Abstract
Background:
Neonatal tetanus is a major public health concern, causing many preventable morbidities and mortalities, particularly in low-income countries. This study estimated its incidence and the years of life lost in Ethiopia from 1990 to 2023.
Methods:
The study used estimates and methods of the Global Burden of Diseases 2023.
Results:
The incidence was 170/105 neonates (95% UI: 60-360), 459/105 early neonates (95% UI: 174-935), and 73/105 late neonates (95% UI: 23-170) in 2023. The years of life lost rate was 9657/105 neonates (95% UI: 3767-18 327), 25 837/105 early neonates (95% UI: 10 803-47 724), and 4190/105 late neonates (95% UI: 1439-9445). There was no significant gender disparity. Moreover, there was a considerable decline in the rates between 1990 and 2023.
Conclusions:
The incidence and years of life lost rates were high, with a notable decline between 1990 and 2023. Moreover, there were age and regional inequalities.
Introduction
Neonatal tetanus is a vaccine-preventable, often fatal infection of newborns caused by Clostridium tetani spores entering the body. 1 The case-fatality rate of untreated neonatal tetanus is close to 100%, and even 1 case of neonatal tetanus is regarded as a failure of the healthcare system, making it essential to remain mindful of this disease’s relevance to public health.2,3 It occurs in settings where neonatal care practices are inadequate, particularly in regions with low vaccination coverage among pregnant women. 4 Neonatal tetanus remains a significant threat in settings with limited healthcare access, despite being preventable through vaccination. 5 In Ethiopia, the burden of neonatal tetanus is concentrated in areas with low antenatal tetanus-toxoid coverage and unskilled deliveries. 6 Cases overwhelmingly occur in newborns (first month) with no sex predilection. 7
The current neonatal tetanus elimination effort in Ethiopia focuses on maternal tetanus immunization, clean delivery, neonatal care, and surveillance.8,9 Consequently, the incidence of neonatal tetanus and the years of life lost sharply declined, but hotspots and subnational disparities persist, contributing to avoidable neonatal deaths. 10 A study on spatial analysis of the Ethiopian Demographic and Health Survey (EDHS) revealed that about 54.13% of births were not protected against neonatal tetanus in Ethiopia, and spatial clusters of unprotected births against tetanus were observed in the eastern (Afar and Somali) and northern (Amhara and Tigray) regions. The hotspots occurred possibly because of poor healthcare infrastructure, high numbers of home births, and poor immunization coverage, especially in pastoralist and rural areas. 7
There is limited up-to-date evidence on the incidence, years of life lost trends, and subnational disparities of neonatal tetanus in Ethiopia. This data gap hinders targeted interventions and progress toward the global maternal and neonatal tetanus elimination goal, limiting evidence-based policy and equitable resource allocation to sustain elimination achievements.
This study aimed to estimate the incidence of neonatal tetanus and the years of life lost in Ethiopia from 1990 to 2023, using the Global Burden of Diseases (GBD) 2023 study’s data and method. The findings will provide updated evidence on national and regional trends, supporting policymakers in identifying high-burden areas. This evidence is crucial for strengthening existing services, improving clean delivery practices, and sustaining progress toward the global goal of eliminating neonatal tetanus.
Methods
Study Setting
This study was carried out in Ethiopia, which is administratively divided into regional states and city administrations, namely Tigray, Addis Ababa, Afar, Amhara, Dire Dawa, Harari, Gambela, Oromia, Sidama, Benishangul Gumuz, Southern Nations, Nationalities, and Peoples (SNNP), Somali, and South West. The country is marked by significant geographical, socio-economic, and cultural diversity, leading to notable regional differences in poverty, infrastructure, and health outcomes. 8
In 2023, Ethiopia’s population was estimated to be 128.7 million, with a median age of 18.7 years. The total fertility rate was ~3.99 children/woman. 9 Tetanus vaccination coverage is mixed, with official reports often showing higher coverage than survey data. 11 For instance, while administrative data suggests a third dose of diphtheria-tetanus-pertussis-containing vaccine (DTP3) coverage of over 95% for children, surveys from 2016 to 2019 found DTP3 coverage to be between 53% and 61%. 9 Moreover, the pooled magnitude of receiving at least 2 doses of tetanus toxoid (TT2+) immunization among women of childbearing age is ~52% to 53%. This coverage is considered low and falls significantly below the WHO targets for preventing maternal and neonatal tetanus. 12 Skilled birth attendant delivery utilization was increased from 27.7% in 2016 to 49.6% in 2019. 13 Births attended by Traditional Birth Attendants (TBAs) increased from 28% in 2000 to 42% in 2016. Home deliveries decreased slightly from 94% to 73%, indicating that rural residents mostly used unskilled birth attendants. 14
Data Sources
This systematic analysis used secondary data from the GBD 2023 study to estimate the incidence of neonatal tetanus and the years of life lost in Ethiopia from 1990 to 2023. The input data included determinants of perinatal mortality among cohorts of pregnant women, the Addis Ababa mortality surveillance program, Ethiopia demographic surveillance verbal autopsy data, and District Health Information Software 2 (DHIS2) causes of death data. This can be available at: https://sources.healthdata.org/collection/sources-2023?components=4&causes=340&locations=179.
Data Analyses
The incidence of neonatal tetanus was estimated using the Bayesian meta-regression tool for disease modeling (DisMod-MR 2.1), which applied a hierarchical approach to improve estimation in data-sparse settings. It integrates sparse, heterogeneous data such as vaccine coverage and maternal protection to produce robust, consistent estimates of incidence across regional states and time. A hierarchical modeling approach allows for information to be shared across locations, strengthening estimates in locations with sparse or missing data. Years of life lost as a measure of premature mortality were determined using a multi-model approach called the Cause of Death Ensemble model (CODEm). Instead of relying on a single statistical method, CODEm combines the results of many different models to produce the most accurate and reliable estimate of how many years of life were lost to neonatal tetanus. The years of life lost were calculated by taking the standard life expectancy at the age of death and subtracting the actual age at death. Rates were smoothed by employing Spatiotemporal Gaussian Process Regression (ST-GPR), which is a sophisticated Bayesian statistical method used to smooth, interpolate, and estimate trends in data over both space and time. The spatiotemporal component allows the model to leverage data from nearby locations and time points to inform estimates where data is missing or sparse. The method also provides 95% uncertainty intervals (95% UIs) around the smoothed rates, allowing researchers to understand the reliability of the estimation. The 95% UIs were estimated to quantify the uncertainty inherent in the statistical models and the input data.
They were derived from the 2.5th and 97.5th percentiles of 1000 draws from the posterior estimate to account for variations in data and the statistical models. Non-overlapping 95% UIs indicated the presence of statistically significant estimates. Rates were calculated per 100 000 population. The overall change in the rates between 1990 and 2023 was determined by comparing values at the baseline (1990) and the end of the study period, using the following formula:
Ethics
This study used publicly available, secondary data from the GBD 2023 study. Moreover, the estimates were aggregated at the population level so that individual-level data were adequately anonymized to ensure confidentiality of information. Therefore, ethical consent for human participation was not required for this study.
Results
Incidence
There were an estimated 467 new cases of neonatal tetanus (95% UI: 165-989) in Ethiopia in 2023, with 289 new cases among males (95% UI: 74-760) and 178 new cases among females (95% UI: 49-437). The equivalent incidence rate was 170 new cases/100 000 neonates (95% UI: 60-360), with 205 new cases/100 000 males (95% UI: 53-540) and 133 new cases/100 000 females (95% UI: 37-326). The rate was estimated to be 459 new cases/100 000 early neonates (95% UI: 174-935) and 73 new cases/100 000 late neonates (95% UI: 23-170). Oromia and Somali had higher incidence rates among early neonates compared to late neonates. There was no significant variation in the distribution of the rate by sex. Compared to the rate in 1990, there was a remarkable decline in the incidence rate nationally (−97%) and subnationally in 2023 (Tables 1 and 2 and Figures 1 and 2).
Incidence of Neonatal Tetanus and the Years of Life Lost by Sex and Region in Ethiopia, 1990 to 2023.
Incidence of Neonatal Tetanus and the Years of Life Lost by Age and Location in Ethiopia, 1990 to 2023.
Incidence rate of neonatal tetanus by sex and location in Ethiopia, 2023.
Incidence rate of neonatal tetanus by age and location in Ethiopia, 2023.
Years of Life Lost
There were an estimated 26 517 years of life lost from neonatal tetanus (95% UI: 103 44-50 325) in Ethiopia in 2023, with 15 675 among males (95% UI: 3707-37 882) and 10 842 years of life lost among females (95% UI: 3348-25 562). The equivalent rate was 9657 YLLs/100 000 neonates (95% UI: 3767-18 327), with 11 132 years of life lost/100 000 males (95% UI: 2632-26 902) and 8105 years of life lost/100 000 females (95% UI: 2502-19 109). The rate was estimated to be 25 837 years of life lost/100 000 early neonates (95% UI: 10 803-47 724) and 4190 years of life lost/100 000 late neonates (95% UI: 1439-9445). Compared to the rate among late neonates, the years of life lost rate was estimated to be higher among early neonates in Addis Ababa and Somali. There was no significant difference in the distribution of the rate by sex. Compared to the rate in 1990, there was a remarkable decline in the rate of years of life lost nationally (−97%) and subnationally in 2023 (Tables 1 and 2 and Figures 3 and 4).
Trends of years of life lost rate from neonatal tetanus by year and location in Ethiopia, 1990 to 2023.
Years of life lost rate from neonatal tetanus by age and location in Ethiopia, 2023.
Discussion
This study aimed to systematically analyze the GBD 2023 estimates to determine the incidence of neonatal tetanus and the years of life lost in Ethiopia by age, sex, and location in Ethiopia from 1990 to 2023. The incidence rate was estimated to be 170 new cases/100 000 neonates (95% CI: 60-360), 459 new cases/100 000 early neonates (95% UI: 174-935), and 73 new cases/100 000 late neonates (95% UI: 23-170). Whereas, the years of life lost rate was estimated to be 9657 years of life lost/100 000 neonates (95% UI: 3767-18 327), 25 837 years of life lost/100 000 early neonates (95% UI: 10 803-47 724), and 4190 years of life lost/100 000 late neonates (95% UI: 1439-9445). Compared to rates among late neonates, higher incidence rates were estimated in Oromia and Somali, whereas higher years of life lost rates were found in Addis Ababa and Somali among early neonates. There was no significant disparity in the distribution of the rates by sex. Moreover, there was a considerable decline in the rates at the national and subnational levels between 1990 and 2023.
The incidence rate of neonatal tetanus was estimated to be substantially higher among early neonates (459 new cases/100 000 early neonates [95% UI: 174-935]) compared to late neonates (73 new cases/100 000 late neonates [95% UI: 23-170]), which reflect the ongoing challenge of eliminating maternal and neonatal tetanus despite Ethiopia’s formal declaration of elimination in 2017. 15 This concentration of cases in the first week of life is primarily attributed to unsterile cord care practices immediately following home deliveries. Moreover, the risk was not uniform across the country. High-incidence cases for tetanus-unprotected births were found in the Oromia and Somali regions. 16
This study estimated a total of 9657 years of life lost/100 000 neonates (95% UI: 3767-18 327) from tetanus in Ethiopia in 2023. Despite improvements in under-5 mortality, neonatal mortality remains high, accounting for nearly 47% of all under-5 deaths in the country. Early neonatal death—occurring in the first week of life—makes up the majority of these deaths, often caused by birth asphyxia, preterm birth, and infections. In addition, Addis Ababa and Somali had higher years of life lost rates among early neonates compared to the rate among late neonates. Studies in Addis Ababa hospitals have indicated that early neonatal mortality is high due to complications and infections during the first few days of life, which often stem from poor prenatal care and lack of timely treatment. In the Somali region, low maternal education and limited access to skilled health professionals, especially in pastoralist areas, increase the likelihood of improper umbilical cord care and home births, which are primary causes of infection.1,2 Between 1990 and 2023, neonatal tetanus incidence and years of life lost rates have considerably declined at the national and subnational levels in Ethiopia; however, no target was met as compared to the significant reductions made globally. 17 This progress signals that there is a need to strengthen systemic issues in implementing vaccination and health programs. It is recommended that existing maternal and neonatal health interventions, including vaccination schedules and community awareness strategies, be revised to better meet neonatal and global tetanus elimination targets. 18
The findings call for urgent policy action to redesign neonatal tetanus prevention strategies in Ethiopia. Strengthening routine maternal tetanus immunization, especially immunization with 2 doses of tetanus toxoid coverage, must be prioritized through improved outreach, defaulter tracking, and integration with antenatal care. 12 Enhancing the quality of intrapartum and immediate newborn care, particularly in rural and underserved settings, is essential to reducing early neonatal infections. 19 Policymakers should reinforce clean delivery initiatives, expand skilled birth attendance, and ensure an uninterrupted supply of vaccines, chlorhexidine, and infection-prevention materials. 20 Additionally, program evaluations should incorporate real-time surveillance and community-based reporting to identify emerging gaps. 21 The persistent high burden demonstrated by the study provides compelling justification for resource reallocation and redesign of maternal and newborn health strategies. 22
This study result should be interpreted with caution. Estimates of neonatal tetanus in Ethiopia rely on modeled data due to limited surveillance systems, introducing uncertainty into the estimates. Misclassification, underreporting of rural deaths, and data variability in quality could also impact estimation accuracy. The modeling assumes consistent risk and healthcare access patterns, potentially obscuring local heterogeneities. Moreover, the reliance on verbal autopsy data and the potential for under-estimation of deaths in remote areas where “home births” are the norm could also affect the validity and reliability of estimates. Despite these limitations, the GBD methods are the most comprehensive approach for analyzing long-term trends in rates of neonatal tetanus.
Conclusion
This study has indicated that the incidence and years of life lost rates from neonatal tetanus remain high and variably distributed sub-nationally in Ethiopia, although there were remarkable reductions in the rates between 1990 and 2023. Moreover, early neonates were disproportionately affected by tetanus compared to late neonates. Strengthening maternal tetanus toxoid immunization, ensuring universal access to skilled and clean delivery services, and expanding community-based awareness are critical. Policymakers should prioritize equitable resource allocation to high-burden regions, improve surveillance systems, and integrate neonatal tetanus elimination strategies into primary healthcare. Sustained multisectoral commitment is essential to accelerate progress toward elimination and reduce preventable neonatal mortality nationwide.
Footnotes
ORCID iDs
Author Contributions
ST and GW conceived the study, designed it, reviewed the original draft, and performed the formal analysis and interpretation. ST, JB, ZT, AM, AG, MT, HM, AG, AKB, YBT, ETW, TGG, BL, AA, AA, GT, MG, TG, GA, GND, AFT, and GW were involved in reviewing the manuscript, analyzing the data, and interpreting the findings. All authors have approved the final version of the manuscript.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.