Re-Enforcing Tetanus Toxoid Containing Vaccine Booster Doses Among Males — A Policy Brief

Summary

Tetanus is a nervous system disorder characterized by muscle spasms caused by toxin producing anaerobe Clostridium tetani found in the soil. The efforts worldwide towards the goal of elimination of maternal and neonatal tetanus has reduced tetanus incidence and mortality in those groups through vaccination during pregnancy and clean delivery and cord-care practices. However, adolescent and adult men seem to have been largely missed by vaccination programmes, as implementation of the World Health Organisation (WHO) recommended fourth to sixth doses of tetanus vaccine to adolescents and adults has been limited

Investigation into tetanus cases identified through voluntary medical male circumcision programmes and an analysis of available global data highlighted a gender gap in tetanus morbidity that excessively affects men. Uganda provides a 3-dose primary series of penta-valent vaccine containing tetanus toxoid (TT) to infant boys and girls through routine immunization services at 6, 10, and 14 weeks of age. Furthermore, Uganda is one of many countries in the African Region that does not yet offer six shots of tetanus vaccine to everybody.

About 80% of infants in Uganda get the first three tetanus vaccine shots, and women are additionally offered the vaccine during pregnancy for protection of mothers and newborns during birth; but older children and men do not get the booster shots. Although Uganda validated the elimination of maternal and neonatal tetanus (MNTE) in 2011 it reports one of the highest rates of Non- neonatal tetanus (Non-NT) in the world.

National and district surveillance staff report weekly, verify and investigate cases of NT using a standard case-investigation form as part of Uganda case-based surveillance system while Non-NT is not. A cross- sectional descriptive analysis of tetanus data from 2012-2016 indicated an incidence of 10/100,000 population with Non-NT contributing the highest proportion[1]. More so, an evaluation of the Tetanus surveillance system revealed 3665 (85%) of the cases as males. We recommend a national policy regarding introduction of tetanus toxoid containing vaccine (TT) booster doses into routine immunization program for both sexes with much emphasis to the males to provide equitable tetanus protection throughout the life-course.

Background

Tetanus is a nervous system disorder characterized by muscle spasms caused by toxin producing anaerobe Clostridium Tetani found in the soil. Tetanus can be life-threatening without treatment with approximately 10-20 percent of the case patients being fatalities [2]. Persons that suffer from tetanus are managed as medical emergencies that require treatment in a modern hospital with intensive care equipment. Fortunately, tetanus is preventable through the use of a vaccine. However this vaccine is not protective for a lifetime, but booster doses are needed to ensure immunity [2]. Because of the easy availability of the vaccine, tetanus is rare in the United States and more common in other countries that don’t yet have strong immunization pro- grams like Sub-saharan Africa.

Through the Expanded Program on Immunization, a 3-dose primary series of penta-valent vaccine containing tetanus toxoid (TT) is provided to infants through routine immunization services at 6, 10, and 14 weeks of age [3]. Uganda does not provide the 3 WHO recommended booster doses of TT at ages 12–23 months, 4–7 years, and 9–15 years. To prevent and maintain maternal and neonatal tetanus elimination (MNTE), up to five doses of TT are provided to women of reproductive age (WRA) [3]. While neonatal tetanus (NT) is reported as a notifiable dis- ease with a standard case definition through the Integrated Disease Surveillance and Response (IDSR) weekly system, Non-NT is not. National and district surveillance staff verify and investigate cases of NT using a standard case-investigation form as part of a case-based surveillance system while Non-NT is not.

Extent of the Problem

Mortality attributed to tetanus is an important public health concern. In developing countries, tetanus is the major cause of death in newborns, and it may still cause death among adults in developed countries as well [4]. Tetanus is completely preventable by active or passive immunization, the best form being ac

tive immunization with tetanus toxoid. Similar to most low- and middle-income countries, the underlying tetanus burden in Uganda may be higher than published as Non-NT tetanus is not reportable on weekly basis as a priority condition [1].

Uganda provides a 3-dose primary series of penta-valent vac- cine containing tetanus toxoid (TT) to infant boys and girls through routine immunization services at 6, 10, and 14 weeks of age [3].

Investigation into tetanus cases identified through voluntary medical male circumcision programmes and an analysis of available global data highlighted a gender gap in tetanus mor- bidity that excessively affects men [5]. The occurrence of teta- nus following voluntary medical male circumcision was rare with fewer cases reported from programmes that have conduct- ed safe procedures. Although Uganda validated MNTE in 2011, the country reports one of the highest rates of non-neonatal tetanus globally [1, 5].

Furthermore, Uganda is one of many countries in the African Region that does not yet offer six shots of tetanus vaccine to everybody. About 80% of infants in Uganda get the first three tetanus vaccine shots, and women are additionally offered the vaccine during pregnancy for protection of mothers and new-borns during birth; but older children and men do not get the booster shots [3].

A cross-sectional descriptive analysis of surveillance tetanus data from 2012-2016 indicated an annual incidence of 10/100,000 population with Non-NT contributing the highest proportion. High mortalities over 50% were noted among the males. More so, an evaluation of the Tetanus surveillance system in Uganda revealed 3665 (85%) of the cases as males. Morbidity and mortality ascribed to tetanus still remains high despite being preventable using affordable and accessible public health measures.

Passive immunization with human tetanus globulin (TIG) shortens the course of tetanus and may lessen its severity. A dose of 500 U may be as effective, Therapeutic TIG (3,000-6,000 units as 1 dose) is also recommended for generalized tetanus. Other treatment measures include ventilator support, high calorie nutritional support and pharmacological agents that treat muscle spasms, rigidity, tetanic seizures and infections. However modern facilities offering such services are very expensive and unaffordable to most of the rural population in Uganda. Several deaths can be averted if the males are given TT during the course of adolescence age to maturity.

Critique of Current Policy

A 3-dose primary series of penta-valent (TT) is provided to infants through routine immunization services in Uganda at 6, 10, and 14 weeks of age [3]. Uganda does not provide the 3 WHO- recommended booster doses of TT at ages 12–23 months, 4–7 years, and 9–15 years. To prevent and maintain MNTE, up to five doses of TT are provided to WRA [3]. There are no opportunities for males to receive TT during their childhood as they grow to maturity.

The efforts worldwide towards the goal of elimination of maternal and neonatal tetanus has reduced tetanus incidence and mortality in those groups through vaccination during pregnancy and clean delivery and cord-care practices. However, adolescent and adult men seem to have been largely missed by vaccination programmes, as implementation of the WHO recommended fourth to sixth doses of tetanus vaccine to adolescents and adults has been limited [6].

Some studies have documented few tetanus cases reported by voluntary medical male circumcision programmes with a known his tory of tetanus vaccination[5]. Less attention, however, has been given to the immunization of males after infancy. This could also probably explain the high morbidity and mortality rates due to Non-NT reported among the males

Conclusion

Eradicating tetanus is very possible and achievable in our com- munities using cost effective public health measures like vaccinations and therefore it is regarded as one of the simplest and most cost effective way to reduce mortality rates attributed to tetanus.

Recommendations 

The government needs to re-focus the implementation of (National Immunization Policy, 2009) and also scale up TT vaccination for male children and adults. Additionally, there is need for male adult vaccination programs to educate the community on health education on the importance and benefits of TT in or- der to increase its acceptance, appreciation and utilization.

References

1. Nanteza, , et al., The burden of tetanus in Uganda. SpringerPlus, 2016. 5(1): p. 705.

2. Control, C.f.D. and Prevention, Vaccine preventable deaths and the Global Immunization Vision and Strategy, 2006-2015. Morbidity and mortality weekly report, 2006. 55(18): p. 511.
3. WHO, , WHO vaccine-preventable diseases monitoring system. Global summary. WHO/IVB/2007, 2007.
4. Yuan, , et al., Diphtheria and tetanus immunity among blood donors in Toronto. Canadian Medical Association Journal, 1997. 156(7): p. 985-990.
5. Dalal, , et al., Tetanus disease and deaths in men reveal need for vaccination. Bulletin of the World Health Organization, 2016. 94(8): p. 613.

6. Thwaites, C. and H. Loan, Eradication of tetanus. British medical bulletin, 2015. 116(1): 69.