Tetanus is an acute, potentially fatal disease caused by a neurotoxin produced by the bacterium Clostridium tetani. (1) Maternal and neonatal tetanus (MNT) are forms of generalized tetanus that affect mothers during pregnancy, caused by unclean abortion or delivery, and infants during the first 28 days of life.
The neonatal tetanus (NT) elimination initiative was launched in 1989 following a World Health Assembly resolution and was relaunched in 1990 as "maternal and neonatal tetanus elimination" (MNTE) to include the maternal component. MNTE is defined as <1 case of NT per 1000 live births in every district each year (2) and comprises 3 strategies for elimination: 1) clean delivery, including appropriate umbilical cord care; 2) vaccination of pregnant women and women of reproductive age (WRA); and 3) strengthening surveillance of NT. (3) There has been a significant decrease in the annual number of reported deaths due to NT, from an estimated 787 000 in 1988 to 25 000 in 2018. (4) Between 1999 and 2018, an estimated cumulative 154 million WRA received at least 2 doses of tetanus toxoid-containing vaccine (TTCV2+) during supplementary immunization activities (SIAs) for protection against tetanus. As of December 2021, elimination of this easily vaccine-preventable disease that remains a public health problem had been validated in 47 of the 59 (80%) priority countries targeted for MNTE. As of 2018, however, an estimated cumulative 47 million (23%) of the total 201 million WRA targeted were not reached and remained unprotected against tetanus. The majority of these women resided in the 12 countries that were yet to eliminate MNT, including Nigeria.
Maternal and neonatal tetanus elimination in Nigeria
Nigeria remains one of the 12 countries yet to eliminate MNT, though the South-East and South-West zones were validated as having achieved elimination in 2017 and 2019, respectively. With implementation of tetanus toxoid-containing vaccine (TTCV) SIAs since 2001, there has been a significant decrease in the number of reported cases of NT, from 468 in 2013 to 55 in 2020. (5) According to demographic and health surveys (DHS) conducted in 2008, 2013 and 2018, core MNTE indicators (TTCV2+, protection at birth (PAB), skilled birth attendance (SBA)) have steadily improved over the past decade, although there are significant disparities in performance between the southern and the northern zones. The 2018 DHS showed that, while 92% of babies in South-East zone were protected at birth against tetanus, only 46% infants in North-West zone were protected. Similarly, 82% of deliveries took place in health facilities in the South-East and 16% in North-West zone, while 85% of deliveries were assisted by SBAs in the South-East and South-West zones and only 16% in North-West (Table 1).
MNTE implementation in the South-South zone
The South-South zone of Nigeria comprises 6 states: Akwa Ibom, Bayelsa, Cross River, Delta, Edo and Rivers. According to data from the 2013 and 2018 DHS, the performance of core MNTE indicators (TTCV2+, PAB and SBA) improved in all states except Bayelsa over the periods covered; however, only Edo and Rivers attained the...