Immunization, Vaccines and Biologicals

Maternal and Neonatal Tetanus (MNT) elimination

The strategies

The recommended strategies for achieving Maternal and Neonatal Tetanus (MNT) elimination include:

  • Strengthening routine immunization of pregnant women with tetanus toxoid vaccine (TTCV)
  • TTCV Supplementary Immunization Activities (SIAs) in selected high risk areas, targeting women of reproductive age with 3 properly-spaced doses of the vaccine
  • Promotion of clean deliveries and clean cord care practices
  • Reliable NT surveillance including case investigation and response

Once MNT elimination has been achieved, maintaining elimination will require continued strengthening of routine immunization activities for both pregnant women and children, maintaining and increasing access to clean deliveries, reliable NT surveillance, and introduction of school-based immunization where feasible

Achieving the elimination

Immunization against tetanus is routinely given to pregnant women

In many countries, immunization against tetanus is routinely given to pregnant women, usually during antenatal care contacts. For women who have never received TT vaccine, or have no documentation of such immunization, a total of five properly-spaced doses is recommended: 2 doses given one month apart in the first pregnancy, the 3rd dose is given at-least 6 months later, then 1 dose in each subsequent pregnancy (or intervals of at least 1 year), to a total of five doses. For recommended schedules, see the summary table on page 207 in the WHO Position Paper on Tetanus links below listed. Routine immunization with TTCV is reported as TT2+; countries report achieved coverage annually to WHO and UNICEF.

The "high-risk approach"

In areas where immunization fails to reach a substantial proportion of pregnant women, TTCV SIAs may be required. This is known as the "high-risk approach". All women of reproductive age living in high risk districts (HRDs) are targeted with 3 properly spaced doses of tetanus toxoid (TT) through specially organized supplementary immunization activities (SIAs). This approach focuses on providing TT vaccination in districts where women have limited or no access to routine vaccination. HRDs are identified by systematic analysis of routinely reported district data, survey data where available and local knowledge.

Clean deliveries

Clean deliveries (deliveries in health facilities and/or assisted by medically trained attendants) effectively reduce MNT and other causes of maternal and neonatal mortality. Health workers who provide TT vaccination to women with limited access to routine services should encourage the use of trained health providers for obstetric care and also provide information about how to reach such services. If obstetric services are not available, or if women prefer to deliver at home without trained attendants, extra efforts should be made to teach pregnant women how to ensure a clean delivery at home, the importance of not using harmful traditional substances for cord care, and when and where to seek care for complications. For more details, please refer to the below website by clicking the link.

Surveillance for neonatal tetanus is poorly developed in most developing countries. It is estimated that less than 10% of NT cases and deaths are actually reported. For more details on NT surveillance, please see WHO-recommended surveillance standard of neonatal tetanus and The number of reported Neonatal Tetanus and Tetanus cases are summarized here

Maintaining MNT elimination

Complete eradication of tetanus is not possible because tetanus spores are found throughout the world in soil and the stool of people and animals - that is exposure to the bacteria causing tetanus cannot be completely prevented.

Countries that have succeeded in eliminating MNT must:

  • Ensure that the majority of pregnant women are immunized against tetanus (at least >80%; see above)

  • Ensure high coverage with tetanus toxoid-containing vaccines in infancy (such as DTP), and consider introducing child booster doses. School-based immunization can be an efficient and effective strategy to deliver booster doses of tetanus-containing vaccines (and other vaccines). The WHO tetanus position paper summarizes WHO's recommendations

  • Ensure access to and use of clean delivery practices (see above)

  • Maintain and improve NT surveillance to monitor continued elimination and identify areas where MNT is still occurring. Good NT surveillance permits effective targeting of interventions when necessary. Because most neonatal deaths occur at home, often where neither births nor deaths are reported (see above), NT surveillance can be quite challenging, It is nonetheless a key component of MNT elimination and serves as a valuable indicator of immunization and maternal and child health (MCH) system performance


Last update:

2 March 2015 11:08 CET