Tetanus risk mitigation

While the risk of tetanus infection following VMMC is a rare adverse event, 12 cases of tetanus (eight of which resulted in death) reported through VMMC programs in four East and Southern African countries between 2014 and May 2016 signified the need for tetanus risk mitigation within VMMC programs, especially in countries with low DPT3 (series of immunizations preventing diphtheria, pertussis, and tetanus) coverage among adolescent and young males.  
In July 2016, a World Health Organization report concluded that there was a higher risk of tetanus following circumcision with the elastic collar compression device. WHO recommends that VMMC programs:

  1. Apply circumcision with a device method only if the client is adequately protected against tetanus by immunization with tetanus-toxoid-containing vaccine (TTCV)
  2. For surgical circumcision, provide at least one shot of tetanus vaccination at the time of circumcision
  3. For device circumcision, provide two shots 4-8 weeks apart, with the second shot given at least two weeks prior to device placement
  4. Follow a clean care approach for all circumcision methods: educate the client about personal cleanliness, follow standard surgical protocols on skin preparation of the genital area; and enhance individual and community education on clean wound care after circumcision

The Ministry of Health of Uganda has been a leader in applying CQI to reduce the risk of tetanus within VMMC services by requiring that all VMMC sites incorporate tetanus vaccination within their service package, either through mass vaccination campaigns as part of demand creation and mobilization and administration of tetanus toxoid vaccine to all men without documentation of tetanus immunization.  The MOH and implementing partners have developed several resources to support integration of tetanus risk mitigation in VMMC services, including a site readiness assessment tool and provider and client information materials.

Quality issues:

  • Integrating tetanus immunization in VMMC sites, including cold chain management and availability of vaccination equipment and supplies
  • Assuring that pre-operation counseling and education accurately explains the risks and benefits of TTCV
  • Assuring that post-operative counseling wound care instructions delivered include information on tetanus prevention (personal hygiene and avoiding harmful wound-care practices) and pain mitigation for vaccinated clients
  • Assuring high return rates for circumcision among clients who receive the first TTCV dose prior to circumcision
  • Assuring that IEC materials address risk of tetanus and benefits of tetanus vaccination
  • Assuring that demand creation activities include community sensitization about tetanus and VMMC
  • Assuring staff are trained in tetanus prevention, vaccination administration, and client education
  • Assuring that sites have data capture systems and tools in place for documenting tetanus vaccination