Tetanus Toxoid Vaccination Coverage and Associated Factors among Childbearing Women in Ethiopia: A Systematic Review and Meta-Analysis.

BACKGROUND: Tetanus is a bacterial disease caused by the Clostridium tetani, which is a highly fatal, noncommunicable, and toxin-mediated disease. Globally, maternal and neonatal tetanus is a public health problem due to low maternal tetanus toxoid immunization. Ethiopia has the highest neonatal mortality and morbidity related to tetanus due to low tetanus toxoid immunization and the high number of home deliveries. The main objective of this systematic review and meta-analysis was to estimate the pooled coverage of at least two doses of tetanus toxoid immunization, and the pooled effect sizes of associated factors in Ethiopia. METHODS: Primary studies for this review were searched from the PubMed/MEDLINE online, ScienceDirect, Hinari, Google, and Google Scholar databases. Primary articles published from 2010 up to August 30, 2020, were included in this meta-analysis. Data were extracted in Microsoft Excel format and exported to STATA Version 14.0. A random-effects meta-analysis model was used to estimate the pooled coverage of two or more tetanus toxoid immunizations and its associated factors. Heterogeneity was evaluated by the I 2 test. Egger's weighted regression test was used to assess publication bias. RESULTS: We retrieved 212 records; of these, 199 articles were excluded for reasons. Finally, 14 studies were included in this meta-analysis. The pooled estimate of receiving at least two doses of tetanus toxoid immunization coverage in Ethiopia was 52.2% (95% CI: 42.47-61.93, I 2 = 98.4%). Antenatal care (OR = 7.8 (95% CI: 3.2, 19.2), I 2 = 96.3%), media exposure (OR = 8.3 (95% CI: 2.1, 33.3), I 2 = 98.1%), distance from the health facility (OR = 2.64 (95% CI: 1.1, 6.6), I 2 = 94.1%), educational status of women (OR = 4.7 (95% CI: 2.07, 9.56), I 2 = 94.2%), and educational status of husbands (OR = 2.995 (95% CI: 1.194, 7.512), I 2 = 92.5%) were factors significantly associated with receiving at least two doses of tetanus toxoid immunization coverage in Ethiopia. CONCLUSIONS: The coverage of tetanus toxoid immunization among childbearing women was low in Ethiopia. Strengthening maternal health service utilization (antinatal care and institutional delivery) to the nearest health facility even in health posts and empowering education for both women and their husbands is recommended to increase tetanus toxoid immunization coverage in Ethiopia.

An investment case for maternal and neonatal tetanus elimination.

INTRODUCTION: Globally, 13 countries have yet to eliminate maternal and neonatal tetanus. While efforts have improved access to tetanus toxoid containing vaccines (TTCVs) and increased clean delivery practices, reaching elimination targets (<1 case of neonatal tetanus per 1000 live births per district per year) may require significant resources to reach the remaining high risk and hard-to-reach districts. METHODS: We estimated the cost to achieve maternal and neonatal tetanus elimination (MNTE) in three years in the remaining 13 countries: Afghanistan, Angola, Central African Republic, Democratic Republic of the Congo, Guinea, Mali, Nigeria, Pakistan, Papua New Guinea, Somalia, South Sudan, Sudan, and Yemen. Costs were estimated for: (1) vaccination campaigns using standard TTCVs and TT-Uniject™ targeting women of reproductive age in high risk areas, (2) additional vaccinations delivered to pregnant women at antenatal care (ANC) clinics, (3) clean delivery and umbilical cord care promotion, (4) neonatal tetanus surveillance strengthening, and (5) validation activities. We forecasted the averted mortality to assess the cost-effectiveness of achieving MNTE. RESULTS: It will cost an estimated US$197.7 million to realize MNTE over three years. These costs include $161.4 million for vaccination campaigns, $6.1 million for routine vaccination during ANC, $23.3 million for promotion of clean delivery practices, $4 million for surveillance, and $3 million for validation of MNTE. Achieving MNTE will avert approximately 70,000 neonatal deaths over ten years of vaccine protection, resulting in approximately 4.4 million life years gained. It will cost $2,900 per death averted and $45 per life year gained. CONCLUSION: Maternal and neonatal tetanus can be eliminated with significant financial investment, high prioritization, and strong political will. While substantial costs must be incurred to reach hard-to-reach populations, MNTE should be accomplished as a matter of health equity, and will significantly contribute to reaching the United Nations' Sustainable Development Goals.

The potential effects of introducing microneedle patch vaccines into routine vaccine supply chains.

BACKGROUND: Microneedle patch (MNP) technology is designed to simplify the process of vaccine administration; however, depending on its characteristics, MNP technology may provide additional benefits beyond the point-of-use, particularly for vaccine supply chains. METHODS: Using the HERMES modeling software, we examined replacing four routine vaccines - Measles-containing vaccine (MCV), Tetanus toxoid (TT), Rotavirus (Rota) and Pentavalent (Penta) - with MNP versions in the routine vaccine supply chains of Benin, Bihar (India), and Mozambique. RESULTS: Replacing MCV with an MNP (5 cm3-per-dose, 2-month thermostability, current single-dose price-per-dose) improved MCV availability by 13%, 1% and 6% in Benin, Bihar and Mozambique, respectively, and total vaccine availability by 1% in Benin and Mozambique, while increasing the total cost per dose administered by $0.07 in Benin, $0.56 in Bihar and $0.11 in Mozambique. Replacing TT with an MNP improved TT and total vaccine availability (3% and <1%) in Mozambique only, when the patch was 5 cm3 and 2-months thermostable but increased total cost per dose administered by $0.14. Replacing Rota with an MNP (at 5-15 cm3-per-dose, 1-2 month thermostable) improved Rota and total vaccine availability, but only improved Rota vaccine availability in Bihar (at 5 cm3, 1-2 months thermostable), while decreasing total vaccine availability by 1%. Finally, replacing Penta with an MNP (at 5 cm3, 2-months thermostable) improved Penta vaccine availability by 1-8% and total availability by <1-9%. CONCLUSIONS: An MNP for MCV, TT, Rota, or Penta would need to have a smaller or equal volume-per-dose than existing vaccine formulations and be able to be stored outside the cold chain for a continuous period of at least two months to provide additional benefits to all three supply chains under modeled conditions.

Tetanus: A Potential Public Health Threat in Times of Disaster.

BACKGROUND: Tetanus is a potentially fatal condition that is rare in urban environments but is seen in developing countries and post-natural-disaster. Therefore, the purpose of this report was to review the epidemiology, pathogenesis, and management of tetanus in the trauma patient. METHODS: A thorough literature review was conducted to look for the most current and thorough guidelines on the prophylaxis and treatment of tetanus. PUBMED (National Center for Biotechnology Information, National Institutes of Health; Bethesda, Maryland USA), MEDLINE (US National Library of Medicine, National Institutes of Health; Bethesda, Maryland USA), and Cochrane Library (The Cochrane Collaboration; Oxford, United Kingdom) databases were searched for articles in English, published from 2005 to 2015, using the keywords "Tetanus," "Trauma/Surgery," and "Disaster." Controlled trials, randomized controlled trials, trials of adult patients, published guidelines, expert opinions, and review articles were selected and extracted. RESULTS: Current vaccination schedules in developed countries provide prophylaxis for tetanus. However, when severe natural disasters occur, many patients may not be able to provide a reliable vaccination history. In these situations, tetanus immune globulin (TIG) is indicated; if resources are not limited, both tetanus toxoid and TIG should be given to those with high-risk wounds. If resources are limited, TIG should be reserved for those that would benefit most or those least likely to have the protective antibodies. CONCLUSIONS: Although tetanus is a disease that has a low incidence in the developed world due to high rates of immunization, during large-scale natural disasters, compounding factors like the types of injuries, lack of medical services and supplies, and the delay in treatment associated with an already low immunization rate result in an increased incidence and outbreaks of the disease that has higher mortality in an underdeveloped society. It is important for the urban physician that cares for trauma and critical patients to become familiar with the protocols for treatment and immunization of patients that have tetanus-prone wounds, as well as recognize the potential for outbreaks in the settings of major natural disasters. Finkelstein P , Teisch L , Allen CJ , Ruiz G . Tetanus: a potential public health threat in times of disaster. Prehosp Disaster Med. 2017;32(3):339-342.

Informe especial: Tétanos otras edades (No neonatal) / Special report: Tetanus other ages (Nonneonatal)

Entre las Semanas Epidemiológicas (SE) 51 del año 2016 y 5 del 2017 (período comprendido entre el 18/12/2016 y el 04/02/2017), la Gerencia Operativa de Epidemiología recibió la notificación de 3 casos de tétanos otras edades a través de alertas del módulo C2 del Sistema Nacional de Vigilancia de la Salud (SNVS). Se trató de 3 pacientes asistidos en el Departamento de Atención Intensiva del Paciente Infeccioso Crítico (D.A.I.P.I.C.), del Hospital de Infecciosas Francisco Muñiz, de la Ciudad de Buenos Aires. Dos casos correspondieron a residentes de Provincia de Buenos Aires y el restante a un residente de la Ciudad. Este informe resume estos tres casos, los cuales destacan la necesidad que los médicos y quienes están encargados de los cuidados de salud, constaten en oportunidad de toda consulta, la cobertura de vacunación antitetánica e indiquen la vacuna a pacientes no vacunados, incompletamente vacunados o con vacunación desconocida.(AU)

The economic value of increasing geospatial access to tetanus toxoid immunization in Mozambique.

BACKGROUND: With tetanus being a leading cause of maternal and neonatal morbidity and mortality in low and middle income countries, ensuring that pregnant women have geographic access to tetanus toxoid (TT) immunization can be important. However, immunization locations in many systems may not be placed to optimize access across the population. Issues of access must be addressed for vaccines such as TT to reach their full potential. METHODS: To assess how TT immunization locations meet population demand in Mozambique, our team developed and utilized SIGMA (Strategic Integrated Geo-temporal Mapping Application) to quantify how many pregnant women are reachable by existing TT immunization locations, how many cannot access these locations, and the potential costs and disease burden of not covering geographically harder-to-reach populations. Sensitivity analyses covered a range of catchment area sizes to include realistic travel distances and to determine the area some locations would need to cover in order for the existing system to reach at least 99% of the target population. RESULTS: For 99% of the population to reach health centers, people would be required to travel up to 35km. Limiting this distance to 15km would result in 5450 (3033-7108) annual cases of neonatal tetanus that could be prevented by TT, 144,240 (79,878-192,866) DALYs, and $110,691,979 ($56,180,326-$159,516,629) in treatment costs and productivity losses. A catchment area radius of 5km would lead to 17,841 (9929-23,271) annual cases of neonatal tetanus that could be prevented by TT, resulting in 472,234 (261,517-631,432) DALYs and $362,399,320 ($183,931,229-$522,248,480) in treatment costs and productivity losses. CONCLUSION: TT immunization locations are not geographically accessible by a significant proportion of pregnant women, resulting in substantial healthcare and productivity costs that could potentially be averted by adding or reconfiguring TT immunization locations. The resulting cost savings of covering these harder to reach populations could help pay for establishing additional immunization locations.

Prevalence and socio-demographic factors associated with non-protective immunity against tetanus among high school adolescents girls in Nigeria.

BACKGROUND: The low uptake of tetanus vaccine and its resultant high burden of tetanus in Nigeria suggest the need to improve routine and booster vaccination in children and adolescents. However, epidemiological evidence for vaccination in the adolescent age group needed for effective strategy and policy formulation is lacking. This study was carried out to determine the prevalence of protective immunity against tetanus and to identify risk factors for non-protective immunity among schooling adolescents. METHODS: Using a three-stage sampling technique, 851 female adolescents were randomly selected from secondary schools in Ibadan, Nigeria. A pre-tested questionnaire was used to obtain data on demographic and socio-economic characteristics and history of tetanus vaccination. An immuno-chromatographic rapid test kit, "Tetanos Quick Stick" was used to test specific anti-tetanus antibody protective level in venous blood samples. Descriptive statistics, Chi-square and logistic regression analyses were done with level of significance set at p = 0.05. RESULTS: Mean age of participants was 14.3 ± 1.9 years. Seroprevalence of protective immunity against tetanus was 38.1% and it significantly decreased with increasing age. More adolescents in public (65.4%) than private (44.7%) schools had non-protective level of immunity. A significantly increasing trend in the risk of non-protective immunity was observed with decreasing level of mothers' education. Also, the Odds of non-protective level of immunity was significantly higher in public than private schools (OR = 2.14; 95% CI =1.39, 3.20) but lower among adolescents who had history of recent tetanus toxoid injection than those who did not (OR = 0.11 95% CI = 0.09, 0.22). However, no significant association was found between protective immunity against tetanus and parents' marital status as well as family size. CONCLUSION: Protective immunity against tetanus among female adolescents was poor, more so in public schools and those who had not received vaccination a year prior to the study. Policy-makers need to consider the inclusion of immunization against tetanus in the school health programme.

Determination of vaccination status of pregnant women during pregnancy and the affecting factors.

AIMS AND OBJECTIVES: To determine the vaccination status of pregnant women during pregnancy and factors affecting their vaccination. BACKGROUND: Immunisation provided through vaccination is one of the most effective ways to reduce or prevent the risks of disease, disability and death. Maternal and newborn health may be protected and morbidity may be decreased through vaccinating pregnant women when necessary. DESIGN: This was a descriptive and cross-sectional survey. METHODS: This study was conducted in a university hospital in Ankara, Turkey, between 01 March and 31 May 2010. The study was carried out with 198 healthy pregnant women who had completed the 26th week of gestation. Data were collected using the data collection form composed of questions enquiring about the demographic and obstetric features of pregnant women and whether or not they knew that vaccinations could be given during pregnancy, and which vaccines could be used during pregnancy, which vaccine/vaccines they had previously received and the reasons for having been vaccinated or not. RESULTS: Approximately half of the participants had received at least one of the vaccines that may be used in pregnancy (52·0%). The pregnant women received vaccinations for tetanus (47·0%), H1N1 (9·1%), seasonal influenza (3·0%) and hepatitis B (0·5%), respectively. The pregnant women who had been educated about vaccinations had been vaccinated at a statistically significantly higher rate compared with those who had not. CONCLUSION: This study revealed that pregnant women's knowledge about the required vaccines during pregnancy affected their behaviour towards vaccination. Acquiring knowledge about vaccines that may be used during pregnancy from health personnel is effective to increase vaccination. This result may be interpreted as 'acquired information affects behaviour towards vaccination'. RELEVANCE TO CLINICAL PRACTICE: Providing information about immunisation to pregnant women at the antenatal clinic is important in terms of maternal and newborn health. Nurses and midwives working in the antenatal field should be sufficiently educated about immunisation.

Recommendations for postexposure interventions to prevent infection with hepatitis B virus, hepatitis C virus, or human immunodeficiency virus, and tetanus in persons wounded during bombings and other mass-casualty events--United States, 2008: recommendations of the Centers for Disease Control and Prevention (CDC).

This report outlines recommendations for postexposure interventions to prevent infection with hepatitis B virus, hepatitis C virus, or human immunodeficiency virus, and tetanus in persons wounded during bombings or other events resulting in mass casualties. Persons wounded during such events or in conjunction with the resulting emergency response might be exposed to blood, body fluids, or tissue from other injured persons and thus be at risk for bloodborne infections. This report adapts existing general recommendations on the use of immunization and postexposure prophylaxis for tetanus and for occupational and nonoccupational exposures to bloodborne pathogens to the specific situation of a mass-casualty event. Decisions regarding the implementation of prophylaxis are complex, and drawing parallels from existing guidelines is difficult. For any prophylactic intervention to be implemented effectively, guidance must be simple, straightforward, and logistically undemanding. Critical review during development of this guidance was provided by representatives of the National Association of County and City Health Officials, the Council of State and Territorial Epidemiologists, and representatives of the acute injury care, trauma and emergency response medical communities participating in CDC's Terrorism Injuries: Information, Dissemination and Exchange (TIIDE) project. The recommendations contained in this report represent the consensus of U.S. federal public health officials and reflect the experience and input of public health officials at all levels of government and the acute injury response community.

A tsunami related tetanus epidemic in Aceh, Indonesia.

In January 2005, a tetanus epidemic was discovered amongst survivors of the Boxing Day Tsunami in Aceh, Indonesia. Our aim was to describe the extent of the tetanus outbreak in tsunami survivors admitted and describe the case outcomes from one hospital. All clinicians were instructed to report suspected cases to a centralised organisation using a standardised data collection tool. Active case finding was carried out by a trained team that visited hospital wards in Aceh. Of the 106 cases, 79% was above 25 years old (the median age was 40 years) and 62% was male. The mortality rate in Aceh was 19% and that of in follow up cases was 17%. Fifteen of the follow-up cases were admitted with severe tetanus associated with superficial wounds, three of whom had a history of immersion. Supplies to treat the tetanus cases in this epidemic were initially limited as disaster relief agencies were not prepared for the resultant tetanus epidemic. The mortality rate of 17%, was significantly less than was usual for tetanus in adults (>50%) and children (80%) in underdeveloped countries. To reduce mortality and morbidity, rapid disaster relief organisations should include supplies for vaccination and treatment of tetanus cases and consider early tracheotomy for severe cases.

Tetanus immunization shortage in the United States.

The purpose of this study is to determine the effect of the tetanus immunization shortage on EDs and the EPs understanding of the prioritization of persons needing tetanus immunization. A survey consisting of questions about knowledge of the tetanus shortage, prioritization of immunizations, incidence of tetanus infections, and understanding of CDC recommendations was mailed to a random sample 20% of the US ED medical directors. The results of the survey were input into the SPSS program (SPSS, version 10, Chicago, IL). The survey was returned by 618 of the 1,375 (44.9%) ED medical directors in the United States. Almost all (97.2%, 601 of 617) were notified about the tetanus shortage and 58.3% (360 of 617) reported a shortage. A total of 42.2% (199 of 472) gave tetanus toxoid (TT), instead of tetanus and diphtheria toxoids adult type (dT) when indicated. Only 11.6% of those surveyed (56 of 482) established a patient callback system. Routine vaccination was stopped in 37.5% of the reporting hospitals, most often for adults and children (57.5%, 69 of 120). Twelve hospitals (1.9%) reported they had an increase in tetanus. Although 87.5% of the respondents (539 of 616) stated they were familiar with the CDC's prioritization for tetanus immunization, only 1.8% (11 of 616) got the prioritization correct. Although EM directors uniformly know about and are experiencing the tetanus shortage, few correctly reported the tetanus immunization priority. Few EDs had a patient callback system.

Deferral of routine booster doses of tetanus and diphtheria toxoids for adolescents and adults.

A shortage of tetanus and diphtheria toxoids (Td) and tetanus toxoid (TT) in the United States has resulted because one of two manufacturers discontinued production of tetanus toxoid-containing products. Aventis Pasteur (Swiftwater, Pennsylvania) is the only major manufacturer of tetanus and Td in the United States. In response to the shortage, Aventis Pasteur has increased production of Td to meet national needs; however, because 11 months are required for vaccine production, the shortage is expected to last for the remainder of 2001.