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Home Eurosurveillance Weekly Release  2007: Volume 12/ Issue 25 Article 2
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Eurosurveillance, Volume 12, Issue 25, 21 June 2007
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Citation style for this article: Giovanetti F, Pellegrino A. A case of tetanus in a child whose parents refused immunisation – Piedmont Region, Italy, 2006. Euro Surveill. 2007;12(25):pii=3223. Available online: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=3223

A case of tetanus in a child whose parents refused immunisation – Piedmont Region, Italy, 2006

F Giovanetti (fgiovanetti@asl18.it)1, A Pellegrino2

1 Azienda Sanitaria Locale Alba Bra, Dipartimento di Prevenzione (Local Health Unit of Alba Bra, Department of Prevention), Alba, Italy
2 Azienda Sanitaria Locale 15, Dipartimento di Prevenzione (Local Health Unit 15, Department of Prevention) Cuneo, Italy

We describe a case of tetanus in a previously healthy 34-month old child living in Piedmont Region, in north-west Italy. His parents refused to continue immunisation after the first dose of vaccine: their decision was remarkably influenced by unfortunate misconceptions about the risks and benefits of immunisation.

At two months of age, the child received the first dose of a hexavalent combination vaccine diphtheria-tetanus-acellular pertussis-hepatitis B-inactivated polio virus-Haemophilus influenzae type b (DTaP-HBV-IPV/Hib). During the following days he was more irritable than usual and on day seven he developed atopic dermatitis. The parents became convinced that the atopic dermatitis had been induced by immunisation and that the administration of further vaccine doses would pose a threat to the health of their child. Moreover, they consulted a paediatrician who advised to postpone immunisation. The Local Health Unit applied the standard operating procedure to overcome their immunisation refusal (see discussion below), but the parents did not change their decision and signed a “refusal-to-immunise” waiver.

The child never presented a true contraindication to immunisation; in particular, there is little evidence that atopic dermatitis can be triggered or worsened by standard childhood vaccinations [1,2]. The “Guide to contraindications to immunisation” of the Italian Network of Immunisation Clinics does not consider atopic dermatitis as a contraindication to routine childhood immunisation [3].

Case description
In June 2006, the child hurt himself on an iron gate, and developed a mild trauma on his left thumb resulting in a superficial laceration which was cleaned and dressed by a physician, and did not require hospitalisation. According to the national recommendations on tetanus wound management, unimmunised or incompletely immunised persons should in such event receive tetanus immunoglobulin and a vaccine dose simultaneously. However, the parents did not indicate the immunisation status of their child, and therefore he did not receive any post-exposure prophylaxis.

Two weeks after the initial injury, the child was admitted to the district hospital with dysphagia, muscular stiffness, opisthotonus and trismus. After an initial assessment, the patient was transferred to the Intensive Care Unit of the Gaslini Hospital for Children in Genoa.

During the hospital stay, in-depth laboratory testing, neuroimaging studies and electromyography were performed. Their results were consistent with the diagnosis of tetanus.

The patient was treated with human tetanus immunoglobulin, ceftriaxone, metronidazole, midazolam, promazine, magnesium sulphate and phenobarbital. Finally, he recovered and after 15 days in hospital was discharged without any further treatment. A full series of vaccinations in accordance with the national immunisation schedule was begun and subsequently continued after hospital discharge, without any adverse event.

It seems unlikely that the vaccine dose administered 32 months before the injury could have modified the severity of tetanus in this case. Actually, there is evidence that the first dose of tetanus toxoid ensures little, if any, protection; only two to four weeks after the second dose the antitoxin usually exceeds the minimum protective concentration of 0.01 IU/ml and, finally, only the third dose induces a high antitoxin production, with mean levels between 1 and 10 IU/ml [4].

Discussion
In Italy, tetanus is subject to statutory reporting. Each case is to be reported within 12 hours to the Local Health Unit from where data are transmitted to the regional and national authorities. According to the national surveillance data, about 100 cases of tetanus occur every year in Italy, nearly all among unvaccinated or incompletely vaccinated elderly persons. During the period 1996-2003, no cases were notified in the age group 0 – 14 years [5,6].

Routine immunisation against tetanus was introduced in Italy for all newborns in 1968. The current vaccination schedule includes three doses of diphtheria, tetanus, acellular pertussis, poliomyelitis, hepatitis B, Haemophilus influenzae type b vaccine in the first year of life followed by a diphtheria, tetanus, acellular pertussis and polio booster dose at 5-6 years of age. The first and second dose of measles, mumps and rubella vaccine are administered at 12-15 months and at 5-6 years of age, respectively. Additional booster doses of a diphtheria, tetanus and acellular pertussis vaccine (adult Tdap formulation) are recommended every ten years.

Since 2000, childhood immunisation coverage in Italy among children below 24 months of age has stayed above 95% for diphtheria, tetanus, pertussis, poliomyelitis, hepatitis B and Haemophilus influenzae type b. Since 2004, the coverage rate for measles, mumps and rubella has been more than 85% [7]. No national data on the vaccine coverage are available for boosters and for 10-yearly boosters.

Immunisation rates in the Piedmont Region are high; in particular, coverage rate for tetanus toxoid (usually administered as a hexavalent vaccine) has always been equal to and in recent years even higher than the national average, ranging from 96.3% to 98.7% during the 2003-2005 period [8].

In Piedmont, childhood vaccination is provided by the immunisation clinics of the Local Health Units. Eligible children are actively offered and administered recommended vaccines, which are free of charge. At the same time, Local Health Units provide surveillance of infectious diseases, immunisation coverage and vaccine refusals.

In developed countries, objection to vaccination is the main risk factor for tetanus among children [9]. In Piedmont, objection to childhood immunisation is rare, accounting for less than 1% of children (range 0.0 – 2.5% according to the geographical area), and it is generally due to personal belief [8]. Regional immunisation guidelines prescribe that parents who delay immunisation without medical grounds or explicitly refuse it must receive from immunisation clinics additional and detailed information about vaccine preventable diseases, risks and benefits of immunisation and risks of missed vaccination. This is followed by a discussion with a physician from the immunisation clinic, who should make the best effort to facilitate an informed choice. Finally, parents who decide against vaccination are requested to sign a “refusal-to-immunise” waiver.

Anti-vaccine groups are quite active in Italy and publicise their theories through public conferences and on the Internet, a source that parents widely use for health information. Vaccine safety has received considerable media attention in Italy during the latest years. Newspaper articles and television programmes reported stories of parents who claimed their children had been damaged by a vaccine. Moreover, the views of individuals (including some physicians) and groups who oppose immunisation are usually widely covered by the media. As a result, parental concerns over vaccination safety issues have risen in recent years. At the same time, since universal immunisation produced an impressive decrease in the incidence of vaccine-preventable diseases, parents are not aware of the devastating effects of poliomyelitis, diphtheria, tetanus, measles and other vaccine-preventable diseases and therefore they may be unable to weigh up the true benefits and risks of vaccination [10].

In such a context, health care providers should be very clear that many common beliefs about the risks of immunisation are not supported by scientific evidence and that avoiding or postponing immunisation because of a false contraindication may have serious consequences. Furthermore, health professionals should educate parents in order to correct any misinformation about immunisation and to provide them with the best knowledge to make an informed decision [11].

References:
  1. Grüber C. Childhood immunisations and the development of atopic disease. Arch Dis Child. 2005;90:553-5.
  2. Kummeling I, Thijs C, Stelma F, Huber M, van den Brandt PA, Dagnelie PC. Diphtheria, pertussis, poliomyelitis, tetanus, and Haemophilus influenzae type b vaccinations and risk of eczema and recurrent wheeze in the first year of life: the KOALA Birth Cohort Study. Pediatrics 2007;119(2):e367-73. Available from: http://pediatrics.aappublications.org/cgi/reprint/119/2/e367
  3. Network italiano dei servizi di vaccinazione. Guida alle controindicazioni. 3^ edizione. 2005. Available from: http://www.epicentro.iss.it/focus/piano_prevenzione/niv.asp
  4. Galazka AM. The immunological basis for immunisation series: Module 3-tetanus.WHO/EPI/GEN/98.13.1993. Geneva: World Health Organization;1993. Available from: http://www.who.int/vaccines-documents/DocsPDF-IBI-e/mod3_e.pdf
  5. Pedalino B, Cotter B, Ciofi degli Atti M, Mandolini D, Parroccini S, Salmaso S. Epidemiology of tetanus in Italy in years 1971-2000. Euro Surveill 2002;7(7):103-110. Available from: http://www.eurosurveillance.org/em/v07n07/0707-221.asp
  6. Ministero della Salute. Malattie infettive. Ricerca dati epidemiologici. Available from: http://www.ministerosalute.it/promozione/malattie/bollettino.jsp
  7. Ministero della Salute. Coperture vaccinali. Available from: http://www.ministerosalute.it/promozione/malattie/dati_statistici.jsp?label=cop
  8. Regione Piemonte. Epidemiologia Piemonte. Coperture e attività vaccinali Regione Piemonte. Available from: http://epidem.asl20.piemonte.it/?sezione=231
  9. Fair E, Murphy TV, Golaz A, Wharton M. Philosophic objection to vaccination as a risk for tetanus among children younger than 15 years. Pediatrics. 2002;109(1):E2. Available from: http://pediatrics.aappublications.org/cgi/content/full/109/1/e2
  10. Chen RT, Orenstein WA. Epidemiologic methods in immunization programs. Epidemiol Rev. 1996;18(2):99-117. Available from: http://epirev.oxfordjournals.org/cgi/reprint/18/2/99.pdf
  11. Douglas S. Diekema and the Committee on Bioethics. Responding to Parental Refusals of Immunization of Children. Pediatrics 2005;115;1428-1431

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