Neonatal Tetanus in Burkina Faso

Frederic W. Nikiema, MD, Msc
Direction Régionale l’Ouest, Institut de Recherche en Sciences de la Sante
Bobo-Dioulasso, Burkina Faso

Introduction

Neonatal tetanus (NT), a brutal and preventable killer, continues to cast a long shadow over newborns in Burkina Faso. Despite significant global progress towards the elimination of Maternal and Neonatal Tetanus (MNT), defined as less than one NT case per 1000 live births annually at the district level, this agonizing disease remains a stark reality in many regions, including Burkina Faso. While official reports from areas like Bobo Dioulasso may show periods without cases, serological investigations reveal a more nuanced and concerning picture: pockets of vulnerability persist, threatening the hard-won gains and demanding renewed, targeted action.

The scope of the problem: a preventable tragedy

Tetanus, caused by the toxin of Clostridium tetani spores ubiquitous in the environment, is not transmitted person-to-person but enters through wounds, notably the unhealed umbilical stump of newborns born to non-immune mothers. Neonatal tetanus manifests as an inability to suck, rigidity, and painful spasms within the first 28 days of life. Even with intensive care, case fatality rates approach 100% without medical intervention. Globally, NT deaths have plummeted from an estimated 787,000 in 1988 to around 25,000 in 2018, a testament to the power of vaccination and clean delivery practices. However, this progress is uneven. In Burkina Faso, NT historically accounted for about half of all reported tetanus deaths, underscoring its disproportionate burden on the nation’s infants. The Centers for Disease Control and Prevention (CDC) estimate over 270,000 NT deaths occur annually worldwide (deaths that are almost entirely preventable).

Why does NT persist in Burkina Faso? unpacking the challenges

The path to NT elimination hinges on two pillars: high tetanus toxoid-containing vaccine (TTCV) coverage among women of childbearing age (especially pregnant women) and ensuring clean delivery and cord care practices. Burkina Faso, like many resource-limited settings, faces formidable challenges on both fronts:

1. Low and inequitable TTCV coverage: achieving and sustaining high vaccination coverage is complex. Barriers include:

• Limited access to Prenatal Care (PNC): many women, particularly in rural areas, have limited access to or utilize PNC services consistently. Without regular PNC contact, receiving the recommended 2+ doses of TTCV during pregnancy becomes difficult.
• Low maternal literacy: as highlighted in the recent Bobo Dioulasso serosurvey (74% illiteracy rate among participants), low education levels correlate with lower health-seeking behaviour and understanding of vaccine importance, impacting PNC attendance and vaccine acceptance.
• Inconsistent vaccination schedules: the study revealed a critical issue: while many women received multiple TTCV doses over successive pregnancies, these doses were often not administered according to the WHO-recommended schedule (e.g., adequate spacing between doses). This ad-hoc approach, driven by reliance on pregnancy as the main point of contact rather than a structured life-course immunization plan, significantly compromises the development and longevity of protective immunity. The research found no significant correlation between the total number of lifetime doses received and current antibody levels, emphasizing that timing and schedule adherence are paramount.
• Weak record keeping: inadequate vaccination records make it difficult to determine a woman’s immune status and ensure she receives the correct number of doses at the right intervals.

2. Suboptimal delivery and cord care practices: despite efforts, unhygienic deliveries, sometimes attended by untrained birth attendants or family members using non-sterile instruments to cut the cord, persist. Contaminated materials used on the umbilical stump remain a significant risk factor.
3. Health System Constraints: weak health infrastructure, shortages of skilled birth attendants, inadequate supply chains for vaccines and sterile delivery kits, and logistical challenges in reaching remote populations compound the difficulties.

The serosurvey: illuminating immunity gaps

The serological investigation conducted in Bobo Dioulasso provides valuable insights beyond simple case reporting. Testing paired maternal and cord blood samples revealed:

1. Generally good immunity: the geometric mean titer (GMT) was 3.69 IU/mL in mothers and 3.76 IU/mL in newborns, indicating that most women receiving some vaccination during pregnancy achieved levels considered protective (>0.51 IU/mL by the ELISA test used).
2. Strong correlation: a highly significant correlation (Spearman’s coefficient=0.86) between maternal and neonatal antibody levels confirmed efficient transplacental transfer in this healthy cohort.
3. Alarming vulnerabilities: crucially, 7% of mothers and 8% of newborns had no detectable tetanus antibodies. These infants were utterly unprotected in their most vulnerable period. Analysis of these cases pointed towards key risk factors: maternal illiteracy and, most significantly, failure to receive any TTCV doses during the current pregnancy (5/7 seronegative mothers received zero doses). One protected newborn was born to a mother with a very low titer (1 IU/mL).
4. The dose and schedule imperative: the study confirmed that receiving TTCV doses during the current pregnancy was moderately correlated with higher antibody levels (Spearman’s coefficient=0.3). However, it starkly highlighted that simply accumulating doses over multiple pregnancies without adhering to the recommended schedule does not guarantee sustained, high-level protection. The number of doses received in the specific current pregnancy was the stronger predictor than the total lifetime doses.

The way forward: precision interventions for elimination

The persistence of non-immune mothers and newborns, even amidst overall reasonable GMTs, signals that Burkina Faso’s MNT elimination strategy needs refinement. Elimination is a binary target: one unprotected infant is one too many. Building on current efforts, here are key recommendations:

1. Strengthen lifelong TTCV immunization: Move beyond relying solely on pregnancy for vaccination. Integrate TTCV into routine adolescent and adult women’s health services. Ensure girls completing childhood vaccination receive adolescent boosters. Implement a robust system to track TTCV doses throughout a woman’s life, using durable, portable records. Vaccination during pregnancy should focus on completing schedules or providing boosters based on documented prior history, not just giving doses indiscriminately at every pregnancy contact.
2. Targeted outreach for zero-dose mothers: Identify and actively reach women who miss PNC or vaccinations during pregnancy. Community health workers are vital for tracing, educating, and facilitating access. The serosurvey clearly identifies these women as the highest risk group for delivering unprotected newborns.
3. Enhanced health education: Develop culturally appropriate, simple messaging (using local languages and concepts) addressing illiteracy barriers. Focus on the importance of at least two correctly timed TTCV doses in each pregnancy, clean delivery, and hygienic cord care. Engage communities, men, and traditional leaders.
4. Invest in clean births: Scale up training and deployment of skilled birth attendants. Ensure consistent availability of sterile delivery kits (including clean blades and cord clamps) at all delivery points, including homes. Promote facility births where possible.
5. Robust surveillance and seromonitoring: Continue and strengthen NT case surveillance. Supplement clinical reporting with periodic serosurveys like the one in Bobo Dioulasso to identify immunity gaps at the sub-national or district level, allowing for micro-targeting of SIAs or outreach programs.
6. Leverage existing platforms: Integrate TTCV promotion and delivery into other high-contact maternal and child health programs (e.g., malaria IPTp distribution, nutrition programs, family planning).

Conclusion

Neonatal tetanus in Burkina Faso is not a mystery; it is a failure of access, systems, and sometimes, implementation precision. The tragedy lies in its preventability. The study, we conducted, shines a light on the critical gap: women slipping through the net and receiving no vaccine during their pregnancy, leaving their newborns defenseless. While commendable progress has been made, true elimination demands moving beyond aggregate coverage figures. It requires a relentless focus on finding every at-risk woman, ensuring she receives at least two properly spaced TTCV doses in each pregnancy based on her lifelong immunization record, and guaranteeing a clean birth for her child. By refining strategies to address these specific vulnerabilities with precision and sustained commitment, Burkina Faso can finally consign neonatal tetanus to the history books, ensuring every child has the chance to survive and thrive free from this devastating disease. The shadow can be lifted.

Sourced from:

Frederic Nikiema, Serge Yerbanga, Aminata Fofana, Fabrice Some, Zachari Kabre, Jean-Bosco Ouedraogo. Immunization against tetanus during pregnancy: Serological investigation for maternal and neonatal antibodies in west region of Burkina Faso, Bobo Dioulasso. 65^th Annual Meeting of the American Society of Tropical Medicine and Hyigiene (ASTMH), Atlanta, Georgia, 2019, poster #464, doi: 10.13140/RG.2.2.34828.51843.