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Update on Maternal and Neonatal
Tetanus Elimination Programme
Strategic Advisory Group of Experts on Immunization
(SAGE) Meeting
Geneva, 19 October 2016
Azhar A Raza, UNICEF HQ
1
Presentation outline
Definition & Strategies to attain MNT elimination
Achievements and successes
Lessons learnt and success factors
Country Experience
Current targets and needs!
Status of remaining 18 countries
Critical challenges
Innovative approaches
2
MNT Elimination
Defined as:
Less than one Neonatal Tetanus (NT) case per 1000 live
births in a year in every district of a country.
If NT is eliminated,
maternal tetanus (MT) is also considered eliminated.
3
Strategies to attain MNTE
Immunization with TTCV
o Pregnant women during routine immunization
o All women of reproductive age (WRA) in high
risk districts through SIAs
Clean delivery & cord care practices
o Clean hands, birthing surface & cutting tools
o Clean cord care
NT surveillance
o As part of Integrated Disease Surveillance &
Response (IDSR)
4
More than 75% reduction in NT mortality
since 2000
5
20
0,0
00
18
0,0
00
12
8,0
00
[VA
LUE]
58
,00
0
49
,00
0
62 62
61
63
61
59 65
70 74
70
68
71 75 66
66
69
0
10
20
30
40
50
60
70
80
90
100
-
50,000
100,000
150,000
200,000
250,000
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Reported TT2+ coverage & estimated NT deaths 2000-2015
Neonatal Tetanus Deaths TT2+ (%)
TT 2+ C
ove
rage (p
erce
ntage
) Es
tim
ate
d n
um
be
r o
f N
T D
eat
hs
Source: WHO vaccine-preventable disease monitoring system, 2016 global summary
More than 150 million WRA received > 2 doses
of TTCV
6
8 14 23
39 45 57 62 69 76
100 112 116 119 123
134 144 148
151
1 3
5
9 11
15 17
19 21
27
30 33 34
37
39
43 44 41
-
50
100
150
200
250
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Wo
me
n o
f R
ep
rod
uc
tive
Ag
e (
WR
A)
(Mil
lio
ns
)
WRA Protected by SIAs WRA targeted but not protected with SIAs
Source: WHO database as of September 2016
Gradual increase in women delivering with assistance of Skilled Birth Attendants
7
94
66
83
69
29 36 36
56
98 93 94
80
49 49 54
75
-
20
40
60
80
100
CEE/CIS EAPR LACR MENA South Asia ESAR WCAR World
Skilled Birth Attendants Trends by region 2000-2015 (%)
2000 2015
Inequities among regions
Source; SOWC 2016
CEE/CIS - Central and Eastern Europe and the Commonwealth of Independent States EAPR - East Asia and the Pacific
LACR - Latin America and Caribbean MENA - Middle East and North Africa
South Asia ESAR - Eastern and Southern Africa WCAR - West and Central Africa
Low ANC4 Coverage and High ANC1-4 dropout
in South Asian and African Region
8
96 95 96
85
69
80 76
85 85 82 87
63
42 45 52
58
-
20
40
60
80
100
CEE/CIS EAPR LACR MENA South Asia ESAR WCAR World
ANC1-ANC4 coverage by region 2015 (%)
ANC1 ANC4
Source; SOWC 2016
CEE/CIS - Central and Eastern Europe and the Commonwealth of Independent States EAPR - East Asia and the Pacific
LACR - Latin America and Caribbean MENA - Middle East and North Africa
South Asia ESAR - Eastern and Southern Africa WCAR - West and Central Africa
41 Countries eliminated MNT between 2000 & Sept 2016 *(Plus Ethiopia except Somali region, and 16 out of 17 regions in Philippines)
Source: WHO/UNICEF Database
Date of slide : 08June 2016
Map production: Immunization Vaccines and
Biologicals, (IVB), World Health Organization
The boundaries and names shown and the designations used on this map do not imply the
expression of any opinion whatsoever on the part of the World Health Organization
concerning the legal status of any country, territory, city or area or of its authorities, or
concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent
approximate border lines for which there may not yet be full agreement.
WHO 2016. All rights reserved
not eliminated
eliminated before 2000
eliminated from 2000- Sept 2016
not applicable
countries yet to eliminate MNT18
1999
2016
6 countries achieved MNT elimination
without any TT SIA !
9
MNT Risk in most of the remaining countries
is narrowed down to few districts (High Risk)
high risk
no risk
medium risk
MNT eliminated
District level elimination status of MNT in the remaining 18 priority countries
Source: WHO/UNICEF Database
Date of slide : 08June 2016
Map production: Immunization Vaccines and
Biologicals, (IVB), World Health Organization
The boundaries and names shown and the designations used on this map do not imply the
expression of any opinion whatsoever on the part of the World Health Organization
concerning the legal status of any country, territory, city or area or of its authorities, or
concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent
approximate border lines for which there may not yet be full agreement.
WHO 2016. All rights reserved
10
Other achievements
• TT Uniject – discussions with manufacturers and donors in
progress 50 million devices needed over 4 years for 18 million WRA
Obtainable!
• Guidelines on sustaining MNTE being finalized in the light of
inputs from SAGE WG members with key focus on: Sustaining high TT2+/PAB coverage
Integration with ANC platform
Opportunities for delivering booster doses of TTCV
Strengthening NT Surveillance
11
Lessons learnt; the success factors
National commitment, ownership and engagement
Timely availability of resources proved critical
Good planning and detailed micro-planning for SIAs ensured quality
implementation
Early and active community engagement in all elimination activities,
but especially TTCV SIA – necessary to avoid rumours
Strong monitoring & supervision of implementation
Strength of the health system for integrated delivery of ANC & EPI
services.
12
Country Experience
Papua New Guinea Risk status of provinces & districts assessed
Prioritization made on areas of focus
Haiti Risk status of departments & communes assessed – all found to be at
low risk
Validation survey initiated – suspended due to Hurricane Matthew
DRC Only 11 out of 517 health zones at high risk
Field assessment for surveillance & TT coverage planned
Monthly review of progress by ICC
South Sudan All planned activities completed (2012-16)
Last round in remaining 3 states – end of 2016
13
Country Experience (2)
China, Eritrea, Namibia, Rwanda, South Africa, Zimbabwe Achieved MNTE without any SIAs
India Validated in 2015
More than 90% reduction in NT case load (~200,000 in 1980 to 11,600
in 2013 – CHERG)
Major investments on safe delivery – financial incentives for institutional
delivery; communication and community mobilizations (ASHAs)
Indonesia Validated in 2016
Key focus on school based tetanus immunization
Regular TTCV boosters – 18m, 1st grade, 2nd grade and 3rd / 5th grade
Nationwide school vaccination campaign - every November
14
Current targets and needs!
18 countries yet to eliminate MNT, 2/3rd of them in Africa
Vaccinate ~70 million WRA with 3 doses of TTCV
Need innovative approaches for ~18 million (27%) of these WRA
that are repeatedly unreached with conventional service delivery
Need US$ 148 million to accomplish the task - including US$ 50
million for TT Uniject
15
Current Status of remaining 18 countries
Conducting last phase of activities & likely to be validated in 2016
(2 countries) - Ethiopia, Haiti(?)
Completing planned activities by end of 2016 for validation in
2017 (7 countries)
o Angola, Chad, DRC, Guinea, Kenya, Philippines, South Sudan
Completing planned activities by end of 2017 for validation in
2018 (3 countries) - PNG, Somalia, Sudan
Mix of low commitment & insecurity requiring advocacy and
appropriate technology for validation by end 2020 (6 countries)
o Afghanistan, CAR, Mali, Nigeria, Pakistan, Yemen
16
Critical challenges
Gap of 98 million US$ to support TT SIAs in high risk areas –
the areas unreached by current health services
Additional 50 million US$ for TT Uniject required to protect 18
million WRA in the hardest to reach areas in 9 countries
(geographical, security & HR constraints)
Ineffective integration of RMNCH and EPI platforms to optimize
maternal immunization
Ineffective communication to prevent and respond to TT vaccine
controversy - for instance Kenya 2014
17
Critical challenges (2)
Insecurity - war and armed conflict – (AFG, CAR, MAL, NIE, PAK, SOM, SUD, SSU, YEM)
Competing activities with limited capacity at national
and subnational levels
Voluntary medical male circumcision for HIV
prevention has exposed tetanus immunity gap in males
18
Innovations to reach ~40% of target WRA in 9/18
countries that are persistently inaccessible
19
1,921,066
-
1,852,455
15,969,450
20,113,077
324,670
3,176,539
1,677,350
3,094,937
29,917,234
1,036,210
987,104
1,234,970
4,530,550
5,290,764
1,231,692
903,490
934,239
2,063,292
18,212,310
0% 20% 40% 60% 80% 100%
Afghanistan (35%)
Central African Republic (100%)
Chad** (40%)
Nigeria (22%)
Pakistan (21%)
Somalia (80%)
Sudan (22%)
Sudan South** (40%)
Yemen (40%)
TOTAL
Accessible target Estimated inaccessible target
TT
Uniject
$3,110,391 $2,962,990
$1,235,670
$13,599,351
$15,881,284
$3,697,170 $2,712,007
$934,768
$6,193,382
$-
$2,000,000
$4,000,000
$6,000,000
$8,000,000
$10,000,000
$12,000,000
$14,000,000
$16,000,000
Afghanistan(35%)
CentralAfrican
Republic(100%)
Chad** (40%) Nigeria (22%) Pakistan(21%)
Somalia(80%)
Sudan (22%) SudanSouth** (40%)
Yemen (40%)
Financial needs to deliver TT Uniject US$
Additional cost of devices
Innovation (TT Uniject) - additional US$ 50 million
needed to reach 18 million WRA
20
Thank you
21
Source: WHO/UNICEF MNTE Database, as at 03 October 2016 For 2016, data is provisional. Date of slide 3 October 2016
Trend in women of reproductive age targeted with TT SIAs
Kiwanis joined P&G + doubling of amount
$62 mil GAVI IFFIm
$26 mil BMGF
8.7 7.4
11.5
20.0
8.3
16.4
6.6
9.0 8.7
30.3
15.6
7.1
4.0
5.9
12.9
14.6
4.9 3.4
0
5
10
15
20
25
30
35
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Wo
me
n o
f re
pro
du
ctiv
e ag
e (W
RA
) (M
illio
ns)
22
More than 90% reduction in NT mortality since 1990
23
1,270,000
787,000
580,000 490,000
248,000 200,000
180,000 128,000 59,000
58,000 49,000 9
16 15 19
21 22 26
29
37
41
55 57 56 55
59 57 58 57
62 59
62 62 61 63
61 59
65
70 74
70 68
71 75
66 66
0
10
20
30
40
50
60
70
80
90
100
-
200,000
400,000
600,000
800,000
1,000,000
1,200,000
1,400,000
Reported TT2+ coverage & Estimated NT Deaths 1980-2015
Est NT Deaths TT2+ (%)WHO-UNICEF Database
TT
2+
Co
ve
rag
e (p
erc
en
tage)
Nu
mb
er
NT
Dea
ths
NT
Eli
min
ati
on
MN
TE
MNTE Validation Surveys – progress & possible timeline
24
Colour of cells indicate the country situation as at 8 June 2016
Validated
Not validated yet/Tentative validation timeline
A ng o la
36* 30 25 C ha d
40 Ug a nda Burkina Fas o Co te dÍvo ire Ethio pia C o ng o D R
Indo nes ia (part) Indo nes ia (part) G. Bis s au Iraq 24 21 Ha it i Guine a N ig e ria
50 48 Co ngo Mo zambique Ethio pia (part) Timo r Les te India (part) India (part) Cambo diaP a kis ta n
(pa rt)Ke nya P N G M a li ® C A R
55# 54 Nepal Egypt 47 Turkey Indo nes ia (part) Ghana Ta nza nia Gabo n India (part) India Eq Guinea M a li ® (pa rt)N ig e ria
(pa rt)
N ig e ria
(pa rt)P a kis ta n
57 56 M a la wi Eritrea 53 To go 50 Za m bia Banglades h B urundi Myammar Liberia Camero o n Lao s P DR Madagas car ® Mauritania Indo nes ia P hilippine sP a kis ta n
(pa rt)
P a kis ta n
(pa rt)Ye m e n
Zimbabwe Namibia So uth Africa India (part) Rwanda Vie tnam India (part) India (part) India (part) Co mo ro s Benin Senegal China Sierra Leo ne ® India (part) P hilippines (part) Niger S o uth S uda n S o m a lia S uda n A fg ha nis ta n
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
# - with the independence of T imor Leste the number of countries increased by one
* - with the independence of South Sudan the number of countries increased by one
2016-17 list is tentative and actual implementation will depend on the outcome of indepths data review
Not validated yet/Confirmed validation timeline
43 .