Prevalence of protective tetanus antibodies and immunological response following tetanus toxoid vaccination among men seeking medical circumcision services in Uganda.

Fredrick Makumbi,John Byabagambi,Anthony K Mbonye,Barbara Nanteza,Valerian Kiggundu,Godfrey Kigozi,Mirwais Rahimzai,Moses Galukande,Jane Ruth Aceng,Emmanuel Njeuhmeli,Esther Karamagi,Stephen Watya,Mugagga Kaggwa,Richard Muwanika,Joshua Musinguzi,Bernard Bagaya,Darix Ssebagala,Ronald Gray,Michel R Popoff

doi:10.1371/journal.pone.0209167

Abstract

IntroductionTetanus infection associated with men who had male circumcision has been reported in East Africa, suggesting a need for tetanus toxoid-containing vaccines (TTCV).ObjectiveTo determine the prevalence of tetanus toxoid antibodies following vaccination among men seeking circumcision.MethodsWe enrolled 620 consenting men who completed a questionnaire and received TTCV at enrollment (day 0) prior to circumcision on day 28. Blood samples were obtained at day 0 from all enrollees and on days 14, 28 and 42 from a random sample of 237 participants. Tetanus toxoid (TT) IgG antibody levels were assayed using EUROIMMUN. Analyses included prevalence of TT antibodies at enrollment and used a mixed effects model to determine the immunological response.ResultsMean age was 21.4 years, 65.2% had knowledge of tetanus, 56.6% knew how tetanus was contracted, 22.8% reported ever receipt of TTCV, and 16.8% had current/recently healed wounds. Insufficient tetanus immunity was 57.1% at enrollment, 7.2% at day 14, 3.8% at day 28, and 0% at day 42. Antibody concentration was 0.44IU/ml (CI 0.35–0.53) on day 0, 3.86IU/ml (CI 3.60–4.11) on day 14, 4.05IU/ml (CI 3.81–4.29) on day 28, and 4.48IU/ml (CI 4.28–4.68) on day 42. TT antibodies increased by 0.24IU/ml (CI 0.23, 0.26) between days 0 and 14 and by 0.023IU/ml (CI 0.015, 0.031) between days 14 and 42 days. Immunological response was poorer in HIV-infected clients and men aged 35+ years.ConclusionInsufficient immunity was common prior to TTCV, and a protective immunological response was achieved by day 14. Circumcision may safely be provided 14 days after vaccination in HIV-uninfected men aged less than 35 years.

Highlights

Tetanus infection associated with men who had male circumcision has been reported in East Africa, suggesting a need for tetanus toxoid-containing vaccines (TTCV)
Insufficient immunity was common prior to TTCV, and a protective immunological response was achieved by day 14
The finding of sero-prevalence of protective tetanus antibody levels of 43% is consistent with DPT3 coverage in Uganda of 50% prior to 2000, the latter increased to 85% in 2007 [12]

Summary

Introduction

Tetanus infection associated with men who had male circumcision has been reported in East Africa, suggesting a need for tetanus toxoid-containing vaccines (TTCV). Uganda adopted a Safe Male Circumcision (SMC) policy in 2010, following three randomized clinical trials showing efficacy for HIV prevention in men [1,2,3]. The prevalence of HIV among adults aged 15 to 64 in Uganda remains high at 6.2%: 7.6% among females and 4.7% among males, and 0.4% among 0–14 years [4]. Ministry of Health (MoH) policy recommends SMC for all ages, males aged 10–49 years. Over the past six years, nearly 3.2 million circumcisions have been performed in Uganda [5] using conventional surgical methods (95%), with a much smaller number circumcised using the PrePex elastic collar device for adult men and the Mogen clamp for infants. Seventy percent of all the circumcisions are conducted in mobile SMC camps

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Results

Conclusion