Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2023 Aug;52(4):1150-1162.
doi: 10.1093/ije/dyad005. Epub 2023 Feb 10.

Field investigation of high reported non-neonatal tetanus burden in Uganda, 2016-2017

Rebecca Mary Casey  1 , Joyce Nguna  2 , Bernard Opar  2 , Immaculate Ampaire  2 , Joseph Lubwama  3 , Patricia Tanifum  4 , Bao-Ping Zhu  5 , Annet Kisakye  6 , Eva Kabwongera  7 , Rania A Tohme  1 , Benjamin A Dahl  1 , Alison D Ridpath  1 , Heather M Scobie  1
Affiliations

Field investigation of high reported non-neonatal tetanus burden in Uganda, 2016-2017

Rebecca Mary Casey et al. Int J Epidemiol. 2023 Aug.

Abstract

Background: Despite providing tetanus-toxoid-containing vaccine (TTCV) to infants and reproductive-age women, Uganda reports one of the highest incidences of non-neonatal tetanus (non-NT). Prompted by unusual epidemiologic trends among reported non-NT cases, we conducted a retrospective record review to see whether these data reflected true disease burden.

Methods: We analysed nationally reported non-NT cases during 2012-2017. We visited 26 facilities (14 hospitals, 12 health centres) reporting high numbers of non-NT cases (n = 20) or zero cases (n = 6). We identified non-NT cases in facility registers during 1 January 2016-30 June 2017; the identified case records were abstracted.

Results: During 2012-2017, a total of 24 518 non-NT cases were reported and 74% were ≥5 years old. The average annual incidence was 3.43 per 100 000 population based on inpatient admissions. Among 482 non-NT inpatient cases reported during 1 January 2016-30 June 2017 from hospitals visited, 342 (71%) were identified in facility registers, despite missing register data (21%). Males comprised 283 (83%) of identified cases and 60% were ≥15 years old. Of 145 cases with detailed records, 134 (92%) were clinically confirmed tetanus; among these, the case-fatality ratio (CFR) was 54%. Fourteen cases were identified at two hospitals reporting zero cases. Among >4000 outpatient cases reported from health centres visited, only 3 cases were identified; the remainder were data errors.

Conclusions: A substantial number of non-NT cases and deaths occur in Uganda. The high CFR and high non-NT burden among men and older children indicate the need for TTCV booster doses across the life course to all individuals as well as improved coverage with the TTCV primary series. The observed data errors indicate the need for data quality improvement activities.

Keywords: Tetanus; Uganda; booster immunization; data quality; public health surveillance; tetanus toxoid; vaccination.

PubMed Disclaimer

Conflict of interest statement

Conflict of interest

None declared.

Figures

Figure 1
Figure 1
National reported number of non-neonatal tetanus (non-NT) cases reported from inpatient and outpatient departments by sex, Uganda, 2012–2017
Figure 2
Figure 2
Reported tetanus cases in Uganda, 2012–2017. (a) Number of reported inpatient neonatal tetanus (NT) and non-neonatal tetanus (non-NT) cases, and incidence of total tetanus (NT + non-NT) per 100 000 population. (b) Incidence of inpatient non-neonatal tetanus by region per 100 000 population
Figure 3
Figure 3
Schematic of patient enrolment for medical records review: Uganda, 1 January 2016–30 June 2017. (a) Number of inpatient non-neonatal tetanus (non-NT) cases reported from hospitals compared with the number identified in the registers, the number with available medical records and documented final diagnosis of tetanus. (b) Number of outpatient non-neonatal tetanus (non-NT) cases reported from health centres compared with the number identified in the registers
Figure 4
Figure 4
Clinically confirmed non-neonatal tetanus (non-NT) cases with available medical records (n = 133),a Uganda, 1 January 2016–30 June 2017. (a) By gender and age group. (b) By age group and region. aOne case record missing age or date-of-birth information
See this image and copyright information in PMC

Similar articles

See all similar articles

Cited by

  • Tetanus: recognition and management.
    Sudarshan R, Sayo AR, Renner DR, de Saram S, Godbole G, Warrell C, Duong HTH, Thwaites CL, Mehta AR, Coughlan C. Sudarshan R, et al. Lancet Infect Dis. 2025 Jun 18:S1473-3099(25)00292-0. doi: 10.1016/S1473-3099(25)00292-0. Online ahead of print. Lancet Infect Dis. 2025. PMID: 40543524 Free PMC article. Review.

References

    1. World Health Organization. Immunization, Vaccines and Biologicals. Vaccine Preventable Diseases Vaccines Monitoring System 2019 Global Summary Reference Time Series: TETANUS (TOTAL). https://immunizationdata.who.int/pages/incidence/TTETANUS.html?GROUP=Cou... (23 December 2022, date last accessed).
    1. Dalal S, Samuelson J, Reed J, Yakubu A, Ncube B, Baggaley R. Tetanus disease and deaths in men reveal need for vaccination. Bull World Health Organ 2016;94:613–21. - PMC - PubMed
    1. World Health Organization. JRF Supplementary Questionnaire on Surveillance Global Immunization Monitoring and Surveillance (GIMS). 2017. https://cdn.who.int/media/docs/default-source/immunization/vpd_surveilla... (23 December 2022, date last accessed).
    1. World Health Organization. Vaccine Preventable Diseases Surveillance Standards. World Health Organization. 2018. https://apps.who.int/iris/handle/10665/275754 (23 December 2022, date last accessed).
    1. World Health Organization. Technical Guidelines for Integrated Disease Surveillance and Response in the WHO African Region. 2019. https://apps.who.int/iris/bitstream/handle/10665/325015/WHO-AF-WHE-CPI-0... (23 December 2022, date last accessed).

Publication types