Vaccination during pregnancy is a cost-effective strategy to improve pregnancy outcome. In this report by Sade Oguntola, experts say that taking at least two doses of tetanus toxoid vaccine during pregnancy also increases child survival from neonatal tetanus.
Though pregnancy is mostly about pampering and happiness, it is also a time for the woman to be extremely cautious. With so many changes happening inside the woman’s body, there are always chances of contracting a disease like tetanus that may prove harmful both to the mother and her unborn baby.
Tetanus is a life-threatening bacterial infection caused by Clostridium tetani, during pregnancy. Unfortunately, the infection can be transmitted to the unborn baby and can be life-threatening for both the mother and the baby.
Anything from light scratch on the skin to a deep wound caused by a bite, burn and cut can aid the germ’s penetration into the skin. Once the germ enters into the skin, it produces a toxin known as tetanospasmin in the bloodstream. It thus attacks the nervous system and can lead to death if not treated on time.
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Vaccines for pregnant women are very important. Study after study has shown us how important this is. Although the tetanus toxoid vaccination has contributed significantly to the dramatic reduction of the incidence of tetanus, the disease remains a public health problem worldwide.
Now, a significant number of pregnant women die every year due to tetanus, most of these deaths occuring in Africa, East and southern Asia. The World Health Organisation (WHO) reported that globally 49,000 newborns died of this disease in 2013 alone.
Newborns can be successfully protected against tetanus by vaccinating women with tetanus toxoid, howbeit, the coverage rate of vaccination with this vaccine proved to be affected by knowledge, attitude and practice of women about antenatal tetanus toxoid vaccine.
Despite high levels of perception of the effectiveness and safety of tetanus immunisation, a cross-sectional study among 254 pregnant women attending the antenatal clinic of Specialist Hospital, Sokoto, still reported low levels of perception and utilisation of the protective doses of the vaccine.
In 2018, researchers in the Journal of Drug Delivery & Therapeutics indicated that only about half (51.1 per cent) of them believed that it protects both mother and newborn baby from tetanus.
Majority of respondents considered tetanus toxoid immunisation to be effective in protecting against tetanus infection (73.3 per cent) and also safe for both mother and baby (79.2 per cent).
About two-thirds of respondents (68.8 per cent) had the misconception that a single dose of totanos toxoid (TT) immunisation protects from tetanus infection. Less than a quarter of respondents (23.6 per cent) had received two or more doses of the vaccine.
The main barriers to utilisation of vaccines were lack of awareness of the vaccine (41.8 per cent), not being aware of its benefits (36.7 per cent), and fear of side effects (21.5 per cent).
Howbeit, Professor Dosu Ojengbede, a consultant obstetrics and gynaecologist, University College Hospital (UCH), Ibadan, Oyo State, stated that in Nigeria, tetanus is still a common cause of death in newborns as well as morbidity and death in mothers who have not been protected.
According to him, even if a woman is delivered in an unhygienic area where she is exposed to the germ that causes tetanus, she will be protected because she had taken doses of tetanus toxoid vaccine during pregnancy.
Professor Ojengbede added that the antibodies against tetanus that the woman develops because of the TT vaccination are passed to her new baby through her breast milk.
According to him, “this is why immunising the mother protects the mother and through the mother protects the baby as well through the neonatal period.
“That is why we encourage women in pregnancy to get immunised against tetanus and every facility running antenatal services should provide tetanus toxoid vaccination.
“They should also encourage mothers to start to breastfeed early and exclusively to ensure that their babies get colostrum, the first part of the milk that comes out after delivery. It is slightly creamish in colour. It contains antibody against tetanus that can protect the new baby from tetanus for some time.”
Tetanus is an extremely deadly infection that is harmful to new-born babies. This mostly occurs due to the use of unsterilised cutting instruments and unhealed umbilical cord stumps.
New-borns are affected because they do not have any immunity of their own. Tetanus spores are ubiquitous in the environment and eradication is not biologically feasible.
Professor Ojengbede expressed concern that immunisation coverage for tetanus is going down.
“We are beginning to see more casualty both in mothers and the newborn that we cannot even quantify. When many of them develop convulsion, people think that it is epilepsy; some may even take it as eclampsia.
“Some will not get to the hospital until they die. That is really the problem because convulsion can kill within a short time, especially severe tetanus.
“Because they were convulsing all the time, they may bleed into their brain. They will not be able to breathe oxygen and perfuse the body. So many of these cases that people say she just delivered and she started convulsing after three or four days may be tetanus. It may not be eclampsia or epilepsy.”
He stated that since there is a preventive strategy for tetanus, government should ensure that women and their families are educated on what to expect when they go for antenatal clinics.
“When we say go for antenatal clinic, we should also tell them what their own take home should be. For instance, we should let them know that she will be given this injection twice.
“But when you do not know what the benefits that should accrue to you from attending ‘that the antenatal clinic,’ as they would put it, the dividend of attending the antenatal clinic may not come.”
TT vaccination has been widely used for over 40 years, leading to a substantial decrease in tetanus newborn babies and an increase in newborn survival, with no sign of possible harm to pregnant women or their unborn babies.
Contributory factors to tetanus in newborns are the cultural diversity of unhygienic childbirth practices and cord care, lack of skilled attendance with delivery, parents’ illiteracy, lack of antenatal care, including a low level of immunisation against tetanus, seasonality, geographical location and climate, the prevalence of spores of C. tetani and rural agricultural settled populations.
In 2013, researchers in a study found that deaths in newborns were significantly lower for infants whose mothers attended four or more antenatal visits, consumed 90 or more folic acid tablets, or received two or more tetanus injections.
The report in the British Medical Journal said tetanus injections reduced the risk of newborn deaths even among women who did not take folic acid or did not attend four antenatal appointments in India.
To ensure protection among newborns against tetanus, mothers are expected to receive two doses of tetanus toxoid vaccine during the current pregnancy or at least three doses of tetanus toxoid in the past.
In 1983, WHO in its bulletin emphasised appropriate timing of antenatal tetanus immunisation for effective protection of newborns. It said protection was conferred on 80 per cent or more of newborns whose mothers received their first of tetanus toxoid injection 60 days or more before delivery.
It indicated that a single-dose schedule provided no protection when less than 70 days before delivery and there was no significant degree of protection when immunisation was carried out less than 20 days before delivery.
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