Immunization, Vaccines and Biologicals

Maternal and Neonatal Tetanus Elimination (MNTE)


Validating MNT elimination

Validation of MNTE is recommended once countries complete the implementation of all planned MNTE activities using the high risk approach and claim that they have achieved MNTE. The validation process consists of several components:

WHO/J.Vandelaer
  • Review of district level data on NT surveillance, TT immunization and ( Maternal Child and Health) MCH services: the data used are a series of core indicators (reported NT cases, TT2+, results of TT SIAs, Clean Delivery coverage), complemented by additional indicators which can be country-specific (DTP3, ANC attendance, urban/rural status, vacancy levels among health staff, women's literacy, etc). When recent relevant survey data are available, they are also used. The objective of the systematic district-level data review is to assess if elimination appears to have been achieved, and to identify districts with weakest performance. *An example of a spreadsheet to collect these data can be found at the end of this page

  • Field visit: when the data review alone does not permit a conclusion on elimination status, field visits to districts with weak performance may be required. Field visit typically include evaluation of health facilities where records are reviewed and health workers, community leaders and women are interviewed. Such field visit, yield a lot of useful information on the performance of the health system, access to care and neonatal care, challenges to service delivery, skill attendance at birth, application of substances to umbilical cord and interactions of the health system with the community. An associated rapid convenience survey gives some useful information on coverage for a number of immunization and reproductive health indicators

  • Validation survey: if the level of risk for MNT is found to be very low in all districts but yet a decision cannot be reached about the MNTE status of a country following the district data review (and field visits, when performed), a MNTE validation survey is conducted. The recommended community-based neonatal mortality survey method uses a combination of a Lot Quality Assurance (LQA) and Cluster Sampling (CS) survey methodologies to judge whether the neonatal tetanus mortality rate (NTMR) is probably greater than 1 NT death/1000 live births in the selected survey district (elimination not achieved) or not (elimination achieved). The LQA-CS survey is carried out in the district(s) found to be the most poorly performing in the country as regard MNTE. The logic is that if NT elimination can be validated in the weakest district(s), elimination can be assumed in the better performing districts, and therefore in the country or geographic entity being validated as whole.

  • Long-term plan for sustaining MNTE: if the outcome of the process outlined above is that neonatal tetanus has not been eliminated, the country under evaluation must review its strategies and implement additional activities as appropriate (e.g. SIAs). If, on the other hand, elimination has been achieved, strategies need to be adjusted to sustain the progress. These can include, but are not limited to, the administration of booster doses of tetanus toxoid-containing vaccines TTCV including through schools, and/or immunization of new cohorts of women of reproductive age with TTCV, increasing access to skilled attendants at birth, and clean cord care practices and NT surveillance. Plans for sustaining MNTE should be included in the comprehensive multi year plan (cMYP) for immunization. The guidelines for such plans can be downloaded HERE