Tetanus is a vaccine-preventable disease that yearly causes a total of 309,000 deaths. Of particular concern is maternal and neonatal tetanus (MNT), which can be prevented through immunization of the mother in pregnancy. In 2000, neonatal tetanus alone was responsible for an estimated 200,000 deaths. While the focus is on 57 priority countries, 90% of the neonatal tetanus deaths occur in 27 countries. UNICEF is spearheading the effort to eliminate MNT by the year 2005, with the support of numerous partners. MNT elimination is defined as less than one case of neonatal tetanus per 1000 live births at district level. The main strategies consist of promotion of clean delivery practices, immunization of women with a tetanus toxoid (TT) containing vaccine, and surveillance. Maternal tetanus immunization is, in most developing countries, implemented as part of the routine immunization program. However, large areas remain underserved, due to logistical, cultural, economical or other reasons. In order to achieve the target of MNT elimination by 2005, and to offer protection to women and children otherwise deprived from regular immunization services, countries are encouraged to adopt the "high risk approach". This approach implies that, in addition to routine immunization of pregnant women, all women of child bearing age living in high risk areas are targeted for immunization with three doses of a tetanus toxoid containing vaccine (TT or Td), implemented as "supplemental immunization activities" (SIAs). Through SIAs, about 17 million women have been reached with at least two doses of TT vaccine in the past 3 years, and it is estimated that another 200 million need to be targeted in the years to come. SIAs should substantially reduce the burden of disease. Countries will also have to improve their existing immunization and clean delivery programs to ensure that the elimination of maternal and neonatal tetanus is maintained.