Maternal and Neonatal Tetanus (MNT) elimination
Validating MNT elimination
Validation of MNT elimination is recommended once countries claim that they have achieved MNT elimination. The validation process consists of several components:
- Review of district level data on NT surveillance, TT immunization and 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 also are 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 indicated. Field visits typically include evaluations of health facilities where records are reviewed and health workers and women are interviewed. Such field visits are most useful in countries where TT SIAs were conducted on a limited scale and in countries with only a few poorly performing districts.
- Validation survey: if a decision cannot be reached about the MNT elimination status of a country following the district data review (and field visits, when performed), a specific MNT elimination validation survey is conducted. The recommended community-based survey method uses a combination of lot quality assurance (LQA) and cluster sampling (CS) techniques to judge whether the neonatal tetanus mortality rate, or NTMR, is probably greater than 1 NT death/1000 live births (elimination not achieved) or not (elimination achieved). The LQA-CS survey is carried out in the district(s) thought to be the most poorly performing in the country. 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 as a whole.
The LQA methodology is described in the Protocol for assessing neonatal tetanus mortality in the community using a combination of cluster and lot quality assurance sampling.
Reports of such LQAs can be found HERE
- Long-term plan for sustaining MNT elimination: 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, school-based booster doses of tetanus toxoid-containing vaccines and/or immunization of new cohorts of child-bearing age women with TT, increasing access to health facility deliveries, etc. Plans for sustaining MNT elimination should be included in the comprehensive multi year plan (cMYP) for immunization. The guidelines for such plans can be downloaded HERE