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Shah SR, Karanje NC. Diphtheria case detection and carrier study of close contacts: A step towards diphtheria eradication. INDIAN J PATHOL MICR 2024; 67:328-331. [PMID: 38394413 DOI: 10.4103/ijpm.ijpm_265_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 06/26/2023] [Indexed: 02/25/2024] Open
Abstract
INTRODUCTION Diphtheria is an infectious disease caused by gram-positive bacilli C. diphtheriae involving nasal, pharyngeal, tonsillar, or laryngeal mucus membranes. The mortality rate is as high as 20%, with India contributing almost 78% of the world incidence. AIMS AND OBJECTIVES We report a fatal case of nasopharyngeal diphtheria with carrier study in close contacts. MATERIALS AND METHODS Seven years child presented with fever, throat pain, and earache for 3 days followed by neck swelling and noisy respiration. On examination, membrane was present in the throat, which was received for Albert and Gram staining and reported as positive for C. diphtheria like organisms followed by culture. The patient was treated with ADS and antibiotics, and intensively managed, but still succumbed to death. Follow-up was done for carriage of C. diphtheriae on the throat and nasopharyngeal swabs of siblings and close contacts. It was isolated in 3 of them. Samples were processed for Gram, Albert stain, and culture. Identification, antibiotic sensitivity, and toxigenicity were done. RESULTS AND DISCUSSION Four samples, one from the patient and three from contacts showed the presence of gram-positive slender bacilli with cuneiform arrangement, less cellular infiltrate on the Gram stain, and the presence of few metachromatic granules in the Albert stain. C. diphtheriae was grown on Potassium Tellurite agar. Antibiogram of all isolates was similar with resistance to Erythromycin and sensitivity to Penicillin. Isolates were confirmed by PCR and ToxA gene was detected. Contacts were treated with Penicillin and repeat swabs were negative. CONCLUSION Present health statistics and this study suggests, fight against diphtheria in India is far from being over. It still lurks in some remote areas. It is a need to remain vigilant, keep tracing, and treating contacts to curtail down the rate of infection. In view of the resurgence, Government has given directives to replace TT with Td in UIP. Still, a lot needs to be done.
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Affiliation(s)
- Shilpa R Shah
- Department of Microbiology, Bharati Vidyapeeth (Deemed to be University), Medical College and Hospital, Sangli, Maharashtra, India
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Microbiological and Clinical Aspects of Diphtheria-Confirmed Cases from Capital City of Indonesia, Jakarta, and Surrounding Areas in 2017. Jundishapur J Microbiol 2021. [DOI: 10.5812/jjm.118751] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background: The World Health Organization reported Indonesia as one of the countries with the most prevalent cases of diphtheria worldwide. The microbiological aspects of diphtheria-inducing bacteria are of great significance in tracing disease transmission and case management. However, clinical aspects are critical for updating clinical features and case management in the field, which may sometimes differ from theoretical foundations. Objectives: This study aimed to identify the microbiological and clinical aspects, including molecular typing and case fatality rates, in diphtheria-confirmed cases from the capital city of Indonesia, Jakarta, and surrounding areas in 2017. Methods: The microbiological aspect of 40 diphtheria-confirmed cases were obtained by re-identify diphtheria-inducing bacteria isolated from the samples, while the clinical aspects of the cases were obtained from the medical records and epidemiological data. The chi-square test was used to examine the correlation between fatal cases and myocarditis and diphtheria antitoxin administration delay. In this study, P ≤ 0.05 was set as the significance level. Results: All 40 diphtheria confirmed cases were induced by toxigenic Corynebacterium diphtheriae with two biotypes, namely intermedius (60.0%) and mitis (40.0%). There are six sequence types of bacteria with two main sequence types, ie, ST534 (46.4%) and ST377 (35.7%). The proportions of cases that had a fever and sore throat were 72.5% and 77.5%, respectively; however, the prevalence rates of the cases with pseudomembrane and bull neck were 100% and 47%, respectively. Most cases were administered a combination of penicillin or erythromycin with other antibiotics (40%), and 22.5% of the cases only received penicillin. Myocarditis was noticed in three fatal cases, and their relationship was statistically significant (P = 0.000). All five fatal cases (12.5% of cases) received diphtheria antitoxin (DAT) lately or had not received it yet. Conclusions: Toxigenic C. diphtheriae with two biotypes (namely mitis and intermedius) and two main sequence types (ie, ST534 and ST377) was the causative agent of diphtheria-confirmed cases from Jakarta and surrounding areas in 2017. It was also concluded that those fatal cases were correlated with myocarditis complications.
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Arguni E, Karyanti MR, Satari HI, Hadinegoro SR. Diphtheria outbreak in Jakarta and Tangerang, Indonesia: Epidemiological and clinical predictor factors for death. PLoS One 2021; 16:e0246301. [PMID: 33539453 PMCID: PMC7861411 DOI: 10.1371/journal.pone.0246301] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 01/16/2021] [Indexed: 11/23/2022] Open
Abstract
Background In 2017, a diphtheria outbreak occurred in several provinces in Indonesia. The aim of this study was to identify predictors of mortality outcome of pediatric patients with clinical diphtheria. Methods A retrospective cohort study was conducted using patient medical records at five referral hospitals in the Province of Jakarta and one in Tangerang District, Banten Province during January 2017 to 31 August 2018. All children in the age group of 1–18 years old discharged with diagnosis of clinical diphtheria formed the study group. All anonymized patient data were evaluated for demographic issues, clinical features, immunization status, complication, laboratory profiles and outcome. Results A total of 283 patients with clinical diphtheria were included in the study group with case fatality rate of 3.5%. All mortal patients had the complication of myocarditis. Regression analyses revealed factors for predicting mortality. Incomplete primary diphtheria toxoid immunization, stridor, bull neck, leukocytosis ≥15 x109 cells/L and thrombocytopenia ≤150 x109 cells/L in each combination for 2 predictors modeling were correlated with death. Conclusions We report key predictors of mortality in pediatric patients with clinical diphtheria. The presence of these features when admitted to the hospital must be taken into account, because they can lead to fatal outcome.
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Affiliation(s)
- Eggi Arguni
- Department of Child Health, Faculty of Medicine, Public Health and Nursing, Universitas Gadjah Mada, Yogyakarta, Indonesia
- * E-mail:
| | - Mulya Rahma Karyanti
- Department of Pediatric, Faculty of Medicine, University of Indonesia, Jakarta, Indonesia
| | - Hindra Irawan Satari
- Department of Pediatric, Faculty of Medicine, University of Indonesia, Jakarta, Indonesia
| | - Sri Rezeki Hadinegoro
- Department of Pediatric, Faculty of Medicine, University of Indonesia, Jakarta, Indonesia
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Pilot E, Murthy GVS, Nittas V. Understanding India's urban dengue surveillance: A qualitative policy analysis of Hyderabad district. Glob Public Health 2020; 15:1702-1717. [PMID: 32431221 DOI: 10.1080/17441692.2020.1767674] [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] [Indexed: 10/24/2022]
Abstract
Dengue's re-emerging epidemiology poses a major global health threat. India contributes significantly to the global communicable disease burden has been declared highly dengue-endemic, exposing public health authorities to severe challenges. Our study aims to provide a deeper understanding of India's urban dengue surveillance policies as well as to explore the organisation, functioning and integration of existing disease control pillars. We conducted a qualitative regional case study, consisting of semi-structured expert interviews and observational data, covering the urban region of Hyderabad in South India. Our findings indicate that Hyderabad's dengue surveillance system predominantly relies on public reporting units, neglecting India's large private health sector. The surveillance system requires further strengthening and additional efforts to efficiently integrate existing governmental initiatives at all geographical levels and administrative boundaries. We concluded with recommendations for improved consistency, accuracy, efficiency and reduction of system fragmentation to enhance the integration of dengue surveillance and improved health information in urban India. Finally, our study underlines India's overall need to increase investment in public health and health infrastructures. That requires coordinated and multi-level action targeting the development of a competent, effective and motivated public health cadre, as well as truly integrated surveillance and epidemic response infrastructure, for dengue and beyond.
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Affiliation(s)
- Eva Pilot
- Department of Health, Ethics and Society, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, Netherlands.,Maastricht Centre for Global Health, Maastricht University, Maastricht, Netherlands.,Centre of Studies in Geography and Spatial Planning (CEGOT), University of Coimbra, Coimbra, Portugal
| | - G V S Murthy
- Public Health Foundation India, Indian Institute of Public Health Hyderabad, Hyderabad, India.,International Centre for Eye Health, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Vasileios Nittas
- Department of Health, Ethics and Society, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, Netherlands
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Chawla K, Gupta A, Gujral M, Singh A. Diphtheria resurgence in India: A case study from south Karnataka. J Family Med Prim Care 2020; 9:5776-5778. [PMID: 33532432 PMCID: PMC7842462 DOI: 10.4103/jfmpc.jfmpc_480_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 04/25/2020] [Accepted: 05/19/2020] [Indexed: 11/16/2022] Open
Abstract
Corynebacterium diphtheriae is a gram-positive bacillus with characteristic polar metachromatic granules. It was a significant public health problem, infecting the throat and upper airways and producing a highly potent exotoxin but with the advent of diphtheria vaccine, cases have rapidly decreased. Now over the last decade, the reemergence of this infection has been noted and case reports from India have been documented. India represents 78% of globally reported cases with significant mortality despite national immunization programs in place. This case study indicates the severity of an improperly managed case, the importance of microbiological diagnosis with a special interest in molecular detection, and reinforces a resurgence of diphtheria infection.
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Rajamani Sekar S, Veeraraghavan B, Anandan S, Devanga Ragupathi N, Sangal L, Joshi S. Strengthening the laboratory diagnosis of pathogenicCorynebacteriumspecies in the Vaccine era. Lett Appl Microbiol 2017; 65:354-365. [DOI: 10.1111/lam.12781] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2017] [Revised: 07/06/2017] [Accepted: 07/20/2017] [Indexed: 01/06/2023]
Affiliation(s)
- S.K. Rajamani Sekar
- Department of Clinical Microbiology; Christian Medical College; Vellore India
| | - B. Veeraraghavan
- Department of Clinical Microbiology; Christian Medical College; Vellore India
| | - S. Anandan
- Department of Clinical Microbiology; Christian Medical College; Vellore India
| | | | - L. Sangal
- World Health Organization (WHO) Country Office; New Delhi India
| | - S. Joshi
- World Health Organization (WHO) Country Office; New Delhi India
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Sangal L, Joshi S, Anandan S, Balaji V, Johnson J, Satapathy A, Haldar P, Rayru R, Ramamurthy S, Raghavan A, Bhatnagar P. Resurgence of Diphtheria in North Kerala, India, 2016: Laboratory Supported Case-Based Surveillance Outcomes. Front Public Health 2017; 5:218. [PMID: 28913330 PMCID: PMC5582196 DOI: 10.3389/fpubh.2017.00218] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2017] [Accepted: 08/04/2017] [Indexed: 11/13/2022] Open
Abstract
Introduction As part of national program, laboratory supported vaccine preventable diseases surveillance was initiated in Kerala in 2015. Mechanisms have been strengthened for case investigation, reporting, and data management. Specimens collected and sent to state and reference laboratories for confirmation and molecular surveillance. The major objective of this study is to understand the epidemiological information generated through surveillance system and its utilization for action. Methods Surveillance data captured from reporting register, case investigation forms, and laboratory reports was analyzed. Cases were allotted unique ID and no personal identifying information was used for analysis. Throat swabs were collected from investigated cases as part of surveillance system. All Corynebacterium diphtheriae isolates were confirmed with standard biochemical tests, ELEK’s test, and real-time PCR. Isolates were characterized using whole genome-based multi locus sequence typing method. Case investigation forms and laboratory results were recorded electronically. Public health response by government was also reviewed. Results A total of 533 cases were identified in 11 districts of Kerala in 2016, of which 92% occurred in 3 districts of north Kerala; Malappuram, Kozhikode, and Kannur. Almost 79% cases occurred in >10 years age group. In <18 years age group, 62% were male while in ≥18 years, 69% were females. In <10 years age group, 31% children had received three doses of diphtheria vaccine, whereas in ≥10 years, 3% cases had received all doses. Fifteen toxigenic C. diphtheriae isolates represented 6 novel sequence types (STs) (ST-405, ST-408, ST-466, ST-468, ST-469, and ST-470). Other STs observed are ST-50, ST-295, and ST-377. Conclusion Diphtheria being an emerging pathogen, establishing quality surveillance for providing real-time information on disease occurrence and mortality is imperative. The epidemiological data thus generated was used for targeted interventions and to formulate vaccine policies. The data on molecular surveillance have given an insight on strain variation and transmission patterns.
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Affiliation(s)
- Lucky Sangal
- WHO India, World Health Organization, New Delhi, India
| | - Sudhir Joshi
- WHO India, World Health Organization, New Delhi, India
| | - Shalini Anandan
- Department of Clinical Microbiology, Christian Medical College, Vellore, India
| | | | | | | | - Pradeep Haldar
- Ministry of Health and Family Welfare, Government of India, New Delhi, India
| | - Ramesh Rayru
- Ministry of Health, Government of Kerala, Thiruvananthapuram, India
| | | | - Asha Raghavan
- WHO India, World Health Organization, Thiruvananthapuram, India
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Murhekar M. Epidemiology of Diphtheria in India, 1996-2016: Implications for Prevention and Control. Am J Trop Med Hyg 2017; 97:313-318. [PMID: 28722581 PMCID: PMC5544098 DOI: 10.4269/ajtmh.17-0047] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 04/19/2017] [Indexed: 11/07/2022] Open
Abstract
Diphtheria is an acute disease caused by exotoxin-producing Corynebacterium diphtheriae. Globally, diphtheria has been showing a declining trend due to effective childhood vaccination programs. A substantial proportion of global burden of diphtheria is contributed by India. Hospital-based surveillance studies as well as diphtheria outbreaks published in last 20 years (1996-2016) indicate that diphtheria cases are frequent among school-going children and adolescents. In some Indian states, Muslim children are affected more. As per the national level health surveys, coverage of three doses of diphtheria vaccine was 80% during 2015-2016. Information about coverage of diphtheria boosters is not routinely collected through these surveys, but is expected to be low. Few studies also indicate low diphtheria immunity among school-going children and adults. The strategies for prevention of diphtheria need to focus on improving coverage of primary and booster doses of diphtheria vaccines administered as a part of Universal Immunization Program as well as introducing diphtheria vaccine for school-going children.
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Affiliation(s)
- Manoj Murhekar
- Division of Epidemiology, National Institute of Epidemiology, Chennai, India
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Sridhar Reddy D, Shoban Babu A, Rathod JBS, Sravan Kumar C, Rajesh S. Study of Ulcero-membranous Lesions of Tonsil in an Indian Scenario. Indian J Otolaryngol Head Neck Surg 2016; 69:16-19. [PMID: 28239572 DOI: 10.1007/s12070-016-0994-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 05/05/2016] [Indexed: 11/30/2022] Open
Abstract
'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.
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Affiliation(s)
- D Sridhar Reddy
- Department of ENT, Osmania Medical College, Plot No: 138, Mallikarjun Nagar, North GSI-Post, Chintalkunta, L. B. Nagar, Hyderabad, 500 068 India
| | - A Shoban Babu
- Department of ENT, Osmania Medical College, Plot No: 138, Mallikarjun Nagar, North GSI-Post, Chintalkunta, L. B. Nagar, Hyderabad, 500 068 India
| | - J B S Rathod
- Department of ENT, Osmania Medical College, Plot No: 138, Mallikarjun Nagar, North GSI-Post, Chintalkunta, L. B. Nagar, Hyderabad, 500 068 India
| | - Ch Sravan Kumar
- Department of ENT, Gandhi Medical College, Secunderabad, India
| | - S Rajesh
- Department of ENT, Narayana Medical College, Nellore, India
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Diphtheria outbreak in Maranhão, Brazil: microbiological, clinical and epidemiological aspects. Epidemiol Infect 2015; 143:791-8. [PMID: 25703400 DOI: 10.1017/s0950268814001241] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We describe microbiological, clinical and epidemiological aspects of a diphtheria outbreak that occurred in Maranhão, Brazil. The majority of the 27 confirmed cases occurred in partially (n = 16) or completely (n = 10) immunized children (n = 26). Clinical signs and characteristic symptoms of diphtheria such as cervical lymphadenopathy and pseudomembrane formation were absent in 48% and 7% of the cases, respectively. Complications such as paralysis of lower limbs were observed. Three cases resulted in death, two of them in completely immunized children. Microbiological analysis identified the isolates as Corynebacterium diphtheriae biovar intermedius with a predominant PFGE type. Most of them were toxigenic and some showed a decrease in penicillin G susceptibility. In conclusion, diphtheria remains endemic in Brazil. Health professionals need to be aware of the possibility of atypical cases of C. diphtheriae infection, including pharyngitis without pseudomembrane formation.
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ARSH 10: Adolescent immunization revisited. Indian J Pediatr 2013; 80 Suppl 2:S244-7. [PMID: 23949868 DOI: 10.1007/s12098-013-1111-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Accepted: 05/27/2013] [Indexed: 10/26/2022]
Abstract
The emerging epidemiological shift in the incidence of vaccine preventable diseases like diphtheria, whooping cough and measles and the recent introduction of the attenuated combination vaccines (Tdap) and human papillomavirus (HPV) vaccine have necessitated the introduction of new vaccination schedules for the adolescents. On the back of this success in the west, it is timely to consider these schedules for the Indian scenario. The details of these vaccines as suggested by IAP COI and its programatic difficulties are discussed. The importance of providing evidence based, accurate information regarding adolescent immunization is emphasized.
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Abstract
SUMMARY A diphtheria outbreak occurred from February to November 2011 in the village of Kimba and its surrounding settlements, in Borno State, northeastern Nigeria. We conducted a retrospective outbreak investigation in Kimba village and the surrounding settlements to better describe the extent and clinical characteristics of this outbreak. Ninety-eight cases met the criteria of the case definition of diphtheria, 63 (64.3%) of whom were children aged <10 years; 98% of cases had never been immunized against diphtheria. None of the 98 cases received diphtheria antitoxin, penicillin, or erythromycin during their illness. The overall case-fatality ratio was 21.4%, and was highest in children aged 0-4 years (42.9%). Low rates of immunization, delayed clinical recognition of diphtheria and absence of treatment with antitoxin and appropriate antibiotics contributed to this epidemic and its severity.
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