Update on available vaccines in India: report of the APPA VU 2010: I

Study of Ulcero-membranous Lesions of Tonsil in an Indian Scenario

'Ulcero-membranous lesions over tonsil' is a special entity, which puzzles every physician and surgeon because of it's diverse etiology. Every insult to the tonsil heals by ulcer and later membrane formation. A retrospective study has been conducted at our institute to analyse the cases of ulcero-membranous lesions of tonsil in terms of etiology, clinical features, diagnosis, treatment protocols and outcome in an Indian context. Diphtheria, if not detected early and treated, can lead to significant morbidity and mortality because of critical complications. Diphtheria mainly affects children aged between 1 and 5 years, however, due to good vaccine coverage, a shift in age incidence has been observed from preschool to school age (5-15 years) with more and more cases now being reported in adults. The health agencies and the government will have to take maximum efforts to increase immunization coverage as India has witnessed the highest number of cases in the world for the year 2015.

Preventing the preventable through effective surveillance: the case of diphtheria in a rural district of Maharashtra, India

BACKGROUND

Epidemic diphtheria is still poorly understood and continues to challenge both developing and developed countries. In the backdrop of poor immunization coverage, non-existent adult boosters, weak case based surveillance and persistence of multiple foci, there is a heightened risk of re-emergence of the disease in epidemic forms in India. Investigating each outbreak to understand the epidemiology of the disease and its current status in the country is therefore necessary. Dhule a predominantly tribal and rural district in Northern Maharashtra has consistently recorded low vaccination coverages alongside sporaidic cases of diphtheria over the last years.

METHODS

This study reports the findings of an onsite survey conducted to assess a recent outbreak of diphtheria in Dhule district and the response mounted to it. Secondary data regarding outbreak detection and response were obtained from the district surveillance office. Clinical data were extracted from hospital records of eleven lab confirmed cases including one death case. Frequency distributions were calculated for each identified clinical and non- clinical variable using Microsoft™ Excel® 2010.

RESULTS

Our findings suggest a shift in the median age of disease to adolescents (10-15 years) without gender differences. Two cases (18%) reported disease despite immunization. Clinical symptoms included cough (82%), fever (73%), and throat congestion (64%). About 64% and 36% of the 11 confirmed cases presented with a well defined pseudomembrane and a tonsillar patch respectively. Drug resistance was observed in all three culture positive cases. One death occurred despite the administration of Anti-Diphtheric Serum in a partially immunized case (CFR 9%). Genotyping and toxigenicity of strain was not possible due to specimen contamination during transport as testing facilities were unavailable in the district.

CONCLUSIONS

The outbreak raises several concerns regarding the epidemiology of diphtheria in Dhule. The reason for shift in the median age despite consistently poor immunization coverage (below 50%) remains unclear. Concomitant efforts should now focus on improving and monitoring primary immunization and booster coverages across all age groups. Gradually introducing adult immunization at ten year intervals may become necessary to prevent future vulnerabilities. Laboratory networks for genotyping and toxigenicity testing are urgently mandated at district level given the endemicity of the disease in the surrounding region and its recent introduction in remote Dhule. Contingency funds with pre- agreements to obtain ADS and DT/Td vaccines at short notice and developing standard case management protocols at district level are necessary. Monitoring the disease, emerging strains and mutations, alongside drug resistance through robust and effective surveillance is a pragmatic way forward.