Immunization against tetanus reduces mother & child deaths in Bangladesh

 

Bangladesh reduces neonatal tetanus death rates by 90%

In Bangladesh, where most women still do not have access to a clean birth or skilled birth attendant, death rates for neonatal tetanus have been reduced by over 90% in just over a decade. Government commitment and support from a range of partnerships have led to a massive increase in tetanus toxoid immunization coverage among women of childbearing age, ensuring that both mothers and babies are protected against tetanus infection.

During 1998, about 215 000 babies worldwide died from neonatal tetanus infections. The disease strikes during the first few days or weeks of life when babies are most vulnerable to infection. Their short and painful lives often go unrecorded -- neither the birth nor death officially registered. Infection usually starts because the umbilical cord stump has been exposed to dirt containing tetanus spores -- through dirty hands or the use of a soiled implement to cut the cord.

Neonatal tetanus has been eliminated today in over 100 countries -- through ensuring that women are immunized with tetanus toxoid during pregnancy and that they have access to a safe birth. The aim is twofold: to protect women against tetanus infection during pregnancy -- which today accounts for 30 000 deaths worldwide -- and to ensure that mothers pass this immunity to their unborn child. In this way, babies are protected against tetanus during the first two months of life, up to the age when they themselves can be immunized against the disease. Tetanus toxoid is one of the cheapest, safest, and most effective vaccines. It costs about US$ 1.20 on average to protect a mother and her newborn babies against tetanus infection -- a sum that includes the purchase and delivery costs of three doses of vaccine as well as efforts to promote clean births. Yet in some of the poorest countries in the world less than one in three women of childbearing age have been immunized.

In Bangladesh, one of the world's least developed countries, over 80% of women give birth without any help from a skilled birth attendant. Most deliveries take place at home, often in conditions of very poor hygiene -- placing the lives of both mother and child at risk. An added problem in Bangladesh, especially in rural areas, is the traditional practice of using home-made ghee (clarified butter) to "heal" the umbilical stump. Yet despite this unpromising start to life, death rates for neonatal tetanus in newborn babies have been reduced by over 90% in Bangladesh in little more than a decade.

The turnaround is the result of mass immunization campaigns to protect women of childbearing age against tetanus infection. Nationwide efforts to increase coverage with tetanus toxoid vaccine have boosted immunization rates from 5% in 1986 to 86% by 1998.

In the mid-1980s, Bangladesh had one of the highest rates of neonatal tetanus in the world: 41 cases for every 1000 live births. Only 5% of women of childbearing age were immunized with tetanus toxoid and only 5% of pregnant women had access to a clean birth. Not surprisingly, neonatal tetanus accounted for one in four infant deaths.

In the mid-1980s, Bangladesh had one of the highest rates of neonatal tetanus in the world: 41 cases for every 1000 live births. Only 5% of women of childbearing age were immunized with tetanus toxoid and only 5% of pregnant women had access to a clean birth. Not surprisingly, neonatal tetanus accounted for one in four infant deaths. Since then, the Bangladesh Government has orchestrated a nationwide effort to immunize all women of childbearing age with tetanus toxoid. With support from a consortium of partners including UNICEF, USAID, and WHO, thousands of vaccinators have been trained and a cold chain system established to ensure the safe storage and transport of vaccine. Vaccinators have used every means of transport at their disposal -- including rickshaws, boats, and bikes -- to ensure that supplies of vaccine are available even in the remotest areas. In the early 1990s, there were fears that progress would be stalled when an inspection of local manufacture of tetanus toxoid revealed that the vaccine was sub-potent. The government responded by temporarily increasing imports of tetanus toxoid from outside suppliers and overhauled local vaccine production with support from the Finnish Government -- ensuring that local production conformed to good manufacturing practices. A survey carried out two years later revealed that neonatal deaths rates were still on a downward trend.

Today, Bangladesh has succeeded in reducing death rates from 41 for every 1000 live births in 1986 to only 4 per 1000 by 1998. And in a final push to reach the WHO global target for elimination of neonatal tetanus -- less than one neonatal tetanus death per 1000 live births in every district in every country -- the focus has now switched to women in the highest-risk areas. In the latest round of this campaign in August 2000, up to 3 million women were targeted in high-risk areas. Contingency plans to use boats to reach and vaccinate women in areas cut off by the seasonal monsoon weather were not needed when the women regrouped to settle temporarily on dry land, making mass immunization a lot easier.

Even when the elimination target has been reached in Bangladesh, routine immunization and disease surveillance will have to continue, together with efforts to promote safe births. Unlike polio, maternal and neonatal tetanus can never be eradicated since the tetanus spores that cause the disease will persist in the environment.