Tetanus Affects Uganda's Medical Male Circumcision Rollout Top story

5541 Views Kampala, Uganda

In short
Hospitals registering lower circumcisions since Ministry of health came out with the guidelines including tetanus toxiod vaccination as part of the Safe Medical Male circumcision.

The number of men seeking medical circumcision services has declined following a requirement by the health ministry that  men seeking to be circumcised must first be immunized  against tetanus.

The Director General of Health Services Dr. Ruth Achieng in December last year issued a circular to health facilities directing that circumcisions could only be done only  after to clients are  immunized against tetanus.

That according to Achieng  would protect the clients against tetanus, a severe and potentially fatal infection caused by the anaerobic bacterium spores found in soil and dust.

Her circular followed confirmation that nine newly circumcised men in Uganda, Rwanda, Kenya and Zambia had died after tetanus infection.

Two of the four tetanus cases recorded in Uganda followed circumcision with the elastic collar  compression device of circumcision, according to the World Health Organization.

The elastic collar compression device, which had been prequalified by WHO in 2013, has been used in research studies and pilot implementation programmes.
It is being progressively rolled out under active surveillance. By September 2014 approximately 25 000 circumcisions had been performed using this method.

In mid-March 2015, the World Health Organisation held a meeting which considered arguments for immunization strategies that Safe Medical Male circumcision for HIV prevention progarmmes  could consider, including  providing one or two tetanus toxiod doses prior to circumcision.

Now in Uganda, men seeking to be circumcised have to be vaccinated, wait for 28 days, return to the health facility to receive another vaccination and then get circumcised.

Safe Medical Male Circumcision service providers say very few circumcisions are being carried out since tetanus vaccination was made part of the requirements.

Dr. Denis Bbaale, the Voluntary Medical Male Circumcision Manager at Infectious Diseases Institute said it was vital for men to be immunized against tetanus. He said it has however posed a challenge  to circumcision as an HIV prevention method.

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Infectious Diseases Institute has had over two hundred thousand men circumcised in Kampala and in mid-Western districts of Hoima, Kibale, Kiryandongo and Masindi.

The drop in the number of men being circumcised as a method for HIV prevention is generating debate on whether Uganda needs to have all men vaccinated against tetanus.

Gulu Regional Referral Hospital is one of the regional hospitals that are offering Safe Medical Male Circumcision under a USAID project known as  Strengthening Uganda's Systems for Treating AIDS Nationally (SUSTAIN).

Hope Kusasira, a surgeon at Gulu Regional Referral Hospital said the number Safe Male Circumcision under Gulu regional referral hospitals have drastically dropped.  

He said tetanus vaccinations have routinely been given to women, girls and all babies at birth but not to men and boys. Men according to Kusasira don't see the value of being vaccinated twice before they could be circumcised.

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He says, clients were not returning for the second vaccination and circumcision after 28 days.
There is no vaccination policy in Uganda for boys and men. In 2011 Uganda was declared to have eliminated maternal and neonatal tetanus.

Meanwhile a source who has been involved in the Safe Medical Male Circumcision told Uganda Radio Network that there seems to be a fight within Ministry of Health on whether or not to implement the two vaccination cycles for circumcision as HIV prevention program.

Also there is concern that providing Tetanus as a requirement for Safe Medical Circumcision would mean diverting vaccines from women of reproductive age.

Part of the problem is the source of funding to equip all the hospitals and health centers offering Safe medical circumcision services. 

Most of the funding for circumcision comes from the US government through  the Presidential Plan for AIDS  Relief(Pepfer) and the Global fund on TB and Malaria.

The two donors according to the source had not planned for Tetanus vaccines as part of Safe Medical Circumcision. 

Officially, the Ministry of Health has not come out with guidelines about how to implement the Tetanus in Safe Medical Circumcision.

One of the Safe Medical Service Providers told Uganda Radio Network that the absence of the official policy on tetanus has been an issue of contention. Some donors requiring results according to the source have asked those they are funding to continue as earlier planned.

Barbra Nanteza, the Safe Medical Male Circumcision coordinator could not be reached for comment. She twice cancelled scheduled appointment for interview about Uganda's progress on circumcision targets. 

Uganda Radio Network has information that a joint meeting to be attended by donors funding circumcision, implementing partners and Ministry of Health will be held on Friday 13th May. The meeting is expecting to discuss how to resolve the current standoff.

Safe Male Circumcision - SMC, (also known as Voluntary Medical Male Circumcision - VMMC) is a scientifically proven biomedical intervention for prevention of female-to-male transmission of HIV.

The World Health Organization and the United Nations Program on HIV/ AIDS recommend SMC for countries with a high prevalence of HIV and low prevalence of male circumcision. 

They said expanding circumcision services to 80% of adult men in fourteen countries in east and Southern Africa within five years would avert 3.4 million new HIV infections and result in net savings of US$16.5 billion by 2025 in treatment costs averted.

According to the Uganda Demographic and Health Survey conducted in 2006, only 25% of adults were circumcised and HIV prevalence among uncircumcised males was higher (6.7%) than in circumcised males (4.5%).

The National Policy on Safe Male Circumcision, developed by the Ugandan Ministry of Health in 2010, aims to circumcise 80% (4.2million) of all uncircumcised men of age 15-49 years by 2015.

Since Safe Male Circumcision began, evidence has shown that HIV incidence in the community in Uganda and South Africa decreased.

It was hoped that having four million men in Uganda circumcised by 2015 would avert about four hundred and thirty thousand new infections countrywide by 2025.

By end of last year, health facilities across the 112 districts were providing male circumcision in public and private hospitals.