Cambodia Between 2000 and 2010, over 1.3 million (more than 70%) women of childbearing age residing in 52 of the country s 77 operational districts and working in more than 400 factories received at least three doses of tetanus toxoid (TT). The National Immunization Programme (NIP) has also strengthened tetanus immunization of childbearing and pregnant women through the routine EPI. One of the specific approaches is village registers, initiated in over 20 of the 77 operational districts. The tetanus toxoid register enables health centre staff and village health volunteers to follow-up with eligible women on their next vaccination date and encourage them to come to the health center or join outreach sessions. At the same time the National Reproductive Health Programme (NRHP) is achieving improvements in overall maternal health delivery in Cambodia with 71% of deliveries attended by skilled birth attendants according to the 2010 Demographic Health Survey, encouraged by incentives for deliveries at health centers. A technical working group for maternal and child health (MCH) under the programme is also looking into aspects of MNT elimination including strengthening outreach and monitoring, involvement of health centre staff, dealing with practices of traditional birth attendants and providing adequate training and equipment. Cambodia has regularly conducted joint reviews with UNICEF, WHO and other partners of district level progress towards the national goal of MNT elimination, using a set of core and surrogate indicators and relevant local conditions and information. Documentation of each assessment is compared with the subsequent one. The most recent national risk assessment in late 2009 had identified four operational districts still at high risk for MNT, 15 at medium risk and the remaining 58 districts at low risk. 3 Health workers meeting community members to discuss MNT
While TT supplementary immunization activities (SIAs) were planned for the high risk districts, actions required in the medium risk districts were further identified at a workshop in July 2010, attended by provincial health directors, district EPI and MCH managers, national EPI managers, international agencies and nongovernmental organizations (NGOs) involved in delivery of immunization and MCH services. Each operational district classified their health centers further according to risk. Among the 175 health centers, 21% were regarded as high risk, 26% as medium risk and 53% as low risk. In addition to targeting almost 150,000 women of childbearing age for TT SIAs in the four high risk operational districts and appropriate activities in medium risk districts to increase immunity levels, neonatal tetanus surveillance is to be strengthened (including case response based on community investigation) and the protection at birth (PAB) indicator will be expanded to the whole country for programme monitoring. Delivery at a health center Proper cord care 4
China The Chinese government s commitment is to achieve the MNT elimination goal by 2010. This target date was set and addressed in the National Programme on Children s Development in China for 2001-2010, endorsed by the State Council. Accordingly, the Safe Motherhood Programme has been carried out since 2000, lead by the Ministry of Health (MOH), the National Working Committee on Children and Women and the Ministry of Finance. The programme has been expanded from 378 national poverty counties (rural areas) in 12 provinces in 2000 to 2,297 counties in 23 provinces by 2009. Increased clean and hospital delivery, as a high public health priority and the main strategy to achieve the MNT elimination goal in China, has resulted in a large decrease in numbers of neonatal tetanus cases. The reported clean delivery rate and hospital delivery rate at national level improved in 2009 to 99% and 96% respectively. These two strategies have been integrated into rural health system reform as a long-term plan to achieving and maintaining MNT elimination. In terms of promoting hospital delivery, the programme provides 300-400 RMB (approximately US$ 45-60) as subsidy to the mother to pay for the delivery costs in hospitals in poor areas. This subsidy can, most of the time, fully cover the costs for a delivery at township hospitals and 50% 70% of cost at county hospitals. In remote mountainous areas, a fast green channel is being established targeting every mother, by providing transportation to improve hospital access. In terms of promoting clean delivery, free delivery kits are provided to health facilities for births still taking place at home. Various trainings are provided to MCH staff and traditional birth attendants (TBAs) and untrained TBAs are gradually being replaced by trained health staff. Supportive supervision monitors clean delivery practices through on-site field visits and meetings with staff concerned. The fast green channel 5
Regional activities As one of EPI s global mandates, MNT elimination featured high on the agenda of the 19th meeting of the Technical Advisory Group on Immunization and Vaccine Preventable Diseases (TAG). The TAG noted the continued momentum in the remaining countries to achieve MNT elimination in the near future and was impressed with the variety of activities being implemented as well as the close collaboration between EPI and MCH programmes. In this context the TAG reiterated its 2009 recommendation that all countries concerned continue their efforts to reach the elimination goal in the near future and strongly encouraged all partners and political decision makers to ensure the necessary priority, support and resources to complete the work. NIPs should, particularly once TT SIAs have been conducted, strengthen neonatal tetanus surveillance to support risk assessment and validation claims. Characteristics of quality neonatal tetanus surveillance include timely investigation of all neonatal tetanus cases, relevant neonatal deaths (e.g. occurring within 3-28 days), regular data and performance analysis, validating areas with under-reporting or absence of reporting, and taking corrective actions based on surveillance findings. TT vaccination in Cambodia A child receiving vitamin A during TT SIA / Child Health Day in Laos The TAG also recommended that where applicable, countries should regularly review their plans to maintain elimination status, including optimizing immunization schedules (e.g. shift from TT vaccination of pregnant women to providing childhood and/or adolescent booster doses) and conducting periodic district level risk assessment with WHO and UNICEF participation as appropriate. As part of continued cross-regional collaboration between the WHO offices for the Western Pacific (WPRO) and South East Asia (SEARO), WPRO participated in the validation of MNT elimination in Java, Indonesia, in July/August 2010 and WHO EPI China in the validation of MNT elimination in Myanmar in May 2010. MNTE validation survey in Java, Indonesia After NIP staff from Cambodia had participated in the validation of risk assessment in the Philippines in 2009, inter-country collaboration continued with the Philippine National EPI Manager participating in the TT SIA monitoring in the Lao People s Democratic Republic in 2010. 10 10
Conclusions While recently MNT elimination efforts in the Region got increased attention, there remains the risk that the programme receives relatively lower focus within EPI due to the competing priorities of measles elimination, hepatitis B control, new vaccine introduction etc. As global targets have repeatedly been missed, these arbitrarily set time goals may have to be revisited and a stronger understanding developed that MNT elimination is about reaching women that are usually unreached and thus offering opportunities for comprehensive health service delivery (EPI, MCH). Frequently, a strong focus remains on TT SIAs while it needs to be realized that the elimination approach coupled with meaningful investments in strengthening routine immunization will achieve the most significant results and benefits in the long term. The SIA approach alone would most likely result in a rapid decrease in the number of cases and deaths attributable to MNT but not be sustainable; mortality could quickly revert within a short period of time. Focusing on routine immunization alone would result in very slow progress in high risk areas as lack of access to routine services (due to various reasons, often beyond the control of routine EPI) is a key factor of risk. While integrated active surveillance systems are recommended for neonatal tetanus, polio (AFP) and measles (rash and fever), neonatal tetanus surveillance remains weakest; with often incomplete and untimely case investigation and limited systematic response based on the surveillance findings. Fully immunized during TT SIAs As this progress report of country activities documents, there are several complementary approaches to increase immunization coverage and utilization of other health interventions to eliminate MNT in various settings. Strong partnerships, collaboration between different health programmes, sensible use of data to assess risk and progress towards the goal and information guiding interventions are key. We need to remember that while neonatal tetanus is highly preventable, babies still die from it every minute of the day. And too many children are still left motherless each year by the women who die from maternal tetanus and other pregnancy related causes. MNT elimination does not only aim for a specific disease control target but, more importantly, strengthens access of women to health care services and subsequently better development opportunities. 11 11