Progress Toward Achieving and Sustaining Maternal and Neonatal Tetanus Elimination — Worldwide, 2000–2022

Camille E. Jones, PhD1,2; Nasir Yusuf, MD3; Bilal Ahmed, MBBS4; Modibo Kassogue, MD4; Annemarie Wasley, ScD2; Florence A. Kanu, PhD2 (View author affiliations)

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Summary

What is already known about this topic?

Tetanus causes considerable mortality among undervaccinated mothers and their infants following unhygienic deliveries, especially in low-income countries. The maternal and neonatal tetanus elimination initiative targets 59 priority countries.

What is added by this report?

During 2000–2022, 47 priority countries achieved maternal and neonatal tetanus elimination, contributing to global declines in neonatal tetanus cases (89%) and neonatal tetanus deaths (84%). Despite progress, the global disruption of routine immunization caused by the COVID-19 pandemic impeded elimination progress. Since 2020, reported neonatal tetanus cases have increased in 18 (31%) priority countries.

What are the implications for public health practice?

Integration of maternal and neonatal tetanus elimination strategies into priority countries’ national immunization activities is needed to achieve and sustain elimination globally.

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Abstract

Tetanus remains a considerable cause of mortality among undervaccinated mothers and their infants following unhygienic deliveries, especially in low-income countries. Strategies of the maternal and neonatal tetanus elimination (MNTE) initiative, which targets 59 priority countries, include strengthening antenatal immunization of pregnant women with tetanus toxoid–containing vaccines (TTCVs); conducting TTCV supplementary immunization activities among women of reproductive age in high-risk districts; optimizing access to skilled birth attendants to ensure clean deliveries and umbilical cord care practices; and identifying and investigating suspected neonatal tetanus cases. This report updates a previous report and describes progress toward MNTE during 2000–2022. By December 2022, 47 (80%) of 59 priority countries were validated to have achieved MNTE. In 2022, among the 50 countries that reported coverage with ≥2 doses of TTCV among pregnant women, 16 (32%) reported coverage of ≥80%. In 2022, among 47 validated countries, 26 (55%) reported that ≥70% of births were assisted by skilled birth attendants. Reported neonatal tetanus cases worldwide decreased 89%, from 17,935 in 2000 to 1,995 in 2021; estimated neonatal tetanus deaths decreased 84%, from 46,898 to 7,719. However, the global disruption of routine immunization caused by the COVID-19 pandemic impeded MNTE progress. Since 2020, reported neonatal tetanus cases have increased in 18 (31%) priority countries. Integration of MNTE strategies into priority countries’ national postpandemic immunization recovery activities is needed to achieve and sustain global elimination.

Introduction

Maternal and neonatal tetanus* remains a substantial cause of mortality among undervaccinated mothers and their infants following unhygienic delivery, especially in low-income countries (1). In 1989, the World Health Assembly endorsed neonatal tetanus elimination. This activity was relaunched in 1999 as the maternal and neonatal tetanus elimination (MNTE)§ initiative, targeting 59 priority countries. Because tetanus spores cannot be eliminated from the environment, and tetanus infection does not confer immunity, elimination requires ongoing active immunization with a tetanus toxoid–containing vaccine (TTCV). To protect infants from tetanus susceptibility at birth, women of reproductive age (usually 15–49 years) should be vaccinated with ≥2 doses of TTCV (TTCV2+), and immunization is recommended for undervaccinated pregnant women early in the third trimester (2). The MNTE initiative includes four strategies: 1) providing antenatal immunization of pregnant women with TTCV2+; 2) conducting TTCV supplementary immunization activities (SIAs)** in selected high-risk districts,†† targeting women of reproductive age for TTCV immunization; 3) supporting clean delivery and umbilical cord care practices through access to skilled birth attendants§§; and 4) identifying and investigating suspected neonatal tetanus cases with reliable surveillance (2,3). Since the MNTE initiative began in 1999, the estimated proportion of neonatal mortality attributed to tetanus decreased 84%, from 2% in 2000 to 0.3% in 2021.¶¶ The remaining risk for maternal and neonatal tetanus infection is concentrated in low-income communities with low TTCV coverage and limited access to hygienic delivery. This report summarizes progress toward achieving and sustaining MNTE during 2000–2022 and updates a previous report (4).

Methods

Immunization Activities, Deliveries by Skilled Birth Attendants, and Surveillance

To estimate TTCV coverage among pregnant women through routine immunization services and the number of neonates protected from tetanus at birth,*** the World Health Organization (WHO) and UNICEF use vaccination coverage survey data and administrative data††† received from member countries (5). WHO and UNICEF also receive summaries of the number of women of reproductive age receiving TTCV during SIAs (6). The percentages of births assisted by skilled birth attendants are estimated from country health facility reports and coverage survey estimates (7). WHO recommends nationwide, case-based neonatal tetanus surveillance, active surveillance through regular visits to reporting sites (8), and country reports of neonatal tetanus case counts.§§§ Because most neonatal deaths occur in remote areas, which might lead to underreporting, neonatal tetanus deaths are estimated using mathematical models that project cause-specific neonatal mortality using Bayesian and multinomial frameworks (9). This activity was reviewed by CDC, deemed not research, and was conducted consistent with applicable federal law and CDC policy.¶¶¶

Validation of Maternal and Neonatal Tetanus Elimination

Once a country’s surveillance data indicate that neonatal tetanus incidence has declined to <1 case per 1,000 live births in all districts, prevalidation assessments are conducted (3). Benchmarks for validating MNTE achievement include reaching <1 neonatal tetanus case per 1,000 live births, ≥80% routine TTCV2+ coverage among pregnant women, and ≥70% of deliveries assisted by skilled birth attendants. Assessments might also review supplementary measures, including TTCV2+ SIA coverage among women of reproductive age, antenatal care coverage,**** infant coverage with 3 doses of diphtheria, tetanus, and pertussis vaccine,†††† socioeconomic indices, field visits to determine health system performance, validation surveys in the poorest performing districts, and assessment of long-term plans for sustaining elimination.§§§§

Maintenance of Maternal and Neonatal Tetanus Elimination

Once MNTE has been validated, WHO recommends that countries conduct annual neonatal tetanus risk analyses as part of immunization program reviews, and postvalidation assessments every 5 years, to determine whether elimination has been sustained and take any necessary corrective actions (3). The following indicators were used to determine maintenance of MNTE countries’ performance: 1) ≥80% TTCV2+ coverage among pregnant women accessing antenatal care, 2) ≥90% routine immunization TTCV coverage among children and adolescents (i.e., receipt of 3 primary infant doses and 3 booster doses), 3) ≥70% of deliveries by a skilled birth attendant, and 4) ≥90% of infants protected at birth against tetanus (2).

Results

Immunization Activities

In 2022, among 59 priority countries, 50 (85%) reported antenatal TTCV2+ coverage data; 16 (32%) of these reported ≥80% TTCV2+ coverage. During 2000–2022, a total of 52 (88%) priority countries conducted TTCV SIAs (Table). Among 41 countries with 2000 and 2022 data available, TTCV2+ coverage increased in 30 (73%). Worldwide, the proportion of infants protected at birth increased from 74% in 2000 to 86% in 2022 (Figure 1), and the number of priority countries that achieved MNTE increased from 1 (2%) of 57 in 2000 to 47 (80%) of 59 in 2022 (Figure 2).

During 2000–2022, SIAs provided TTCV2+ to 177 million (70%) of 252 million women of reproductive age targeted to receive vaccination. During 2021–2022, seven countries conducted TTCV SIAs, vaccinating 13 million women of reproductive age. However, by the end of 2022, 68 million women who were targeted for protection by TTCV SIAs remained unreached.

Deliveries Assisted by Skilled Birth Attendants

In 2022, among 47 priority countries with available data, 26 (55%) reported that ≥70% of births were assisted by skilled birth attendants (Table). Compared with the most recent report (4), the proportions of births assisted by skilled birth attendants was higher in 12 countries (Afghanistan, Burkina Faso, Cambodia, Chad, Côte d’Ivoire, Egypt, Kenya, India, Malawi, Mauritania, Niger, and Nigeria) in 2022 than in 2020.

Neonatal Tetanus Surveillance and Incidence

Among the 59 MNTE priority countries, 11 (19%) reported zero neonatal tetanus cases in 2022; however, seven countries reported more cases in 2022 than in 2000 (Table). Worldwide, reported neonatal tetanus cases decreased by 89%, from 17,935 in 2000 to 1,995 in 2021. Estimated neonatal tetanus deaths decreased 84%, from 46,898 in 2000 to 7,719 in 2021, accounting for 2% and 0.3% of all-cause neonatal mortality, respectively (Figure 1). Since 2020, reported neonatal tetanus cases have increased in 18 (31%) priority countries, including 13 previously validated countries.

Validation of Maternal and Neonatal Tetanus Elimination

During 2000–2022, 47 (80%) of the 59 priority countries were validated to have achieved MNTE (Table). No countries achieved validation during 2020–2022; however, MNTE was validated in Mali in 2023.

Maintenance of Maternal and Neonatal Tetanus Elimination

As of 2022, among 47 MNTE-validated countries, 15 (32%) achieved ≥90% coverage with 3 primary doses of routine immunization TTCV. TTCV booster doses were included in the routine immunization schedule for children aged 12–23 months in 14 (30%) of those countries, and for children and adolescents aged 4–7 and 9–15 years in 11 (23%) countries. In 46 (98%) countries, ≥70% of infants were protected at birth against tetanus; and in 26 (55%), ≥70% of births were assisted by a skilled birth attendant (Table). Six countries have conducted postvalidation assessments.

Discussion

Substantial progress has been made toward global MNTE, with 80% of priority countries validated as having achieved elimination by the end of 2022. TTCV2+ coverage increased in 30 priority countries, and in 26 countries, skilled birth attendants assisted in ≥70% of births. Since 2000, 52 priority countries have conducted TTCV SIAs. During 2021–2022, seven countries yet to achieve MNTE conducted SIAs, reaching 13 million (42%) women of reproductive age with TTCV2+ and contributing to a 16% increase in the number of infants protected at birth. Worldwide, during 2000–2022, the number of reported neonatal tetanus cases declined by 89%, from 17,935 to 1,995, and estimated neonatal tetanus mortality decreased 84%, from 46,898 to 7,719, since 2000. In addition, by 2022 four of six geopolitical zones in Nigeria, and Punjab province in Pakistan were validated to have achieved elimination.¶¶¶¶

Although progress has been substantial, challenges to MNTE remain, some of which were amplified by the COVID-19 pandemic and its global disruption of immunization services.***** Many countries that have not yet validated MNTE have fragile health systems with barriers to improving vaccination coverage and accessing skilled birth attendants. For example, in countries experiencing political instability and conflict, more areas might be hard to reach, magnifying the challenges to providing immunization and safe hygienic deliveries, as well as ensuring reliable detection of and response to occurrent neonatal tetanus cases. Recovery of national immunization programs has been challenging in some countries that experienced increases in some vaccine-preventable diseases in the wake of the COVID-19 pandemic.

In addition to continuing measures to achieve global MNTE, more attention is needed to ensure that elimination is sustained in countries previously validated to have achieved MNTE. Since 2020, reported neonatal tetanus cases have increased in 13 previously validated countries. This increase might indicate better surveillance system sensitivity; however, it might also reflect lack of protection at birth and the need for improved antenatal vaccination measures. By 2022, only one third of 43 MNTE–validated countries sustained ≥80% TTCV2+ coverage, and in 12 MNTE-validated countries, fewer than 70% of births were assisted by skilled birth attendants. As of 2022, fewer than one third of validated countries had introduced ≥1 TTCV booster dose into their routine immunization schedule. This slow introduction might be attributed to lower prioritization of MNTE activities after validation because of funding constraints, putting countries at risk for reemergence of neonatal tetanus (3).

Sustaining MNTE requires strong commitments from priority countries and the global community. Countries will need to improve resource and program efficiency by integrating postvalidation assessments with immunization program reviews and TTCV booster dose vaccination with other immunization activities (e.g., school vaccination programs). Innovative activities to integrate neonatal tetanus case-based surveillance into surveillance for other vaccine-preventable diseases, such as polio and measles, might support system efficiency and sustainability, and public engagement might help raise awareness and strengthen community-based vaccine-preventable disease surveillance systems (8).

Limitations

The findings in this report are subject to at least three limitations. First, reported TTCV2+ coverage among pregnant women can underestimate actual protection because it does not account for women who received TTCV doses in previous pregnancies but were unvaccinated during their current pregnancy (2). Second, whereas MNTE validation is based on district-level assessments, reports of immunization coverage used in this update are based on national estimates and might obscure interdistrict differences. Finally, neonatal deaths are estimated using mathematical models (9); thus, estimates are subject to model assumptions.

Implications for Public Health Practice

MNTE has been included in the WHO Immunization Agenda 2030††††† global strategy as an endorsed vaccine-preventable disease elimination target. As part of the worldwide effort to increase immunization coverage after the COVID-19 pandemic, integration of MNTE activities with those of other vaccine-preventable diseases is needed to improve progress toward MNTE. One such strategy includes promoting a life course approach to vaccination by integrating TTCV booster doses in school health programs and in other life course immunization platforms (10). Promotion of equitable access to health services, such as clean deliveries, is also important to achieving MNTE.

Acknowledgments

Jose Chivale, Angola World Health Organization (WHO) country office; Constance Razaiarimanga, Central African Republic WHO country office; Mouctar Kande, Guinea WHO country office; Iwowore Dede, Olanike Olayiwola, Nigeria WHO country office; Muhammad Khan, Pakistan WHO country office; Sylvester Maleghemi, South Sudan WHO country office; Javed Iqbal, Yemen WHO country office; Joseph Biey, Andre Bita, Quamrul Hasan, Sudhir Khanal, Yolande Masembe, Pamela Mitula, WHO regional offices; Obiora Ezebilo, Khalid Nawaz, Mohamed Diaaeldin Omer, Azhar Abid Raza, Ahmadu Yakubu, UNICEF country offices.

Corresponding author: Camille E. Jones, uqv2@cdc.gov.


1Epidemic Intelligence Service, CDC; 2Global Immunization Division, Center for Global Health, CDC; 3Immunization, Vaccines and Biologicals, World Health Organization, Geneva, Switzerland; 4Maternal, Newborn, and Adolescent Health Program Division, UNICEF, New York, New York.

All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.


* Tetanus is an infection caused by Clostridium tetani, a bacterium that produces a potent toxin. Maternal tetanus occurs during pregnancy or within 6 weeks of the end of pregnancy and might occur during abortion, miscarriage, or birth with unhygienic delivery. Neonatal tetanus occurs during the first 28 days of life, after either the cutting of the umbilical cord under nonsterile conditions or applying nonsterile traditional remedies to the umbilical stump in an infant who does not have passively (transplacentally) acquired maternal antibodies (i.e., the mother is not immune to tetanus).

The occurrence of <1 neonatal tetanus case per 1,000 live births per year in every district in every country.

§ Neonatal tetanus elimination is considered a proxy for maternal tetanus elimination; the same strategies for elimination are common to both.

Afghanistan, Angola, Bangladesh, Benin, Burkina Faso, Burma, Burundi, Cambodia, Cameroon, Central African Republic, Chad, China, Comoros, Republic of the Congo, Côte d’Ivoire, Democratic Republic of the Congo, Egypt, Equatorial Guinea, Eritrea, Ethiopia, Gabon, Ghana, Guinea, Guinea-Bissau, Haiti, India, Indonesia, Iraq, Kenya, Laos, Liberia, Madagascar, Malawi, Mali, Mauritania, Mozambique, Namibia, Nepal, Niger, Nigeria, Pakistan, Papua New Guinea, Philippines, Rwanda, Senegal, Sierra Leone, Somalia, South Africa, Sudan, Togo, Turkey, Uganda, Tanzania, Vietnam, Yemen, Zambia, and Zimbabwe. The creation of Timor-Leste in 2002 and South Sudan in 2011 increased the number of priority countries to 59.

** Mass vaccination campaigns conducted in three rounds to administer 3 doses of TTCV to women of reproductive age in high-risk districts.

†† Districts considered to be at high risk because the estimated neonatal tetanus case rate exceeds one per 1,000 live births, clean delivery coverage is <70%, and 3-dose TTCV coverage among pregnant women during the previous 5 years is <80%.

§§ A doctor, nurse, midwife, or health worker trained in providing lifesaving obstetric care, including giving necessary supervision, care, and advice to women during pregnancy, childbirth, and the postpartum period.

¶¶ Neonatal mortality data were unavailable for 2022. https://platform.who.int/data/maternal-newborn-child-adolescent-ageing/indicator-explorer-new/mca/number-of-neonatal-deaths—by-cause

*** The status of an infant born to a mother who received 2 doses of TTCV during the previous birth, ≥2 doses with the last dose received ≤3 years before the last delivery, ≥3 doses with the last dose received ≤5 years earlier, ≥4 doses with the last dose received ≤10 years earlier, or receipt of ≥5 previous doses.

††† Administrative data to calculate the number of neonates protected at birth estimates the number of doses administered through routine services (numerator) divided by the number in target group (denominator) × 100.

§§§ https://www.who.int/data/gho/data/indicators/indicator-details/GHO/neonatal-tetanus—number-of-reported-cases

¶¶¶ 45 C.F.R. part 46.102(l)(3), 21 C.F.R. part 56; 42 U.S.C. Sect. 241(d); 5 U.S.C. Sect. 552a; 44 U.S.C. Sect. 3501 et seq.

**** Antenatal care coverage is the percentage of females aged 15–49 years with a live birth who received antenatal care provided by a skilled birth attendant at least once during pregnancy.

†††† https://www.who.int/data/gho/data/indicators/indicator-details/GHO/diphtheria-tetanus-toxoid-and-pertussis-(dtp3)-immunization-coverage-among-1-year-olds-(-)

§§§§ https://cdn.who.int/media/docs/default-source/immunization/mnte/who-ivb-18.15-eng.pdf

¶¶¶¶ https://www.who.int/initiatives/maternal-and-neonatal-tetanus-elimination-(mnte)/the-partnership

***** https://www.who.int/news/item/15-07-2021-covid-19-pandemic-leads-to-major-backsliding-on-childhood-vaccinations-new-who-unicef-data-shows

††††† https://www.who.int/teams/immunization-vaccines-and-biologicals/strategies/ia2030

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TABLE. Indicators of achievement of maternal and neonatal tetanus elimination — 59 priority countries,* 2000–2022Return to your place in the text
Country Year of MNTE validation ≥2 TTCV doses among pregnant women, %†,§ Newborns protected at birth, % Women of reproductive age vaccinated during TTCV SIAs** Skilled birth attendant at delivery, %†† No. of neonatal tetanus cases§§
2000 2022 % Change 2000–2022 2000 2022 % Change 2000–2022 No. of TT2+/Td2 doses administered % Vaccinated 2000¶¶ 2022¶¶ % Change 2000–2022 2000 2022 % Change 2000–2022
Bangladesh*** 2008 89 47 −48 89 98 10 1,438,374 47 12 59 388 376 19 –95
Benin*** 2010 81 89 10 87 83 −5 1,399,461 97 66 78 19 52 18 –65
Burkina Faso††† 2012 NA 93 NA 57 95 67 2,306,835 91 38 96 154 22 1 –95
Burma 2010 81 55 −32 79 88 11 8,170,763 87 57 NA NA 41 14 –66
Burundi 2009 28 60 114 51 87 71 679,222 55 25 77 204 16 0 –100
Cambodia 2015 40 69 72 58 93 60 2,099,471 79 32 99 210 295 7 –98
Cameroon 2012 40 54 35 54 81 50 2,687,461 85 56 69 23 279 40 –86
Chad 2019 12 84 598 39 75 92 3,222,840 84 14 47 245 142 269 89
China 2012 NA NA NA NA NA NA NA NA 97 NA NA 3,230 18 –99
Comoros 2009 40 78 96 57 83 46 160,767 55 62 NA NA NA 2 NA
Côte d’Ivoire 2013 78 72 −8 76 83 9 5,924,527 85 63 84 34 30 27 –10
Democratic Republic of the Congo 2019 25 96 284 45 80 78 10,342,937 92 61 85 40 77 15 –81
Egypt 2007 71 97 37 80 88 10 2,518,802 87 61 97 59 321 1 –100
Equatorial Guinea 2016 30 21 −30 61 60 −2 26,466 9 65 NA NA NA 0 NA
Eritrea 2003 25 65 160 80 99 24 NA NA 28 NA NA 4 0 –100
Ethiopia 2017 32 NA NA 54 85 57 13,210,107 84 6 50 789 20 NA NA
Gabon††† 2013 16 43 171 39 83 113 79,343 90 86 95 11 8 8 0
Ghana 2011 73 63 −13 69 90 30 1,666,666 87 47 79 68 80 0 –100
Guinea-Bissau*** 2012 NA 30 NA 49 80 63 312,669 98 32 54 69 NA 3 NA
Haiti 2017 NA 37 NA 41 78 90 2,785,588 88 24 42 75 40 NA NA
India 2015 80 85 7 85 93 9 7,643,440 94 43 89 110 3,287 65 –98
Indonesia 2016 81 70 −14 82 83 1 1,442,264 50 66 95 43 466 21 –95
Iraq 2013 55 NA NA 75 73 −3 111,721 96 65 96 47 37 NA NA
Kenya††† 2018 51 65 27 68 85 25 4,463,695 67 43 89 109 1,278 NA NA
Laos 2013 45 5 −89 58 93 60 968,323 90 17 64 286 21 NA NA
Liberia 2011 25 64 156 51 90 76 288,984 57 51 84 66 152 12 –92
Madagascar 2014 40 51 27 58 75 29 2,705,588 72 47 46 –3 13 19 46
Malawi 2002 61 1 −98 84 90 7 NA NA 56 96 73 12 5 –58
Mali§§§ 2023 62 70 13 50 83 66 4,158,201 49 41 67 66 73 3 –96
Mauritania 2015 NA 29 NA 44 81 84 586,277 76 53 70 32 NA 0 NA
Mozambique††† 2010 61 NA NA 75 84 12 605,640 79 48 68 42 42 105 150
Namibia 2001 60 36 −41 74 90 22 NA NA 76 NA NA 10 0 –100
Nepal 2005 60 93 55 67 91 36 4,537,864 86 12 77 549 134 3 –98
Niger 2016 31 80 158 63 83 32 2,184,277 92 16 44 178 55 20 –64
Philippines 2017 58 NA NA 55 91 65 1,034,080 78 58 84 46 281 54 –81
Republic of the Congo 2009 39 83 114 67 87 30 273,003 91 83 91 9 2 8 300
Rwanda*** 2004 NA 76 NA 81 97 20 NA NA 31 94 201 5 7 40
Senegal 2011 45 100 123 62 96 55 359,845 92 58 75 29 0 1 NA
Sierra Leone 2013 20 84 320 53 93 75 1,704,814 102 37 87 134 36 5 –86
South Africa 2002 65 NA NA 68 88 29 NA NA 91 NA NA 11 0 –100
Tanzania 2012 77 90 17 79 90 14 987,575 NA 43 64 46 48 13 –73
Timor-Leste 2012 NA 34 NA NA 85 NA 24,141 53 24 NA NA NA 1 NA
Togo 2005 47 74 58 63 83 32 262,130 87 35 69 96 33 12 –64
Turkey 2009 36 68 89 50 97 94 1,242,674 58 83 97 17 26 0 –100
Uganda 2011 42 59 41 70 81 16 2,448,527 86 39 NA NA 470 NA NA
Vietnam*** 2005 90 88 −2 86 96 12 367,842 69 59 96 63 142 33 –77
Zambia 2007 61 NA NA 78 83 6 330,030 81 42 80 91 130 50 –62
Zimbabwe 2000 60 NA NA 76 89 17 NA NA NA 86 NA 16 0 –100
Maternal and neonatal tetanus elimination not validated by the end of 2023
Afghanistan 20 92 361 32 60 88 5,212,394 45 14 62 332 139 20 –86
Angola NA 39 NA 60 65 8 7,097,552 84 NA 50 NA 131 239 82
Central African Republic 20 84 320 36 65 81 2,595,415 42 32 40 27 37 38 3
Guinea 43 90 109 79 80 1 4,957,272 49 49 55 14 245 85 –65
Nigeria*** NA 43 NA 57 67 18 13,820,506 51 35 51 44 1,643 55 –97
Pakistan 51 66 29 71 86 21 28,219,661 81 23 68 196 1,380 509 –63
Papua New Guinea*** 10 36 256 24 65 171 450,739 15 39 56 45 138 13 –91
Somalia 22 74 234 47 57 21 497,561 27 19 32 65 966 0 –100
South Sudan NA 51 NA NA 65 NA 6,247,983 56 NA 40 NA NA 0 NA
Sudan 34 NA NA 61 81 33 7,365,615 86 NA NA NA 88 NA NA
Yemen 31 24 −23 54 73 35 3,612,931 51 27 NA NA 174 132 −24

Abbreviations: MNTE = maternal and neonatal tetanus elimination; NA = not available; SIA = supplementary immunization activity; TT2+ and Td2+ = ≥2 doses of tetanus toxoid and tetanus-diphtheria toxoid; TTCV = tetanus toxoid–containing vaccine; WHO = World Health Organization.
* Afghanistan, Angola, Bangladesh, Benin, Burkina Faso, Burma, Burundi, Cambodia, Cameroon, Central African Republic, Chad, China, Comoros, Côte d’Ivoire, Democratic Republic of the Congo, Egypt, Equatorial Guinea, Eritrea, Ethiopia, Gabon, Ghana, Guinea, Guinea-Bissau, Haiti, India, Indonesia, Iraq, Kenya, Laos, Liberia, Madagascar, Malawi, Mali, Mauritania, Mozambique, Namibia, Nepal, Niger, Nigeria, Pakistan, Papua New Guinea, Philippines, Republic of the Congo, Rwanda, Senegal, Sierra Leone, Somalia, South Africa, South Sudan, Sudan, Tanzania, Timor-Leste, Togo, Turkey, Uganda, Vietnam, Yemen, Zambia, and Zimbabwe.
TTCV data from WHO/UNICEF Joint Reporting Form on Immunization (2000–2022).
§ Includes first-year SIA conducted in Bangladesh in 1999 and first- and second-year SIAs conducted in Ethiopia in 1999.
Protected at birth data from WHO/UNICEF Joint Reporting Form on Immunization (2000–2022).
** SIA data from WHO/UNICEF MNTE Database, as of March 2024.
†† Skilled birth attendant data from WHO Global Health Observatory Data Repository (2000–2022).
§§ Neonatal tetanus case data from WHO Global Health Observatory Data Repository (2000–2022).
¶¶ Includes skilled birth attendant surveys conducted within 5 years for years 2000 and 2022.
*** Administrative ≥2-dose TTCV coverage among women of reproductive age was used when official data were unavailable for selected country.
††† Skilled birth attendant data were extracted from country-specific demographic health surveys. https://www.dhsprogram.com/data/available-datasets.cfm
§§§ MNTE was not validated in Mali by the end of 2022; however, elimination was validated in 2023.

Return to your place in the textFIGURE 1. Estimated number of neonatal tetanus deaths*, and estimated percentage of infants protected at birth§, against tetanus — worldwide, 2000–2022**
The figure is a histogram indicating the estimated number of neonatal tetanus deaths and the estimated percentage of infants protected at birth against tetanus worldwide during 2000–2022.

Abbreviations: TTCV = tetanus toxoid-containing vaccine; WHO = World Health Organization.

* The number of deaths is estimated from mathematical models that compute the yearly incidence and mortality for each country using the baseline rate of neonatal tetanus before TTCV introduction and promotion of clean deliveries, with adjustment for the estimated proportion of women vaccinated with TTCV and deliveries assisted by trained personnel.

Neonatal tetanus data from Child and Adolescent Cause of Death Estimation Group.

§ Protected at birth data from WHO/UNICEF Joint Reporting Form on Immunization (2000–2022).

The status of an infant born to a mother who received 2 doses of TTCV during the last birth, ≥2 doses with the last dose received ≤3 years before the last delivery, ≥3 doses with the last dose received ≤5 years earlier, ≥4 doses with the last dose received ≤10 years earlier, or receipt of ≥5 previous doses.

** Death data for 2022 were not available.

Return to your place in the textFIGURE 2. Number of women of reproductive age protected by tetanus toxoid–containing vaccine* received during supplementary immunization activities, number targeted but not yet vaccinated, number not yet targeted,§ and number of countries achieving maternal and neonatal tetanus elimination — 59 priority countries, worldwide, 2000–2022
The figure is a combination bar graph and line graph indicating the number of women of reproductive age protected by tetanus toxoid–containing vaccine received during supplementary immunization activities, the number targeted but not yet vaccinated, the number not yet targeted, and the number of countries achieving maternal and neonatal tetanus elimination in 59 priority countries worldwide during 2000–2022.

Source: WHO/UNICEF Maternal and Neonatal Tetanus Elimination Database, as of March 2024.

Abbreviations: MNTE = maternal and neonatal tetanus elimination; SIAs = supplementary immunization activities; WHO = World Health Organization.

* Protected with 2 doses of tetanus toxoid or tetanus and diphtheria toxoids.

Women of reproductive age included in SIA coverage goals.

§ Women of reproductive age estimated to be living in high-risk districts, which are yet to be targeted for tetanus toxoid–containing vaccine SIAs, primarily for programmatic reasons.

Afghanistan, Angola, Bangladesh, Benin, Burkina Faso, Burma, Burundi, Cambodia, Cameroon, Central African Republic, Chad, China, Comoros, Congo, Côte d’Ivoire, Democratic Republic of the Congo, Egypt, Equatorial Guinea, Eritrea, Ethiopia, Gabon, Ghana, Guinea, Guinea-Bissau, Haiti, India, Indonesia, Iraq, Kenya, Laos, Liberia, Madagascar, Malawi, Mali, Mauritania, Mozambique, Namibia, Nepal, Niger, Nigeria, Pakistan, Papua New Guinea, Philippines, Rwanda, Senegal, Sierra Leone, Somalia, South Africa, South Sudan, Sudan, Timor-Leste, Togo, Turkey, Uganda, Tanzania, Vietnam, Yemen, Zambia, and Zimbabwe.


Suggested citation for this article: Jones CE, Yusuf N, Ahmed B, Kassogue M, Wasley A, Kanu FA. Progress Toward Achieving and Sustaining Maternal and Neonatal Tetanus Elimination — Worldwide, 2000–2022. MMWR Morb Mortal Wkly Rep 2024;73:614–621. DOI: http://dx.doi.org/10.15585/mmwr.mm7328a1.

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