Control of neonatal tetanus in southern Thailand
Background: Prior to 1989, Krabi and Satun, two neighbouring provinces with similar socioeconomic background and health service coverage, had the highest reported incidence rates of neonatal tetanus in Thailand (3 per 1000 livebirths). A control programme was conducted between 1989 and 1991.
Objective: The objective of this study was to examine changes in prevalence of risk factors among the population and changes in incidence rates of this disease due to this programme.
Methods: Two 30-cluster surveys to measure prevalence rates of risk factors were conducted in Krabi, before and after the campaign. Information on incidence was obtained from routine surveillance. The intervention in Krabi consisted of mass immunization and intensive education for traditional birth attendants (TBA) whereas only the latter was carried out in Satun.
Results: The incidence of neonatal tetanus in both provinces declined dramatically to less than 0.4 per 1000 livebirths in 1990 and 1991. From 1989 to 1991, in Krabi Province, the coverage of at least two doses of tetanus toxoid injections at any time prior to delivery, delivery by trained health personnel, acceptable sterile technique for umbilical cord cutting and correct method of dressing the umbilical stump rose from 70 to 88%, 55-80% cent, 80-94% and 40-74%, respectively.
Conclusion: Reduction in the incidence rate of neonatal tetanus was achieved by strengthening of routine health services with or without additional mass immunization. Considering that the coverage of immunization has not yet been completed and the prevalence rates of different risk factors are still high, further attempts to improve the problem of neonatal tetanus are necessary.
Additional Notes: Between 1989 and 1991 in Krabi province in peninsular Thailand on the Andaman Sea, public health workers conducted 4 successive campaigns for mass immunization of all 15-45 year old women with at least 2 doses of tetanus toxoid (TT) and intensive education for traditional birth attendants (TBAs). Local radio spots, announcements during meetings of village leaders and government officers, and health centers, hospitals, and health workers announcing the mass campaigns during home visits were ways to communicate the campaigns. At the same time, in the neighboring province of Satun, also located on the Andaman Sea, intensive education for TBAs was the only intervention. Researchers wanted to examine whether these 2 interventions would change the prevalence of risk factors among the population and incidence rates of neonatal tetanus in these 2 provinces, where the incidence rates of neonatal tetanus were the highest in Thailand. Between 1989 and 1991 in Krabi, the proportion of women immunized with TT increased from 70 to 88% The proportion of cord cutting under aseptic conditions and acceptable cord dressing increased from 82 to 94% and 40 to 74%, respectively. The proportion f deliveries conducted by trained medical personnel also improved (55-80%). In Satun, the proportion of immunization with 2 doses of TT among pregnant women was 76% in 1991. In 1991 in both provinces, the incidence of neonatal tetanus fell to a point which was 8-10 times lower than the 1989 baseline and ranged .2-.l4/1000 live births. These findings showed that improving routine health services with or without mass immunization was responsible for the reduction of the neonatal tetanus incidence rate. Nevertheless, many risk factors for neonatal tetanus were still present in these provinces. Further, health workers failed to reach immunization coverage goals. Thus, public health leaders need to continue trying to eliminate neonatal tetanus in Krabi and Satun.