In 1997, Italy had the highest number of tetanus cases in the European Union; cases in the Marches region were more numerous than in France or Germany. In a retrospective study of the patients infected in Marches in 1996-1999, subjects or relatives were interviewed to ascertain disease severity, infection mode, occupation and immunization state at the time of infection. There were 32 cases, 29 (90.6%) females and three (9.4%) males, mean age 74.65 years (SD 9.06). The raw annual incidence was 5.6 per million and raw annual mortality 0.5 (n = 3). Twenty-seven patients (84.4%) were agricultural workers and five (15.6%) housewives; 25 (78.2%) had never been vaccinated, two (6.2%) had been immunized several years earlier and five (15.6%) had received only the first dose of vaccine at least 15 years earlier. In Italy, tetanus vaccination is compulsory for agricultural workers. Occupational health physicians should monitor workers' tetanus immunization state during their periodic surveillance visits.