Cochrane review: Vaccines for women to prevent neonatal tetanus
Authors: Demicheli V , Barale A , Rivetti A 
Published: October 2007

Background

Tetanus is an acute, often fatal, disease caused by an exotoxin produced by Clostridium tetani. It occurs in newborn infants born to mothers who do not have sufficient circulating antibodies to protect the infant passively, by transplacental transfer. Prevention may be possible by the vaccination of pregnant and/or non‐pregnant women with tetanus toxoid, and the provision of clean delivery services. Tetanus toxoid consists of a formaldehyde‐treated toxin which stimulates the production of antitoxin.

Objectives

To assess the effectiveness of tetanus toxoid, administered to women of childbearing age or pregnant women, to prevent cases of, and deaths from, neonatal tetanus.

Search strategy

We searched the Cochrane Pregnancy and Childbirth Group Trials Register (December 2004) , The Cochrane Library (Issue 1, 2005), MEDLINE (1966 to December 2004), EMBASE (1974 to December 2004). We also used the results from handsearching and consultations with manufacturers and authors.

Selection criteria

Randomised or quasi‐randomised trials evaluating the effects of tetanus toxoid in pregnant women or women of childbearing age on numbers of neonatal tetanus cases and deaths.

Data collection and analysis

Three review authors independently assessed trials for inclusion, data extraction and trial quality.

Main results

Two trials (10,560 infants) were included. One study (1919 infants) assessed the effectiveness of tetanus toxoid in preventing neonatal tetanus deaths. After a single dose, the relative risk (RR) was 0.57 (95% confidence interval (CI) 0.26 to 1.24), and the vaccine effectiveness was 43%. With a two or three dose course, the RR was 0.02 (95% CI 0.00 to 0.30); vaccine effectiveness was 98%. No effect was detected on causes of death other than tetanus. The RR of cases of neonatal tetanus after at least one dose of tetanus toxoid was 0.20 (95% CI 0.10 to 0.40); vaccine effectiveness was 80%. Another study, involving 8641 children, assessed the effectiveness of tetanus‐diptheria toxoid in preventing neonatal mortality after one or two doses. The RR was 0.68 (95% CI 0.56 to 0.82); vaccine effectiveness was 32%. In preventing deaths at 4 to 14 days, the RR was 0.38 (95% CI 0.27 to 0.55), and vaccine effectiveness 62% (95% CI 45% to 73%).

Authors' conclusions

Available evidence supports the implementation of immunisation practices on women of childbearing age or pregnant women in communities with similar, or higher, levels of risk of neonatal tetanus, to the two study sites. More information is needed on possible interference of vaccination by malaria chemoprophylaxis on the roles of malnutrition and vitamin A deficiency, and on the quality of tetanus toxoid production and storage.

Plain language summary

Vaccinating childbearing women against tetanus rather than influenza or cholera appears to decrease incidence of tetanus in newborn babies but possible adverse effects not assessed

Neonatal tetanus is an infection causing rigidity, muscle spasm and often death in newborn babies. It is quite common in income‐poor countries and comes from insufficient protection being passed from mother to baby in utero together with infection getting into the baby through the umbilical cord stump. The review of studies assessing vaccinating women of childbearing age showed fewer cases of neonatal tetanus when two or three doses were used, but no potential adverse effects were assessed. Administrative and operational aspects also need to be of good quality for vaccination programmes to be effective.