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WHO goal: Eliminating neonatal tetanus

In 1989 the General Assembly of the World Health Organization set a target date of 1995 for the elimination of neonatal tetanus (NNT). This was subsequently expressed as a rate of NNT cases of below 1/1000 live births in every region of every country. Unlike the programs to eliminate small-pox or polio, the disease potential is always present with NNT even after the target is reached, due to the nature of organisms found everywhere in the environment. Continuity of surveillance and services is extremely important.
NNT is an underreported disease, with barely 5% of the cases reported. Only recently has awareness of the problem come forward, but timeliness and completeness of reporting are lagging. The program for elimination of NNT was prompted by the fact that NNT is the second-greatest killer of children below the age of I (only measles is greater). In many African and Asian countries, mortality may reach as high as 5/1000 live births. Countries at risk include almost all of the African countries and countries of South and East Asia.
Immunization was identified by the Expanded Programme on Immunization (EPI) as one of the important elements of child survival and development; hence, it is crucial to maintain high immunization coverage, including tetanus toxoid (TT), for women of childbearing age.
The strategy for NNT elimination includes the following:
  • Identify high-risk areas through active search review of health records and proper case investigation to identify unimmunized women.
  • Increase TT coverage by ensuring that any prenatal care or any visit to an EPI facility includes tetanus immunization, if needed.
  • Monitor progress toward NNT elimination by requiring monthly routine reporting of NNT by all health facilities and monthly routine reporting of the proportion of newborns protected at birth by tetanus immunization of their mothers.
  • Ensure quality of the TT used (to WHO standard) by regular evaluation of the cold chain.
Within Saudi Arabia, a standard case definition was formulated and distributed to all health units in 1992, the same year that zero reporting for NNT became required. Reporting timeliness and completeness are now monitored closely at both regional and central levels. Every case of NNT should be immediately reported and thoroughly investigated.
Since 1986, the Kingdom has achieved a level of more than 90% coverage for DPT [3] among children 1 year old. Knowledge, attitudes and practices toward tetanus immunization, antenatal services and postnatal care were first investigated through the mother and child health survey of 1991, which was based on a national random sample of 150 clusters, with 6,305 urban and rural households.
The following are some of the findings:
  • Knowledge about TT among ever-married females: 68%
  • Ever-married females who received two or more TT doses: 63%
  • Pregnant women who have regularly attended antenatal care clinics: 85%
  • Postnatal care at government institutions: 76%; at private clinics: 10%; at home: 14%
Home deliveries were four times greater in rural areas than in urban (27% vs. 7%). They were highest in the southern regions (31%) and smallest in the central (5%) and eastern regions (3.5%).
Also in 1986, the Kingdom achieved the objective of NNT elimination, with an overall incidence be-low 0.1/1000 live births. In 12 of the 19 regions, the range of NNT incidence is between 0 and 0.5/1000 live births.
Intensive training and education are continuing in the area of maternity and child health. Continuing education through supervisory visits helps to ensure quality and the maintenance of the cold chain.
The objectives in the Kingdom are to reach and maintain a coverage level of 97% for all EPI antigens by 2000 and to raise TT coverage among pregnant women by 1995 to match the levels reached by childhood vaccines.
By next year, all areas in which NNT cases are occurring will be identified. Campaigns, followed by outreach mobile clinics, will be used to vaccinate all pregnant women and all women of childbearing age in those areas. Safe facilities for delivery will be provided within easy reach.
By 2000, 97% of pregnant women will be vaccinated with at least two TT doses, and 95% of deliveries will be supervised by qualified medical personnel.