[Cardiovascular events in the course of tetanus: a prospective study on 30 cases in the infectious diseases clinic, in the Fann teaching hospital, Dakar]

Tetanus disease and deaths in men reveal need for vaccination

With efforts focused on the elimination of maternal and neonatal tetanus, less attention has been given to tetanus incidence and mortality among men. Since 2007 voluntary medical male circumcision has been scaled-up in 14 sub-Saharan African countries as an effective intervention to reduce the risk of human immunodeficiency virus (HIV) acquisition among men. As part of a review of adverse events from these programmes, we identified 13 cases of tetanus from five countries reported to the World Health Organization (WHO) up to March 2016. Eight patients died and only one patient had a known history of tetanus vaccination. Tetanus after voluntary medical male circumcision was rare among more than 11 million procedures conducted. Nevertheless, the cases prompted a review of the evidence on tetanus vaccination coverage and case notifications in sub-Saharan Africa, supplemented by a literature review of non-neonatal tetanus in Africa over the years 2003–2014. The WHO African Region reported the highest number of non-neonatal tetanus cases per million population and lowest historic coverage of tetanus-toxoid-containing vaccine. Coverage of the third dose of diphtheria–tetanus–polio vaccine ranged from 65% to 98% across the 14 countries in 2013. In hospital-based studies, non-neonatal tetanus comprised 0.3–10.7% of admissions, and a median of 71% of patients were men. The identification of tetanus cases following voluntary medical male circumcision highlights a gender gap in tetanus morbidity disproportionately affecting men. Incorporating tetanus vaccination for boys and men into national programmes should be a priority to align with the goal of universal health coverage.

Maternal and neonatal tetanus

Maternal and neonatal tetanus is still a substantial but preventable cause of mortality in many developing countries. Case fatality from these diseases remains high and treatment is limited by scarcity of resources and effective drug treatments. The Maternal and Neonatal Tetanus Elimination Initiative, launched by WHO and its partners, has made substantial progress in eliminating maternal and neonatal tetanus. Sustained emphasis on improvement of vaccination coverage, birth hygiene, and surveillance, with specific approaches in high-risk areas, has meant that the incidence of the disease continues to fall. Despite this progress, an estimated 58,000 neonates and an unknown number of mothers die every year from tetanus. As of June, 2014, 24 countries are still to eliminate the disease. Maintenance of elimination needs ongoing vaccination programmes and improved public health infrastructure.