Expanded programme on immunization

Neonatal tetanus (NT) and Non-Neonatal tetanus

Tetanus, also known as lockjaw, is a serious but preventable disease that affects the body's muscles and nerves. It typically arises from a skin wound that becomes contaminated by a bacterium called Clostridium tetani, which is often found in soil. Common first signs of tetanus are a headache and muscular stiffness in the jaw, followed by stiffness of the neck, difficulty in swallowing, rigidity of abdominal muscles, spasms, sweating and fever. As the toxin produced by the bacteria circulates more widely, the toxin interferes with the normal activity of nerves throughout the body, leading to generalized muscle spasms. Symptoms usually begin 8 days after the infection, but may range in onset from 3 days to 3 weeks. Without treatment, tetanus can be fatal. Vaccination is the best way to protect against tetanus.

Neonatal tetanus is a form of generalized tetanus in newborn infants that do not have protective passive immunity because the mother is not immune. It usually occurs through infection of the unhealed umbilical stump, particularly when the stump is cut with an unsterile instrument. Neonatal tetanus is estimated to kill over 200,000 newborns each year; almost all these deaths occur in developing countries while it is very rare in developed nations.

Reducing deaths from neonatal tetanus is one of the simplest and most cost-effective means to reduce the neonatal mortality rate. Tetanus transmission can be prevented during childbirth by improving immunization services, especially for pregnant women, promoting clean delivery and cord-care practices, and strengthening disease surveillance and case investigation. Vaccination with tetanus toxoid (TT) will also protect the mothers from maternal tetanus during pregnancy and delivery. Although data are very incomplete it is estimated that maternal tetanus is responsible for 5% of maternal mortalities, particularly in the developing world. Although the World Health Assembly, the governing body of WHO, called for the elimination of neonatal tetanus in 1989, the disease continues to be a significant public health problem in some countries. Neonatal tetanus is one of the most underreported notifiable diseases. As it tends to occur in areas with poor or no access to health care, it often remains silent within the community. Many of the non-reported cases and deaths occur at home before the baby reaches two weeks of age. However, cases that do reach a health facility are often not reported by the health staff. For these reasons, neonatal tetanus is often called the “invisible killer”.

WHO continues to work closely with the United Nations Children's Fund (UNICEF) and United Nations Population Fund (UNFPA) to reach worldwide elimination, which means the reduction of neonatal tetanus cases to fewer than 1 case per 1000 live births in every district of every country. Maternal tetanus has now been added to the elimination goal. The inclusion recognizes that tetanus threatens mothers as well as babies during pregnancy and delivery and that the elimination of tetanus benefits them equally. Because maternal tetanus elimination has not been defined, the achievement of neonatal tetanus elimination is being used as a proxy for maternal tetanus elimination.

A primary series of 3 doses of TT containing vaccine(TTCV is recommended, with the first dose administered from 6 weeks of age. Immunization programmes should ensure that 3 TTCV booster doses are provided i.e. 12–23 months of age; 4–7 years of age; and 9–15 years of age. TT is available as a single-antigen vaccine and in combination vaccines to protect against other vaccine-preventable diseases including diphtheria, pertussis, poliomyelitis, hepatitis B and illness caused by Haemophilus influenzae type b (Hib). Use of TTCV combinations with diphtheria toxoid are strongly encouraged and single antigen vaccines should be discontinued whenever feasible to help maintain both high diphtheria and high tetanus immunity throughout life course.

It should be realized how in prevention of tetanus there is a great opportunity for various public health programmes to collaborate in a broader context and make an impact far beyond health alone. Every year close to 600 000 women—more than one woman every minute - die globally from complications related to pregnancy and childbirth [see Maternal and newborn care]. In addition, these complications contribute to more than three million infant deaths within their first week of life. A maternal death has implications for the family, the community and the society in general. However, its impact is most immediate and especially severe on young children. A significant proportion of these deaths can be prevented by safe, inexpensive vaccinations.

Globally, approximately 13,500 tetanus cases were reported in 2016 through the WHO/UNICEF Joint Reporting Form, with 85% of cases occurring after the neonatal period (aged >28 days; hereafter referred to as non-neonatal tetanus, or non-NT). This number is likely an underestimate; true tetanus incidence is uncertain.