Process of neonatal tetanus elimination in Nepal

In late 2005, Nepal demonstrated through surveys that it had reached the World Health Organization criterion for having eliminated neonatal tetanus (NT), i.e. NT cases occurred at a rate of less than 1 per 1000 live births in every district. This article summarizes how a combination of strat-egies contributed to this success. Through routine immunization of pregnant women with tetanus toxoid (TT), NT cases had decreased substan-tially by 1999, but the final push was provided through the national TT supplemental immunization activities in 2000–2004, which raised the proportion of children protected at birth against tetanus to above 80%. Although NT surveillance has improved since the extensive acute flaccid paralysis/polio surveillance infrastructure in Nepal was made available for the NT elimination initiative, it is likely that a number of cases still occur without being reported, particularly in rural areas. The introduction and further expansion of the school-based immunization program will, in combination with diphtheria–tetanus–pertussis vaccine given in infancy, reduce the need for future cohorts of childbearing age women to be immunized at every pregnancy. However, booster doses will still need to be given in early adulthood to ensure ongoing protection