PEPFAR, Health Ministry Disagree on Tetanus for Circumcision Top story

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In short
Health Ministry and the donor disagree over the package for implement safe medical circumcision. Circumcision rates have gone down since the tetanus was introduced as a package. Health Ministry concerned about the government cost of extra tetenus vaccines for men.

The President's Emergency Plan for AIDS Relief (PEPFAR) and Ministry of Health are locked in a fight over Tetanus vaccination for Safe Medical Circumcision in Uganda.

The President's Emergency Plan for AIDS Relief (PEPFAR) insists all its partners conducting circumcision surgeries must immunize the men seeking to be circumcised. PEPFAR is the biggest donor to the circumcision for HIV prevention in Uganda.

PEPFAR's argument is that the men who want to be circumcised need to be protected against tetanus. The Health Ministry of health however says Safe Male circumcision can still go on without tetanus vaccination provided those circumcising stick to the guidelines.

The Ministry insists tetanus infection can be avoided once those seeking the services are properly educated about the hygiene requirements. The Ministry of health is concerned about the likely impact on the stock of Tetanus vaccines in the country.

Tetanus vaccines in the country are mainly stocked for women of reproductive age and babies. 

Dr Barbara Nanteza, the Safe Medical Circumcision national Coordinator at the health ministry told Uganda Radio Network that she thinks the tetanus must not be a requirement.

She says only thirteen men out of the 2.7 million circumcisions carried out in the country died of tetanus. She says instead of pegging tetanus on circumcision, the vaccines should be provided through the Expanded Programme on Immunization.

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PEPFAR however requires all its medical circumcision implementing agencies to include tetanus as part of the circumcision package.

In December last year, the Director General of Health Services Jane Achieng sent out a circular about the need to have men twice immunized against Tetanus.  Circumcision service providers in both NGO and government facilities have since January used vaccines from the districts for Safe Medical Male Circumcision.
  
A meeting was held on May 13 at Silver Springs Hotel in Kampala in effort to find a common ground to the standoff. It emerged that PEPFAR has been promising to procure extra tetanus vaccines but it had not delivered the doses since January.
 
A source attending the closed door meeting confirmed that an official from PEPFAR office in Kampala had indicated 1.6 million doses of the tetanus vaccines had been procured and would be in the country before end of this month.
 
The vaccines are reportedly to be channeled through National Medical Stores to the districts but will not be labeled that they are meant for only Safe Medical Circumcision.

Dr Nanteza confirmed that PEPFAR committed to procure extra doses of the vaccine.     
During April 2012 - November 2015, PEPFAR's Voluntary Male Medical Circumcision Program reported 12 tetanus cases in five sub-Saharan African countries.

Three cases occurred in 2012 - 2013 (one in Uganda and two in Zambia), six in 2014 (one each in Kenya, Rwanda, and Tanzania and three in Uganda), and three in 2015 (one in Rwanda and two in Uganda).

Three patients in Kenya, Tanzania, and Uganda reportedly had applied traditional remedies to aid healing after the surgeries.

It is suspected that remedies might have contained substances contaminated with spores of Clostridium tetani, the causative agent of tetanus.

The deaths led to World Health Organisation meeting which came out with a recommendation for Tetanus as part of the medical male circumcision.  

Safe medical male circumcision or Voluntary medical male circumcision (VMMC) - a surgical procedure that involves the complete removal of the foreskin by a trained medical professional - has been shown to be effective in the prevention of HIV transmission.

In 2007, WHO and the Joint United Nations Programme on HIV /AIDS  recommended that 14 priority countries with high HIV and low male circumcision prevalence in Southern and Eastern Africa consider implementing VMMC as a key intervention in their HIV prevention portfolio.

This massive public health intervention launched in 2009 with support from WHO/UNAIDS calling for 80% coverage of male circumcision by 2016. 

In Uganda about 2.7 million circumcisions have been carried out since 2010. The health ministry had targeted to have 4.2 million men by end of this year.