Abstract
With efforts focused on the elimination of maternal and neonatal tetanus, less attention has been given to tetanus incidence and mortality among men. Since 2007 voluntary medical male circumcision has been scaled-up in 14 sub-Saharan African countries as an effective intervention to reduce the risk of human immunodeficiency virus (HIV) acquisition among men. As part of a review of adverse events from these programmes, we identified 13 cases of tetanus from five countries reported to the World Health Organization (WHO) up to March 2016. Eight patients died and only one patient had a known history of tetanus vaccination. Tetanus after voluntary medical male circumcision was rare among more than 11 million procedures conducted. Nevertheless, the cases prompted a review of the evidence on tetanus vaccination coverage and case notifications in sub-Saharan Africa, supplemented by a literature review of non-neonatal tetanus in Africa over the years 2003-2014. The WHO African Region reported the highest number of non-neonatal tetanus cases per million population and lowest historic coverage of tetanus-toxoid-containing vaccine. Coverage of the third dose of diphtheria-tetanus-polio vaccine ranged from 65% to 98% across the 14 countries in 2013. In hospital-based studies, non-neonatal tetanus comprised 0.3-10.7% of admissions, and a median of 71% of patients were men. The identification of tetanus cases following voluntary medical male circumcision highlights a gender gap in tetanus morbidity disproportionately affecting men. Incorporating tetanus vaccination for boys and men into national programmes should be a priority to align with the goal of universal health coverage.