Recording vaccine doses administered: A global analysis of tally sheet design for infant and child immunizations

Recording vaccine doses administered: A global analysis of tally sheet design for infant and child immunizations | medRxiv /* */ /* */ <!-- <!-- /*! * yepnope1.5.4 * (c) WTFPL, GPLv2 */ (function(a,b,c){function d(a){return"[object Function]"==o.call(a)}function e(a){return"string"==typeof a}function f(){}function g(a){return!a||"loaded"==a||"complete"==a||"uninitialized"==a}function h(){var a=p.shift();q=1,a?a.t?m(function(){("c"==a.t?B.injectCss:B.injectJs)(a.s,0,a.a,a.x,a.e,1)},0):(a(),h()):q=0}function i(a,c,d,e,f,i,j){function k(b){if(!o&&g(l.readyState)&&(u.r=o=1,!q&&h(),l.onload=l.onreadystatechange=null,b)){"img"!=a&&m(function(){t.removeChild(l)},50);for(var d in y[c])y[c].hasOwnProperty(d)&&y[c][d].onload()}}var j=j||B.errorTimeout,l=b.createElement(a),o=0,r=0,u={t:d,s:c,e:f,a:i,x:j};1===y[c]&&(r=1,y[c]=[]),"object"==a?l.data=c:(l.src=c,l.type=a),l.width=l.height="0",l.onerror=l.onload=l.onreadystatechange=function(){k.call(this,r)},p.splice(e,0,u),"img"!=a&&(r||2===y[c]?(t.insertBefore(l,s?null:n),m(k,j)):y[c].push(l))}function j(a,b,c,d,f){return q=0,b=b||"j",e(a)?i("c"==b?v:u,a,b,this.i++,c,d,f):(p.splice(this.i++,0,a),1==p.length&&h()),this}function k(){var a=B;return a.loader={load:j,i:0},a}var l=b.documentElement,m=a.setTimeout,n=b.getElementsByTagName("script")[0],o={}.toString,p=[],q=0,r="MozAppearance"in l.style,s=r&&!!b.createRange().compareNode,t=s?l:n.parentNode,l=a.opera&&"[object Opera]"==o.call(a.opera),l=!!b.attachEvent&&!l,u=r?"object":l?"script":"img",v=l?"script":u,w=Array.isArray||function(a){return"[object Array]"==o.call(a)},x=[],y={},z={timeout:function(a,b){return b.length&&(a.timeout=b[0]),a}},A,B;B=function(a){function b(a){var a=a.split("!"),b=x.length,c=a.pop(),d=a.length,c={url:c,origUrl:c,prefixes:a},e,f,g;for(f=0;f<d;f++)g=a[f].split("="),(e=z[g.shift()])&&(c=e(c,g));for(f=0;f<b;f++)c=x[f](c);return c}function g(a,e,f,g,h){var i=b(a),j=i.autoCallback;i.url.split(".").pop().split("?").shift(),i.bypass||(e&&(e=d(e)?e:e[a]||e[g]||e[a.split("/").pop().split("?")[0]]),i.instead?i.instead(a,e,f,g,h):(y[i.url]?i.noexec=!0:y[i.url]=1,f.load(i.url,i.forceCSS||!i.forceJS&&"css"==i.url.split(".").pop().split("?").shift()?"c":c,i.noexec,i.attrs,i.timeout),(d(e)||d(j))&&f.load(function(){k(),e&&e(i.origUrl,h,g),j&&j(i.origUrl,h,g),y[i.url]=2})))}function h(a,b){function c(a,c){if(a){if(e(a))c||(j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}),g(a,j,b,0,h);else if(Object(a)===a)for(n in m=function(){var b=0,c;for(c in a)a.hasOwnProperty(c)&&b++;return b}(),a)a.hasOwnProperty(n)&&(!c&&!--m&&(d(j)?j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}:j[n]=function(a){return function(){var b=[].slice.call(arguments);a&&a.apply(this,b),l()}}(k[n])),g(a[n],j,b,n,h))}else!c&&l()}var h=!!a.test,i=a.load||a.both,j=a.callback||f,k=j,l=a.complete||f,m,n;c(h?a.yep:a.nope,!!i),i&&c(i)}var i,j,l=this.yepnope.loader;if(e(a))g(a,0,l,0);else if(w(a))for(i=0;i (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0];var j=d.createElement(s);var dl=l!='dataLayer'?'&l='+l:'';j.src='//www.googletagmanager.com/gtm.js?id='+i+dl;j.type='text/javascript';j.async=true;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-P4HH5NV'); Skip to main content Home About Submit ALERTS / RSS Search for this keyword Advanced Search Recording vaccine doses administered: A global analysis of tally sheet design for infant and child immunizations Ariel Higgins-Steele , View ORCID Profile Stephanie Shendale , View ORCID Profile Jan Grevendonk , Marta Gacic-Dobo , M. Carolina Danovaro-Holliday doi: https://doi.org/10.1101/2025.07.10.25331280 Ariel Higgins-Steele 1 Department of Immunization, Vaccines and Biologicals, World Health Organization , 1211 Geneva, Switzerland Find this author on Google Scholar Find this author on PubMed Search for this author on this site For correspondence: higginssteelea{at}who.int Stephanie Shendale 1 Department of Immunization, Vaccines and Biologicals, World Health Organization , 1211 Geneva, Switzerland Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Stephanie Shendale Jan Grevendonk 1 Department of Immunization, Vaccines and Biologicals, World Health Organization , 1211 Geneva, Switzerland Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Jan Grevendonk Marta Gacic-Dobo 1 Department of Immunization, Vaccines and Biologicals, World Health Organization , 1211 Geneva, Switzerland Find this author on Google Scholar Find this author on PubMed Search for this author on this site M. Carolina Danovaro-Holliday 1 Department of Immunization, Vaccines and Biologicals, World Health Organization , 1211 Geneva, Switzerland Find this author on Google Scholar Find this author on PubMed Search for this author on this site Abstract Full Text Info/History Metrics Data/Code Preview PDF Abstract Most countries use tally sheets across immunization programmes for health workers to mark vaccine doses administered to every person, alongside home-based records, yet their design and use is poorly understood at the global level. This paper presents a multi-country analysis on routine childhood immunization tally sheet content and design sourced from the annual electronic WHO/UNICEF Joint Reporting Form on Immunization (eJRF), which collected these forms for the first time in 2024 (for 2023). Of the total submissions (N=71) of tally sheets by reporting entities, 51 submissions met the criteria for inclusion as a valid tally sheet allowing for data extraction. The 51 tally sheets were from countries across all six regions of the World Health Organization (WHO) and all four World Bank income classifications. Analysis showed heterogeneity in immunization tally sheet design, core data fields, and the extent that the available tally sheets aligned with globally recommendations found in recent vaccine-specific and programmatic guidance related to catch-up vaccination. As national immunization programmes and vaccination schedules protect against more diseases, and thereby become more complex, fit-for-purpose tally sheet design and instructions as well as support mechanisms for health workers on tally sheet use are essential, similar to what is recommended for home-based records. Introduction Tally sheets are the main recording tool for health workers to mark each time a vaccine dose is given at the point-of-delivery. They are also used to aggregate total doses administered, often monthly, but sometimes more frequently, to monitor performance against health facility targets. [ 1 ]. Tally sheets complement other immunization and primary health care recording and reporting tools such as vaccine stock management tracking and immunization registers and home-based records, often known as vaccination cards, where doses are also recorded each time an individual is vaccinated. Global immunization guidance recommends tally sheets include specific data elements, e.g. neonatal tetanus protection at birth [ 2 ], hepatitis B birth dose timing (timely ≤24 hours or >24 hours) [ 3 ], and age segregation of on-time vaccine doses and late or delayed vaccine doses [ 4 ]. Beyond these recommendations, there is currently no global guidance specific to the design of tally sheets due to the heterogeneity of vaccination schedules and immunization data systems. Furthermore, though often just for immunization, some tally sheets may include other interventions such as vitamin A supplementation and antiparasitic drugs. Most supplementary immunization activities (vaccination campaigns) employ different tally sheets designed specifically for said campaign. Global guidance for home-based records [ 5 , 6 ] provides considerations on simple, user-friendly design, though it is for a different vaccination record and geared towards a caregiver. A country updates its tally sheet and other recording and reporting tools each time a new vaccine or dose is introduced, or when any change in the recommended vaccination schedule occurs [ 7 ]. New vaccine introduction and renewed emphasis on making catch-up an integral part of immunization programmes, including initiatives such as the Big Catch-up [ 8 , 9 ] provide opportunities for a country to review and revise its immunization tally sheet. To accurately capture doses administered, a well-designed tally sheet includes date, vaccination clinic or post and session characteristics (e.g. fixed or outreach), some data about the person receiving the vaccine, and dose and vaccine information aligned to the national immunization schedule. These data fields should be displayed in a simple, user-friendly format with instructional elements for a health worker to mark doses administered during vaccination activities. This paper presents a multi-country analysis on routine childhood immunization tally sheet design and content sourced from the annual electronic WHO/UNICEF Joint Reporting Form on Immunization (eJRF), which collected these forms for the first time in 2024 (for tally sheets used in 2023). Materials and Methods In 2023, as part of the annual electronic WHO/UNICEF Joint Reporting Form on Immunization (eJRF) process, all reporting entities (N=214) were asked what type of system (paper, digital, or hybrid) was used to record routine vaccination doses. A total of 208 reporting entities submitted eJRF data in 2024 for the previous year. Those responding paper or hybrid to record routine doses were requested to submit a copy of their immunization tally sheet. The request was included within the systems indicators section of the eJRF, under paper-based systems, and worded as: “please upload a copy or image of the tally sheet and other aggregate/summary forms”. Tally sheets used by the national immunization programme for routine immunization, and not for vaccination campaigns, were requested. This was the first time that countries were asked to share tally sheet documents via the eJRF; this question was added in order to have more information to guide catch-up efforts and thus allowing for a cross-country analysis and comparison of submitted tally sheets. Documents submitted by countries were reviewed by at least two of the authors and screened for inclusion. Document types excluded from the analysis included formats corresponding to reports (monthly, annual, or vaccine stock), home-based records, and tally sheets specifically for vaccines beyond childhood (e.g. HPV vaccination for adolescents). Priority data elements of tally sheets were jointly identified by three members of the research team with expertise in immunization data systems and life-course strategies for vaccination. Tally sheets in English, French and Spanish were verified by members of the team with fluency in the language and assisted by Google Lens for other languages. Data was then extracted, cross-checked, and analyzed. Descriptive analysis provided the number and proportion of WHO reporting entities of included tally sheets, and results were compiled at the global and WHO regional levels, as well as by World Bank income classification (2024 revision) [ 10 ]. Of the total submissions (n=71) under the category of tally sheets, 51 submissions met the criteria for inclusion as a valid tally sheet sufficient for data extraction 1 ; 20 were excluded as classified in Figure 1 . Download figure Open in new tab Figure 1. Selection process for tally sheet analysis Of the retained tally sheets 49 were for member states and 2 were from other reporting entities, i.e. territories. There are several limitations to this analysis. Tally sheet review was restricted to the submitted document; a country may have a tally sheet example, though if it was not submitted or a document not meeting inclusion criteria was submitted in its place, it is not part of the analysis. Varying quality of some tally sheets (e.g. partial screenshot or blurry photo) led to exclusion of one tally sheet. The sample of tally sheets reviewed is not representative. The review does not include associated materials, i.e. if there are accompanying materials, i.e. a cover page with location information, or instructions on how to use a country’s tally sheet that were not submitted. Finally, this analysis focuses on tally sheet design and does not assess how tally sheets are used in practice alongside other recording and reporting tools. Results Tally sheets Among the 51 retained tally sheets, these are from all six WHO regions and all four World Bank income classifications [ 10 ] (see Table 1 ). In terms of language, 21 tally sheets retained are in English, 13 are in French, 5 are in Spanish and the remaining 12 were in other languages. View this table: View inline View popup Download powerpoint Table 1. Tally sheets retained for analysis by WHO region and World Bank income Three broad styles are observed (see Figure 2 ): tally by doses and age groups for which a vaccine is administered, contact points for doses of vaccine by recommended age of administration and age group given, and register-style line-listing children by name, date of birth, and date of vaccine doses administered. Download figure Open in new tab Download figure Open in new tab Figure 2. Types of tally sheets (illustrative) Site and session characteristics Core elements of immunization site and session characteristics include location or health facility name, date/timeframe, and service delivery modality. A location field to designate where doses are administered was observed in most tally sheets (n=44, 86%); some tally sheets included write-in section for subnational administrative areas whereas others simply had a field titled “location” or “health facility” with a line to fill in text. Date was included in almost all tally sheets (n=50, 98%) either at the top of the sheet indicating a month or specific date of the immunization activity. In register-style design (C in the examples above), date fields were multiple and linked to an individual visit and/or vaccines doses administered on specific dates. Service delivery modality refers to whether the doses tallied were at a fixed site such as a health facility, at an outreach location, or by a mobile team. Service delivery modality was specified in 28 or 55% of tally sheets and not specified in 22 or 43%. Data entry fields specifying location and date were observed in most (44 or 86% for location; 50 or 98% for date), but not all submissions reviewed. It is possible that electronically generated or booklet versions of the tally sheets with elements or fields not seen may have this information. Service modality specifying whether doses were given at a fixed site, through outreach by health workers to a designated location in a community, or through mobile teams was observed most frequently in submissions from the African region (18 of 23 tally sheets from countries in this region). View this table: View inline View popup Table 2. Occurrence of characteristics by WHO region for recording immunization data on country tally sheets View this table: View inline View popup Table 3. Occurrence of characteristics by World Bank income classification for recording immunization data on country tally sheets by country income Child characteristics More than three quarters of tally sheets (n=42, 82%) have the possibility of capturing older aged children being vaccinated with delayed doses (also called catch-up), i.e. for age ranges above the recommended target age for vaccination according to the national schedule. Age segregation may be under-/over-specific a specific age, e.g. 1 year, or have dose and age-related specifications, e.g. 0-11 months, 12-23 months, and 24-59 months. For example, if measles-containing vaccine second dose (MCV2) is recommended at 15 or 18 months, a tally sheet that permits recording of catch-up doses would include a space to record an MCV2 dose given at or after 24 months of age. Of the tally sheets with age segregation, 23 tally sheets did not have an upper age by which catch-up vaccine doses could be recorded (i.e. age column remained open, for example, 24m+), whereas 13 tally sheets indicated a closed age threshold such as 12-59 months, or specific to each dose (e.g. Rotavirus dose 1 given between 2-4 months and Rotavirus 2 given between 4-7 months). Nine tally sheets (18%) were restrictive by age to infants and young children with upper age thresholds at or below 24 months. Other dimensions of disaggregation observed included sex, ethnicity, legal status, and specific population groups. Download figure Open in new tab Figure 3. Age groupings for recording late doses For sex-disaggregation, 20 tally sheets (39%) included data elements to mark whether the child is female or male, and 31 tally sheets (61%) did not specify. Almost a quarter of tally sheets (n=12 or 24%) had a field to mark whether a child was fully immunized. Three of these tally sheets specify fully immunized below 1 year of age; one tally sheet specified whether fully immunized by 2 years of age. One tally sheet has in line instructions to assess a child’s immunization status, i.e. “Fully Immunized (FIC) after MR1. Verify if the child has received BCG, OPV 1-3, PCV 1-3), Penta 1-3), RVV 1-2, MR1 and Y/Fever vaccines according to schedule.” Download figure Open in new tab Figure 4. Example tally sheet for indicating fully vaccinated by two age groupings Vaccine and dose information A few countries (n=9, 18%) included tally fields related to newborn protection against tetanus. Among these, all have achieved neonatal tetanus elimination and none corresponded to the 10 countries where maternal and neonatal tetanus is still a public health problem [ 11 ]. Some countries include brief instructions, i.e. one tally sheet specifies: “verify from mother’s Td [tetanus/diphtheria vaccine] record.” Another tally sheet indicates to check children vaccinated for Penta1 [first dose of a pentavalent vaccine DTP-Hib-HepB] if protected at birth against neonatal tetanus, and a third tally sheet’s in-line instruction for tetanus protection at birth is to: “tally a child who’s [sic] mother has received 2 or more doses of Td doses during the last pregnancy.” For Hepatitis B birth dose timing, 14 (28%) tally sheets have separate fields for below 24 hours and above 24 hours. Among these countries, the upper age limit varies, e.g. two countries (>24 hours and up to 14 days or 2 weeks), one country (2 to 42 days), another example (>24 hours and up 11 months), and another (>24 hours and up to 11 months, 1-4 years, or 5-14 years) For the upper age limit for rotavirus vaccination, 21 tally sheets (41%) had some designation: 11 indicated an upper age limit of 2 years, 9 indicated an upper age limit of 12 months, and one indicated an upper age limit of 8 months. The remaining countries either did not specify or do not have rotavirus in the national vaccination schedule. Format A majority of tally sheets line list doses (n=43, 84%), typically vertically, while the remaining tally sheets group by contact (n=6, 16%). Almost half of tally sheets (n=24, 47%) have an explicit way of marking a dose given, i.e. with a fill-in circle or box. More than half of tally sheets (n=27, 53%) have a blank field which allows for different ways of marking, i.e. hash marks, numbers. etc. Subtotal and grand totals are seen with different data elements, e.g. when there is age and/or sex segregation for specific doses. Subtotals and grand totals provide fields to summarize values on a tally sheet for other recording tools, e.g. monthly reports. 35 (69%) of tally sheets had subtotals, and 17 (33%) had grand totals (see Figure 5 for examples). Subtotals may be for age of dose given or by sex: for example, the tally sheet of one African country will subtotal doses given >1 year and <1 year for each dose, (and does not have a grand total). Grand totals fields exist in 17 (33%) of tally sheets. Download figure Open in new tab Download figure Open in new tab Figure 5. Examples of tally sheets fields for aggregation Instructions Few tally sheets included basic instructions and/or examples of how to fill a tally sheet (n=8, 16%) whereas the rest (n=43, 84%) had no instructions. Examples of instructions ranged from basic, i.e. one country in the AFRO region: “ Pour chaque vaccin administré à l’enfant barrer un cercle correspondant à l’âge et à l’antigène concerné. Le total pour chaque antigène d’après la tranche d’âge sera reporté dans le formulaire n° 1 PEV du mois en cours ” [For each vaccine administered to the child, cross out a circle corresponding to the age and the antigen concerned. The total for each vaccine does according to the age group will be reported on EPI form no. 1 for the current month], to more detailed including visual diagrams. Discussion Tally sheets are unequivocally an essential tool for health workers and programme managers. Especially in low-resource settings, the tally sheet is the primary data recording and reporting instrument for health workers alongside the register book [ 12 , 13 ]. Basic recording and reporting practices link to several factors including design aspects presented in this analysis [ 14 ]. This first global analysis, though limited by only about a quarter of reporting entities submitting documents retained, shows heterogeneity in immunization tally sheet design and variation in the extent that sampled tally sheets are aligned with globally recommended elements found in recent vaccine-specific and programmatic guidance related to catch-up vaccination. Data elements in the tally sheets reviewed included site and session characteristics, national vaccine schedule, and programmatic priorities. Date and location provide a timeframe and area for which vaccine doses are given and tallied. Having service delivery strategy denoted – e.g. at a health facility fixed site, outreach, and mobile – captures data on the service modality by which children were reached, i.e. through care-seeking to a fixed site or by health workers bringing immunization services closer to communities. This service delivery data compiled across tally sheets can inform catchment area microplanning by considering proportion of infants and children in the catchment area reached by each service and refine resource allocation and scheduling [ 15 ]. Timely vaccination is important to ensure that populations are protected against vaccine-preventable diseases as early as possible, however, vaccinations may be missed for a wide variety of reasons leaving individuals vulnerable unless caught up. Restrictive data recording and reporting tools has been often cited as a barrier for health workers to administer delayed vaccination to children who are missing doses and contributes to missed opportunities for vaccination [ 16 ]. Catch-up vaccination has gained momentum globally with the Big Catch-up and countries have updated policies, schedules, and recording and reporting tools to reach older aged children who missed routine vaccinations [ 17 , 18 ]. Age segregation is critical to distinguish between ‘on-time’ vaccinations given and doses caught up among older children missing recommended doses, and tally sheets should be designed in a way that guides health workers to accurately record all vaccination doses, in line with the national catch-up policy and schedule [ 4 ]. For Hepatitis B birth dose, it is recommended for the tally sheet to distinguish between ‘timely’ doses given <24 hours – the main indicator for coverage – and more than 24 hours after birth [ 3 ]. Rotavirus vaccine doses have a recommended upper age threshold [ 19 ] seen in some of the tally sheet examples reviewed. MCV2 introduction experiences [ 20 ], and for all new vaccines introduced such as malaria vaccine with multiple doses [ 21 ], require appropriate age segregation in the tally sheet design. Gender inequality is a known predictor of childhood immunization coverage [ 22 ] but differences in coverage by sex, which is systematically monitored by immunization coverage surveys and electronic immunization registries where they exist, are generally not significant at the national level [ 23 ]. Sex segregation of doses administered, as seen in some tally sheets in this analysis, can further assist in identifying and understanding inequities in specific subnational areas, however, in order for this data to be actionable, reliable sex-specific denominators are needed. Sex disaggregation adds more data fields and variables so should be considered in relation to programme objectives, and with practical considerations like space on the page and font size as a factor. Ease of use of a tally sheet relates to the layout and clear designated ways to mark or tick, such as fill-in circles or boxes. To assist in reducing arithmetic errors during monthly data compilation [ 24 ], the format should be pre-tested and intuitive, and benefits from including sub-totals and grand totals to assist in aggregating as well as looking back to try to identify source or location of discrepancies. Instructions can provide some clarity for filling the tally sheet through an explanatory page, example filled format, and/or in-line brief definitions or reminders. Tally sheets are complementary to other immunization recording and reporting tools such as registers, monthly reports and home-based records. Review and revision of these tools should be done concurrently and with the appropriate definitions and instructional elements. Written tally sheet instructions alone are insufficient for good tally practice and require reinforcing through performance feedback, supportive supervision, and other mechanisms [ 25 ]. Immunization data quality in low and middle-income countries, characterized as varied, can be improved by appropriate data collection tools, increasing health workers’ capacities and motivation through training, motivation, and feedback [ 26 , 27 ]. Digitizing health worker tools through person-centered point of service systems is promising [ 28 , 29 ]. Reliance on paper-based methods at the point of delivery will continue in many countries in the meantime. Thus, efforts should be made to improve these tools and make them more user-centered. Furthermore, electronic immunization registries could eventually help reduce some of the challenges with paper systems, but feasibility needs to be assessed before completely replacing basic tools [ 30 ]. Even when the tally sheet is well designed, it needs to be available at all service delivery points. Stockouts of tally sheets occur in many countries [ 31 , 32 ] similar to stock-outs of home-based records [ 33 ], and relate to different factors such as changes in immunization schedules requiring updates to these records, with associated costs, and unclear responsibilities for printing and distribution [ 34 ]. As national immunization programmes and vaccination schedules protect against more diseases, and thereby become more complex, support mechanisms to health workers including fit-for-purpose tally sheet design and instruction, and associated supportive supervision and feedback are essential [ 35 ]. Data Availability Data related to the WHO/UNICEF Joint Reporting Form on Immunization can be found at: https://immunizationdata.who.int https://immunizationdata.who.int Ethics and consent No individual-level data were used in this study. Only country-level data officially reported by Ministries of Health to WHO and UNICEF were used. As a result, ethical approval and consent was not required. Competing interests None. Disclaimer The authors alone are responsible for the views expressed in this article and they do not necessarily represent the views, decisions or policies of the institutions with which they are affiliated. Author contributions Conceptualization: MCD-H, MGD, AHS Data extraction and analysis: AH-S, MCD-H, SS Validation: MCD-H, JG, SS, MGD Visualization: AH-S Writing – original draft: AH-S Writing – review and editing: MCD-H, JG, SS, MG-D Footnotes ↵ 1 Of the retained tally sheets 49 were for WHO member states and 2 were from other reporting entities, i.e. territories References 1. ↵ World Health Organization . Immunization in practice: a practical guide for health staff. 2015 update . Geneva : World Health Organization ; 2015 [cited 2025 Jun 4]. Available from: https://apps.who.int/iris/handle/10665/193412 2. ↵ World Health Organization . Protecting all against tetanus: guide to sustaining maternal and neonatal tetanus elimination (MNTE) and broadening tetanus protection for all populations . Geneva : World Health Organization ; 2019 [cited 2025 Jun 4]. Available from: https://iris.who.int/bitstream/handle/10665/329882/9789241515610-eng.pdf?sequence=1 3. ↵ World Health Organization . 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