A ten-year review of neonatal tetanus cases managed at a tertiary health facility in a resource poor setting: The trend, management challenges and outcome.

BACKGROUND: Neonatal Tetanus (NNT) is a vaccine preventable disease of public health importance. It is still being encountered in clinical practice largely in developing countries including Nigeria. NNT results from unhygienic delivery practices and some harmful traditional cord care practices. The easiest, quickest and most cost-effective preventive measure against NNT is vaccination of the pregnant women with the tetanus toxoid (TT) vaccine. The case-fatality rate from tetanus in resource-constrained settings can be close to 100% but can be reduced to 50% if access to basic medical care with adequate number of experienced staff is available. MATERIALS AND METHODS: This retrospective study reviewed the admissions into the Special Care Baby Unit (SCBU) of the Ekiti State University Teaching Hospital, Ado-Ekiti from January 2011 to December 2020. The folders were retrieved from the records department of the hospital; Information obtained from folders were entered into a designed proforma for the study. RESULTS: During the study period, NNT constituted 0.34% of all neonatal admissions with case fatality rate of 52.6%. Seven [36.8%] of the babies were delivered at Mission home/Traditional Birth Attendant's place while 5 [26.3%] were delivered in private hospitals. Cord care was with hot water compress in most of these babies16 [48.5%] while only 9% of the mothers cleaned the cord with methylated spirit. Age at presentation of less than one week was significantly associated with mortality, same with presence of autonomic dysfunction. Low family socio-economic class 5 was significantly associated with poor outcome, so also maternal age above 24 years. CONCLUSION: This study revealed that neonatal tetanus is still being seen in our clinical practice with poor outcome and the risk factors are the same as of old. Increased public health campaign, promotion of clean deliveries, safe cord care practices, affordable and accessible health care provision are recommended to combat NNT scourge.

Safety and efficacy of Magnesium Sulfate in the management of Tetanus: A systematic review.

Tetanus is a rare life-threatening condition often complicated by repetitive spasms, dysautonomia and neuromuscular respiratory failure contributing to high fatality rates in its severe form. Benzodiazepines used to treat muscle spasms pose a high risk of respiratory failure requiring mechanical ventilation, which is unaffordable and inaccessible for many. Magnesium sulfate, a cheap and widely available medication in all urban and rural health centres of LMICs for the treatment of eclampsia, can be used to control muscle spasms and dysautonomia. We thus conducted a systematic review of evidence to assess the safety and efficacy of magnesium sulfate in the treatment of tetanus. Any study published before April 15, 2021, discussing the efficacy and/or safety of MgSO4 infusion in the treatment of tetanus was systemically reviewed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Our systematic review included data from 13 studies, three were randomised, double-blind and controlled trials. The remaining ten studies were observational; six prospective and four retrospective studies. Our review showed no mortality benefit associated with the use of magnesium sulfate. However, magnesium sulfate was found to be effective in reducing spasms along with diazepam, leading to better control of dysautonomia, reduced need for mechanical ventilation and shorter hospital stay by 3-7 days. The incidence of magnesium toxicity was very low in the studies included.

Prevalence and predictors of taking tetanus toxoid vaccine in pregnancy: a cross-sectional study of 8,722 women in Sierra Leone.

BACKGROUND: Immunization of women during pregnancy to protect them and their infants against tetanus, pertussis and influenza is recommended by the World health Organization (WHO). However, there is limited information about the coverage rate and associated factors in low-income countries. The aim of this study was to measure the prevalence and predictors of taking tetanus toxoid among pregnant women in Sierra Leone. METHODS: This study was based on the fifth round of Multiple Indicator Cluster Survey (MICS 5) conducted in Sierra Leone in 2017. In total 8722 women aged between 15 and 49 years were included in this study. Outcome variable was taking of Tetanus Toxoid vaccination during the last pregnancy. Data were analyzed using cross-tabulation and logistic regression methods. RESULTS: The overall prevalence of receiving TT immunization during women's last pregnancy was 96.3% and that of taking at least two doses was 82.12%. In the regression analysis, women from Mende ethnicity had a 0.48 fold lower chance of being immunized (OR = 0.480, 95% CI = 0.385,0.59768) than those from the other ethnicity. In addition, women who attended at least four ANC visits had higher odds of receiving TT vaccine (OR = 1.919, 95% CI = 1.639,2.245) compared to those who attended less ANC visits. Stratified by areas, this association was observed in both urban (OR = 2.661, 95% CI = 1.924,3.679) and rural areas (OR = 1.716, 95% CI = 1.430,2.059). Attending at least four ANC visits showed a positive association with receiving at least two doses TT (OR = 2.434, 95% CI = 1.711,3.464) in both urban (OR = 2.815, 95% CI = 1.413,5.610) and rural areas (OR = 2.216, 95% CI = 1.463,3.356) as well. CONCLUSION: Higher number of ANC visits, mass media exposure and higher wealth quintile increased the odds of receiving TT immunization. In addition, minimum two doses which were identified to reduce neonatal mortality. Therefore, immunization campaigns targeting improved utilization of healthcare and immunization services by women of childbearing age in Sierra Leone are strongly recommended.

Multicenter Study of Tetanus Patients in Fujian Province of China: A Retrospective Review of 95 Cases.

BACKGROUND: Tetanus is a life-threatening disease in developing countries and is accompanied by a high mortality rate. Although China is the world's largest developing country, there have been few clinical studies on tetanus in China. The purpose of this study was to investigate the epidemiology, incidence, and management of tetanus in Fujian Province and to understand the current treatment and prognosis of tetanus patients. METHODS: This was a retrospective, multicenter observational study of patients who presented with a clinical diagnosis of tetanus at 5 general hospitals in Fujian from January 2008 to December 2018. Data were analyzed using a computer software system. RESULTS: A total of 95 patients were recruited, including 6 newborns. The average age of the adult tetanus patients was 55.53 ± 15.39 years old. None of the patients knew their previous history of tetanus immunization. The rate of having received human tetanus immunoglobulin (HTIG) was 9.47%. A total of 73 (76.84%) patients were cured, 17 (17.89%) patients had an unknown prognosis, and 5 (5.26%) patients died. Age, severity of illness, and complications all increased the total duration of hospitalization. Compared with endotracheal intubation, tracheotomy increased the length of stay in the ICU (Intensive Care Unit) but did not affect the total hospital length of stay for mechanical ventilation. CONCLUSIONS: With the promotion of nationwide immunization against tetanus and the development of critical care medicine, morbidity and mortality rates of tetanus in Fujian are low. It is important to increase awareness among local physicians and staff in charge of tetanus immunization programs and with regard to neonatal tetanus and drug-induced tetanus. The prevention and treatment of tetanus in developing countries should arouse widespread concern in society.

The Prevalence and Case-Fatality Rates of Post-Neonatal Tetanus in a Population of Hospitalized Nigerian Children: An 8-Year Retrospective Review.

BACKGROUND: Although tetanus is a vaccine-preventable disease, reports indicate that it remains a significant cause of morbidity and mortality in both neonatal and post-neonatal periods especially in most developing countries. AIM: This study aimed to determine the prevalence and case fatality rates of post-neonatal tetanus among children managed at the Federal Medical Centre Asaba, Delta State, Nigeria over 8 years. METHOD: The study was a retrospective review of the records of the children above 1 month of age admitted into Federal Medical Centre, Asaba, with a clinical diagnosis of tetanus from January 2008 to May 2016. Data analysis was conducted on descriptive and inferential statistics using Statistical Package for Social Sciences version 22.0. Mean, standard deviation and other relevant parameters were calculated. Level of significance was set at p < 0.05. RESULTS: During the study period, 32 out of 3693 admitted Paediatric patients had post-neonatal tetanus: giving a prevalence rate of 0.9%. The male : female ratio was 1.9 : 1 and patients' ages ranged from 2 to 15 years with a mean age 8.9 ± 3.1 years. Twenty-nine percent of them had complete immunization during infancy, but none had booster doses. Also, 60.9% of them presented with lower limb injuries as the portal of entry. Over 17.4% of the patients had very severe tetanus. Of the 32 patients studied, 62.5% resided in the neighbouring rural communities, while 50.0% were admitted for ≤10 days. The calculated case fatality rate was 50%. CONCLUSION: The prevalence and case fatality rates of post-neonatal tetanus are still relatively high in this clime. Given the prevalent nature of the disease in children aged 5 years and above, there is a need to include the booster doses of tetanus toxoid in the country's National Programme on Immunization schedule.

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.

Tetanus Immunity and Epidemiology in Australia, 1993-2010.

BACKGROUND: This study evaluates trends in tetanus immunity and epidemiology over the last two decades in Australia, drawing on two national serological surveys and national tetanus morbidity data, to justify current Australian adult tetanus booster recommendations. METHODS: We compare tetanus immunity level between two national serosurveys, and examine incidence trends using the most accurate estimation of the true number of cases by correcting for under-ascertainment. RESULTS: Tetanus immunity in people aged <60 years is high, but the elderly, particularly the female elderly, may not be adequately protected. Over the past twenty years older people have regularly accounted for the highest number of tetanus cases, with an increasing proportion of cases. CONCLUSION: Despite a positive decrease in tetanus incidence, there remains a significant burden in the elderly population of an entirely preventable disease. Supplying a funded booster dose of dTpa at 65 years would be, potentially, an effective strategy to prevent tetanus cases in Australia.

Tetanus in Poland in 2017

INTRODUCTION: In the last decade, the number of tetanus cases in Poland has not exceeded 20 cases. Since 1984, neonatal tetanus has not been reported. OBJECTIVE OF THE WORK: The aim of the study is to present the data of epidemiological surveillance of tetanus in 2017 in a historical perspective, taking into account the role of protective vaccination and a reference to activities for the elimination of neonatal tetanus on a global scale. SUMMARY AND CONCLUSIONS. Tetanus is an infectious disease acquired in the environment and associated with wound pollution. Few cases of illness in Poland are associated with non-compliance with recommendations for booster vaccinations. MATERIAL AND METHODS: The material of the study are individual reports on tetanus sent to the Department of Epidemiology, NIZP-PZH and the bulletin "Infectious diseases and poisoning in Poland in 2017. The historical data is based on earlier Polish and foreign studies. RESULTS: In 2017, 11 cases of tetanus were reported. Four men and seven women got sick. One man died in the age > 69.

Disease burden of varicella versus other vaccine-preventable diseases before introduction of vaccination into the national immunisation programme in the Netherlands.

IntroductionEstimating burden of disease (BoD) is an essential first step in the decision-making process on introducing new vaccines into national immunisation programmes (NIPs). For varicella, a common vaccine-preventable disease, BoD in the Netherlands was unknown.AimTo assess national varicella BoD and compare it to BoD of other vaccine-preventable diseases before their introduction in the NIP.MethodsIn this health estimates reporting study, BoD was expressed in disability-adjusted life years (DALYs) using methodology from the Burden of Communicable Diseases in Europe (BCoDE)-project. As no parameters/disease model for varicella (including herpes zoster) were available in the BCoDE toolkit, incidence, disease progression model and parameters were derived from seroprevalence, healthcare registries and published data. For most other diseases, BoD was estimated with existing BCoDE-parameters, adapted to the Netherlands if needed.ResultsIn 2017, the estimated BoD of varicella in the Netherlands was 1,800 (95% uncertainty interval (UI): 1,800-1,900) DALYs. Herpes zoster mainly contributed to this BoD (1,600 DALYs; 91%), which was generally lower than the BoD of most current NIP diseases in the year before their introduction into the NIP. However, BoD for varicella was higher than for rotavirus gastroenteritis (1,100; 95%UI: 440-2,200 DALYs) and meningococcal B disease (620; 95%UI: 490-770 DALYs), two other potential NIP candidates.ConclusionsWhen considering the introduction of a new vaccine in the NIP, BoD is usually estimated in isolation. The current approach assesses BoD in relation to other vaccine-preventable diseases' BoD, which may help national advisory committees on immunisation and policymakers to set vaccination priorities.

Prognostic factors for generalized tetanus in adults: A retrospective study in a Chinese hospital.

BACKGROUND: We evaluated factors associated with mortality in patients with moderate/severe generalized tetanus. METHODS: This retrospective study included patients with moderate/severe generalized tetanus admitted to the Affiliated Hospital of Nantong University (China) between January 2005 and January 2017. Clinical data were extracted from medical records. Patients were divided into two groups based on outcome (survival or death). Factors associated with mortality were analyzed using univariate and multivariate logistic regression. RESULTS: Seventy-five patients were included (57.3% male; age, 57.9 ±â€¯18.4 years; APACHE II score, 10.6 ±â€¯3.4; severe tetanus, 49.3%; mortality, 25.3%). Multivariate analysis identified severe tetanus (odds ratio [OR], 30.364; 95% confidence interval [CI], 2.459-374.896) and APACHE II score (OR, 1.536; 95%CI, 1.051-2.243) as positively associated with mortality, whereas high-calorie nutrition (OR, 0.027; 95%CI, 0.002-0.359) and dexmedetomidine use (OR, 0.035; 95%CI, 0.003-0.467) were negatively associated with mortality (all P < 0.05). CONCLUSION: Tetanus severity and APACHE II score were associated with mortality in patients with generalized tetanus, whereas high-calorie nutrition and dexmedetomidine use reduced the odds of death. High-calorie nutrition and dexmedetomidine administration may improve prognosis in adult patients with moderate/severe generalized tetanus.

A 6-year review of post-neonatal tetanus at Usmanu Danfodiyo University Teaching Hospital, Sokoto

Background: Tetanus is a vaccine-preventable disease but its incidence has remained unacceptably high in developing countries. Objective: To determine the prevalence, risk factors and outcome of post-neonatal tetanus at Usmanu Danfodiyo University Teaching Hospital (UDUTH), Sokoto. Methods: A retrospective descriptive study from 1st January 2010 to 31st December 2015. Children aged 1 month to 15 years diagnosed with post-neonatal tetanus were studied. Information from the admission files was extracted. Data was analysed using SPSS version 20. Results: Total admissions during the study period were 14,458; 61 had post-neonatal tetanus, giving a prevalence of 0.4%. The M: F ratio was 1.5:1. The mean age was 7.4±3.2 years. Fifty-nine (96.7%) were not immunised against tetanus. Portal of entry for the organism was trauma injuries to the foot in 33(54.1%). Thirty-one (50.8%) were discharged, 5(8.2%) DAMA, while 25(41.0%) died, and case fatality was 41.0%. Conclusion: Post-neonatal tetanus is a major cause of morbidity and mortality in Sokoto. There is need for improved health education, sustainability of immunisation programmes and coverage to eradicate this scourge

Managing Severe Tetanus without Ventilation Support in a Resource-limited Setting in Bangladesh.

Tetanus, a vaccine-preventable and potentially fatal disease, continues to remain prevalent in low- and middle-income countries. Furthermore, physicians are often unfamiliar with management of severe tetanus without ventilator support. Therefore, we proposed a modified treatment protocol that provides a low-cost and effective solution for the management of severe tetanus in resource-constrained settings. This is an observational study of 42 patients with severe tetanus treated during 2015-2016 at Surya Kanta Hospital, Bangladesh. This facility does not have an intensive care unit (ICU), and patients admitted here were provided treatment with the modified protocol. A total number of 42 patients with severe tetanus were treated with the modified protocol. Among them, 24 (57.1%) recovered completely, six (14.3%) recovered with the sequela, and 12 (28.6%) died. Among those who recovered with the sequela, four needed mechanical support during walking and two had a visual impairment. No significant adverse event was recorded during the treatment period. The results gathered during this case series provide a sustainable, low-cost, and effective solution to management of severe tetanus in resource-constrained settings where ICUs are unavailable.

Tetanus in Poland in 2016

THE PURPOSE of the STUDY: The purpose of the study was to provide data on tetanus incidence in 2016 in the basic categories of epidemiological surveillance. MATERIAL AND METHODS: The study is based on the individual forms of tetanus cases submitted to the NIZP-PZH Epidemiology Department and the data of the bulletin "Infectious Diseases and Poisoning in Poland in 2016. RESULTS: The number of tetanus cases in 2016 was 12, exactly as it was in the previous year 2015. Among the infected people there were six men and six women. Among the infected people two men and one women died. All the fatalities were in the age groups of 70 and older. SUMMARY AND CONCLUSIONS: The environmental nature of tetanus infections makes the immunity of individual exposed persons the basic preventive tool, which underlines the role of individual vaccinations.

Pre-post effects of a tetanus care protocol implementation in a sub-Saharan African intensive care unit.

BACKGROUND: Tetanus is a vaccine-preventable, neglected disease that is life threatening if acquired and occurs most frequently in regions where vaccination coverage is incomplete. Challenges in vaccination coverage contribute to the occurrence of non-neonatal tetanus in sub-Saharan countries, with high case fatality rates. The current WHO recommendations for the management of tetanus include close patient monitoring, administration of immune globulin, sedation, analgesia, wound hygiene and airway support [1]. In response to these recommendations, our tertiary referral hospital in Tanzania implemented a standardized clinical protocol for care of patients with tetanus in 2006 and a subsequent modification in 2012. In this study we aimed to assess the impact of the protocol on clinical care of tetanus patients and their outcomes. METHODS AND FINDINGS: We examined provision of care and outcomes among all patients admitted with non-neonatal tetanus to the ICU at Bugando Medical Centre between 2001 and 2016 in this retrospective cohort study. We compared three groups: the pre-protocol group (2001-2005), the Early protocol group (2006-2011), and the Late protocol group (2012-2016) and determined associations with mortality by univariable logistic regression. We observed a significant increase in provision of care as per protocol between the Early and Late groups. Patients in the Late group had a significantly higher utilization of mechanical ventilation (69.9% vs 22.0%, p< 0.0001), provision of surgical wound care (39.8% vs 20.3%, p = 0.011), and performance of tracheostomies (36.8% vs 6.7%, <0.0001) than patients in the Early group. Despite the increased provision of care, we found no significant decrease in overall mortality in the Early versus the Late groups (55.4% versus 40.3%, p = 0.069), or between the pre-protocol and post-protocol groups (60.7% versus 50.0%, p = 0.28). There was also no difference in 7-day ICU mortality (30.1% versus 27.8%, p = 0.70). Analysis of the causes of death revealed a decrease in deaths related to airway compromise (30.0% to 1.8%, p<0.001) but an increase in deaths due to presumed sepsis (15.0% to 44.6%, p = 0.018). CONCLUSION: The overall mortality in patients suffering non-neonatal tetanus is high (>40%). Institution of a standardized tetanus management protocol, in accordance with WHO recommendations, decreased immediate mortality related to primary causes of death after tetanus. However, this was offset by an increase in death due to later ICU complications such as sepsis. Our results illustrate the complexity in achieving mortality reduction even in illnesses thought to require few critical care interventions. Improving basic ICU care and strengthening vaccination programs to prevent tetanus altogether are essential components of efforts to decrease the mortality caused by this lethal, neglected disease.

Clinical features and outcomes of tetanus: Analysis using a National Inpatient Database in Japan.

PURPOSE: This study was performed to elucidate the current clinical features and outcomes of tetanus using a national inpatient database in Japan. MATERIALS AND METHODS: We used the Japanese Diagnosis Procedure Combination inpatient database to retrospectively investigate patients with tetanus from July 2010 to March 2016. We examined the patients' characteristics; the proportions of patients requiring tracheal intubation, mechanical ventilation, and tracheostomy; and the discharge status. RESULTS: We identified 499 patients who were diagnosed with tetanus. No patient had a diagnosis of tetanus neonatorum or obstetric tetanus. The median age was 74years. Overall, 53.5% of the patients required intubation and mechanical ventilation. Among patients who required intubation and mechanical ventilation, 80.6% started it within 3days of admission, and 77.5% required tracheostomy during hospitalization. The median duration of mechanical ventilation was 23days. The median length of hospitalization was 35days. The proportions of patients who were discharged to home and to locations other than home were 58.1% and 35.1%, respectively. The in-hospital mortality was 6.8%. CONCLUSION: The present study suggests that acute-care physicians should be ready to provide intensive care for patients with tetanus and cooperate with medical social workers and families for subsequent long-term nursing care.

Achieving neonatal tetanus elimination in Nigeria: undisclosed challenges and prospects.

The global initiative for neonatal tetanus elimination was launched in 1989 following the unacceptably high neonatal morbidity and mortality from tetanus. Since then tremendous progress has been made evidenced with a 94% reduction in mortality. Despite this impressive progress, two global target dates have been missed, the latest being in 2005; which led to a further target of 2015 as the global neonatal tetanus elimination date. This target date has probably been missed again as there are still 21 countries yet to be validated. Nigeria is one such country and contributes two-thirds of the burden of neonatal tetanus globally. What are the prospects and challenges of neonatal tetanus elimination in Nigeria? This paper discusses these and other relevant issues regarding neonatal tetanus elimination and sustaining clearance.

Post-neonatal Tetanus in a PICU of a Developing Economy: Intensive Care Needs, Outcome and Predictors of Mortality.

Objectives: To evaluate pediatric intensive care unit (PICU) needs, outcome and predictors of mortality in post-neonatal tetanus. Materials and methods: Review of 30 consecutive post-neonatal tetanus cases aged 1 months to 12 years admitted to a PICU in north India over a period of 10 years (January 2006 to December 2015). Results: Chronic suppurative otitis media was the commonest portal of entry. All received tetanus toxoid, human tetanus immunoglobulin (HTIG) and appropriate antibiotics; 7 (23.3%) received intrathecal HTIG. Common complications were respiratory failure, rhabdomyolysis, autonomic dysfunction, acute kidney injury and healthcare-associated infections. PICU needs were as follows: ventilation; benzodiazepine, morphine and magnesium sulfate infusion; neuromuscular blockers, inotropes, tracheostomy and renal replacement therapy. Mortality rate was 40%; severity Grade IIIb, autonomic dysfunction, use of vasoactive drugs and those who did not receive intrathecal HTIG were significantly associated with mortality. Conclusion: Post-neonatal tetanus is associated with high mortality, and PICU needs include management of spasms, autonomic dysfunction and complications and cardiorespiratory support.

Clinical Profile and Outcome of Pediatrics Tetanus: The Experience of a Tertiary Hospital in Ethiopia.

BACKGROUND: Tetanus is an acute vaccine preventable illness manifested by neuromuscular dysfunction due to a potent exotoxin, tetanospasmin produced by Clostridium tetani. It is a common health problem in developing countries like Ethiopia. The aim of this study was to assess clinical profile and outcome of Pediatrics tetanus in a referral hospital, South Ethiopia. METHODS: This is a retrospective cross-sectional study of medical records of 24 Pediatric tetanus patients who were admitted from July 2014 to June 2016 to the Pediatrics Department of Hawassa University Comprehensive Specialized Hospital, Hawassa-Ethiopia. Tetanus was diagnosed clinically. Data were entered and analyzed using SPSS statistical software. RESULTS: The median age at diagnosis was 8 years with 19 (79.2%)of the study subjects being males. There were 3 male neonatal tetanus cases with 2 deaths. From post-neonatal cases, only 8(38.1%) were fully vaccinated for infant Expanded Period of Immunization (EPI). Booster vaccination with TT (tetanus toxoid) was only given to 5(29.4%) of discharged patients. Trauma was common in above 5 years of age and documented in 19(79.2%) of patients. All tetanus cases were generalized type with mild, moderate and severe grades comprising 7(29.2%), 8(33.3%), 7(29.2%) and 2(8.3%) respectively. Case fatality rate was 29.2% (7) with more deaths in higher grades. Respiratory failure 6(85.7%), and aspiration pneumonia 1(14.3%) were causes of death. CONCLUSION: In this study, case fatality rate was high. Hence, health promotion with scale-up of EPI for infant tetanus immunization and large scale studies to provide support for booster vaccination schedules are recommended.