A Decade Later, India Still Tetanus-Free: WHO-UNICEF Validate Continued Elimination

A WHO-UNICEF assessment in June 2024 confirmed that India has successfully maintained maternal and neonatal tetanus elimination a decade after validation. Despite strong immunization and health system performance, the report urges targeted efforts for underserved and migrant populations to sustain progress.

India’s historic success in eliminating maternal and neonatal tetanus (MNTE) has been reaffirmed in a recent post-validation assessment jointly conducted by the World Health Organization (WHO) and UNICEF, with strong support from the Ministry of Health and Family Welfare and the National Immunization Technical Advisory Group (NITAG). Carried out between June 19 and 27, 2024, the assessment focused on three high-risk districts Alirajpur (Madhya Pradesh), Jamnagar (Gujarat), and Jhansi (Uttar Pradesh) each having reported five or more NT cases in the previous five years. Teams comprising experts from WHO headquarters in Geneva, its South-East Asia Regional Office, state health departments, and UNICEF’s New Delhi office deployed to these regions to evaluate whether India has successfully sustained its MNTE status a decade after it was officially validated in 2014.

From Crisis to Control: A 30-Year Health Transformation

India’s journey to MNTE has been nothing short of monumental. In the early 1980s, the country bore the brunt of neonatal tetanus, with mortality rates ranging from 5 to 40 deaths per 1,000 live births in various states. Nationwide estimates placed the number of neonatal deaths from tetanus between 150,000 and 200,000 annually most of them caused by unsafe home deliveries, poor umbilical cord care, and low immunization coverage. In response to the World Health Assembly’s 1989 resolution to eliminate NT by 1995, India intensified efforts under the global MNTE initiative. Tetanus toxoid vaccination for pregnant women, widespread training for birth attendants, the promotion of hygienic delivery practices, and campaigns like Mission Indradhanush formed the backbone of this national strategy. From 2003 to 2014, a series of phased validation surveys across Indian states confirmed the nation had achieved elimination defined as less than one NT case per 1,000 live births in every district.

Digging Deeper: A Ground-Level Reality Check

The 2024 assessment was not merely symbolic it was a data-driven dive into the heart of India’s public health delivery systems. The methodology included district and health facility reviews, document analysis, stakeholder interviews, and rapid community surveys. Twelve communities were visited across the three selected districts, where 123 women of reproductive age who had delivered within the past 24 months were interviewed. The findings painted a clear and positive picture. All three districts exceeded the elimination threshold of 80% Td2+ (tetanus-containing vaccine) coverage among pregnant women. Skilled birth attendance and health facility delivery rates also surpassed 70% in all surveyed areas. Most importantly, none of the districts reported NT rates exceeding one per 1,000 live births thus affirming the continued maintenance of elimination.

Bright Spots and Blind Spots in Service Delivery

While the assessment revealed commendable strengths such as widespread vaccine availability, functional cold chain systems, active disease surveillance, and well-trained personnel it also exposed critical gaps. Health infrastructure in remote rural areas continues to suffer from underinvestment, with some facilities lying vacant due to a lack of incentives for healthcare workers. Migrant populations remain underrepresented in micro-plans and are often excluded from immunization drives and maternal health services. The data collection systems, though increasingly digitalized, showed inconsistencies, particularly in disaggregating data between outreach and fixed sessions. Private sector contributions to maternal and child health go largely untracked, affecting comprehensive coverage estimates. Cultural practices also remain a concern. While most deliveries now occur in institutional settings, some families still apply ash or mustard oil to the umbilical cord stump a risky tradition that could reintroduce infection pathways.

Looking Ahead: Strengthening Systems for the Long Haul

Based on the combined findings, the WHO-led team concluded that India continues to meet all criteria for MNTE maintenance, not just in the assessed districts but nationwide. No district has reported NT rates exceeding the elimination benchmark since 2014. Still, the report stressed the urgency of strengthening fragile links in the healthcare chain. Recommendations include adopting the WHO-recommended five-dose tetanus toxoid schedule for life-course protection, regularly calculating protection at birth (PAB) indicators, and enhancing outreach to migrant and marginalized populations. Health workers should be further trained in ANC-based vaccine screening and data monitoring. Stronger collaboration with private healthcare providers and tailored community awareness campaigns particularly in local languages were also emphasized. Infrastructure gaps must be addressed by revitalizing abandoned rural health centers and offering incentives to health workers willing to serve in remote areas. The use of electronic tools like the eVIN system should be expanded to ensure real-time monitoring of vaccine storage and supply chains.

India’s Ministry of Health, in coordination with WHO and UNICEF, is expected to finalize a national MNTE maintenance plan by the fourth quarter of 2024. Implementation and routine monitoring are set to begin in January 2025. As the report makes clear, the road ahead demands consistency, innovation, and inclusion. The country’s success in eliminating maternal and neonatal tetanus is a beacon for public health efforts globally, but sustaining it requires relentless commitment. The last mile in public health is often the hardest and in this case, it lies in reaching the unreached, educating the unaware, and strengthening systems that must not falter. With the right mix of political will, community engagement, and data-driven interventions, India is poised not only to preserve its MNTE victory but to set a gold standard in long-term disease elimination.