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Nurse Lakshmi Rai sits in the room at Kanti Children’s Hospital, Kathmandu, reserved for babies suffering from neonatal tetanus She is looking at the register where the admission and deaths of infants from neonatal tetanus are recorded. Photo: UNICEF/Tom Kelly
This bare, scrubbed room, located off a quiet ground floor corridor of Kanti Children's Hospital in Kathmandu (Nepal) is reserved for babies who suffer from neonatal tetanus. Other private rooms like this cost money but the room for neonates suffering from tetanus is free and so is the nursing care and medicines they receive. Anyone can come here for help, no matter how poor.
Parvati, her husband and their son travelled for five hours straight from their home in Gorkha to Kanti. They entered that room on January 22, 2002. The nurse lay their four-day-old son on the hospital bed, and attached an intravenous drip through his scalp. Parvati stayed with her son, resting fitfully on a narrow cot. Most of the time the boy was unconscious but sometimes he made painful noises through his frozen mouth. Crying – that most basic of baby communication – was denied to him. His stiffening back and limbs could not yield to a mother's embrace. Uncontrollable fever raged through his tiny body and sometimes surged into convulsions. Nurse Lakshmi Rai explained the causes of the child's disease to the parents – the unclean delivery of the child, the way the umbilical cord was cut and treated and the fact that Parvati herself had not been immunized against tetanus. Lakshmi never told the parents straight out that there was no hope for the child, but it seemed as if they already knew. The baby boy died the next day.
In the previous two months, four babies had died from tetanus in that room at Kanti, and all had come from outside the Kathmandu Valley. That Parvati and the other parents had got as far as the hospital was remarkable. Tetanus rages through newborns within days of their exposure to the bacteria and almost always delivers a swift, brutal and painful death. The quick reaction of the parents was testament to the fact that nowadays tetanus is more immediately recognized as a dangerous disease and that the referral system to Nepal's only hospital for children is improving. Yet these cases are a tiny fraction of those in the country as a whole.
Tetanus is known as the "silent killer" because it hardly ever shows up in medical statistics. Children who are most vulnerable are born at home and die in their first week of life usually without being registered and without the disease being diagnosed. The few indicators that are available show that many infants in Nepal are at risk. Some 90 per cent of births happen at home without professional assistance. Husbands, mothers-in-law and other relatives usually help with the delivery but more than 10 per cent (national rate 8.7 per cent, hill/mountain 13 per cent) of pregnant women give birth alone, sometimes in animal sheds or in the open air. Overall, at least 40 per cent of births are considered dangerous to the mother and/or the child. Tetanus is a major risk because unsterile instruments are often used to cut the umbilical cord and because it is customary in some communities for cow dung or soil, which may harbour tetanus spores, to be applied to the freshly cut umbilicus.
In the absence of any data on the incidence of tetanus, a survey supported by UNICEF of more than 46,000 female community health volunteers suggested that there are at least 6,700 cases of neonatal tetanus in Nepal every year – an incidence of 8 per 1,000 live births. One in every 125 infants is likely to suffer, and will most likely die, from neonatal tetanus and this is probably an underestimate.
Immunization against tetanus is provided through the Nepal health service to all pregnant women who seek antenatal care but official figures suggest that, in 2000, only 56 per cent of such women were immunized with at least two doses of the tetanus toxoid (TT) vaccine. The reasons are not only due to the inadequate reach and poor functioning of health services: women in their prime child-bearing years have little influence over decisions concerning their own health care.
In 2000, Nepal joined the global campaign to eliminate maternal and neonatal tetanus. The aim was to reach 80 per cent of women in each of the 75 districts with three doses of TT vaccine – which provides 15 years of protection. Women are encouraged to obtain two further doses through clinic services to obtain lifetime protection. In cooperation with WHO and Save the Children-US, UNICEF played a leading role in the campaign, contributing funds of more than US$ 1.2 million and helping national and district health officials to plan, train and evaluate campaign activities.
The first pilot phases of the campaign involving eight districts took off in November 2000. Health workers and assistants were trained in the use and safe disposal of the new auto-disable syringes. Vaccines, safety boxes for disposal, registration books and record cards were delivered – some to remote areas that could only be reached on foot. Thousands of female community health volunteers (FCHV) were trained in the causes and dangers of neonatal tetanus and to mobilize women in their communities to respond to the campaign. Posters, radio announcements, teachers, politicians and religious leaders also helped to spread the word.
In that first phase more than 663,000 women received three doses of the TT vaccine – representing an overall coverage of 78 per cent. Extenuating circumstances, including the brutal massacre of the Nepal Royal Family days before the third round, meant that the campaign fell just short of its target of 80 per cent of women. In the second phase, which aimed to reach 1.8 million women in 17 districts, more than 90 per cent of women were reached. The next two phases of the campaign will ensure all 75 districts are covered and will aim to reduce the incidence of tetanus to less than 1 per 1,000 live births.
Poverty and geography present enormous obstacles to reaching 80 per cent of Nepali women with three doses of TT but UNICEF immunization project officer, Prabhat Bangdel, is optimistic: "People do not know the name 'tetanus'," he said, "but they do know the disease that leaves a newborn baby, and sometimes women, stretched like a bow. It is a terrifying disease and when they know that we aim to make this disease almost as rare as polio, then they will do everything possible to help."
Tetanus cannot be eradicated but with clean birth practices and immunization it can become extremely rare. A couple of years from now the walls of that bare room in Kanti Children's Hospital should have no more stories to tell.
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