RATIONALE FOR SURVEILLANCE
Targeted for elimination (9GPW). The 3 primary strategies towards this goal are:
1. High tetanus toxoid (TT) coverage of pregnant women.
2. Clean delivery.
3. Identification of high risk areas and implementation of corrective action(immunization of childbearing-age women) in these areas.
Epidemiological surveillance is particularly useful in order to identify high risk areas and monitor the impact of interventions.
RECOMMENDED CASE DEFINITION
Clinical case definition and case classification
Suspected case: Any neonatal death between 3-28 days of age in which the cause of death is unknown; or any neonate reported as having suffered from neonatal tetanus between 3-28 days of age and not investigated.
Confirmed case: Any neonate with a normal ability to suck and cry during the first two days of life, and who between 3 and 28 days of age cannot suck normally, and becomes stiff or has convulsions (i.e. jerking of the muscles) or both. Hospital-reported cases of neonatal tetanus are considered confirmed.
The diagnosis is purely clinical and does not depend upon laboratory or bacteriological confirmation.
RECOMMENDED TYPES OF SURVEILLANCE
The number of confirmed neonatal tetanus cases must be included in routine monthly surveillance reports of all countries and reported as a separate item from other (non-neonatal) tetanus. Zero reporting is required at all levels.
Active surveillance in major health facilities on a regular basis (at least once a year).
In "low risk" geographical areas (incidence < 1/1000 live births with effective surveillance), all suspect cases should be investigated to confirm the case and identify the cause.
Community surveillance in "silent" areas (i.e. where routine reporting is not functional but where, based on other indicators, neonatal tetanus could be a problem).
RECOMMENDED MINIMUM DATA ELEMENTS
Aggregated data for reporting
• Number of cases
• Doses of TT administered to pregnant women or women of child-bearing age (depending on national policy) or percentage of newborns protected at birth (PAB); see Special Aspects
• Completeness/timeliness of monthly reports
Case-based data, individual patient records for investigation
• Unique identifier
• Geographical information
• Date of birth
• Age (in days) of infant at onset
• Sex of infant
• Parity of mother (total number of deliveries including current delivery or pregnancy)
• Date of case investigation
• Type of birth: 1 = institution; 2 = home with trained attendant
• 3 = home with untrained attendant; 4 = home without attendant; 5 = other; 9 = unknown
• Tetanus immunization status of mother when she gave birth: 1 = up-to-date; 2 = not up-to-date; 3 = unimmunized; 9 = unknown
• Final classification: 1 = confirmed; 2 = suspected; 3 = discarded
• Mother given protective TT dose within 3 months of report: 1 = yes; 2 = no; 9 = unknown
• Supplemental immunization conducted within same locality as case: 1 = yes; 2 = no; 9 = unknown
RECOMMENDED DATA ANALYSES, PRESENTATION. REPORTS
For aggregated data (i.e. routine monthly reporting)
• Incidence rate per 1000 live births by geographic area, month, and year
• TT2+ (or %PAB*) by year and geographic area
• Completeness/timeliness of monthly reporting
• Geographical areas considered at high risk for neonatal tetanus compared to those where corrective actions were taken
* See Special Aspects
For case based data (case investigations only) same as for aggregated data plus
• Confirmed neonatal tetanus cases by delivery type, sex, TT2+ status of mother
• % of confirmed cases for which the mother later received a protective TT dose
PRINCIPAL USES OF DATA FOR DECISION-MAKING
• Monitor progress towards achieving and sustaining high routine TT2+ (or PAB) coverage in all geographical areas
• Monitor progress towards eliminating neonatal tetanus in every geographical area
• Investigate suspect neonatal tetanus cases in areas not considered at risk for neonatal tetanus to confirm and determine cause
• Identify high risk geographical areas and conduct 3 rounds of supplemental TT immunization in those areas
• Periodically validate sensitivity of neonatal tetanus reporting and surveillance by comparing the number of reported cases with the number of cases identified through active surveillance
"% PAB (Protected at Birth)" is an alternative method of determining coverage (particularly where TT2+ is unreliable). To monitor this, health workers record during DTP1 visits whether the infant was protected at birth by the mother's TT status and/or delivery status (clean/unclean). % PAB is then estimated from the ratio of infants protected/number of live births. If the child was unprotected, the mother should receive a dose of tetanus toxoid during the same visit and should be followed up with a subsequent TT dose for protection.
See Regional Communicable Disease contacts on section "Communicable disease contacts in Regional Offices".
Headquarters: 20 Avenue Appia, CH-1211 Geneva 27, Switzerland
Vaccines and Other Biologicals (VAB)/Expanded Programme on Immunization (EPI)
E-mail: email@example.com / Surveillancekit@who.ch
Tel: (4122) 791 4693/4417/2111
Fax: 791 4193 attn EPI