Protecting adolescent girls against tetanusBMJ 1995; 311 doi: https://doi.org/10.1136/bmj.311.6997.73 (Published 08 July 1995) Cite this as: BMJ 1995;311:73
- Loretta Brabin,
- Julia Kemp,
- Sheila M Maxwell,
- John Ikimalo,
- Orikomaba K Obunge,
- Nimi D Briggs
- Senior lecturer in women's health Senior research fellow Liverpool School of Tropical Medicine, Liverpool L3 5QA
- Senior lecturer in biochemistry John Moores University, Liverpool L3 5UX
- Consultant obstetrician Senior registrar in microbiology Professor in obstetrics University of Port Harcourt, Port Harcourt, Nigeria
- Loretta Brabin and Julia Kemp are supported by the Overseas Development Administration.
Would save many lives in the developing world
Time and again tetanus has been described as a neglected disease.1 An estimated 8 million babies and 2 million children and adults may die from tetanus during the 1990s, mostly in developing countries--despite the World Health Organisation's call to eliminate the disease by this year. Vaccination to prevent post-abortal and maternal tetanus has been largely ignored. The primary aim of prevention programmes has been to eliminate neonatal tetanus2; the two commonest prevention programmes--immunisation of preschool children and of pregnant women--have omitted adolescent girls.
Fauveau and colleagues collected data on 1101 cases of maternal tetanus in developing countries published between 1958 and 1990: 27% were attributed to post abortal and 67% to post partum sepsis.3 One third of all cases described were from Nigeria, which has a high rate of induced abortion, many of them performed under septic conditions. In a population based study in south east Nigeria, which found high rates of reported abortion,4 we also found that a high proportion of girls were seronegative for antibodies to tetanus--so that they were at a high risk of infection (unpublished observation).
Ekanem et al report that many unvaccinated pregnant women are young and single, and lack of money is cited as the main reason why they do not register at health centres when pregnant. This shows the negative effect of incorporating tetanus vaccination with prenatal services for which fees are charged.5 Vaccinating adolescent girls would therefore reduce tetanus related maternal deaths in Nigeria and could have a similar impact in other places where abortion rates are high and tetanus vaccination coverage is low.
Current monitoring is ineffective
The World Health Organisation is now promoting vaccination of all women of childbearing age by screening a woman's tetanus toxoid vaccine status at every contact with the health services,6 but this approach says little about adolescents. Most developing countries still administer tetanus toxoid only to pregnant women and since WHO's policy is delivered through health facilities, adolescents will be poorly covered because most are not regular attenders. Paradoxically, the success of a policy to vaccinate women of child bearing age can only be established by immunisation records or serological studies that show high levels of immunity in adolescent girls.6 Monitoring systems are currently ineffective, however, and virtually no information exists on coverage of the female adolescent population (A Galazka, personal communication).
A strategy expressly targeting girls would be feasible in some countries. It would require five properly spaced injections and would most likely provide protection from tetanus for life.1 7 Even four doses of tetanus may protect for as long as 20 years, and if delivered at the end of primary school would certainly protect during adolescence and possibly beyond. In developing countries the proportion of children, including girls, attending primary schools is growing. Analysis of statistics collected by Unicef shows that in many of the countries with high death rates in children under 5, the proportion of pregnant women who have been vaccinated is low.8
A school health service delivering a programme of tetanus vaccination may be a feasible route for improving coverage of adolescent girls who otherwise may not be vaccinated during pregnancy. There are other advantages to immunising schoolgirls, including the opportunity to raise health consciousness at an early age and to encourage the use of personal vaccination records. School based delivery of health interventions is currently of great interest and, in developing countries, could be combined with distribution of vitamin A and anthelmintics. In this regard, some evidence exists that giving vitamin A at the time of tetanus vaccination significantly improves the response to vaccine.9
Recently it has been suggested that a late dose of an acellular pertussis vaccine and a second dose of measles vaccine should be given towards the end of childhood or in adolescence--to reduce the pool of susceptible girls and to protect future infants.10 In developed countries, such reasoning has led to the targeting of adolescents for rubella vaccination.
Vaccinating adolescent girls against tetanus could bring about substantial long term gains. Implementation will require an assessment of the proportion of girls who can be reached in schools or who can be called in to local schools on vaccination days. High risk areas, perhaps based on reported abortion rates, could be targeted.11 Young women should be strongly urged to acquire an immunisation card, high potency primary vaccination and tetanus boosters must be free, while a system to monitor antibody responses among girls needs to be in place.