New evidence on the impact of the quality of prenatal care on neonatal and infant mortality in India.

Evidence on the impact of the quality of prenatal care on childhood mortality is limited in developing countries, including India. Therefore, using nationally representative data from the latest round of the National Family Health Survey (2015-16), this study examined the impact of the quality of prenatal care on neonatal and infant mortality in India using a multivariable binary logistic regression model. The effect of the essential components of prenatal care services on neonatal and infant mortality were also investigated. The results indicate that improvement in the quality of prenatal care is associated with a decrease in neonatal (OR: 0.93, 95% CI: 0.91-0.97) and infant (OR: 0.94, 95% CI: 0.92-0.96) mortality in India. Tetanus toxoid vaccination, consumption of iron-folic acid tablets during pregnancy and having been weighed during pregnancy were statistically associated with a lower risk of neonatal and infant mortality. Educating women on pregnancy complications was also associated with a lower risk of neonatal mortality. No effect of blood pressure examination, blood test and examination of the abdomen during pregnancy were found on either of the two indicators of childhood mortality. Although the coverage of prenatal care has increased dramatically in India, the quality of prenatal care is still an area of concern. There is therefore a need to ensure high-quality prenatal care in India.

Association of BCG, DTP, and measles containing vaccines with childhood mortality: systematic review.

OBJECTIVES:  To evaluate the effects on non-specific and all cause mortality, in children under 5, of Bacillus Calmette-Guérin (BCG), diphtheria-tetanus-pertussis (DTP), and standard titre measles containing vaccines (MCV); to examine internal validity of the studies; and to examine any modifying effects of sex, age, vaccine sequence, and co-administration of vitamin A. DESIGN:  Systematic review, including assessment of risk of bias, and meta-analyses of similar studies. STUDY ELIGIBILITY CRITERIA:  Clinical trials, cohort studies, and case-control studies of the effects on mortality of BCG, whole cell DTP, and standard titre MCV in children under 5. DATA SOURCES:  Searches of Medline, Embase, Global Index Medicus, and the WHO International Clinical Trials Registry Platform, supplemented by contact with experts in the field. To avoid overlap in children studied across the included articles, findings from non-overlapping birth cohorts were identified. RESULTS:  Results from 34 birth cohorts were identified. Most evidence was from observational studies, with some from short term clinical trials. Most studies reported on all cause (rather than non-specific) mortality. Receipt of BCG vaccine was associated with a reduction in all cause mortality: the average relative risks were 0.70 (95% confidence interval 0.49 to 1.01) from five clinical trials and 0.47 (0.32 to 0.69) from nine observational studies at high risk of bias. Receipt of DTP (almost always with oral polio vaccine) was associated with a possible increase in all cause mortality on average (relative risk 1.38, 0.92 to 2.08) from 10 studies at high risk of bias; this effect seemed stronger in girls than in boys. Receipt of standard titre MCV was associated with a reduction in all cause mortality (relative risks 0.74 (0.51 to 1.07) from four clinical trials and 0.51 (0.42 to 0.63) from 18 observational studies at high risk of bias); this effect seemed stronger in girls than in boys. Seven observational studies, assessed as being at high risk of bias, have compared sequences of vaccines; results of a subset of these suggest that administering DTP with or after MCV may be associated with higher mortality than administering it before MCV. CONCLUSIONS:  Evidence suggests that receipt of BCG and MCV reduce overall mortality by more than would be expected through their effects on the diseases they prevent, and receipt of DTP may be associated with an increase in all cause mortality. Although efforts should be made to ensure that all children are immunised on schedule with BCG, DTP, and MCV, randomised trials are needed to compare the effects of different sequences.

Vaccines for women to prevent neonatal tetanus.

BACKGROUND: Tetanus is an acute, often fatal, disease caused by an exotoxin produced by Clostridium tetani. It occurs in newborn infants born to mothers who do not have sufficient circulating antibodies to protect the infant passively, by transplacental transfer. Prevention may be possible by the vaccination of pregnant or non-pregnant women, or both, with tetanus toxoid, and the provision of clean delivery services. Tetanus toxoid consists of a formaldehyde-treated toxin which stimulates the production of antitoxin. OBJECTIVES: To assess the effectiveness of tetanus toxoid, administered to women of childbearing age or pregnant women, to prevent cases of, and deaths from, neonatal tetanus. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 October 2012), The Cochrane Library (2012, Issue 10), PubMed (1966 to 31 October 2012), EMBASE (1974 to 31 October 2012). We also used the results from handsearching and consultations with manufacturers and authors. SELECTION CRITERIA: Randomised or quasi-randomised trials evaluating the effects of tetanus toxoid in pregnant women or women of childbearing age on numbers of neonatal tetanus cases and deaths. DATA COLLECTION AND ANALYSIS: Three review authors independently assessed trials for inclusion and trial quality, and extracted data. MAIN RESULTS: Two trials (10,560 infants) were included. It should be noted that these trials are very old,1966 and 1980 respectively, and one trial randomised exclusively non-pregnant women. The main outcomes were measured on infants born to a subset of those randomised women who became pregnant during the course of the studies. One study (1919 infants) assessed the effectiveness of tetanus toxoid in comparison with influenza vaccine in preventing neonatal tetanus deaths. After a single dose, the risk ratio (RR) was 0.57 (95% confidence interval (CI) 0.26 to 1.24), and the vaccine effectiveness was 43%. With a two- or three-dose course, the RR was 0.02 (95% CI 0.00 to 0.30); vaccine effectiveness was 98%. No effect was detected on causes of death other than tetanus. The RR of cases of neonatal tetanus after at least one dose of tetanus toxoid was 0.20 (95% CI 0.10 to 0.40); vaccine effectiveness was 80%. Another study, involving 8641 children, assessed the effectiveness of tetanus-diptheria toxoid in comparison with cholera toxoid in preventing neonatal mortality after one or two doses. The RR was 0.68 (95% CI 0.56 to 0.82); vaccine effectiveness was 32%. In preventing deaths at four to 14 days, the RR was 0.38 (95% CI 0.27 to 0.55), and vaccine effectiveness 62% (95% CI 45% to 73%). AUTHORS' CONCLUSIONS: Available evidence supports the implementation of immunisation practices on women of childbearing age or pregnant women in communities with similar, or higher, levels of risk of neonatal tetanus, to the two study sites. More information is needed on possible interference of vaccination by malaria chemoprophylaxis on the roles of malnutrition and vitamin A deficiency, and on the quality of tetanus toxoid production and storage.

Maternal tetanus toxoid vaccination and neonatal mortality in rural north India.

OBJECTIVES: Preventable neonatal mortality due to tetanus infection remains common. We aimed to examine antenatal vaccination impact in a context of continuing high neonatal mortality in rural northern India. METHODS AND FINDINGS: Using the third round of the Indian National Family Health Survey (NFHS) 2005-06, mortality of most recent singleton births was analysed in discrete-time logistic model with maternal tetanus vaccination, together with antenatal care utilisation and supplementation with iron and folic acid. 59% of mothers reported receiving antenatal care, 48% reported receiving iron and folic acid supplementation and 68% reported receiving two or more doses of tetanus toxoid (TT) vaccination. The odds of all-cause neonatal death were reduced following one or more antenatal dose of TT with odds ratios (OR) of 0.46 (95% CI 0.26 to 0.78) after one dose and 0.45 (95% CI 0.31 to 0.66) after two or more doses. Reported utilisation of antenatal care and iron-folic acid supplementation did not influence neonatal mortality. In the statistical model, 16% (95% CI 5% to 27%) of neonatal deaths could be attributed to a lack of at least two doses of TT vaccination during pregnancy, representing an estimated 78,632 neonatal deaths in absolute terms. CONCLUSIONS: Substantial gains in newborn survival could be achieved in rural North India through increased coverage of antenatal TT vaccination. The apparent substantial protective effect of a single antenatal dose of TT requires further study. It may reflect greater population vaccination coverage and indicates that health programming should prioritise universal antenatal coverage with at least one dose.

Determinants of tetanus and sepsis among the last neonatal deaths at household level in a peri-urban area of India.

BACKGROUND: India contributes to one quarter of the total number of newborn deaths in the world. Less explored are the causes of these deaths, and household factors and decision makers for antenatal and postnatal care and their association with neonatal mortality. OBJECTIVE: This study estimated neonatal mortality rate due to tetanus and sepsis (TS) and tried to identify the risk factors for TS in a peri-urban area of India characterised by a high level of infant and neonatal mortality rate. METHODS: An intensive cross-sectional study was conducted during January to March 2008. A structured interview schedule was developed, after reviewing major demographic and health studies done in India, to collect data from all women selected in the sample villages, situated at a distance of 3-5 km from a primary health centre. RESULTS: Of the 894 married women (<50 years of age), 109 reported their last pregnancy outcome as neonatal death, and 84 cases of TS were noted. Using forward conditional stepwise logistic regression the risk factors of TS identified were women's age, socioeconomic score, antenatal care, pregnancy complications, and treatment after delivery during the neonatal period. CONCLUSIONS: Independent of social class there is high prevalence of neonatal mortality. There is a close association between utilisation of health care services during pregnancy, postnatal period and neonatal deaths due to TS. It is argued that there is a need for a two pronged approach to reduce neonatal mortality due to TS: (1) to train traditional birth attendants, and expand the reach of existing antenatal care and childbirth facilities; and (2) to empower women to increase their awareness to take decisions about seeking proper medical assistance during pregnancy and childbirth.

A survey of neonatal tetanus at a district general hospital in north-east Nigeria.

Neonatal tetanus (NNT) remains among the leading causes of morbidity and mortality in Nigeria and a huge challenge in achieving the fourth goal of the Millennium Development Goals. We reviewed the morbidity and mortality pattern among neonates with NNT admitted to the District General Hospital in north-east Nigeria from 2006 to 2009. Half of the patients were from rural areas and were delivered at home by untrained traditional birth attendants with no prior antenatal health care. Razor blades and scissors were the instruments used to cut the cord in nonhygienic conditions. Spasticity, lack of sucking, trismus, fever, omphalitis, risus sardonicus and opisthotonus were the most common presenting signs and symptoms. Overall, mortality was 56%. Health education of mothers and traditional birth attendants, the promotion of hospital delivery and antenatal tetanus immunization of all pregnant women, particularly in rural areas, are recommended if NNT is to be prevented.

Neonatal tetanus in Turkey; what has changed in the last decade?

BACKGROUND: Neonatal tetanus (NT) is still considered as one of the major causes of neonatal death in many developing countries. The aim of the present study was to assess the characteristics of sixty-seven infants with the diagnosis of neonatal tetanus followed-up in the Pediatric Infectious Diseases Ward of Dicle University Hospital, Diyarbakir, between 1991 and 2006, and to draw attention to factors that may contribute (or may have contributed) to the elimination of the disease in Diyarbakir. METHODS: The data of sixty-seven infants whose epidemiological and clinical findings were compatible with neonatal tetanus were reviewed. Patients were stratified into two groups according to whether they survived or not to assess the effect of certain factors in the prognosis. Factors having a contribution to the higher rate of tetanus among newborn infants were discussed. RESULTS: A total of 55 cases of NT had been hospitalized between 1991 and 1996 whereas only 12 patients admitted in the last decade. All of the infants had been delivered at home by untrained traditional birth attendants (TBA), and none of the mothers had been immunized with tetanus toxoid during her pregnancy. Twenty-eight (41.8%) of the infants died during their follow-up. Lower birth weight, younger age at onset of symptoms and at the time admission, the presence of opisthotonus, risus sardonicus and were associated with a higher mortality rate. CONCLUSION: Although the number of neonatal tetanus cases admitted to our clinic in recent years is lower than in the last decade efforts including appropriate health education of the masses, ensurement of access to antenatal sevices and increasing the rate of tetanus immunization among mothers still should be made in our region to achieve the goal of neonatal tetanus elimination.

Transient renal glucosuria in patients with tetanus.

BACKGROUND/AIMS: During our early years of experience with patients suffering from tetanus, some of them were found to have unexplained renal glucosuria. METHODS: Thus, all the normoglycemic patients with tetanus who were consecutively encountered over the subsequent 8 years were studied for the presence of renal glucosuria. RESULTS: From 92 cases of tetanus admitted to the intensive-care unit, 63 patients had normal blood sugar in the course of their illness. The quantitative measurement of 24-hour urine confirmed the presence of significant renal glucosuria in 52% (n = 33) of these cases. The renal glucosuria was of transient nature and decreased to normal levels in the recovery stage (4 weeks after discharge from the hospital). There was no significant difference in age, sex, severity of disease and site of entry between the two groups of the patients with and without renal glucosuria. CONCLUSION: Significant but transient glucosuria of renal origin possibly induced by tetanospasmin is common in patients with tetanus.

Factors associated with neonatal tetanus mortality in northern Nigeria.

Over a 12-month period, a cluster survey on Neonatal tetanus (NNT) mortality was conducted in Northern Nigeria. The relative contributions of knowledge, attitude and practice (KAP) to certain epidemiological factors associated with NNT deaths were evaluated. NNT mortality was 20.6/1000 live-births (i.e. over 65% of neonatal mortality). Poor cord management showed the strongest association with NNT mortality with comparable contributions from KAP. Less than 40% of 2,623 live-births recorded during the survey followed two or more ante natal visits. This was significantly associated with NNT mortality with virtually equal contributions from KAP. Over 60% of the births had traditional surgeries performed with highly significant association with NNT mortality. Knowledge deficit was the most important contributor to performance of traditional procedures. Tetanus toxic coverage (32.0%) was also associated with NNT mortality with knowledge and attitudinal deficits accounting for over 75% of poor coverage. Most deliveries were outside hospitals and related facilities with highly significant association with NNT deaths. Attitude and practice contributed over 80% to this observation. In view of the associated epidemiological factors, and the relative roles of KAP, community--specific prevention strategies are suggested. Training and involvement of traditional birth attendants is emphasized. Domicilliary service are also suggested in view of the widely practised purdah system.

Neonatal tetanus among rural-born Nigerian infants.

PROBLEM: Identify factors that influence the high rate of tetanus among infants born in rural areas. SUBJECTS: Home-born infants (n = 39) admitted to a medical center with fever. Males (n = 24) and females (n = 15); age range 3-15 days. METHOD: Retrospective, descriptive design. The author used a 10-item interview schedule and a 9-item clinical checklist, including observation of infants' umbilical cords and physical state. FINDINGS: Of the 39 infants, 27 contracted neonatal tetanus; 11 died. All infants with tetanus were delivered at home by traditional, nonprofessional attendants. Factors contributing to high tetanus incidence included: lack of sepsis control, cord care, mothers' lack of immunization, delivery in settings. CONCLUSIONS & IMPLICATIONS FOR NURSING: Traditional nonprofessional attendants need training by professional nurses and midwives, and integration into the national health services. Immunization programs and health education are necessary, and can be delivered by nurses and midwives.

Field test of a rapid assessment technique against a probabilistic community survey: operational implications for neonatal tetanus elimination.

Neonatal tetanus (NNT) is a leading cause of neonatal mortality in developing countries and is frequently called 'the silent epidemic'. It is endemic in over 90 countries throughout the world. Incidence is often not known, obstructing cost-effective resource management for control measures. In many developing countries NNT is responsible for one-half of the neonatal mortality and up to one-quarter of infant mortality. Case-fatality rates (CFR) can, even with treatment, reach 80-90%. Operational tools for the rapid identification of NNT risk areas need to be developed for WHO's programme which calls for the elimination of NNT by 1995. Results of a rapid assessment technique, carried out in 1990, were compared with those found in a household survey, which was independently carried out in Jalisco, Mexico, in 1988. One approach used random sample survey techniques in rural communities, which in previous years had reported NNT. Of 40 neonatal deaths, 8 (20%) were attributable to NNT. The annual incidence rate was 4.6/1000 livebirths. Using this as the 'gold standard', a rapid assessment technique was evaluated. The NNT cases seen at health services were randomly matched with other neonatal illnesses obtained from health records and then mapped. Age-specific catchment areas for hospitals under investigation and risk areas for NNT were obtained. Areas without NNT cases but with other neonatal illnesses have been operationally considered to be at low risk for NNT. The use of health services by neonates with other pathologies supports the hypothesis that an NNT case, if it occurred within the same time period and area under investigation, would most probably have been admitted.(ABSTRACT TRUNCATED AT 250 WORDS)

Uvulectomy as an epidemiological factor in neonatal tetanus mortality:- observations from a cluster survey.

A total of 2,623 live-births were recorded over a 12-month period during a cluster survey on Neonatal tetanus (NNT) mortality in Kano metropolis, Northern Nigeria. There were 79 neonatal deaths including 54 NNT deaths. NNT mortality was 20.6/1000 live-births. Although there was a male preponderance (55.6%) amongst NNT deaths, the association between sex and NNT death was not significant. Traditional Surgery was performed in over 80% of NNT deaths. The association between NNT death and traditional surgery was highly significant. Uvulectomy was the most frequently performed traditional surgery while circumcision was the least performed. There was also a highly significant association between uvulectomy and NNT death. Indeed, uvulectomy alone had a much stronger association with NNT death than traditional surgeries combined. There was no association between sex and performance of uvulectomy. It is reported that circumcision is not an important epidemiological factor in NNT mortality in this region. Health education is suggested to improve utilization of health facilities and discourage uvulectomy and other traditional surgeries.

Experimental study upon the efficacy of some accelerated vaccination schedules in tetanus prophylaxis.

In an attempt to accelerate the antitetanic vaccine-induced immune response necessary particularly in subjects with tetanigenic wounds, groups of guinea pigs or rabbits were i.d. or s.c. immunized with a nonadsorbed purified and concentrated toxoid. Concomitantly, lots of control animals were i.m. immunized with tetanic vaccine adsorbed on aluminium phosphate. The immune response was estimated by testing the serum antitetanus antitoxic titre and the resistance of guinea pigs to tetanic intoxication. The results obtained revealed a variety of responses to vaccination in which differed terms of the species of animals and the applied immunization schedule. When single vaccine doses were used the protective antitetanus limit was reached in seven days in rabbits and after ten days in guinea pigs; the adsorbed vaccine induced a stronger immune response than the non-adsorbed vaccine. When multiple immunization doses were used the non-adsorbed tetanus vaccine induced, especially in rabbits, a more rapid response that the adsorbed vaccine. The vaccination schedules used in laboratory animals and which have yielded the best results in this experiment will be analysed and checked on human subjects in a further study.

Epidemiological factors associated with neonatal tetanus mortality: observations from a cluster survey in Nigeria.

A cluster survey on neonatal tetanus (NNT) mortality was conducted in Kano Metropolis, Northern Nigeria, to investigate epidemiological factors associated with NNT mortality. The survey was a two-stage cluster sampling technique and lasted for two weeks. A total of 2,623 live-births were recorded over a 12-month period. Less than 40% of the births followed two or more antenatal visits and tetanus toxoid coverage was 32.0%. Over 60% of births were outside hospitals and related facilities. Of the epidemiological factors investigated, only antenatal care, tetanus toxoid coverage, hospital delivery, poor cord management and traditional surgery showed significant association with NNT death. It is suggested that an appropriate community-specific prevention strategy for the region should include health education to improve utilisation of antenatal and hospital-delivery facilities, discourage traditional surgery and improve tetanus toxoid coverage. A case is also made for training and involvement of traditional birth attendants (TBAs) since most deliveries occurred outside hospitals and related facilities.

PIP: Data obtained from a survey conducted in Kano Metropolis in northern Nigeria in July 1990 on a cluster sample of 2623 live births within the year were used to investigate epidemiological factors associated with neonatal tetanus (NNT) mortality. The sample included 1283 males and 1340 females, of which 79 died (54 from NNT). The NNT mortality rate is a high 20.6/1000. 51% of births in the sample were to mothers who received at least one prenatal visit. 37.9% of births involved mothers who received two or more prenatal visits, which is the typical pattern in developing countries. 32% were immunized with a tetanus toxoid vaccine, which is much higher than the typical 14% in developing countries. 40% were hospital or related health facility births. Low socioeconomic status was attributed to 60% of the infants. Over 80% of mothers practiced purdah, and 83% had a health facility within their cluster. Prenatal care, tetanus toxoid vaccine coverage, hospital delivery, poor cord management, and traditional surgery were related to NNT. Poor cord management and traditional surgery increased the risk of mortality, and the other factors reduced the risk. There were relative, but insignificant, risks associated with a male birth, low socioeconomic status, and the purdah system. One recommendation is for improvements in traditional birth attendant training. Affordability and use of health facilities are affected by the purdah system and the low socioeconomic status of most mothers. Prevention should stress good cord management, which Chinese studies show to be effective in reducing NNT mortality. Tetanus toxoid vaccine is recommended for all mothers who are attending any health facility for any reason. Mass immunization campaigns are an additional means of supplementing coverage. Traditional surgery such as circumcision, vulvectomy, ear piercing, and facial marking should be discouraged. Health education is recommended as a means of increasing use of health care facilities, discouraging unhealthful practices, and increasing immunization.

Expanded programme on immunization. Neonatal tetanus, 1970-1992.

PIP: Weekly notification of neonatal tetanus (NT) has been required in Venezuela since 1970. This disease was a major cause of infant mortality in the 1970s, even though the case-fatality rate was low compared to that of other countries. Due to a very sensitive surveillance system, false-positives are included among reported cases. All states of the country recorded cases of NT. In the effort to reduce the incidence of disease, in 1970, traditional birth attendants (TBA) were recruited and trained, hospital deliveries were encouraged, and pregnant women were vaccinated with tetanus toxoid. Related morbidity and mortality decreased 87% and 86%, respectively, between 1970-74 and 1985-89. Morbidity and mortality declined even further if one compares the first five-year period against the years 1990 and 1991. An epidemiological investigation of 64 NT cases yielded the following results for 1990 and 1991: the risk of NT is twelve times greater in rural areas than in urban areas; 92% of the mothers of NT cases had received either none or one dose of tetanus toxoid; 93% of NT cases occurred as a result of out-of-hospital births; regarding care during delivery, 58% of cases occurred at birth when deliveries were attended by unqualified personnel, 37% when attended by a TBA, and 5% when attended by doctors; 50% of the mothers of NT cases were illiterate or had only one year of schooling; the mothers had an average of five children; and almost 50% of all cases during 1989-91 occurred among the indigenous Wayu population living in the Guajira region in the state of Zulia. 46% of all reported cases in the past three years have been from Zulia. The plan of action is briefly described.^ieng

Impact of a tetanus toxoid immunization mass campaign on neonatal tetanus mortality in Aceh Province, Indonesia.

Neonatal tetanus mortality declined dramatically in Pidie district (Aceh Province) Indonesia between 1984 and 1987. Baseline and follow-up survey results demonstrated an 85% reduction in neonatal tetanus mortality during this period, from 32.1/1000 live births to 4.9/1000 live births. During 1985 a tetanus toxoid mass campaign was conducted in Pidie district which resulted in 84% of women 10-45 years of age receiving two tetanus toxoid injections. Analysis of the results of the two surveys provides very strong evidence of the impact of the tetanus toxoid mass campaign on neonatal tetanus mortality.

Risk factors of neonatal tetanus in Senegal.

A case-control study for evaluating the risk factors of neonatal tetanus was conducted in a rural area of Senegal under demographic surveillance (Niakhar). Some 45 neonatal tetanus deaths that occurred in the study area between March 1983 and March 1986 were investigated. They were matched with 187 controls. Neonatal tetanus accounted for one-third of all neonatal deaths; mortality from neonatal tetanus was 16/1000 livebirths. The effect of various demographic, socioeconomic, epidemiological and behavioural factors was investigated in a multivariate analysis using linear logistic regression. There was no difference associated with socioeconomic factors between cases and controls. Factors associated with the skill and behaviour of birth attendant and mother were highly significant and were associated with high odds ratio (OR) and included whether the hands of the person cutting the cord were washed with soap (OR = 5.22; p = 0.001); whether the person who dressed the cord was skilled (OR = 4.71; p = 0.012); whether the age of the mother was less than 18 years (OR = 7.03; p = 0.027) and whether the birth attendant arrived before delivery (OR = 4.15, p = 0.023). Conversely, the type of tool used to cut the cord did not have a significant effect (p = 0.239). Data analysis suggests that a main source of Clostridium tetani may be the hands of the birth attendant and that the main mode of contamination may be the dressing of the wound stump. Results suggest that teaching mothers and birth attendants simple hygienic principles and basic techniques may have a significant impact on neonatal tetanus mortality.