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Prygiel M, Mosiej E, Polak M, Krysztopa-Grzybowska K, Wdowiak K, Formińska K, Zasada AA. Challenges of Diphtheria Toxin Detection. Toxins (Basel) 2024; 16:245. [PMID: 38922140 PMCID: PMC11209151 DOI: 10.3390/toxins16060245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Revised: 05/22/2024] [Accepted: 05/24/2024] [Indexed: 06/27/2024] Open
Abstract
Diphtheria toxin (DT) is the main virulence factor of Corynebacterium diphtheriae, C. ulcerans and C. pseudotuberculosis. Moreover, new Corynebacterium species with the potential to produce diphtheria toxin have also been described. Therefore, the detection of the toxin is the most important test in the microbiological diagnosis of diphtheria and other corynebacteria infections. Since the first demonstration in 1888 that DT is a major virulence factor of C. diphtheriae, responsible for the systemic manifestation of the disease, various methods for DT detection have been developed, but the diagnostic usefulness of most of them has not been confirmed on a sufficiently large group of samples. Despite substantial progress in the science and diagnostics of infectious diseases, the Elek test is still the basic recommended diagnostic test for DT detection. The challenge here is the poor availability of an antitoxin and declining experience even in reference laboratories due to the low prevalence of diphtheria in developed countries. However, recent and very promising assays have been developed with the potential for use as rapid point-of-care testing (POCT), such as ICS and LFIA for toxin detection, LAMP for tox gene detection, and biosensors for both.
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Affiliation(s)
| | | | | | | | | | | | - Aleksandra A. Zasada
- Department of Sera and Vaccines Evaluation, National Institute of Public Health NIH—National Research Institute, Chocimska 24, 00-791 Warsaw, Poland; (M.P.); (E.M.); (M.P.); (K.K.-G.); (K.W.); (K.F.)
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Lovelock T, du Plessis M, van der Westhuizen C, Janson JT, Lawrence C, Parker A, Pecoraro A, Prozesky H, von Gottberg A, Taljaard J. Non-toxigenic Corynebacterium diphtheriae endocarditis: A cluster of five cases. S Afr J Infect Dis 2024; 39:539. [PMID: 38444885 PMCID: PMC10913159 DOI: 10.4102/sajid.v39i1.539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 08/08/2023] [Indexed: 03/07/2024] Open
Abstract
Background Classical toxin-mediated respiratory diphtheria has become less common because of widespread effective vaccination globally but invasive disease as a result of non-toxigenic strains of Corynebacterium diphtheriae is not prevented by vaccination and may result in severe disease, including infective endocarditis (IE). Objectives To describe the outbreak and subsequent investigation of a cluster of five cases of non-toxigenic C. diphtheriae endocarditis. Method A retrospective observational case series of five cases of non-toxigenic C. diphtheriae endocarditis identified in the rural West Coast district of the Western Cape province of South Africa between May 2021 and June 2021. Results Non-toxigenic C. diphtheriae IE had an aggressive clinical course with high mortality in this cohort. Only one of five patients survived to hospital discharge. The surviving patient received a prompt diagnosis with early surgical intervention but still had a complicated clinical course. Notably, only one case had a pre-existing risk factor for IE, namely a prosthetic valve. Whole genome sequencing of clinical isolates confirmed that all isolates were of the same novel sequence type of non-toxigenic C. diphtheriae but despite a thorough investigation no epidemiological link was ever found between the cases. Conclusion Non-toxigenic strains of C. diphtheriae are less well known but may be highly virulent and cause severe invasive disease. Contribution This is the largest cluster of non-toxigenic C. diphtheriae IE ever described in South Africa and expands the body of literature on this unusual but possibly emerging infection.
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Affiliation(s)
- Tamsin Lovelock
- Division of Infectious Diseases, Department of Medicine, Faculty of Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Mignon du Plessis
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases, Johannesburg, South Africa
- School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Clinton van der Westhuizen
- Department of Medical Microbiology, Tygerberg Hospital, National Health Laboratory Service, Cape Town, South Africa
- Division of Medical Microbiology and Immunology, Department of Pathology, Tygerberg Hospital/Stellenbosch University, Cape Town, South Africa
| | - Jacques T Janson
- Division of Cardiothoracic Surgery, Department of Surgery, Tygerberg Hospital/Stellenbosch University, Cape Town, South Africa
| | - Charlene Lawrence
- Western Cape Government, Department of Health and Wellness, Emergency and Clinical Services Support, Service Priorities Coordination, Communicable Disease Control and Outbreak Response, Cape Town, South Africa
| | - Arifa Parker
- Division of Infectious Diseases, Department of Medicine, Faculty of Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Alfonso Pecoraro
- Division of Cardiology, Department of Medicine, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Hans Prozesky
- Division of Infectious Diseases, Department of Medicine, Faculty of Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - Anne von Gottberg
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases, Johannesburg, South Africa
- School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Jantjie Taljaard
- Division of Infectious Diseases, Department of Medicine, Faculty of Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
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Natrajan MS, Hall JM, Weigand MR, Peng Y, Williams MM, Momin M, Damron FH, Dubey P, Tondella ML, Pawloski LC. Genome-based prediction of cross-protective, HLA-DR-presented epitopes as putative vaccine antigens for multiple Bordetella species. Microbiol Spectr 2024; 12:e0352723. [PMID: 38054724 PMCID: PMC10783135 DOI: 10.1128/spectrum.03527-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 11/07/2023] [Indexed: 12/07/2023] Open
Abstract
IMPORTANCE Pertussis, caused by Bordetella pertussis, can cause debilitating respiratory symptoms, so whole-cell pertussis vaccines (wPVs) were introduced in the 1940s. However, reactogenicity of wPV necessitated the development of acellular pertussis vaccines (aPVs) that were introduced in the 1990s. Since then, until the COVID-19 pandemic began, reported pertussis incidence was increasing, suggesting that aPVs do not induce long-lasting immunity and may not effectively prevent transmission. Additionally, aPVs do not provide protection against other Bordetella species that are observed during outbreaks. The significance of this work is in determining potential new vaccine antigens for multiple Bordetella species that are predicted to elicit long-term immune responses. Genome-based approaches have aided the development of novel vaccines; here, these methods identified Bordetella vaccine candidates that may be cross-protective and predicted to induce strong memory responses. These targets can lead to an improved vaccine with a strong safety profile while also strengthening the longevity of the immune response.
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Affiliation(s)
- Muktha S. Natrajan
- Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
- Laboratory Leadership Service, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Jesse M. Hall
- Department of Microbial Infection and Immunity, College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Michael R. Weigand
- Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Yanhui Peng
- Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Margaret M. Williams
- Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Mohamed Momin
- Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Frederick Heath Damron
- Department of Microbiology, Immunology, and Cell Biology, West Virginia University, Morgantown, West Virginia, USA
| | - Purnima Dubey
- Department of Microbial Infection and Immunity, College of Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Maria Lucia Tondella
- Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Lucia C. Pawloski
- Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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4
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Virtanen J, Hautala K, Utriainen M, Dutra L, Eskola K, Airas N, Uusitalo R, Ahvenainen E, Smura T, Sironen T, Vapalahti O, Kant R, Virtala AMK, Kinnunen PM. Equine dermatitis outbreak associated with parapoxvirus. J Gen Virol 2023; 104. [PMID: 38117290 DOI: 10.1099/jgv.0.001940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2023] Open
Abstract
Parapoxviruses (PPV) cause skin and mucous membrane lesions in several animal species, and of the five recognized PPVs, at least three are zoonotic. Equine PPV (EqPPV) is the sixth one initially described in humans in the United States and later in a severely sick horse in Finland in 2013-2015. In 2021-2022, a large-scale pustulo-vesicular pastern dermatitis outbreak occurred in horses all over Finland. This study aimed at analysing the outbreak, identifying and describing the causative agent, describing clinical signs, and searching for risk factors. EqPPV was identified as a probable causative agent and co-infections with several potentially pathogenic and zoonotic bacteria were observed. Histopathologically, suppurative and ulcerative dermatitis was diagnosed. Due to the lack of specific tests for this virus, we developed a novel diagnostic EqPPV-PCR with sensitivity of 10 copies/reaction. Based on a large proportion of the genome sequenced directly from clinical samples, very little variation was detected between the sequences of the case from 2013 and the cases from 2021 to 2022. Based on an epidemiological survey, the main risk factor for pastern dermatitis was having racehorses. Approximately one third of the horses at each affected stable got clinical dermatitis, manifesting as severe skin lesions. Skin lesions were also occasionally reported in humans, indicating potential zoonotic transmission. Case stables commonly reported attendance at race events before acquiring the disease. Survey also identified differences in practises between case and control stables. Taken together, these results enable a better preparedness, diagnostics, and guidelines for future outbreaks.
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Affiliation(s)
- Jenni Virtanen
- Department of Veterinary Biosciences, Faculty of Veterinary Medicine, University of Helsinki, Helsinki, Finland
- Department of Virology, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Katja Hautala
- Department of Veterinary Biosciences, Faculty of Veterinary Medicine, University of Helsinki, Helsinki, Finland
| | - Mira Utriainen
- Department of Virology, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Lara Dutra
- Department of Virology, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Katarina Eskola
- Department of Equine and Small Animal Medicine, Faculty of Veterinary Medicine, University of Helsinki, Helsinki, Finland
- Animal Health and Welfare Department, Finnish Food Authority, Helsinki, Finland
| | - Niina Airas
- Department of Veterinary Biosciences, Faculty of Veterinary Medicine, University of Helsinki, Helsinki, Finland
| | - Ruut Uusitalo
- Department of Veterinary Biosciences, Faculty of Veterinary Medicine, University of Helsinki, Helsinki, Finland
- Department of Virology, Faculty of Medicine, University of Helsinki, Helsinki, Finland
- Department of Geosciences and Geography, Faculty of Science, University of Helsinki, Helsinki, Finland
| | - Ella Ahvenainen
- Department of Virology, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Teemu Smura
- Department of Virology, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Tarja Sironen
- Department of Veterinary Biosciences, Faculty of Veterinary Medicine, University of Helsinki, Helsinki, Finland
- Department of Virology, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Olli Vapalahti
- Department of Veterinary Biosciences, Faculty of Veterinary Medicine, University of Helsinki, Helsinki, Finland
- Department of Virology, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Ravi Kant
- Department of Veterinary Biosciences, Faculty of Veterinary Medicine, University of Helsinki, Helsinki, Finland
- Department of Virology, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Anna-Maija K Virtala
- Department of Veterinary Biosciences, Faculty of Veterinary Medicine, University of Helsinki, Helsinki, Finland
| | - Paula M Kinnunen
- Department of Veterinary Biosciences, Faculty of Veterinary Medicine, University of Helsinki, Helsinki, Finland
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Prygiel M, Polak M, Mosiej E, Wdowiak K, Formińska K, Zasada AA. New Corynebacterium Species with the Potential to Produce Diphtheria Toxin. Pathogens 2022; 11:1264. [PMID: 36365015 PMCID: PMC9693595 DOI: 10.3390/pathogens11111264] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 10/20/2022] [Accepted: 10/27/2022] [Indexed: 07/30/2023] Open
Abstract
Only three Corynebacterium species are known to produce a lethal exotoxin called diphtheria toxin. These are C. diphtheriae, C. ulcerans and C. pseudotuberculosis. The diphtheria toxin gene (tox) is carried in a family of closely related corynebacteriophages and therefore the toxin can be produced only through lysogenisation, in which the corynephage encoding tox is stably inserted into the chromosome. However, 'nontoxigenic tox gene-bearing' (NTTB) strains, which are genotypically tox-positive but do not express the protein, have been described. The emergence of NTTB strains was first observed during the 1990s diphtheria epidemic in Eastern Europe and nowadays such isolates have been detected in many countries in the world. Recently, novel species of Corynebacterium genus have been described which might have the potential of producing the diphtheria toxin due to the possession of the diphtheria toxin gene but it has not produced toxin in laboratory tests. The circulation of NTTB strains could be related to the increased risk for diphtheria disease arising from the risk of re-emerging toxin expression. The article presents the mechanism of diphtheria toxin expression and action, recently described novel species of NTTB corynebacteria as well as the taxonomic changes within the C. diphtheriae group.
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Mangutov EO, Alieva AA, Kharseeva GG, Voronina NA, Alekseeva LP, Evdokimova VV, Yakusheva OA, Popivnenko MD. Corynebacterium spp.: relationship of pathogenic properties and antimicrobial resistance. Klin Lab Diagn 2022; 67:519-524. [PMID: 36099461 DOI: 10.51620/0869-2084-2022-67-9-519-524] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Corynebacterium spp. are part of the human microbiome, but can cause the development of inflammatory diseases of various localization. Purpose - to evaluate the relationship between pathogenic properties and resistance to antimicrobial drugs (AMD) of Corynebacterium spp. from patients with inflammatory diseases of the respiratory tract. Strains of Corynebacterium spp. isolated from patients with inflammatory diseases of the respiratory tract (99 pcs.) and practically healthy individuals (33 pcs.). Isolates were identified by mass spectrometric method (MALDI-ToFMS), their adhesive and invasive activity on Hep-2 cells, cytopathic effect (CPE) in CHO-K1 cell culture, and resistance to antimicrobial drugs (AMD) were determined. Indicators of adhesion (3.65±0.679(CFU±m)x102/ml), invasion (1.72±0.230 (CFU±m)x102/ml), cytotoxicity (69.1±3.8% of dead CHO-K1 cells ) Corynebasterium spp. strains isolated from patients are higher (p≤0.05) than similar indicators in practically healthy people. 90.9% of isolates from patients had resistance to AMD, in most cases (57.6±4.9%) resistance to only one AMP was noted, less often to two (25.2±4.3%), three or more (8.08±2.7%). According to the results of correlation-regression analysis, pathogenic properties (adhesiveness, invasiveness, cytotoxicity) of Corynebacterium spp. strains isolated from patients are in close direct relationship with resistance to AMD. This indicates the importance of identifying strains of non-diphtheria corynebacteria resistant to AMDs, which, under the influence of developing resistance to AMDs, can increase their pathogenic potential, moving from commensalism to parasitism.
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Affiliation(s)
- E O Mangutov
- Federal State Educational Institution of Higher Education «Rostov State Medical University» Ministry of Health of Russia
| | - A A Alieva
- Federal State Educational Institution of Higher Education «Rostov State Medical University» Ministry of Health of Russia
| | - Galina Georgievna Kharseeva
- Federal State Educational Institution of Higher Education «Rostov State Medical University» Ministry of Health of Russia
| | - N A Voronina
- Federal State Educational Institution of Higher Education «Rostov State Medical University» Ministry of Health of Russia
| | | | | | | | - M D Popivnenko
- Federal State Educational Institution of Higher Education «Rostov State Medical University» Ministry of Health of Russia
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Tyler R, Rincon L, Weigand MR, Xiaoli L, Acosta AM, Kurien D, Ju H, Lingsweiler S, Prot EY. Toxigenic Corynebacterium diphtheriae Infection in Cat, Texas, USA. Emerg Infect Dis 2022; 28:1686-1688. [PMID: 35876749 PMCID: PMC9328917 DOI: 10.3201/eid2808.220018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
We report a toxigenic strain of Corynebacterium diphtheriae isolated from an oozing dermal wound in a pet cat in Texas, USA. We also describe the epidemiologic public health efforts conducted to identify potential sources of infection and mitigate its spread and the molecular and genetic studies performed to identify the bacterium.
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Kawase J, Sakai T, Iwaki M, Umeda K, Fukuma A, Fujisawa N, Kawakami Y, Hayashi H, Wada M. Rapid detection and discrimination of potentially toxigenic Corynebacterium ulcerans and Corynebacterium pseudotuberculosis by multiplex real-time PCR and amplicon melting curve analysis. J Microbiol Methods 2022; 195:106454. [DOI: 10.1016/j.mimet.2022.106454] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 03/16/2022] [Accepted: 03/23/2022] [Indexed: 12/27/2022]
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9
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Application of Polymerase Chain Reaction in Diphtheria Laboratory Examination: A Field Need. Jundishapur J Microbiol 2021. [DOI: 10.5812/jjm.117884] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Indonesia is one of the five countries with the highest number of diphtheria cases worldwide. Diphtheria is caused by the toxigenic strains Corynebacterium diphtheriae, C. ulcerans, and C. pseudotuberculosis. The diphtheria-causing bacteria can be identified using conventional and molecular methods, including polymerase chain reaction (PCR) assay. We used the PCR assay as additional testing, because in island countries like Indonesia, specimen transport is a serious challenge to maintaining bacterial survival. Objectives: This study aimed to evaluate the PCR assay as additional testing to identify diphtheria-causing bacteria in the diphtheria laboratory. Methods: In this cross-sectional study, a total of 178 pairs of the throat and nasal swabs from diphtheria suspected cases and close contacts were collected from seven provinces in Indonesia in 2016. All samples were directly identified by the conventional method and multiplex PCR assay. Statistical analysis was conducted using the 2 × 2 tables to determine the sensitivity and specificity of both methods, while the χ2 test was used to examine the correlation between specimen examination delay and the differentiation of results. A P-value < 0.05 was considered as statistically significant. Results: Out of 178 examined samples, eight samples were identified as diphtheria-positive by both the conventional method and PCR assay, while nine samples were only detected by the PCR assay. All diphtheria-causing bacteria found in the positive samples were toxigenic C. diphtheriae. The diphtheria-causing bacteria were found in 27.6% of cases and 6.0% of close contacts using the PCR assay versus 13.8% of cases and 2.7% of close contacts using the conventional method. Statistical analysis showed that the PCR assay is about twice more sensitive than the conventional method. There was a significant correlation between the differentiation of results and > 72 hours’ specimen examination delay with a P-value of 0.04 (< 0.05). Conclusions: The PCR assay is more sensitive than the conventional method to identify diphtheria-causing bacteria and may be applied as additional testing to increase the positivity rate of diphtheria-confirmed cases in Indonesia as an archipelago country where geographical factors and specimen transport are real obstacles.
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Draft Genome Sequences of Corynebacterium diphtheriae Clinical Isolates from Colombia. Microbiol Resour Announc 2021; 10:e0033521. [PMID: 34292063 PMCID: PMC8297446 DOI: 10.1128/mra.00335-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Since the implementation of the diphtheria-tetanus-pertussis (DTP) vaccine in Colombia, there has been a decrease in the reporting of cases. Here, we report two isolates of Corynebacterium diphtheriae bv. mitis isolated in the reference laboratory at Instituto Nacional de Salud from samples received from Norte de Santander and La Guajira; both areas are located on the northeast border of Colombia.
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Weil LM, Williams MM, Shirin T, Lawrence M, Habib ZH, Aneke JS, Tondella ML, Zaki Q, Cassiday PK, Lonsway D, Farrque M, Hossen T, Feldstein LR, Cook N, Maldonado-Quiles G, Alam AN, Muraduzzaman AKM, Akram A, Conklin L, Doan S, Friedman M, Acosta AM, Hariri S, Fox LM, Tiwari TSP, Flora MS. Investigation of a Large Diphtheria Outbreak and Cocirculation of Corynebacterium pseudodiphtheriticum Among Forcibly Displaced Myanmar Nationals, 2017-2019. J Infect Dis 2021; 224:318-325. [PMID: 33245764 PMCID: PMC10846527 DOI: 10.1093/infdis/jiaa729] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 11/20/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Diphtheria, a life-threatening respiratory disease, is caused mainly by toxin-producing strains of Corynebacterium diphtheriae, while nontoxigenic corynebacteria (eg, Corynebacterium pseudodiphtheriticum) rarely causes diphtheria-like illness. Recently, global diphtheria outbreaks have resulted from breakdown of health care infrastructures, particularly in countries experiencing political conflict. This report summarizes a laboratory and epidemiological investigation of a diphtheria outbreak among forcibly displaced Myanmar nationals in Bangladesh. METHODS Specimens and clinical information were collected from patients presenting at diphtheria treatment centers. Swabs were tested for toxin gene (tox)-bearing C. diphtheriae by real-time polymerase chain reaction (RT-PCR) and culture. The isolation of another Corynebacterium species prompted further laboratory investigation. RESULTS Among 382 patients, 153 (40%) tested tox positive for C. diphtheriae by RT-PCR; 31 (20%) PCR-positive swabs were culture confirmed. RT-PCR revealed 78% (298/382) of patients tested positive for C. pseudodiphtheriticum. Of patients positive for only C. diphtheriae, 63% (17/27) had severe disease compared to 55% (69/126) positive for both Corynebacterium species, and 38% (66/172) for only C. pseudodiphtheriticum. CONCLUSIONS We report confirmation of a diphtheria outbreak and identification of a cocirculating Corynebacterium species. The high proportion of C. pseudodiphtheriticum codetection may explain why many suspected patients testing negative for C. diphtheriae presented with diphtheria-like symptoms.
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Affiliation(s)
- Lauren M. Weil
- Epidemic Intelligence Service, Division of Scientific Education and Professional Development, Center for Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Margaret M. Williams
- Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Tahmina Shirin
- Institute of Epidemiology, Disease Control and Research, Dhaka, Bangladesh
| | - Marlon Lawrence
- Laboratory Leadership Service, Division of Scientific Education and Professional Development, Center for Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Zakir H. Habib
- Institute of Epidemiology, Disease Control and Research, Dhaka, Bangladesh
| | - Janessa S. Aneke
- IHRC Inc, Contractor to US Centers for Disease Control and Prevention, Division of Bacterial Diseases, Atlanta, Georgia, USA
| | - Maria L. Tondella
- Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Quazi Zaki
- Institute of Epidemiology, Disease Control and Research, Dhaka, Bangladesh
| | - Pamela K. Cassiday
- Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - David Lonsway
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Mirza Farrque
- Bangladesh Field Epidemiology Training Program, Institute of Epidemiology, Disease Control and Research, Dhaka, Bangladesh
| | - Tanvir Hossen
- Bangladesh Field Epidemiology Training Program, Institute of Epidemiology, Disease Control and Research, Dhaka, Bangladesh
| | - Leora R. Feldstein
- Epidemic Intelligence Service, Division of Scientific Education and Professional Development, Center for Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Nicholas Cook
- IHRC Inc, Contractor to US Centers for Disease Control and Prevention, Division of Bacterial Diseases, Atlanta, Georgia, USA
| | - Gladys Maldonado-Quiles
- IHRC Inc, Contractor to US Centers for Disease Control and Prevention, Division of Bacterial Diseases, Atlanta, Georgia, USA
| | - Ahmed N. Alam
- Institute of Epidemiology, Disease Control and Research, Dhaka, Bangladesh
| | | | - Arifa Akram
- Institute of Epidemiology, Disease Control and Research, Dhaka, Bangladesh
| | - Laura Conklin
- Global Immunization Division, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Stephanie Doan
- Division of Global Health Protection, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Michael Friedman
- Division of Global Health Protection, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Anna M. Acosta
- Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Susan Hariri
- Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - LeAnne M. Fox
- Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Tejpratap S. P. Tiwari
- Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Meerjady S. Flora
- Institute of Epidemiology, Disease Control and Research, Dhaka, Bangladesh
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Polonsky JA, Ivey M, Mazhar MKA, Rahman Z, le Polain de Waroux O, Karo B, Jalava K, Vong S, Baidjoe A, Diaz J, Finger F, Habib ZH, Halder CE, Haskew C, Kaiser L, Khan AS, Sangal L, Shirin T, Zaki QA, Salam MA, White K. Epidemiological, clinical, and public health response characteristics of a large outbreak of diphtheria among the Rohingya population in Cox's Bazar, Bangladesh, 2017 to 2019: A retrospective study. PLoS Med 2021; 18:e1003587. [PMID: 33793554 PMCID: PMC8059831 DOI: 10.1371/journal.pmed.1003587] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 04/21/2021] [Accepted: 03/15/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Unrest in Myanmar in August 2017 resulted in the movement of over 700,000 Rohingya refugees to overcrowded camps in Cox's Bazar, Bangladesh. A large outbreak of diphtheria subsequently began in this population. METHODS AND FINDINGS Data were collected during mass vaccination campaigns (MVCs), contact tracing activities, and from 9 Diphtheria Treatment Centers (DTCs) operated by national and international organizations. These data were used to describe the epidemiological and clinical features and the control measures to prevent transmission, during the first 2 years of the outbreak. Between November 10, 2017 and November 9, 2019, 7,064 cases were reported: 285 (4.0%) laboratory-confirmed, 3,610 (51.1%) probable, and 3,169 (44.9%) suspected cases. The crude attack rate was 51.5 cases per 10,000 person-years, and epidemic doubling time was 4.4 days (95% confidence interval [CI] 4.2-4.7) during the exponential growth phase. The median age was 10 years (range 0-85), and 3,126 (44.3%) were male. The typical symptoms were sore throat (93.5%), fever (86.0%), pseudomembrane (34.7%), and gross cervical lymphadenopathy (GCL; 30.6%). Diphtheria antitoxin (DAT) was administered to 1,062 (89.0%) out of 1,193 eligible patients, with adverse reactions following among 229 (21.6%). There were 45 deaths (case fatality ratio [CFR] 0.6%). Household contacts for 5,702 (80.7%) of 7,064 cases were successfully traced. A total of 41,452 contacts were identified, of whom 40,364 (97.4%) consented to begin chemoprophylaxis; adherence was 55.0% (N = 22,218) at 3-day follow-up. Unvaccinated household contacts were vaccinated with 3 doses (with 4-week interval), while a booster dose was administered if the primary vaccination schedule had been completed. The proportion of contacts vaccinated was 64.7% overall. Three MVC rounds were conducted, with administrative coverage varying between 88.5% and 110.4%. Pentavalent vaccine was administered to those aged 6 weeks to 6 years, while tetanus and diphtheria (Td) vaccine was administered to those aged 7 years and older. Lack of adequate diagnostic capacity to confirm cases was the main limitation, with a majority of cases unconfirmed and the proportion of true diphtheria cases unknown. CONCLUSIONS To our knowledge, this is the largest reported diphtheria outbreak in refugee settings. We observed that high population density, poor living conditions, and fast growth rate were associated with explosive expansion of the outbreak during the initial exponential growth phase. Three rounds of mass vaccinations targeting those aged 6 weeks to 14 years were associated with only modestly reduced transmission, and additional public health measures were necessary to end the outbreak. This outbreak has a long-lasting tail, with Rt oscillating at around 1 for an extended period. An adequate global DAT stockpile needs to be maintained. All populations must have access to health services and routine vaccination, and this access must be maintained during humanitarian crises.
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Affiliation(s)
- Jonathan A. Polonsky
- World Health Organization, Geneva, Switzerland
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- * E-mail:
| | - Melissa Ivey
- Médecins Sans Frontières, Amsterdam, the Netherlands
| | | | - Ziaur Rahman
- Ministry of Health and Family Welfare, Dhaka, Bangladesh
| | - Olivier le Polain de Waroux
- World Health Organization, Geneva, Switzerland
- Global Outbreak Alert and Response Network (GOARN), Geneva, Switzerland
- Public Health England, London, United Kingdom
- London School of Hygiene and Tropical Medicine, London, United Kingdom
- UK-Public Health Rapid Support Team, London, United Kingdom
| | - Basel Karo
- Global Outbreak Alert and Response Network (GOARN), Geneva, Switzerland
- Information Centre for International Health Protection (ZIG 1), Robert Koch Institute (RKI), Berlin, Germany
| | - Katri Jalava
- World Health Organization Country Office for Bangladesh, Dhaka, Bangladesh
| | - Sirenda Vong
- World Health Organization South-East Asia Regional Office, New Delhi, India
| | - Amrish Baidjoe
- London School of Hygiene and Tropical Medicine, London, United Kingdom
- World Health Organization South-East Asia Regional Office, New Delhi, India
| | - Janet Diaz
- World Health Organization, Geneva, Switzerland
| | - Flavio Finger
- Global Outbreak Alert and Response Network (GOARN), Geneva, Switzerland
- London School of Hygiene and Tropical Medicine, London, United Kingdom
- Epicentre, Paris, France
| | - Zakir H. Habib
- Institute of Epidemiology Disease Control and Research (IEDCR), Dhaka, Bangladesh
| | | | | | - Laurent Kaiser
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Ali S. Khan
- Global Outbreak Alert and Response Network (GOARN), Geneva, Switzerland
- College of Public Health, University of Nebraska Medical Center, Nebraska, United States of America
| | - Lucky Sangal
- World Health Organization Country Office for India, New Delhi, India
| | - Tahmina Shirin
- Institute of Epidemiology Disease Control and Research (IEDCR), Dhaka, Bangladesh
| | - Quazi Ahmed Zaki
- Institute of Epidemiology Disease Control and Research (IEDCR), Dhaka, Bangladesh
| | | | - Kate White
- Médecins Sans Frontières, Amsterdam, the Netherlands
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Otshudiema JO, Acosta AM, Cassiday PK, Hadler SC, Hariri S, Tiwari TSP. Respiratory illness caused by Corynebacterium diphtheriae and C. ulcerans, and use of diphtheria anti-toxin in the United States, 1996-2018. Clin Infect Dis 2020; 73:e2799-e2806. [PMID: 32818967 DOI: 10.1093/cid/ciaa1218] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Indexed: 01/30/2023] Open
Abstract
Respiratory illness caused by Corynebacterium diphtheriae and C. ulcerans, and use of diphtheria anti-toxin in the United States, 1996-2018. BACKGROUND Respiratory diphtheria is a toxin-mediated disease caused by Corynebacterium diphtheriae. Diphtheria-like illness, clinically indistinguishable from diphtheria, is caused by C. ulcerans, a zoonotic bacterium that can also produce diphtheria toxin. In the United States, respiratory diphtheria is nationally notifiable: specimens from suspected cases are submitted to the Centers for Disease Control (CDC) for species and toxin confirmation, and diphtheria antitoxin (DAT) is obtained from CDC for treatment. We summarize the epidemiology of respiratory diphtheria and diphtheria-like illness and describe DAT use during 1996-2018 in the United States. METHODS We described respiratory diphtheria cases reported to the National Notifiable Diseases Surveillance System (NNDSS) and C. ulcerans-related diphtheria-like illness identified through specimen submissions to CDC during 1996-2018. We reviewed DAT requests from 1997-2018. RESULTS From 1996-2018, 14 respiratory diphtheria cases were reported to NNDSS. Among these 14 cases, 1 was toxigenic and 3 were non-toxigenic C. diphtheriae by culture and Elek, 6 were culture-negative but PCR-positive for diphtheria toxin gene, 1 was culture-positive without further testing, and the remaining 3 were either not tested or tested negative. Five cases of respiratory diphtheria-like illness caused by toxigenic C. ulcerans were identified. DAT was requested by healthcare providers for 151 suspected diphtheria cases between 1997-2018, with an average of 11 requests per year from 1997-2007, and 3 per year from 2008-2018. CONCLUSIONS Respiratory diphtheria remains rare in the United States, and requests for DAT have declined. Incidental identification of C. ulcerans-related diphtheria-like illness suggests surveillance of this condition might be warranted.
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Affiliation(s)
- John O Otshudiema
- Epidemic Intelligence Service Program, Division of Scientific Education and Professional Development, Center for Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention, Atlanta, GA, United States.,Meningitis and Vaccine-Preventable Diseases Branch, Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Anna M Acosta
- Meningitis and Vaccine-Preventable Diseases Branch, Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Pamela K Cassiday
- Meningitis and Vaccine-Preventable Diseases Branch, Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Stephen C Hadler
- Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Susan Hariri
- Meningitis and Vaccine-Preventable Diseases Branch, Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, United States
| | - Tejpratap S P Tiwari
- Meningitis and Vaccine-Preventable Diseases Branch, Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA, United States
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