Maternal and neonatal tetanus (MNT) (1) remains a major cause of neonatal mortality, with an 80-100% case-fatality rate among neonates born to insufficiently vaccinated mothers after unhygienic deliveries, especially in low-income countries. (2) In 1989, the World Health Assembly endorsed elimination (3) of neonatal tetanus; the activity was relaunched in 1999 as the maternal and neonatal tetanus elimination (MNTE) (4) initiative, targeting 595 priority countries. MNTE strategies include achieving [greater than or equal to] 80% coverage with [greater than or equal to] 2 doses of tetanus toxoid-containing vaccine (TTCV2+) (6) among women of reproductive age through routine and supplementary immunization activities (SIAs) (7) in high-risk districts; (8) achieving [greater than or equal to]70% of deliveries by a skilled birth attendant (SBA); (9) and implementing neonatal tetanus case-based surveillance. (10) This report summarizes progress towards achieving and sustaining MNTE during 2000-2020 and updates a previous report. (11) By December 2020, 52 (88%) of the 59 priority countries had conducted TTCV SIAs. Globally, the proportion of infants protected at birth (PAB) (12) against tetanus increased from 74% (2000) to 86% (2020), and the proportion of deliveries assisted by an SBA increased from 64% (2000-2006) to 83% (2014-2020). The number of neonatal tetanus cases reported worldwide decreased by 88%, from 17 935 (2000) to 2229 (2020), and the estimated number of deaths decreased by 92%, from 170 829 (2000) to 14 230 (2019). (13) By December 2020, 47 (80%) of 59 priority countries were validated as having achieved MNTE, 5 of which had conducted post-validation assessments. (14) To achieve and sustain elimination in the 12 remaining countries, innovation is necessary, including integrating SIAs to cover multiple vaccine-preventable diseases and implementing TTCV life-course vaccination.
To estimate TTCV vaccination coverage delivered through routine immunization services and the number of neonates PAB from tetanus, WHO and the United Nations Childrens' Fund (UNICEF) use data from administrative records and vaccination coverage surveys reported annually by member countries. (15) WHO and UNICEF receive summaries of the number of women of reproductive age who receive TTCV during SIAs. (16) In 2020, 16 (27%) of the 59 priority countries achieved [greater than or equal to]80% TTCV2+ coverage, with 34 countries increasing coverage since 2000 (Table 1). In 2020, of 58 priority countries for which data were available, 46 (79%) reported that [greater than or equal to]80% of infants were PAB. The global proportion of infants PAB increased from 74% (2000) to 86% (2020) (Table 1).
During 2000-2020, 52 priority countries conducted TTCV SIAs, and 168 million (67%) of the targeted 250 million women of reproductive age received [greater than or equal to]2 doses of TTCV (Table 1, Figure 1). In 2020, 59 million women targeted for protection in TTCV SIAs remained unreached, and TTCV SIA activities targeted to an estimated 16 million women of reproductive age in 5 countries were postponed because of COVID-19 disruption in immunization services (Figure 1). (17)
Deliveries assisted by skilled birth attendants
WHO and UNICEF estimate the percentage of births assisted by an...