A big boost for public health

Unlike polio and smallpox, the risk of maternal and neonatal tetanus will always exist. Tetanus spores are always a part of the environment. Thus ‘elimination’ must be seen as an enduring pursuit.

Maternal and neonatal tetanus (MNT) is no longer a major public health problem in the World Health Organisation (WHO) South-East Asia region. The WHO South-East Asia Region has eliminated MNT as a major public health problem.As immunisation coverage and access to maternal and newborn health care has increased, the number of mothers and newborns suffering agonising deaths on account of the disease has declined to below one in every 1,000 live births at the district level. This is a major achievement.

In 1989, when the fight against neonatal tetanus (and, consequently, maternal tetanus) began, tetanus toxins were claiming the lives of approximately 7,87,000 newborns across the world. Unhygienic conditions during delivery and inadequate umbilical cord care saw to it that these toxins could infect mother and child, causing muscle spasms, lockjaw, and often death.

With recent elimination successes in India and Indonesia, the South-East Asia region has reached a milestone.

Though elimination took longer than expected, it is a victory that must be savoured. At the same time, however, it is a victory that is by no means final.

Unlike the situation with diseases such as polio and smallpox, the risk of MNT will always exist. Tetanus spores are always a permanent part of the environment, meaning public health setbacks could once again compromise mothers and their newborns. In relation to MNT, “elimination” must be seen as an enduring pursuit.

Strengthening measures that facilitated elimination in the first instance can best guarantee the ongoing safety of mothers and their newborns.

Innovative strategies

Sustaining and enhancing access to quality maternal and newborn health care is critical. By providing expectant mothers the ability to access quality antenatal and safe-birthing services, health systems throughout the region diminish the risk of tetanus infection, as well as other potentially lethal complications. Though countries in the region have made important gains have been made in the region, the momentum must be accelerated. There must be innovative strategies deployed to reach those ‘unreached’, such as increased training of skilled birth attendants at community-level facilities, or providing cash transfers to every mother who has an institutional delivery, for example.

Immunisation coverage must be maintained and enhanced. Expectant mothers must receive the necessary tetanus toxoid vaccine, or combination vaccine, as a matter of priority and at the appropriate stages of pregnancy.

As Indonesia’s campaign to vaccinate brides-to-be demonstrates that positive initiatives need not be confined to the pregnancy or neonatal periods. Just as newborns receive tetanus immunisations as part of their routine immunisation schedule, children must receive booster doses as and when appropriate. A good place for this to happen is at school. Despite the region’s newly validated status, health authorities must ensure that preventing maternal and neonatal tetanus remains prominent on the list of vaccine-preventable diseases, and that opportunities to immunise against tetanus are grasped.

Effective engagement with communities is essential. Communities that have difficulties accessing care or which lack experience doing so must be further encouraged to avail themselves of the benefits maternal and newborn health care brings. Messages related to tetanus immunisation and safe-birthing must remain integrated with other outreach activities, and disseminated among the most vulnerable. Harmful traditional practices should be discouraged, while at the same time continuing to build relationships that promote trust, respect and inclusiveness.

A positive experience with health care providers can have far-ranging effect, not only for an individual but also a community.

Tracking progress

A robust and effective surveillance system is vital to tracking progress in these key areas. After all, the failure of any one of them can mean the death of a mother or newborn through tetanus infection. By closely monitoring incidences ofMNT, authorities can evaluate the impact of their efforts, and, if found lacking, better calibrate them in future. In-depth knowledge of the causes of every case of maternal or neonatal tetanus, combined with a resolve to ensure it is not repeated, can be the only appropriate response. However great the recent achievement is, it remains unacceptable that any woman or child should suffer the devastating disease.

Along with conducting routine vaccine-preventable disease surveillance, WHO is committed to realising the unfinished Millennium Development Goal agenda as it relates to maternal and newborn health, which will in turn help allay tetanus’s menace. Efforts to achieve Universal Health Coverage — a priority area of WHO in the South-East Asia region — will similarly enhance health equity, ensuring that tetanus’s tendency to prey on the most vulnerable is rebuffed. It is no coincidence that the first countries in the region to eliminate the problem also had the strongest health systems.

That MNT has been eliminated as a major public health problem in the South-East Asia region is reason to celebrate.

Newborns across the region are now safer from the disease than at any other time in history, but we must not be misled by our successes.

Maternal and neonatal tetanus remains a burden, and could make a comeback in significant numbers in future. By enhancing the reach and quality of maternal and newborn health care, increasing immuniSation coverage, leveraging greater community buy-in, and ensuring detailed surveillance, we can avert this possibility.