http://www.vh.org/Providers/Publications/MMWR/1994/12.09.94.html

Editorial Note: NT results from the effect of a neurotoxin elaborated by the anaerobic organism Clostridium tetani (6). Infection occurs when the
umbilical cord becomes contaminated as a result of unclean childbirth or cord-care practices. Access to clean birth practices is ultimately the long-term
goal for prevention; however, most infants in developing countries continue to be born at home under unsanitary conditions. Although global tetanus
toxoid coverage levels nearly doubled to 45% during 1989-1993 in countries that administer the vaccine, reported coverage levels are underestimated
because annual estimates do not include doses administered during previous years. In addition, many women do not maintain vaccination records,
making verification of vaccination status difficult (7). WHO now recommends that women receive and maintain life-long vaccination records and that
tetanus toxoid coverage be monitored nationally by determining the proportion of children protected at birth when they seek their first diphtheria and
tetanus toxoids and pertussis vaccine dose. 

The findings in this report are subject to at least two limitations. First, because NT cases are grossly underreported, NT incidence is underestimated.
Second, the numbers of NT deaths and prevented deaths are based on projections from national data (which often are estimated) or data extrapolated
from other countries. 

As of August 1, 1994, the estimated NT case rate was less than one per 1000 live births nationwide (i.e., not by district) in 83 countries. In addition, in
57 countries, the estimated rate of NT was one to five cases per 1000 nationwide, while in 25 countries the estimated rate was higher than five cases per
1000. Although progress has been made toward eliminating NT as a public health problem, present resources and commitments must be increased and
activities greatly accelerated if the 1995 goal is to be achieved by all countries (8). In 1993, the Global Advisory Group of WHO's Expanded Program
on Immunization identified four constraints to NT elimination (2): 1) insufficient funds to purchase tetanus toxoid in selected high-risk countries; 2)
lack of adequate health-care infrastructure in many countries, resulting in limited tetanus toxoid vaccination activities and poor access to clean birth
practices; 3) civil unrest in some high-risk countries; and 4) high levels of NT underreporting. 

To reach the global elimination goal for NT, efforts must be accelerated, especially in the 12 countries from which 80% of NT cases were reported in
1993 and in countries where the incidence rate is higher than five per 1000 live births. Each country must identify areas where the incidence rate is
higher than one per 1000 live births, coverage levels are low, or there is limited access to clean deliveries or trained birth attendants. These high-risk
areas must be targeted for intensified vaccination efforts, including the use of mass vaccination campaigns. In addition, surveillance activities in all
areas must be strengthened. Finally, because NT is not a communicable disease, and C. tetani cannot be eradicated from the environment, ensuring
long-term elimination of NT will require the development of adequate health-care delivery systems to reach those at greatest risk--infants of poor
women residing in rural areas in developing countries. 

References
1. World Health Organization. Neonatal tetanus elimination. Tokyo: World Health Organization, Expanded Program on Immunization, Global
Advisory Group, October 16-20, 1989; publication no. WHO/EPI/GAG/89/WP.9. 
2. Global Advisory Group, Expanded Program on Immunization, World Health Organization. Achieving the major disease control goals. Wkly
Epidemiol Rec 1994;69:29-31,34-5. 
3. World Health Assembly. Expanded Program on Immunization. Geneva: World Health Organization, May 19, 1989. (Resolution WHA42.32). 
4. World Health Organization. Revised plan of action for neonatal tetanus elimination. Geneva: World Health Organization, Expanded Program on
Immunization, 1993; publication no. WHO/EPI/GEN/93.13. 
5. World Health Organization. The global elimination of neonatal tetanus: progress to date. Bull World Health Organ 1994;72:155-64. 
6. Galazka AM. Tetanus: the immunologic basis for immunization. Geneva: World Health Organization, Expanded Program on Immunization, 1993;
publication no. WHO/EPI/GEN/93.13. 
7. Deming MS. Monitoring tetanus toxoid immunization coverage. Geneva: World Health Organization, Expanded Program on Immunization, 1990;
document no. EPI/NNT/90/WP.3/Rev1. 
8. World Health Organization. Global programme for vaccines and immunization: proceedings of the Meeting of the Scientific Advisory Group of
Experts. Geneva: World Health Organization, October 17-19, 1994. 

* Estimates of NT deaths are derived from national mortality data, NT mortality rates from NT surveys, or in the absence of surveys, by assuming that
rates are similar for countries with similar socioeconomic conditions and from tetanus toxoid coverage levels. 

** Because the case-fatality rate for NT is high (100% in some countries), WHO estimates only the number of deaths for NT, not number of cases. 

*** Countries are categorized as developing based on criteria developed by the United Nations and used by WHO for analytic purposes only. 

**** The number of NT deaths prevented was calculated for each country using the number of live births, NT mortality rate, and tetanus toxoid
coverage and efficacy.