*Article* **Tetanus and Diphtheria Seroprotection among Children Younger Than 15 Years in Nigeria, 2018: Who Are the Unprotected Children?**

**Rania A. Tohme 1,\*,†, Heather M. Scobie 1,†, Oyeladun Okunromade 2, Temitope Olaleye 3, Faisal Shuaib 4, Tunde Jegede 2, Ridwan Yahaya 2, Ndodo Nnaemeka 2, Bola Lawal 2, Abiodun Egwuenu 2, Nishanth Parameswaran 5, Gretchen Cooley 5, Qian An 1, Melissa Coughlin 6, Bassey B. Okposen 4, Ifedayo Adetifa 2, Omotayo Bolu <sup>1</sup> and Chikwe Ihekweazu <sup>2</sup>**


**Abstract:** Serological surveys provide an objective biological measure of population immunity, and tetanus serological surveys can also assess vaccination coverage. We undertook a national assessment of immunity to tetanus and diphtheria among Nigerian children aged <15 years using stored specimens collected during the 2018 Nigeria HIV/AIDS Indicator and Impact Survey, a national cross-sectional household-based survey. We used a validated multiplex bead assay to test for tetanus and diphtheria toxoid-antibodies. In total, 31,456 specimens were tested. Overall, 70.9% and 84.3% of children aged <15 years had at least minimal seroprotection (≥0.01 IU/mL) against tetanus and diphtheria, respectively. Seroprotection was lowest in the north west and north east zones. Factors associated with increased tetanus seroprotection included living in the southern geopolitical zones, urban residence, and higher wealth quintiles (*p* < 0.001). Full seroprotection (≥0.1 IU/mL) was the same for tetanus (42.2%) and diphtheria (41.7%), while long-term seroprotection (≥1 IU/mL) was 15.1% for tetanus and 6.0% for diphtheria. Full- and long-term seroprotection were higher in boys compared to girls (*p* < 0.001). Achieving high infant vaccination coverage by targeting specific geographic areas and socio-economic groups and introducing tetanus and diphtheria booster doses in childhood and adolescence are needed to achieve lifelong protection against tetanus and diphtheria and prevent maternal and neonatal tetanus.

**Keywords:** seroprevalence; tetanus; diphtheria; Nigeria; serology; vaccine preventable diseases
