Tetanus prone wounds management in Italy: new recommandations from the Ministry of Health
Recently, the Italian Ministry of Health released a recommendation updating the tetanus immunization pattern with a focus on the tetanus prone wounds management1. In a nutshell, the main change is that instead of a tetanus mono-valent vaccine (T) or a diphtheria-tetanus vaccine (DT), a trivalent diphtheria-tetanus-pertussis vaccine (dtp) is now recommended in the tetanus prone wounds management. Of note, dtp vaccine is still free of charge as it is included in the DPCM 2017 for LEA classification. A summary of the Recommendation1 is shortly reported here in the First Aid/DEA perspective.
Epidemiological changes in Italy that lead to the switch from T/DT to dtp
Pertussis is considered by the Istituto Superiore di Sanità as an emerging problem in Italy. Hence, the 2017–2019 Italian National Immunization Prevention Plan (Piano Nazionale di Prevenzione Vaccinale, PNPV)2 has introduced pertussis boosters for adults/older adults every 10 years2. This measure aims to achieve individual protection as well as to reduce B. pertussis circulation and transmission to unvaccinated population such as infants2. The Italian Ministry of Health has recently reiterated that all the vaccinations included in the national schedule were to be included in the new Essential Levels of Assistance (LEA)2. Such a scenario impacted also on the tetanus prone wounds management, which was recently updated by the Ministry of Health1 as briefly summarized below.
Post traumatic prophylaxis with dtp vaccine
Before proceeding with vaccination, it is necessary to evaluate the wound. Wounds can be clean or contaminated / dirty, superficial or deep and penetrating. Compared to clean wounds, dirty wounds have an increased risk for tetanus. The wounds are to be considered dirty if they are contaminated by dirt, earth, dust, faeces or saliva (for example, animal or human bites). Even penetrating wounds or punctures can pose a high risk for tetanus. Finally, lesions with devitalized tissue (for example necrotic wounds) or from freezing or crushing, exposed fractures and burns are situations favourable to the proliferation of Clostridium tetani1. All wounds must be cleaned by removing dirt, foreign objects and necrotic material before they are disinfected. In addition to the characteristics of wounds, the need for prophylaxis is dictated by the patient’s immune status towards tetanus1. Prophylaxis should be administered possibly within 72 hours of possible infection. If the protocol involves the simultaneous administration of immunoglobulins, vaccination should be carried out at a different site of inoculation1.
On the use of dtp vaccine
dtp combinations can be used safely in subjects in whom the vaccination status is unknown or have already received a dose of diphtheria or pertussis vaccine in the last 5-10 years1. Furthermore, it is emphasized that a recent dose of anti-tetanus vaccine (for example, administered following a traumatic injury or as a requirement for work fitness) does not represent a contraindication to the recall with dtp, recommended every 10 years, or to administration of the vaccine during week 28 in pregnant women, or any need for vaccination or booster against pertussis or diphtheria. In fact, although a slightly higher frequency of adverse events (generally local, such as pain, swelling, redness at the injection site) is reported in the case of administration of combined vaccines containing the anti-tetanus component after a short interval from a previous dose of vaccine anti-tetanus, the benefits in terms of protection against pertussis and diphtheria are far superior1. Since the risk of any adverse events in the tetanus component of the combined vaccines is slightly greater if a high number of doses is administered over a few years, it is important that the vaccination is always correctly recorded and a certificate is always delivered to the vaccinated: in this avoids the administration of useless doses in already immune subjects of which, however, the immune status could be ignored in case of failure to certify the previous doses1. For patients with HIV infection or other severe immunodeficiencies, in the presence of an injury at risk of tetanus, administration of immunoglobulins is recommended, irrespective of the vaccine history against tetanus1. Ministry of Health reiterate the importance of pre-vaccination history, according to the Guide to contraindications – 2018 edition3, and of the timely and correct reporting of any adverse vaccination events, as per current legislation1.
The new epidemiological scenario of pertussis in Italy lead the Ministry of Health to update the pertussis vaccination national calendar introducing a dtp booster every 10 years to all adults2. Accordingly, tetanus prone wound management has evolved to the use of dtp vaccine instead of previous mono-valent tetanus or bivalent diphtheria-tetanus1. First Aid/DEA professionals are all called to implement dtp vaccination when appropriate.
Vaccination status unknown
Incomplete vaccination schedule (< 3 doses)
yes (schedule to be completed)1
3 tetanus doses or more. Last dose administered > 10 years before
3 tetanus doses or more. Last dose administered > 5 years before
3 tetanus doses or more. Last dose administered < 5 years before
Table 1. Summary of tetanus prone wound management in First Aid/DEA1
*No if the wound is not deep or it is “clean”
1) In case more vaccine doses are needed to complete the schedule, please administer dtp vaccine and then address the patient to Public Health offices for schedule completion
- Ministero della Salute, Circolare Ministeriale del 3 luglio 2018, “Indicazioni in merito alla vaccinazione anti-tetanica” http://www.trovanorme.salute.gov.it/norme/renderNormsanPdf?anno=2018&codLeg=64975&parte=1%20&serie=null (last accessed October 2019)
- Piano Nazionale Prevenzione Vaccinale 2017-19 http://www.salute.gov.it/imgs/C_17_pubblicazioni_2571_allegato.pdf (last accessed October 2019)
- Ministero della Salute, Guida alle controindicazioni alla vaccinazione, ed 2018 http://www.salute.gov.it/imgs/C_17_pubblicazioni_2759_allegato.pdf (last accessed October 2019)