Tetanus Epidemiology in Europe and in Italy: A Review
Tetanus Epidemiology in Europe and in Italy: A Review
Tetanus Epidemiology in Europe and in Italy: A Review
O RIGINAL A RTICLE
Ke y w o r ds
Tetanus Epidemiology
Su m m ary
A review of tetanus epidemiology in Europe and in Italy was
undertaken.
To this purpose data were collected from the following sources:
World Health Organizations Web page;
Eurosurveillance Weekly (Bulletin and Web page);
Italian Ministry of Health (Bulletin and Web page);
Publications from the National Institute of Statistics (ISTAT);
Tuscany Region Web page.
Moreover, a seroepidemiological study was performed on a sample of 522 subjects belonging to the open population of Southern Tuscany using an ELISA test.
Introduction
Seroepidemiological studies
SAMPLE SIZE
To estimate the sample size required, we preliminarily
studied 362 subjects stratified by sex and by the following age groups: 2-3, 13-14, 18-20, 23-24, 30-65 and
> 65 years. Based on the percentages of protected
subjects in each age group, (antitoxin titre > 0.1 IU/ml),
we estimated the sample size, admitting a 5% risk of
error, within each group, and a maximum of 10% inaccuracy. The total number of studied subjects was 522.
RECRUITMENT OF SUBJECTS
Subjects were recruited in 1997 by means of a systematic random sampling design. Blood samples were
drawn from subjects of a healthy open population who
applied to laboratories for screening purposes.
ANTITOXIN TITRATION
Sera were stored at -20C until titration and were tested
for tetanus antitoxin antibodies by enzyme linked immunosorbent assay (ELISA) (ARNIKA, Diagnostic Line, Milan, Italy).
The antibody titre was expressed in IU/ml in order to
compare it with standard international serum.
For the interpretation of results, the following scheme
was used 18:
< 0.1 IU/ml: no protection;
0.1-5 IU/ml: short term protection;
> 5 IU/ml: long-term protection.
STATISTICAL ANALYSIS
The following softwares were utilized: [Excel-version
8 (Microsoft-Corporation, Redmond, WA); Statviewversion 4 (Abacus-Concepts, Inc. Berkeley, CA) and
EPINFO-version 6.04 (Center for Disease ControlCDC, Atlanta)].
Results
VACCINE COVERAGE
According to WHO data, worldwide childrens vaccine
coverage against tetanus exceeds 80% 26 and immunization coverage with 2 doses of tetanus toxoid among
pregnant women catches up 64% 28. Coverage is generally high in Europe. In Finland and Hungary, for instance, it is virtually estimated at 100%, while in most
States it ranges from 90 % to 99% and is lower than
90% in the following Nations: Spain (88%), Armenia
(87%), Russia (87%), Estonia (85%), Greece (85%),
Malta (84%), Bosnia (79%), Turkey (79%), Latvia
(75%), Belgium (62%) and Germany (45%).
Further data released by the European Union are in disagreement with those mentioned above; the Weekly
Eurosurveillance Bulletin, for example, reports 94%
and 85% vaccine coverage for Belgium and Germany,
respectively.
Italian vaccine coverage, as shown by a research of the
Ministry of Health 17, as well as by a study conducted
by the Italian Vaccine Coverage Survey Working
Group 19 is around 95%. In particular, the initial results of the Icona project, achieved in 1998 by the Italian Ministry of Health, show levels of vaccine coverage for tetanus which range from a minimum of 88.6%
in Campania to a maximum of 100% in Valle dAosta.
The average coverage in the country amounts to 94.8%
(95% CI = 93.6-96.0).
In Tuscany, 92.8% coverage (95% CI = 86.4-99.2) was
detected at 12 months (subjects vaccinated in time)
with an increase to 95.7% (95% CI = 92.7-98.5) at 24
months.
ASSESSMENT OF THE NUMBER OF CASES IN COHORTS
SUBJECT TO COMPULSORY VACCINATION
Data from the Ministry of Health regarding reported tetanus cases show that, during the period 1992-96, 64%
78
Fig. 2. Te tan us incid e nce in Euro p e, rat e p er 1,000,000 in habitan ts d urin g 1993 or 1994.
79
Discussion
Fig. 4. Te tan us im m u nity: p erce n tag es o f pro t ect e d su bjects accordin g t o g e n d er an d ag e-gro u p, So u t h ern Tuscany, 1997.
80
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Acknowledgements: Funding: Research was funded by the Italian University and Scientific Technological Research. 40% share.
Correspondence: dr. Montomoli Emanuele, Institute of Hygiene,
University of Siena, via Aldo Moro, 53100 Siena - Tel. +39
0577234134 - Fax +39 0577234090 - E-mail: [email protected]
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