RISK CHARACTERIZATION OF MATERNAL AND NEONATAL TETANUS IN VIEW OF TETANUS VACCINATION CAMPAIGNS IN PAKISTAN.

BACKGROUND: Pakistan is one of the remaining 24 countries which have not yet achieved Maternal and Neonatal Tetanus Elimination (MNTE), The country adopted high-risk approach for 56 out of 119 districts with country-wide Tetanus Toxoid (TT) provision in Routine Immunization (RI) during early 2000-2003. The TT's mass campaigns could only cover 13% of high risk districts for 2009- 2011, and mostly for the Punjab province. To achieve MNT elimination, the country needs risk mapping for cost-effective intervention. METHODS: We used both the quantitative and qualitative methods to conduct risk characterization. All the three available data sets (Reported EPI coverage data, PDHS 2012-13, and PSLM 2010-11) were assessed. A mix of core and surrogate indicators-for risk categorization was used through ranking and scoring the aggregated data and considering the past tetanus campaigns' coverage. Tetanus Toxoid (TT2+)-coverage of pregnant women and delivery in health facility, both received more weightage in scoring. We based the higher and lower cuts off points for each indicator on data ranges. The districts with higher scores, i.e., 10.5 and above were ranked good followed by medium (5.5-10.4) and low performing (less than 5.5). Consultations with the national and provincial field officers were utilized to understand the local context. RESULTS: In Pakistan, there are 139 districts out of which, 60 are the high risk districts for tetanus. Highest percentage is for Baluchistan (83%) followed by Sindh (52%), and Khyber Pakhtunkhwa (40%). Most of the Punjab is at medium risk (55%), followed by KP (52%), and Sindh (39%). CONCLUSION: Pakistan is at medium to high risk of MNT with a great variation at the sub-national level. Campaigns aiming to these districts may bring the country closer to MNT elimination target.

Maternal and neonatal tetanus elimination: from protecting women and newborns to protecting all.

A total of 35 of the 59 countries that had not eliminated maternal and neonatal tetanus (MNT) as a public health problem in 1999 have since achieved the MNT-elimination goal. Neonatal tetanus deaths have decreased globally from 200,000 in 2000 to 49,000 in 2013. This is the result of increased immunization coverage with tetanus toxoid-containing vaccines among pregnant women, improved access to skilled birth attendance during delivery, and targeted campaigns with these vaccines for women of reproductive age in high-risk areas. In the process, inequities have been reduced, private-public partnerships fostered, and innovations triggered. However, lack of funding, poor accessibility to some areas, suboptimal surveillance, and a perceived low priority for the disease are among the main obstacles. To ensure MNT elimination is sustained, countries must build and maintain strong routine programs that reach people with vaccination and with clean deliveries. This should also be an opportunity to shift programs into preventing tetanus among all people. Regular assessments, and where needed appropriate action, are key to prevent increases in MNT incidence over time, especially in areas that are at higher risk. The main objective of the paper is to provide a detailed update on the progress toward MNT elimination between 1999 and 2014. It elaborates on the challenges and opportunities, and discusses how MNT elimination can be sustained and to shift the program to protect wider populations against tetanus.