Looking back on his 15-year career as a field level immunization worker in Dinajpur district, Bangladesh, Motiar Rahman visualizes the image of many mothers and newborns babies who lost their lives to tetanus. He moves on to the picture of the present day, where there are almost no maternal deaths due to tetanus and hardly any cases of neonatal tetanus (NT) in the country. Bangladesh achieved MNT elimination status in 2008, Motiar Rahman is a working witness to the progress of this achievement.
Overcoming barriers
Unhygienic circumstances during delivery can put mothers and their newborn babies at risk of a variety of life-threatening infections. Maternal and neonatal tetanus (MNT) have been among the most common lethal consequences of unclean deliveries and umbilical cord care practices. When tetanus develops, mortality rates are extremely high, especially when appropriate medical care is not available. Deaths from MNT can easily be prevented by hygienic delivery and cord care practices, and/or by immunizing mothers with tetanus toxoid (TT) vaccine, which is effective and offered free of charge by the Government of Bangladesh through its Expanded Programme on Immunization (EPI).
Fouzia Sultana is a trained Health Assistant whose job involves counselling pregnant mothers, carrying out antenatal checkups and giving vaccinations. In the quest to eliminate MNT, she emphasizes the importance of building awareness in the community and educating pregnant mothers to keep their children safe from tetanus. While sharing her experience she adds that local and social misconceptions and cultural barriers still need to be overcome at the rural level.
When 21-year-old Lucky was pregnant with her first child, health workers were unable to convince her of the importance of vaccination during pregnancy. As an illiterate housewife, living in a remote village in Shariatpur district, Lucky demonstrated negative health seeking behaviour, with no faith in immunization. Eventually, she delivered a baby boy, Younus, at home through a normal vaginal delivery. The delivery was assisted by a conventional dai who used a blade to cut the umbilical cord. Four days after he was born, Younus became sick; he was unable to suck and suffered from convulsions and stiffness. He was admitted to the Maternal and Child Welfare Centre, diagnosed with NT and referred to Dhaka Infectious Disease Hospital. Younus recovered after being treated in hospital for one month.
Local health workers and the upazila health team took this opportunity to educate all members of Lucky’s family and the local community about vaccination. After several meetings they were finally able to convince Lucky and her community members about the importance of vaccination of mother and child. Today, Lucky has completed two doses of TT vaccine and is awaiting her third dose. Baby Younus is alive and well and has already completed the second doses of pentavalent vaccine, oral polio vaccine, and pneumococcal conjugate vaccine with bacille Calmette-Guerin.
Technical support
Health workers continue to address social misconceptions and cultural barriers by ensuring repeated visits for counselling and involving the Imam or local responsible persons in their efforts. The combination of better social awareness and teamwork among the health sector is key to keeping Bangladesh free of MNT.
WHO provides technical support to help Bangladesh maintain its MNT elimination status. WHO Bangladesh provides this support through its network of Surveillance Medical Officers by training health personnel on identifying and reporting NT cases. WHO also helps to ensure that every suspected NT case is investigated by government officials as per national surveillance guidelines, investigation forms are filled out and case response immunization is carried out in the locality. WHO Bangladesh continues to review routine immunization coverage in the country and provides feedback to upazila and district managers as appropriate, to help improve vaccination coverage.
The global MNT Elimination Initiative aims to reduce MNT cases to such low levels that the disease is no longer a major public health problem. Unlike polio and smallpox, tetanus cannot be eradicated (tetanus spores are present in the environment worldwide), but through immunization of pregnant women and other women of reproductive age and promotion of more hygienic deliveries and cord care practices, MNT can be eliminated. In 2013, the Initiative reported that over 118 million women of child-bearing age had been vaccinated against tetanus in 52 countries since 1999.
