality rate among neonates, especially in areas with poor immunization coverage and limited access to clean deliveries (i.e., delivery in a health facility or assisted by medically trained attendants in sanitary conditions) and umbilical cord care (1). In 1989, the World Health Assembly endorsed the elimination † of neonatal tetanus (NT), and in 1999, the initiative was relaunched and renamed the MNT elimination § initiative, targeting 59 ¶ priority countries (1). Elimination strategies include 1) achieving ≥80% coverage with ≥2 doses of tetanus toxoidcontaining vaccine (TTCV) among women of reproductive age through routine immunization of pregnant women and supplementary immunization activities (SIAs)** in high-risk areas and districts † † ; 2) achieving care at ≥70% of deliveries by a skilled birth attendant (SBA) § § ; and 3) enhancing surveillance for NT cases (1). This report summarizes progress toward achieving MNT elimination during 2000-2018. Coverage with ≥2 doses of TTCV (2 doses of tetanus toxoid [TT2+] or 2 doses of tetanus-diphtheria toxoid [Td2+]) among women of reproductive age increased by 16%, from 62% in 2000 to 72% in 2018. By December 2018, 52 (88%) of 59 priority countries had conducted TTCV SIAs, vaccinating 154 million (77%) of 201 million targeted women of reproductive age with TT2+/Td2+. Globally, the percentage of deliveries assisted * Maternal tetanus is defined as tetanus occurring during pregnancy or within 6 weeks of the end of pregnancy (birth, miscarriage, or abortion). Maternal tetanus infection occurs during abortion, miscarriages, or unhygienic delivery. Neonatal tetanus occurs during the first 28 days of life; neonatal tetanus infection occurs following cutting the umbilical cord under nonsterile conditions or applying nonsterile traditional remedies to the umbilical stump in an infant without passively (transplacentally) acquired maternal antibodies. † Neonatal tetanus (NT) elimination is defined as the occurrence of less than one NT case per 1,000 live births per year in every district in every country. § NT elimination is considered a proxy for maternal tetanus elimination, and both share the same strategies for elimination. ¶ Initially, the total number of priority countries was 57. The creation of Timor-Leste in 2002 and South Sudan in 2011 increased the number of priority countries to 59. ** SIAs are mass vaccination campaigns that aim to administer doses of tetanuscontaining vaccines to women of childbearing age. † † High-risk areas and districts are defined as those in which the estimated NT case rate exceeds 1 per 1,000 live births, clean delivery coverage is less than 70%, and coverage with at least 3 tetanus toxoid-containing vaccine (TTCV) doses among pregnant women or women of reproductive age is less than 80% during the past 5 years. § § A skilled birth attendant is defined as a midwife, trained nurse, doctor, or a health extension or community health worker.

A total of 35 of the 59 countries that had not eliminated maternal and neonatal tetanus (MNT) as a public health problem in 1999 have since achieved the MNT-elimination goal. Neonatal tetanus deaths have decreased globally from 200,000 in 2000 to 49,000 in 2013. This is the result of increased immunization coverage with tetanus toxoid-containing vaccines among pregnant women, improved access to skilled birth attendance during delivery, and targeted campaigns with these vaccines for women of reproductive age in high-risk areas. In the process, inequities have been reduced, private–public partnerships fostered, and innovations triggered. However, lack of funding, poor accessibility to some areas, suboptimal surveillance, and a perceived low priority for the disease are among the main obstacles. To ensure MNT elimination is sustained, countries must build and maintain strong routine programs that reach people with vaccination and with clean deliveries. This should also be an opportunity to shift programs into preventing tetanus among all people. Regular assessments, and where needed appropriate action, are key to prevent increases in MNT incidence over time, especially in areas that are at higher risk. The main objective of the paper is to provide a detailed update on the progress toward MNT elimination between 1999 and 2014. It elaborates on the challenges and opportunities, and discusses how MNT elimination can be sustained and to shift the program to protect wider populations against tetanus.

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Despite the availability of effective tetanus prevention strategies, as of 2016, Maternal and Neonatal Tetanus Elimination (MNTE) has not yet been achieved in 18 countries globally. In this paper, we review the status of MNTE in the World Health Organization African Region (AFR),and provide recommendations for achieving and maintaining MNTE in AFR. As of November 2016, 37 (79%) AFR countries have achieved MNTE, with 10 (21%) countries remaining. DTP3 coverage increased from 52% in 2000 to 76% in 2015. In 2015, coverage with at least 2 doses of tetanus containing vaccine (TT2+) and proportion of newborns protected at birth (PAB) were 69% and 77%, compared with 44% and 62% in 2000, respectively. Since 1999, over 79 million women of reproductive age (WRA) have been vaccinated with TT2+ through supplementary immunization activities (SIAs). Despite the progress, only 54% of births were attended by skilled birth attendants (SBAs), 5 (11%) countries provided the 3 WHO-recommended booster doses to both sexes, and about 5.5 million WRA still need to be reached with SIAs. Coverage disparities still exist between countries that have achieved MNTE and those that have not. In 2015, coverage with DTP3 and PAB were higher in MNTE countries compared with those yet to achieve MNTE: 84% vs. 68% and 86% vs. 69%, respectively. Challenges to achieving MNTE in the remaining AFR countries include weak health systems, competing priorities, insufficient funding, insecurity, and sub-optimal neonatal tetanus (NT) surveillance. To achieve and maintain MNTE in AFR, increasing SBAs and tetanus vaccination coverage, integrating tetanus vaccination with other opportunities (e.g., polio and measles campaigns, mother and child health days), and providing appropriately spaced booster doses are needed. Strengthening NT surveillance and conducting serosurveys would ensure appropriate targeting of MNTE activities and high-quality information for validating the achievement and maintenance of elimination.

This systematic review assessed the progress and barriers towards maternal and neonatal tetanus elimination in the 12 countries that are yet to achieve elimination, globally. Coverage of at least 80% (the coverage level required for elimination) was assessed among women of reproductive age for five factors: (1) at least two doses of tetanus toxoidcontaining vaccine, (2) protection at birth, (3) skilled birth attendance, (4) antenatal care visits, and (5) health facility delivery. A scoping review of the literature and data from Demographic and Health Surveys and Multiple Indicator Cluster Surveys provided insights into the barriers to attaining maternal and neonatal tetanus elimination. Findings showed that none of the 12 countries attained at least 80% coverage for women of reproductive age receiving at least two doses of tetanus toxoid-containing vaccine or protection at birth according to the data from Demographic and Health Surveys or Multiple Indicator Cluster Surveys. Barriers to maternal and neonatal tetanus elimination were mostly related to health systems and socioeconomic factors. Modification to existing maternal and neonatal tetanus elimination strategies, including innovations, will be required to accelerate maternal and neonatal tetanus elimination in these countries.