Tetanus Toxoid Vaccination Coverage and Associated Factors among Childbearing Women in Ethiopia: A Systematic Review and Meta-Analysis

Determinants of tetanus immunization among pregnant women where tetanus has not been eliminated: a multilevel analysis of 6 countries

Background

Two or more doses of the tetanus toxoid (TT) vaccine in pregnancy afford the fetus passive immunity and reduce neonatal mortality by 96%. In developing nations, the use of TT during pregnancy is still uncommon but presents a serious risk to public health. Thus, the current study aimed to identify determinants of adequate TT immunization among pregnant women in six countries that have not eliminated maternal and neonatal tetanus.

Methods

A cross-sectional study was conducted using recent demographic and health survey datasets from 6 countries that didn't achieve maternal and neonatal tetanus elimination. A total of 84,248 weighted samples were included. A multilevel logistic regression model was fitted. An adjusted odds ratio with a 95% CI and p-value < 0.05 was used to declare significant factors.

Results

Being married [AOR = 1.36, CI: 1.20, 1.54], poorest [AOR = 1.46, CI: 1.36, 1.57], the poorer [AOR = 1.48, CI: 1.39, 1,59], middle [AOR = 1.33, CI: 1.26, 1.42], and the richer [AOR = 1.19, CI: 1.13, 1.26] wealth quintile, giving birth between the ages of 24 and 30 years [AOR = 1.10, CI: 1.04, 1.16], being primiparous [AOR = 1.09; CI: 1.02, 1.17], female house head [AOR = 1.13; CI: 1.06, 1.20], 4 and above antenatal care (ANC) visits [AOR = 5.94, CI: 5.60, 6.30], attending post-natal checkup [AOR = 1.18, CI: 1.13, 1.23], and institutional delivery [AOR = 1.22, CI: 1.18, 1.27] were positively related to adequate TT immunization. While unemployment [AOR = 0.68, CI: 0.66, 0.71], poor health facility visits [AOR = 0.72, CI: 0.70, 0.75], abortion [AOR = 0.89, CI: 0.85, 0.93], low community media exposure [AOR = 0.74, CI: 0.67, 0.81], and rural residence [AOR = 0.80, CI: 0.77, 0.84] were significant risk factors for inadequate TT immunization.

Conclusion

Marital status, wealth index, age at first birth, decision about women's health care, parity, sex of household head, ANC, postnatal checkup, distance to health facility, and health insurance were significant predictors of adequate TT vaccination. Therefore, TT immunization can be improved by promoting maternal employment, improving post-abortion care, media coverage, community literacy, and health accessibility, and encouraging pregnant women to receive ANC and postnatal care.

Sociodemographic Factors Associated With Established and Novel Antenatal Vaccination Uptake in a Cohort of Pregnant Women in Uganda

INTRODUCTION

Vaccination is a key strategy to safeguard the health of pregnant women and newborns. Although vaccine acceptance is often higher in low- and middle-income countries, the COVID-19 pandemic has highlighted increasing vaccine hesitancy. Vaccine hesitancy, specifically in pregnant women, must be understood to increase uptake. We used data from a Ugandan pregnancy registry study to examine sociodemographic factors linked to uptake of vaccines (tetanus toxoid and later COVID-19) in pregnancy.

METHODS

Pregnant women were recruited in Kampala, Uganda, as part of the PREPARE (Prevention of invasive Group B Streptococcus disease in young infants: a pathway for the evaluation & licensure of an investigational maternal GBS vaccine) study from September 1, 2020 until February 24, 2022. Demographic, socioeconomic and obstetric data were collected alongside COVID-19 and tetanus vaccination.

RESULTS

One thousand five hundred sixty-eight participants were included: 151 (10%) were unvaccinated, 11 (1%) received COVID-19 vaccine only, 1230 (78%) received a tetanus vaccine only and 176 (11%) received both. Lower vaccination rates were seen in participants attending fewer than 4 antenatal care episodes (P < 0.001), and those with higher parity (P = 0.036). Higher vaccination rates were seen with a managerial or professional occupation or higher maternal education level, but paternal occupation was not significantly associated with maternal vaccination. Parish vaccination rates varied from 0% to 100%, with 49 (29%) of parishes showing a vaccination rate <90%.

CONCLUSIONS

This study highlights antenatal care as a key route for health promotion, and the stark difference in uptake between new and established antenatal vaccines. Further qualitative studies should investigate effective interventions to establish the safety and benefit of newer maternal vaccines across all demographic groups.

Protective doses of tetanus toxoid immunization and its associated factors among mothers in southern Ethiopia

The World Health Organization recommends tetanus toxoid immunization before or during pregnancy for all women of childbearing age. The goal is to reduce maternal and neonatal mortality due to tetanus. According to the 2016 Ethiopia Demographic and Health Survey (EDHS) report, more than half (51%) of women did not receive protective doses of tetanus immunization. To the best of our knowledge, this study uniquely tried to assess the level of protective doses of tetanus toxoid immunization in southern Ethiopia. A community-based cross-sectional study was conducted among 580 randomly selected participants. Variable with p-value of less than .25 in the bivariate analysis were included in the multivariable logistic regression analysis. Finally, statistical significance was declared at a p-value of less than .05. The proportion of protective doses of tetanus toxoid immunization uptake in the area was found to be 41.9% (95% CI: 38-46%). Being enrolled in formal education [AOR = 6.55, 95% CI: 3.23-9.01], having at least two postnatal care visits [AOR = 3.82; 95% CI: 1.78-6.40], having at least four antenatal care visits [AOR = 2.56; 95% CI: 1.41-4.34], and being visited by Health Extension Workers [AOR = 2.66; 95% CI: 1.42-4.01] were found to be factors enhancing the uptake of protective doses of tetanus toxoid immunization. Generally, the uptake or prevalence of the protective doses of tetanus toxoid immunization in the area was lower than the World Health Organization's target. Therefore, all responsible bodies, including healthcare providers, need to strengthen counseling mothers to enhance the uptake of tetanus toxoid immunization.

Hotspot areas of tetanus-unprotected births and its associated factors in Ethiopia: Spatial analysis of EDHS data

Neonatal tetanus persists as a public health problem in many developing countries including Ethiopia. Maternal tetanus toxoid vaccination is a cornerstone to prevent neonatal tetanus. However, its prevalence is low in Ethiopia, and little has been devoted to its spatial epidemiology and associated factors. Hence, this study aimed to explore the spatial pattern and factors affecting tetanus-unprotected births in Ethiopia. A further analysis of the 2016 Ethiopia Demographic and Health Survey data was conducted, and a weighted sample of 7590 women was used for analysis. Spatial analysis was done using ArcGIS and SaTScan software. A binary logistic regression model was fitted to identify factors and variables with a p-value <.05 were considered as statistically significant. About 54.13% (95% CI: 53.01, 55.25) of births were not protected against neonatal tetanus, and spatial clustering of tetanus unprotected births was observed (Moran's I = 0.144, p-value = .028). The primary and secondary SaTScan clusters were detected in Northeastern Tigray, Eastern Amhara, and almost the entire Afar (RR = 1.34 & LLR = 66.5, p < .01), and in the Somali region, and the western border of Gambela (RR = 1.44 & LLR = 31.3, p < .01), respectively. Tetanus unprotected births were higher among women without formal education (AOR = 1.63; 95% CI: 1.29, 2.04), came from poor households (AOR = 1.27; 95% CI: 1.12, 1.45), who had no ANC contact (AOR = 6.97; 95% CI: 6.21, 7.88), and who were not exposed to the media (AOR = 1.26; 95% CI: 1.09, 1.47). Hence, tetanus-unprotected birth hotspots require priority interventions, and it is good if the targeted interventions consider the identified factors.

Number of tetanus toxoid injections before birth and associated factors among pregnant women in low and middle income countries: Negative binomial poisson regression

BACKGROUND

In low- and middle-income countries where vaccination rates are low, tetanus is still an important threat to public health. Although maternal and neonatal tetanus remains a major global health concern, its magnitude and determinates are not well studied. Therefore, this study aimed to assess the number of tetanus toxoid injections and associated factors among pregnant women in low- and middle-income countries.

METHODS

Data from the most recent Demographic and Health Surveys, which covered 60 low- and middle-income countries from 2010 to 2022, was used for secondary data analysis. The study included a total of 118,704 pregnant women. A statistical software package, STATA 14, was used to analyze the data. A negative binomial regression of a cross-sectional study was carried out. Factors associated with the number of tetanus vaccinations were declared significant at a p-value of < 0.05. The incidence rate ratio and confidence interval were used to interpret the results. A model with the smallest Akaike Information Criterion and Bayesian Information Criterion values and the highest log likelihood was considered the best-fit model for this study.

RESULTS

In low- and middle-income countries, 26.0% of pregnant women took at least two doses of the tetanus toxoid vaccine. Factors such as maternal education, primary (IRR = 1.22, 95% CI: 1.17, 1.26), secondary (IRR = 1.19, 95% CI: 1.15, 1.23), higher (IRR = 1.16, 95% CI: 1.12, 1.20), employment (IRR = 1.11, 95% CI: 1.09, 1.13), 1-3 ANC visits (IRR = 2.49, 95% CI: 2.41, 2.57), ≥4 visits (IRR = 2.94, 95% CI: 2.84, 3.03), wealth index (IRR = 1.06; 95% CI: 11.04, 1.08), ≥birth order (IRR = 1.04, 95% CI: 1.02, 1.27), distance to health facility (IRR = 1.02, 95% CI: 1.00, 1.03), and health insurance coverage (IRR = 1.08; 95% CI: 1.06, 1.10) had a significant association with the number of tetanus vaccinations among pregnant women.

CONCLUSIONS AND RECOMMENDATIONS

This study concludes that the number of tetanus toxoid vaccinations among pregnant women in low- and middle-income countries is low. In the negative binomial model, the frequency of tetanus vaccinations has a significant association with maternal employment, educational status, wealth index, antenatal care visits, birth order, distance from a health facility, and health insurance. Therefore, the ministries of health in low and middle-income countries should give attention to those women who had no antenatal care visits and women from poor wealth quantiles while designing policies and strategies.

Uptake of protective tetanus toxoid vaccine doses and maternal associated factors during pregnancy in armed conflict zone, hospital-based cross-sectional study

Background

Vaccinating pregnant women with tetanus toxoid (TT) is crucial to prevent neonatal tetanus, reducing related deaths by 94%. In conflict zones with restricted access to deliveries, neonates face a fatality rate of 80%-100%. This study explores the uptake of protective TT vaccine doses and maternal associated factors during pregnancy in an armed conflict zone.

Methods

A hospital-based, descriptive, cross-sectional study was conducted of 357 pregnant women at delivery using simple random sampling. Data were collected through interviews with a structured questionnaire, and entered using Epi-data version 3.1, and exported using SPSS version 22 for further analysis. Binary and multivariable logistic regression analyses were used to identify significant variables for receiving protective TT doses during pregnancy at P < 0.05.

Result

In this study, 355 pregnant women were included, with response rate of 99.4%. The mean age of the participants was 27.65 ± 6.23 years. During the study period, 67.3% of pregnant women received a protective TT vaccine dose while 33.3% were missed due to escalated armed conflict. The dropout rates were significant from TT5 to TT2 (17.6%), TT5 to TT3 (11.9%), and TT5 to TT4 (6.1%). However, maternal associated factors for the uptake of the TT protective vaccine dose were identified, including being aged 36-49 years [adjusted odds ratio (AOR) = 3.7; 95% confidence interval (CI) 1.54-7.8; P = 0.001], completing high school (AOR = 3.05; 95% CI 1.5-8.9; P = 0.02), having an antenatal care follow-up (AOR = 9.4; 95% CI 2.9-24.3; P = 0.001), previous media exposure (AOR = 15.5; 95% CI 7.5-25.3; P = 0.001), and good maternal knowledge (AOR = 2.7; 95% CI 1.8-4.9; P = 0.02).

Conclusion

The uptake of the protective TT vaccine dose among pregnant women in a continued armed conflict area was low compared with previous study findings. Efforts should be made to increase vaccine uptake and reduce dropout rates by addressing both community and individual-level factors.

Prevalence and factors associated with rural mothers' protection against tetanus: a cross-national analysis in 33 sub-Saharan African countries

BACKGROUND

Sub-Saharan Africa (SSA) and South Asia account for most new cases of tetanus. Despite efforts by the World Health Organization to eradicate tetanus, it still causes many maternal mortalities. We examined the prevalence and risk factors associated with tetanus protection among rural mothers in 33 SSA countries.

METHODS

Data were extracted from the most recent Demographic and Health Surveys of 33 SSA countries. A sample of 162 601 women from rural areas was drawn. Both descriptive and binary logistic regression analyses were conducted.

RESULTS

Overall, approximately half (49.3%) of rural mothers were protected against tetanus. The association between maternal age, education, marital status, working status, distance to the health facility and number of antenatal visits were statistically significant with rural mothers' protection from tetanus. Also, relationship to the household head, household size and frequency of listening to radio, reading a newspaper and watching television were statistically significant in predicting rural mothers' protection from tetanus.

CONCLUSIONS

Policies and interventions by stakeholders must target high-risk populations, including adult women, those of poorer wealth status, those without media exposure and mothers with low educational attainment.

Prevalence and determinants of two or more doses of tetanus toxoid-containing vaccine immunization among pregnant women in sub-Saharan Africa: Evidence from recent demographic and health survey data

INTRODUCTION

Tetanus is a major public health problem in low and middle income countries including in sub-Saharan Africa. Tetanus toxoid vaccine immunization during pregnancy is a global strategy against mortality due to maternal and neonatal tetanus. Recent data on tetanus toxoid-containing vaccination during pregnancy provides insight to policymakers for better implementation of the vaccine. Hence, this study aimed to determine prevalence and determinants of immunization with tetanus toxoid containing vaccine among pregnant women in sub-Saharan Africa.

METHODS

Secondary analysis of the recent demographic and health survey data was done using a sample of 173,032 pregnant women. Stata 14 statistical software was used for analysis and multilevel logistic regression model was applied to determine associated factors of two or more tetanus toxoid-containing vaccine immunization. P-value less than 0.05 for adjusted odds ratio was used to identify factors significantly associated with the outcome.

RESULT

The prevalence of immunization with two and more doses of tetanus toxoid-containing vaccine in sub-Saharan Africa was found to be 49.8 %. Women's age 36-49, women's education, poor household wealth index, unwanted pregnancy, women's occupation, husband education, and community illiteracy were significantly associated with two or more doses of tetanus toxoid-containing vaccine immunization in sub-Saharan Africa.

CONCLUSION

In sub-Saharan Africa, less than half of pregnant women were immunized with two or more doses of tetanus toxoid-containing vaccine. Women's education and women's employment positively affected immunization with two or more doses of tetanus toxoid-containing vaccine. Women's age group of 36-49 years, unwanted pregnancy, poor household wealth index, husbands having no formal education, and community illiteracy negatively affected receipt of two or more doses of tetanus toxoid-containing vaccine. Therefore, policymakers should take into account the determinants of tetanus toxoid immunization throughout its implementation so as to boost the coverage of tetanus toxoid immunization in sub-Saharan Africa.

Spatial distribution and associated factors of poor tetanus toxoid immunization among pregnant women in Ethiopia: spatial and multilevel analysis

Background

Neonatal mortality from tetanus can be reduced by 94% when pregnant women receive at least two doses of tetanus toxoid. In Ethiopia, immunization programs are suboptimal despite their importance. Therefore, the aim of this study was to examine the geographic distribution and associated factors of poor tetanus toxoid (TT) immunization among pregnant women in Ethiopia.

Methods

Secondary data analysis was used using the 2016 Ethiopian Demographic and Health Survey (EDHS). ArcGIS version 10.8 statistical software was used to explore the spatial distribution of poor TT immunization and SaTScan version 9.6 software was used to identify significant hotspot areas of poor TT immunization. For associated factors, a multilevel binary logistic regression model was fitted using STATA version 14 software. In the multivariable multilevel analysis, adjusted OR (AOR) with 95% CI was reported to reveal significantly associated factors of poor TT immunization.

Result

In Ethiopia, the spatial distribution of poor tetanus toxoid immunization was clustered with Global Moran's I = 0.59 at p-value of <0.0001. The highest poor TT immunization clusters were observed in the East and South Tigray, the central part of Amhara, West Afar, East Somali, and West Gambella. Pregnant women with no Antenatal care (ANC) visits [Adjusted Odds Ratio (aOR) = 10.46, 95% CI: (8.82, 12.41))], pregnant women with 1-3 ANC visits [aOR = 1.51, 95% CI: (1.31, 1.73)], media exposure [aOR = 1.45, 95% CI: (1.26, 1.67)], poor wealth index [aOR = 1.22; 95% CI: (1.03, 1.45)], middle wealth index [aOR = 1.23; 95% CI: (1.03, 1.47)], family planning use [aOR = 1.28; 95% CI: (1.11, 1.57)] and community level education [aOR = 1.43, 95% CI: (1.14, 1.80)] were significantly associated with poor tetanus toxoid immunization.

Conclusion

Poor tetanus toxoid immunization among pregnant women varies in Ethiopia. It was highest in East and South Tigray, the central part of Amhara, West Afar, East Somali, and West Gambella. Therefore, public health programs should design targeted interventions in identified hot spots to improve tetanus toxoid immunization. Health programmers should be promoting optimal ANC visits, women's education, and family planning use.

Predictors of Tetanus Vaccine Uptake among Pregnant Women in Khartoum State, Sudan: A Hospital-Based Cross-Sectional Study

Tetanus toxoid (TT) vaccination during pregnancy has been proven as an effective preventative measure to reduce the incidence of maternal and neonatal morbidity and mortality worldwide. This study aimed to assess the determinants of TT vaccine uptake among pregnant women at two public maternity specialized hospitals in Sudan. A hospital-based cross-sectional study was conducted at two public hospitals, Omdurman Maternity Hospital and Al Saudi Hospital in Omdurman, Khartoum State, in Sudan from February to April 2020. Logistic regression analysis was carried out to identify factors associated with receiving three or more doses of the TT vaccine among pregnant women, presented as odds ratios, with p-values < 0.05 considered significant (at a 95% confidence interval). The study recruited 350 pregnant women, with 313 participants included in the analysis. This study found that only 40% of the pregnant women had received three doses or more of the TT vaccine. Pregnant women who attended Al Saudi Hospital were less likely to be vaccinated with the recommended dose of the TT vaccine in districts at high risk (received ≥3 doses) compared to those who attended Omdurman Hospital [OR = 0.49 (95% C.I. 0.29-0.82), p-value < 0.05]. Furthermore, the number of children at home was a significant predictor of the mothers' immunization status as those with five children or more were ten times more likely to be vaccinated with three doses or more [OR = 10.54 (95% C.I. 4.30-25.86), p-value < 0.05]. We conclude that this low rate of TT vaccine uptake found in this study among pregnant women increases the number of newborn babies susceptible to contracting neonatal tetanus. The findings of this study should be considered in the development of communication strategies targeting and prioritizing at-risk groups to increase TT vaccine uptake among pregnant women in Sudan.

Assessment of tetanus Immunization among healthcare workers in Mogadishu, Somalia

Tetanus is still a major problem in sub-Saharan African countries. This study aims to evaluate tetanus disease and vaccine awareness among healthcare workers in Mogadishu. This descriptive, cross-sectional study was scheduled for January 2-7, 2022. A questionnaire consisting of 28 questions was applied in a face-to-face manner to 418 healthcare workers. Only health workers aged≥18 living in Mogadishu were included. Questions about sociodemographic characteristics, tetanus disease, and vaccines were developed. 71.1% of the participants were female, 72% were ˂25 years old, 42.6% were nursing students, and 63.2% had a university education. It was observed that 46.9% of the volunteers had an income level of <$250, and 60.8% resided in the city center. 50.5% of the participants received a tetanus vaccine in their childhood. Questions to determine participants' level of knowledge about tetanus and the tetanus vaccine were responded to with an accuracy of between 44 and 77%. Although 38.5% of the participants reported that they were exposed to trauma at least once a day, the rate of those who had three or more doses of the vaccine was only 10.8%. On the other hand, 51.4% reported that they had received training about tetanus and vaccination. There was a significant difference (p < .001) in terms of knowledge level among sociodemographic characteristics. The fear of side effects was the most important reason for not being vaccinated. Healthcare workers in Mogadishu have little awareness of tetanus disease and vaccines. Efforts to improve education and other factors will be sufficient to eliminate the disadvantage brought about by the socio-demographic structure.

High-Throughput IgG Epitope Mapping of Tetanus Neurotoxin: Implications for Immunotherapy and Vaccine Design

Tetanus is an acute, fatal disease caused by exotoxins released from Clostridium tetani during infections. A protective humoral immune response can be induced by vaccinations with pediatric and booster combinatorial vaccines that contain inactivated tetanus neurotoxin (TeNT) as a major antigen. Although some epitopes in TeNT have been described using various approaches, a comprehensive list of its antigenic determinants that are involved with immunity has not been elucidated. To this end, a high-resolution analysis of the linear B-cell epitopes in TeNT was performed using antibodies generated in vaccinated children. Two hundred sixty-four peptides that cover the entire coding sequence of the TeNT protein were prepared in situ on a cellulose membrane through SPOT synthesis and probed with sera from children vaccinated (ChVS) with a triple DTP-vaccine to map continuous B-cell epitopes, which were further characterized and validated using immunoassays. Forty-four IgG epitopes were identified. Four (TT-215-218) were chemically synthesized as multiple antigen peptides (MAPs) and used in peptide ELISAs to screen post-pandemic DTP vaccinations. The assay displayed a high performance with high sensitivity (99.99%) and specificity (100%). The complete map of linear IgG epitopes induced by vaccination with inactivated TeNT highlights three key epitopes involved in the efficacy of the vaccine. Antibodies against epitope TT-8/G can block enzymatic activity, and those against epitopes TT-41/G and TT-43/G can interfere with TeNT binding to neuronal cell receptors. We further show that four of the epitopes identified can be employed in peptide ELISAs to assess vaccine coverage. Overall, the data suggest a set of select epitopes to engineer new, directed vaccines.