Process of neonatal tetanus elimination in Nepal.
BACKGROUND
In late 2005, Nepal demonstrated through surveys that it had reached the World Health Organization criterion for having eliminated neonatal tetanus (NT), i.e. NT cases occurred at a rate of less than 1 per 1000 live births in every district. This paper summarizes how a combination of strategies contributed to this success.


METHODS
For each of the 4 strategies (clean delivery, routine immunization, supplemental immunization campaigns, and surveillance) activities before and after 2000 are described and achievements are summarized using published and unpublished data.


RESULTS
Through routine immunization of pregnant women with tetanus toxoid (TT), NT cases had decreased substantially by 1999, but the final push was provided through the national TT supplemental immunization activities in 2000-2004, which raised the proportion of children protected at birth against tetanus to above 80%. Fewer than 20% of deliveries take place with trained assistance. Although NT surveillance has improved since the extensive Acute Flaccid Paralysis/Polio surveillance infrastructure in Nepal was made available for the NT elimination initiative, it is likely that a number of cases still occur without being reported, particularly in rural areas.


CONCLUSIONS
NT elimination was achieved in 2005 in Nepal, but activities must continue and be strengthened to ensure that NT incidence will not increase in the future. The introduction and further expansion of school-based immunization will, in combination with diphtheria-tetanus-pertussis vaccine given in infancy, reduce the need for future cohorts of childbearing age women to be immunized at every pregnancy. However, booster doses will still need to be given in early adulthood to ensure ongoing protection.
Vandelaer
Jos
J
UNICEF, Health Section, Geneva, Switzerland. vandelaerj@who.int
Partridge
Jeffrey
J
Suvedi
Bal Krishna
BK
D000293:Adolescent; D000328:Adult; D003017:Clostridium tetani / Q000276:immunology; D005260:Female; D006801:Humans; D017589:Immunization Programs / Q000458:organization & administration*; D007226:Infant Mortality; D007231:Infant, Newborn; D009390:Nepal / Q000453:epidemiology; D011159:Population Surveillance; D011247:Pregnancy; D011634:Public Health; D013742:Tetanus / Q000453:epidemiology / Q000517:prevention & control*; D013745:Tetanus Toxoid; D055815:Young Adult
D013745:Tetanus Toxoid