Thursday, June 29, 2017

PRO/EDR> Tetanus - Italy: (SD) unimmunized child [EXTERNAL]

TETANUS - ITALY: (SARDINIA) UNIMMUNIZED CHILD
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[1]
Date: Wed 28 Jun 2017 14:50
Source: ANSA [edited]
<http://www.ansa.it/english/news/general_news/2017/06/28/first-tetanus-case-in-30-years_afb31c37-713f-4623-90bf-384dad9fd460.html>


An unvaccinated 10-year-old boy has developed tetanus, the 1st case in
children in Italy for 30 years, after falling off his bike and cutting
his head in Sardinia last weekend [24-25 Jun 2017], sources said. The
boy's parents reportedly refused treatment with an anti-tetanus gel,
sources at Oristano hospital said.

The boy's condition is improving and his life is not in danger
although he has typical symptoms including muscle cramps and some
paralysis of cranial nerves, they said.

--
Communicated by:
ProMED-mail from HealthMap Alerts
<promed@promedmail.org>

[It is unclear from the report what is meant by "anti-tetanus gel" but
probably is specific hyper-immune tetanus immunoglobulin although the
following post states it was tetanus toxoid. If the child was truly
unimmunized against tetanus, a combination of passive protection with
immunoglobulin and active immunization with toxoid is always
recommended. - Mod.LL]

******
[2]
Date: Thu 29 Jun 2017 10:17 CEST+02:00
Source: The Local [edited]
<https://www.thelocal.it/20170629/childs-tetanus-case-is-first-in-30-years>


A 10-year-old boy in Sardinia has been diagnosed with tetanus. "It's
an incredibly rare case," Giovani Zanda, head of the pediatric ward at
San Martino Di Oristano Hospital in western Sardinia, told Corriere
della Sera. It is the 1st registered case of tetanus in a child in
Italy for 30 years, according to a spokesperson for the country's
National Health Institute.

The 10-year-old boy was admitted to hospital with a cut to his
forehead caused by a bicycle injury a few weeks ago. Doctors back then
suggested a tetanus vaccination as a precaution but the parents
apparently refused it. When the child returned to hospital weeks
later, the tetanus had already incubated and reached an acute stage,
according to a report in ANSA. Doctors were alerted to the tetanus
symptoms after the patient experienced facial paralysis. The child has
been treated and is said to be in a stable condition.

The case however has raised alarm bells and adds weight to the
government's much-discussed recent law that makes vaccinations a
mandatory part of school inscription. The law makes 12 vaccinations
obligatory for all children. These include, among others, preventive
vaccinations for measles, hepatitis B and, tetanus. Several northern
regions have legally challenged the decree. According to the new law,
families who don't vaccinate their children aged between 6 and 16 will
be fined and directed to make an appointment with their closest health
center.

Families who don't adhere to the law could be fined up to 7500 or even
have be stripped of custody, according to Wired. The law comes into
effect from the beginning of the 2017-2018 school year and there is a
one-year transition period envisioned.

According to the Ministry of Health's own guidelines, the main changes
to the law involve an increase in the number of compulsory
vaccinations from 4 to 12. Vaccinations also become a mandatory
prerequisite for registration in kindergartens for children aged up to
6.

"The tetanus case represents an exception that certainly could have
been avoided if the young patient had been vaccinated," said Zanda,
the doctor who treated the child with tetanus, as reported in Corriere
della Sera.

--
Communicated by:
ProMED-mail
<promed@promedmail.org>

[This case is reported to be the 1st case of tetanus in a child in
Italy but certainly not the 1st case of tetanus in 30 years overall.
The following paper discusses adult cases of tetanus in the county
occurring in the period between 2001 and 2010:

Filia A, Bella A, von Hunolstein C, et al: Tetanus in Italy 2001-2010:
a continuing threat in older adults. Vaccine. 2014;32: 639-644.

Abstract:
"Despite being a completely preventable disease, tetanus cases
continue to occur in Italy and notification and hospitalization rates
have been reported to be higher with respect to European and other
industrialized countries. We examined statutory notification,
hospitalization, mortality and seroprevalence data to describe tetanus
epidemiology in Italy from 2001 to 2010. A total of 594 tetanus cases
were notified, with an average annual incidence of 1.0/1 000 000
population. Most cases were unvaccinated or incompletely vaccinated.
80 percent of cases occurred in subjects aged >64 years and a higher
proportion of females with respect to males were reported in this age
group. The annual number of hospital admissions was 1.4-1.7 times
greater than the number of notifications in the same year. The mean
annual number of reported deaths was 21. Seroprevalence data show
progressively higher susceptibility levels with increasing age. Over
50 percent of persons aged 45-64 years and over 2 3rds of subjects
≥65 years had tetanus antibody levels <0.01 IU/ml. Results show that
tetanus is a continuing problem in Italy and, as in other countries,
most cases occur in older adults, especially elderly women. The
observed differences in notification and hospitalization rates suggest
underreporting by physicians. In recent years, Italy has accounted for
most cases reported annually in the European Union (EU) but different
case definitions are used. In Italy, a confirmed case is one that
meets the clinical case definition while the EU case definition
classifies confirmed cases as those with laboratory confirmation of
disease. The incidence of clinical tetanus in Italy is 10-fold higher
than in other industrialized countries, like Australia and Canada,
likely due to higher susceptibility levels in Italy. In view of the
low prevalence of tetanus antibodies in adults ≥45 years, strategies
to improve vaccine uptake in this population group need to be
implemented."


Tetanus is a potentially fatal disease characterized by skeletal
muscle rigidity and painful convulsive spasms, which are caused by a
potent neurotoxin, tetanospasmin, produced by the vegetative form of
_Clostridium tetani_, an anaerobic spore-forming Gram-positive
bacillus. _C. tetani_ is a member of the normal intestinal flora of
animals, including humans. Tetanus usually occurs following
contamination of wounds by soil or animal feces in which the spores of
_C. tetani_ can be found.

Tetanus may follow surgical procedures, burns, deep puncture wounds,
crush wounds, otitis media, dental infection, animal bites, abortion
and pregnancy. The presence of necrotic tissue and/or foreign bodies
increases risk for tetanus because they favor growth of _C. tetani_.
Tetanus can also follow injection of contaminated illicit drugs.

Neonatal tetanus occurs usually in developing countries in infants
with infection of the umbilical stump who are born to a non-immune
mother. Infants of actively immunized mothers acquire passive immunity
that protects them from neonatal tetanus. Tetanus is not directly
transmitted from person to person.

Tetanus occurs in people who are inadequately immunized, i.e., people
who have not completed the primary series and received appropriate
boosters. Recovery from tetanus is not necessarily associated with
immunity, and primary immunization is indicated after recovery from
tetanus.

A discussion of wound management and treatment of tetanus can be found
at:
<http://www.cdc.gov/vaccines/pubs/pinkbook/downloads/tetanus.pdf>.

The following is extracted from the CDC vaccination recommendations
for tetanus
(<http://www.cdc.gov/vaccines/vpd-vac/tetanus/default.htm>):

"There are 4 combination vaccines used to prevent diphtheria, tetanus
and pertussis: DTaP, Tdap, DT, and Td. Two of these (DTaP and DT) are
given to children younger than 7 years of age, and 2 (Tdap and Td) are
given to older children and adults. Several other combination vaccines
contain DTaP along with other childhood vaccines.

Children should get 5 doses of DTaP, one dose at each of the following
ages: 2, 4, 6, and 15-18 months and 4-6 years. DT does not contain
pertussis and is used as a substitute for DTaP for children who cannot
tolerate pertussis vaccine. Td is a tetanus-diphtheria vaccine given
to adolescents and adults as a booster shot every 10 years, or after
an exposure to tetanus under some circumstances. Tdap is similar to Td
but also contains protection against pertussis. Adolescents 11-18
years of age (preferably at age 11-12 years) and adults 19 through 64
years of age should receive a single dose of Tdap. For adults 65 and
older who have close contact with an infant and have not previously
received Tdap, one dose should be received. Tdap should also be given
to 7-10 year olds who are not fully immunized against pertussis. Tdap
can be given no matter when Td was last received.

[Upper-case letters in these abbreviations denote full-strength doses
of diphtheria (D) and tetanus (T) toxoids and pertussis (P) vaccine.
Lower-case "d" and "p" denote reduced doses of diphtheria and
pertussis used in the adolescent/adult-formulations. The "a" in DTaP
and Tdap stands for "acellular," meaning that the pertussis component
contains only a part of the pertussis organism.]." - Mod.LL

A HealthMap/ProMED-mail map can be accessed at:
<http://healthmap.org/promed/p/13544>.]

[See Also:
Tetanus - Australia (02): (SA) child
http://promedmail.org/post/20170428.5001940
Tetanus - Australia: (NSW) unimmunized child
http://promedmail.org/post/20170325.4925759
Tetanus, obstetric - USA: (KY) unvaccinated woman
http://promedmail.org/post/20170323.4921358
2016
----
Tetanus - Solvenia http://promedmail.org/post/20161017.4566112
Yaws, maternal/neonatal tetanus - India: elimination
http://promedmail.org/post/20160717.4350313
2015
----
Tetanus - Bangladesh: (Rangpur)
http://promedmail.org/post/20151002.3683738
Tetanus - Canada: (ON) unimmunized child
http://promedmail.org/post/20150603.3404735
Tetanus - USA: (CA) missed postexposure prophylaxis, 2008-14
http://promedmail.org/post/20150315.3230177
2014
----
Tetanus - USA: (Alaska) http://promedmail.org/post/20141229.3059009
2011
----
Tetanus - USA: (MI) http://promedmail.org/post/20110731.2301
2007
----
Tetanus, injection-related - USA (NY) ex Dominican Republic (03)
http://promedmail.org/post/20070613.1927
Tetanus, injection-related - USA (NY) ex Dominican Republic (02)
http://promedmail.org/post/20070612.1915
Tetanus, injection-related - USA (NY) ex Dominican Republic
http://promedmail.org/post/20070611.1904
2005
----
Tetanus, earthquake-related - Pakistan
http://promedmail.org/post/20051028.3143
Tetanus, tsunami-related - Asia (Indonesia) (04)
http://promedmail.org/post/20050116.0133
Tetanus, tsunami-related - Asia (Indonesia) (03)
http://promedmail.org/post/20050114.0120
Tetanus, tsunami-related - Asia (Indonesia)(02)
http://promedmail.org/post/20050107.0039
Tetanus, tsunami-related - Asia (Indonesia): RFI
http://promedmail.org/post/20050106.0030
2003
----
Tetanus, parenteral drug users - UK
http://promedmail.org/post/20031129.2952]
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