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OPINION article

Front. Reprod. Health, 12 January 2023
Sec. Gynecology
Volume 3 - 2021 |

Routine Vaccination During COVID-19: A Case of Maternal Neonatal Tetanus From Pakistan

  • 1College of Pharmacy, Al Ain University, Abu Dhabi, United Arab Emirates
  • 2Department of Public Health and Allied Sciences, Fatima Jinnah Women University, Rawalpindi, Pakistan
  • 3Department of Anthropology, Fatima Jinnah Women University, Rawalpindi, Pakistan
  • 4Department of Social and Cultural Anthropology, University of Vienna, Vienna, Austria


Various factors—including natural disasters and health emergencies—considerably affect vaccination programs. The reasons can be multiple. This is visible during the 2 years of the ongoing coronavirus pandemic causing COVID-19, which has overwhelmed the entire world and yet fearing its consecutive waves of various variants, e.g., Omicron (1). With no exception, the significant health effects are associated with measures to contain COVID-19, such as physical distancing (2). Consequently, all routine immunization activities including Maternal Neonatal Tetanus (MNT) vaccination have been affected around the world, including in Pakistan (3).

MNT: A Brief Overview

What is tetanus begs a brief overview. It is a life threatening disease caused by the toxin of gram-positive bacillus Clostridium tetani (C. tetani), which invades the body through any wound contamination (4). The neurotoxin of C. tetani affects the nervous system, spasms of respiratory, laryngeal, and abdominal muscles and ultimately results in a failure of respiration leading to death (5). Maternal tetanus toxoid (TT) vaccination is an important endeavor to prevent higher maternal mortalities caused by MNT infection (6). It is recommended since the 1980s and has been administered to millions of women for preventing maternal and neonatal tetanus (7).

However, MNT is still a substantial cause of significant maternal mortalities in low-income countries including Pakistan. Inadequate antenatal care (ANC) facilities, unsatisfactory vaccination coverage, unhygienic delivery practices are key causative factors for the prevalence of MNT in Pakistan (8, 9). WHO (4) recommended that women should initiate early ANC in the 1st trimester of conception for better feto-maternal outcomes. Yet, not a sufficient progress has been observed in Pakistan to seek ANC as the National Nutrition Survey data showed that a significant number of pregnant women (63.5%) sought ANC only during their last trimester of pregnancy (10).

Similarly, “disinfected” childbirth practices in homes and healthcare centers with provided sterilize instruments could also be an important preventive measure to reduce maternal neonatal tetanus toxoid (11). It has been reported that only 55% of births in Pakistan are attended by skilled health personnel (12). That means the remaining portion consults a Dai (traditional community midwife) who can be officially recognized and integrated frontline caregivers for decreasing the impact on the healthcare system of the country, and these should be given appropriate skills (13).

Furthermore, to minimize MNT, around 7 million pregnant women were immunized against vaccine-preventable diseases including TT vaccine in 2018 (14). Nonetheless, Pakistan is still one among the priority countries which have failed to achieve WHO's MNT elimination target of neonatal tetanus (< 1 per 1,000 live births per year) in all district of country (4). As mentioned earlier, this vaccination has further been affected by the pandemic.

Discussion and Conclusion

The sustainable development goals 2030 emphasized the development of vaccines and medicines research with easy access to cheap essential medicines and vaccines specially for low-income countries (12). In addition, for preventing maternal and neonatal mortality, WHO has provided a global guideline for vaccination schedule to eliminate global MNT and to ensure lifetime protection against tetanus through tetanus-toxoid-containing vaccines such as tetanus-diphtheria (4) (see Table 1). However, there is evidence that when vaccination is halted, the vaccine-preventable diseases (VPDs) cause severe outbreaks (3), as it was observed during the 2013–16 Ebola outbreak in West Africa. The similar has also been observed during the ongoing pandemic. This mainly happened due to the interrupted vaccination programmes and shifting of resources toward the ongoing challenge.


Table 1. Immunization schedule of tetanus-diphtheria (Td) vaccinesa.

Similar to the entire vaccination program in Pakistan, the tetanus vaccination is significantly affected. During the COVID-19 pandemic, neither pregnant women might visit a healthcare facility to receive the required vaccine nor lady health workers could make it possible to visit these women to give them the required vaccine. It can be truly anticipated that many women will deliver their babies at homes not at any healthcare facilities (13). Consequently, there are greater chances that cases of tetanus would considerably increase during the ongoing pandemic.

Hence, it is highly necessary for the government to deal with the pressing context-specific issues that affect the vaccination programme in the country. Undoubtedly, all efforts should be made to run the routine vaccination drives during these overwhelming times to avert further challenges posed by other microorganisms.

Author Contributions

SI and IA: conceptualization and writing—original draft, literature search, review, and validity. IA: critical reading, discussion, revisions, and editing. Both authors contributed to the article and approved the submitted version.


Both of us acknowledge the Higher Education Commission (HEC) of Pakistan's grant—IA (PD/OSS-II/Batch-IV/Austria/2012/9903) and SI (PD/OSS-II/Batch-VI/Austria/2016/73769)—which supported the Ph.D. work that has significantly informed this article.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher's Note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


1. Ali I. COVID-19: are we ready for the second wave? Disaster Med Public Health Prep. (2020) 2020:1–3. doi: 10.1017/dmp.2020.329

PubMed Abstract | CrossRef Full Text | Google Scholar

2. Ali I. Impact of COVID-19 on vaccination programs: adverse or positive? Hum. Vaccin Immunother. (2020) 16:1–7. doi: 10.1080/21645515.2020.1787065

PubMed Abstract | CrossRef Full Text | Google Scholar

3. Ali I. Covid-19 and cancelled vaccination programs: forecasting outbreaks of vaccine preventable diseases (vpds) in pakistan. Vaccine X. (2022) 10:100151. doi: 10.1016/j.jvacx.2022.100151

PubMed Abstract | CrossRef Full Text | Google Scholar

4. World Health Organization (WHO). Tetanus vaccines: WHO position paper, February 2017 – recommendations. Vaccine. (2018) 36:3573–5. doi: 10.1016/j.vaccine.2017.02.034

PubMed Abstract | CrossRef Full Text | Google Scholar

5. Hassel B. Tetanus: pathophysiology, treatment, and the possibility of using botulinum toxin against tetanus-induced rigidity and spasms. Toxins. (2013) 5:73–83. doi: 10.3390/toxins5010073

PubMed Abstract | CrossRef Full Text | Google Scholar

6. Chu HY, Englund JA. Maternal immunization. Clin Infect Dis. (2014) 59:560–8. doi: 10.1093/cid/ciu327

PubMed Abstract | CrossRef Full Text | Google Scholar

7. Englund JA. Maternal immunization - promises and concerns. Vaccine. (2015) 33:6372–3. doi: 10.1016/j.vaccine.2015.07.084

PubMed Abstract | CrossRef Full Text | Google Scholar

8. Lambo JA, Nagulesapillai T. Neonatal tetanus elimination in Pakistan: progress and challenges. Int J Infect Dis. (2012) 16:e833–42. doi: 10.1016/j.ijid.2012.07.015

PubMed Abstract | CrossRef Full Text | Google Scholar

9. Iqbal S, Ali I, Ekmekcioglu C, Kundi M. Increasing frequency of antenatal care visits may improve tetanus toxoid vaccination coverage in pregnant women in Pakistan. Hum Vaccines Immunother. (2020) 16:1529–32. doi: 10.1080/21645515.2019.1705693

PubMed Abstract | CrossRef Full Text | Google Scholar

10. Government of Pakistan UNICEF. National Nutrition Survey Pakistan 2011. Gov. Pakistan UNICEF Pakistan (2011). p. 1–104. Available online at: (accessed August 23, 2020).

Google Scholar

11. Aqeel AY, Arishi HM, Ageel HI, Arishi NH. Epidemiological and clinical aspects of neonatal tetanus from a tertiary care hospital. Int J Pediatr Adolesc Med. (2017) 4:71–4. doi: 10.1016/j.ijpam.2016.10.001

PubMed Abstract | CrossRef Full Text | Google Scholar

12. World Health Organization. World Health Statistics 2017 : Monitoring Health for the SDGs. World Heal. Organ. (2017). p. 103. Available online at: (accessed August 23, 2020).

Google Scholar

13. Ali I, Sadique S, Ali S, Davis-Floyd R. Birthing between the “Traditional” and the “Modern”: dāī practices and childbearing women's choices during COVID-19 in Pakistan. Front Sociol. (2021) 6:622223. doi: 10.3389/fsoc.2021.622223

PubMed Abstract | CrossRef Full Text | Google Scholar

14. Government of Pakistan. Pakistan Economic Survey 2018-19. Econ. Advis. Wing, Financ. Div. Gov. Pakistan, Islam. (2019). p. 1–503. Available online at: (accessed August 23, 2020).

Google Scholar

Keywords: COVID-19, routine immunization, tetanus vaccination, Pakistan, pandemic

Citation: Iqbal S and Ali I (2023) Routine Vaccination During COVID-19: A Case of Maternal Neonatal Tetanus From Pakistan. Front. Reprod. Health 3:790647. doi: 10.3389/frph.2021.790647

Received: 07 October 2021; Accepted: 17 December 2021;
Published: 12 January 2023.

Edited by:

Kedra Wallace, University of Mississippi Medical Center, United States

Reviewed by:

Mohamed Farghali, Ain Shams University, Egypt

Copyright © 2023 Iqbal and Ali. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Inayat Ali,