{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,6,15]],"date-time":"2025-06-15T00:26:39Z","timestamp":1749947199737,"version":"3.37.3"},"reference-count":52,"publisher":"Public Library of Science (PLoS)","issue":"5","license":[{"start":{"date-parts":[[2022,5,19]],"date-time":"2022-05-19T00:00:00Z","timestamp":1652918400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/publicdomain\/zero\/1.0\/"}],"funder":[{"DOI":"10.13039\/100000865","name":"bill and melinda gates foundation","doi-asserted-by":"publisher","award":["OPP106668"],"award-info":[{"award-number":["OPP106668"]}],"id":[{"id":"10.13039\/100000865","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS ONE"],"abstract":"<jats:sec id=\"sec001\">\n<jats:title>Background<\/jats:title>\n<jats:p>Tetanus is a potentially fatal disease that is preventable through vaccination. While the Democratic Republic of the Congo (DRC) has continued to improve implementing routine vaccination activities throughout the country, they have struggled to maintain high childhood vaccine coverage. This study aims to examine the seroprevalence of tetanus in children 6 to 59 months to identify areas for intervention and improvement of vaccination coverage.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec002\">\n<jats:title>Methods<\/jats:title>\n<jats:p>In collaboration with the 2013\u20132014 Demographic and Health Survey, we assessed the seroprevalence of tetanus antibodies among children in the DRC. Dried blood spot samples collected from children 6\u201359 months of age were processed using a prototype DYNEX Multiplier\u00ae chemiluminescent automated immunoassay instrument with a multiplex measles, mumps, rubella, varicella and tetanus assay. Multivariable logistic regression was used to determine factors associated with tetanus vaccination and seroprotection.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec003\">\n<jats:title>Results<\/jats:title>\n<jats:p>Overall, 36.1% of children 6\u201359 months of age reported receiving at least 1 dose of tetanus vaccine while 28.7% reported receiving 3 doses; tetanus seroprotection was 40%. Increasing age in children was associated with decreased tetanus seroprotection, but increased number tetanus vaccinations received. Factors related to increased tetanus seroprotection included number of children in the household, wealth index of the family, urban residence compared to rural, level of maternal education, and province and geography.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec004\">\n<jats:title>Conclusions<\/jats:title>\n<jats:p>Our findings in this nationally representative sample indicate that serology biomarkers may help identify children who are not fully immunized to tetanus more accurately than reported vaccination. While children may be captured for routine immunization activities, as children age, decreasing seroprevalence may indicate additional need to bolster routine vaccination activities and documentation of vaccination in school aged children. Additionally, the study highlights gaps in rural residential areas and vaccination coverage based on maternal education, indicating that policies targeting maternal education and awareness could improve the coverage and seroprevalence of tetanus antibodies in the DRC.<\/jats:p>\n<\/jats:sec>","DOI":"10.1371\/journal.pone.0268703","type":"journal-article","created":{"date-parts":[[2022,5,19]],"date-time":"2022-05-19T17:37:03Z","timestamp":1652981823000},"page":"e0268703","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":6,"title":["Tetanus seroprotection among children in the Democratic Republic of the Congo, 2013\u20132014"],"prefix":"10.1371","volume":"17","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-2281-1798","authenticated-orcid":true,"given":"Alvan","family":"Cheng","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Angie","family":"Ghanem-Uzqueda","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1770-6304","authenticated-orcid":true,"given":"Nicole A.","family":"Hoff","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8530-0904","authenticated-orcid":true,"given":"Hayley","family":"Ashbaugh","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Reena H.","family":"Doshi","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9312-9345","authenticated-orcid":true,"given":"Patrick","family":"Mukadi","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Roger","family":"Budd","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Stephen G.","family":"Higgins","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Christina","family":"Randall","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Sue","family":"Gerber","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Michel","family":"Kabamba","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Guilluame","family":"Ngoie Mwamba","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Emile","family":"Okitolonda-Wemakoy","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jean Jacques","family":"Muyembe-Tanfum","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Anne W.","family":"Rimoin","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"340","published-online":{"date-parts":[[2022,5,19]]},"reference":[{"key":"pone.0268703.ref001","unstructured":"UpToDate. Tetanus. 2018. Available: https:\/\/www.uptodate.com\/contents\/tetanus"},{"journal-title":"Tetanus. World Health Organization","year":"2019","author":"World Health Organization","key":"pone.0268703.ref002"},{"key":"pone.0268703.ref003","first-page":"53","article-title":"Tetanus vaccines: WHO position paper","volume":"92","author":"World Health Organization","year":"2017","journal-title":"Wkly Epidemiol Rec"},{"key":"pone.0268703.ref004","doi-asserted-by":"crossref","first-page":"e1100","DOI":"10.1016\/j.ijid.2013.05.016","article-title":"Prognostic factors for mortality in neonatal tetanus: a systematic review and meta-analysis","volume":"17","author":"JA Lambo","year":"2013","journal-title":"Int J Infect Dis"},{"key":"pone.0268703.ref005","doi-asserted-by":"crossref","first-page":"292","DOI":"10.1016\/j.jns.2016.07.025","article-title":"Case fatality of adult tetanus in Africa: Systematic review and meta-analysis","volume":"368","author":"YW Woldeamanuel","year":"2016","journal-title":"J Neurol Sci"},{"key":"pone.0268703.ref006","doi-asserted-by":"crossref","first-page":"179","DOI":"10.1186\/s12889-017-4111-4","article-title":"Mortality from tetanus between 1990 and 2015: findings from the global burden of disease study 2015","volume":"17","author":"HH Kyu","year":"2017","journal-title":"BMC Public Health"},{"key":"pone.0268703.ref007","doi-asserted-by":"crossref","first-page":"1204","DOI":"10.1016\/S0140-6736(20)30925-9","article-title":"Global burden of 369 diseases and injuries in 204 countries and territories, 1990\u20132019: a systematic analysis for the Global Burden of Disease Study 2019","volume":"396","author":"C Abbafati","year":"2020","journal-title":"Lancet"},{"journal-title":"The immunological basis for immunization series: module 3: tetanus.","year":"2018","author":"WHO","key":"pone.0268703.ref008"},{"key":"pone.0268703.ref009","doi-asserted-by":"crossref","first-page":"3573","DOI":"10.1016\/j.vaccine.2017.02.034","article-title":"Tetanus vaccines: WHO position paper, February 2017 \u2013Recommendations","volume":"36","author":"World Health Organization","year":"2018","journal-title":"Vaccine"},{"key":"pone.0268703.ref010","doi-asserted-by":"crossref","first-page":"120","DOI":"10.2105\/AJPH.82.1.120","article-title":"Maternal Recall Errror Child Vaccination Status","volume":"82","author":"JJ Valadez","year":"1992","journal-title":"Am J Public Health"},{"key":"pone.0268703.ref011","doi-asserted-by":"crossref","first-page":"1560","DOI":"10.1016\/j.vaccine.2012.10.089","article-title":"Validity of vaccination cards and parental recall to estimate vaccination coverage: a systematic review of the literature","volume":"31","author":"M Miles","year":"2013","journal-title":"Vaccine"},{"key":"pone.0268703.ref012","doi-asserted-by":"crossref","first-page":"1022","DOI":"10.1016\/S0140-6736(03)14411-X","article-title":"Validity of reported vaccination coverage in 45 countries","volume":"362","author":"CJL Murray","year":"2003","journal-title":"Lancet"},{"key":"pone.0268703.ref013","doi-asserted-by":"crossref","first-page":"2","DOI":"10.1111\/j.1365-3156.2008.02181.x","article-title":"Accuracy and quality of immunization information systems in forty-one low income countries","volume":"14","author":"X Bosch-Capblanch","year":"2009","journal-title":"Trop Med Int Heal"},{"key":"pone.0268703.ref014","doi-asserted-by":"crossref","first-page":"2031","DOI":"10.1016\/S0140-6736(08)61869-3","article-title":"Tracking progress towards universal childhood immunisation and the impact of global initiatives: a systematic analysis of three-dose diphtheria, tetanus, and pertussis immunisation coverage","volume":"372","author":"SS Lim","year":"2008","journal-title":"Lancet"},{"key":"pone.0268703.ref015","first-page":"11","article-title":"Immunization coverage surveys and linked biomarker serosurveys in three regions in Ethiopia","author":"MA Travassos","year":"2016","journal-title":"PLoS One."},{"key":"pone.0268703.ref016","first-page":"696","article-title":"Tetanus toxoid coverage as an indicator of serological protection against neonatal tetanus","volume":"80","author":"MS Deming","year":"2002","journal-title":"Bull World Health Organ"},{"issue":"16","key":"pone.0268703.ref017","first-page":"117","volume":"71","author":"WH Organization","year":"1996","journal-title":"Weekly Epidemiological Record"},{"key":"pone.0268703.ref018","first-page":"4893","article-title":"Issues and considerations in the use of serologic biomarkers for classifying vaccination history in household surveys","author":"A MacNeil","year":"2014","journal-title":"Vaccine. 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