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  1. 1

    Diphtheria, pertussis, and tetanus vaccination [letter]

    Cutts FT; Begg N

    Lancet. 1992 May 30; 339(8805):1355-6.

    Researchers compared the immune responses of infants vaccinated at 2, 3, and 4 months of age with the diphtheria-pertussis-tetanus (DPT) conjugate vaccine with those of infants vaccinated at 3, 5, and 9 month intervals. The antibody titer for pertussis was the same for both the old and new schedules. Further, no reliable immunological correlates of protection existed for pertussis. Different batches of DPT vaccine and maternal antibodies may have accounted for the variation in immune responses. No one measured maternal antibodies in the infants in the 3, 5, and 9 month group, though. The protective level of antitoxin for tetanus and diphtheria (0.01 neutralizing units/ml) cannot be applied to ELISA assays, since the relationship between the 2 assays is inadequate at levels less than 0.1 IU/ml. 1964 research of 9 injection schedules showed that when infants received the first dose at 3 months rather than later, or when the intervals were 1 month long instead of 2 months, diphtheria and tetanus antitoxin titers were lower 2 weeks after series completion. Therefore, clinical researchers should do lengthy longitudinal studies of infants vaccinated at 2, 3, and 4 months before the clinicians can actually determine the persistence of immunity to school entry. The UK Public Health Laboratory Service is doing a longitudinal study of early and long term antibody responses to the new schedules. In fact, the accelerated vaccination schedule has improved coverage during the first year of life. 20-30% of pertussis cases are less than 6 months old in developing countries. WHO's Expanded Programme on Immunization encourages health workers to begin vaccine series as early in life as possible and to keep the intervals as short as possible. Even though no primary series of 3 doses of DPT protects an infant for a lifetime, health workers should achieve high coverage with early doses and shorter intervals. WHO already advocates giving women of reproductive age in developing countries 5 doses of tetanus toxoid to reduce neonatal deaths.
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  2. 2

    Neonatal tetanus: strategies for disease control.

    Frank DL

    [Unpublished] 1987 Apr 30. [4], 53 p.

    Neonatal tetanus, caused by the toxin of Clostridium tetani, is transmitted via unclean instruments used to cut the umbilical cord or contaminated dressings applied to the stump. The symptoms are inability to suck, trismus, convulsions, and (in 80-90% of cases) death on the 7th or 8th day. In the US between 1982 and 1984 only 2 cases of neonatal tetanus were reported; in the developing world an estimated 800,000 infants die of neonatal tetanus every year. The survey methodology used to determine the neonatal tetanus death rate was a 2-stage sampling method, known as the Expanded Program on Immunization 30 cluster sampling method, followed by questionnaires. Such surveys contain a certain amount of built-in bias due both to fact that the final selection of households is never completely random and that retrospectively gathered information is subject to recall bias. The surveys indicated that neonatal tetanus incidence was highest in rural areas, especially where animals were present; in the slums of cities; among families with many children; where mothers received no prenatal care; and where birth attendants were untrained. The best preventive strategy against neonatal tetanus is provided through immunization of the mother with tetanus toxoid, since the antibodies cross the placenta and protect the infant through the neonatal period. Unfortunately, the tetanus vaccination program lags at least 30% behind other World Health Organization Expanded Program on Immunization coverage. The World Health Organization recommends an initial immunization with .01 antitoxin International Units per milliliter of serum, a 2nd dose 4 weeks later (at least 2 weeks before delivery) and booster doses on each successive pregnancy up to 5; the 5th booster provides lifetime protection. Immunization should also be carried out among nonpregnant women of childbearing age and children. The World Health Organization has proposed that neonatal tetanus be made a reportable disease, which should be combatted by prenatal immunization of mothers and training of traditional birth attendants. Between 60% and 80% of all births in developing countries are attended by traditional birth attendants, but, except in China, the training of traditional birth attendants has not contributed as much to reduction of neonatal tetanus as has immunization. Alternative strategies for carrying out tetanus immunization programs include integrating them into prenatal clinics, schools, family planning programs, maternal food distribution programs, well-baby care centers, mass campaigns (especially in urban areas), and mobile team outreach strategies in rural areas. Tetanus immunization could also be linked to other Expanded Program on Immunization programs even though these are mainly targeted at children rather than mothers and other women of childbearing age. Indonesia initiated a tetanus immunization program in 1977 and a traditional birth attendant training program with assistance from the UN Childrens Fund in 1978. However, 3 neonatal tetanus surveys, conducted in 19 provinces, the city of Jakarta, and Java, estimated the total number of deaths/year from neonatal tetanus as 71,150--a neonatal tetanus mortality rate of 11/1000. 3 provincial level studies, also using the Expanded Program on Immunization 30 cluster sampling method, in Nusa Tenggara Barat, West Sumatra Province, and Daerah Istemewah Aceh revealed neonatal tetanus mortality rates of 8.3/1000, 18.5/1000, and 8.4/1000 respectively. In the Health portion of Indonesia's 4th 5-year plan (Pelita IV), the 1st priority is given to reducing the neonatal death rate of 93/1000 live births; the 7th priority is reduction of mortality due to neonatal tetanus by ensuring adequate immunization as part of routine health services and by requiring 2 tetanus immunizations of all women applying for a marriage certificate.
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