Diphtheria outbreak in Jakarta and Tangerang, Indonesia: Epidemiological and clinical predictor factors for death

The Improvement of Adaptive Immune Responses towards COVID-19 Following Diphtheria-Tetanus-Pertussis and SARS-CoV-2 Vaccinations in Indonesian Children: Exploring the Roles of Heterologous Immunity

BACKGROUND

Routine childhood vaccination, e.g., for diphtheria, tetanus, and pertussis (DTP), might provide additional protection against SARS-CoV-2 infection. This concept of heterologous immunity was explored in healthy children receiving both DTP and inactivated SARS-CoV-2 vaccines.

METHODS

A cross-sectional study was performed on 154 healthy children aged 6-8 years old in Jakarta, Indonesia. Their vaccination status for the DTP (including a diphtheria-tetanus booster vaccine at 5 years old) and CoronaVac (from 6 years old) vaccines were recorded. Peripheral blood samples were collected from all participants, in which anti-diphtheria toxoid IgG and anti-SARS-CoV-2 S-RBD antibodies and T cell-derived IFN-γ were measured.

RESULTS

The study participants with complete DTP vaccination had significantly higher titers of anti-diphtheria toxoid IgG than the ones without (median = 0.9349 versus 0.2113 IU/mL; p < 0.0001). Upon stratification based on DTP and CoronaVac vaccination statuses, the participants with complete DTP and CoronaVac vaccinations had the highest titer of anti-SARS-CoV-2 S-RBD antibodies (median = 1196 U/mL) and the highest concentration of SARS-CoV-2-specific T cell-derived IFN-γ (median = 560.9 mIU/mL) among all the groups.

CONCLUSIONS

Healthy children aged 6-8 years old with complete DTP and CoronaVac vaccinations exhibited stronger SARS-CoV-2-specific T cell immune responses. This might suggest an additional benefit of routine childhood vaccination in generating protection against novel pathogens, presumably via heterologous immunity.

Eleven-Year Report of High Number of Diphtheria Cases in Children in East Java Province, Indonesia

A high incidence of diphtheria cases in children in East Java province, Indonesia, has been observed since the beginning of this century. Despite many efforts, the outbreaks continue. This study aims to explain the high incidence of diphtheria in children in East Java province since 2013. This cross-sectional surveillance report-based study used data from 38 districts in East Java since 1 January 2013. Collected data included demographics, clinical information, additional examinations, immunization history, and close contact management. Over eleven years, there were 4009 diphtheria patients, of whom 2921 (72.86%) were under 18 years of age. Boys (59.77%) outnumbered girls, and the most common age category was >60-144 months (51.66%). Most cases had incomplete or zero immunization (76.16%). Tonsillopharyngeal diphtheria was the most common type (69.60%). The five top districts with the most cases were Surabaya, Sidoarjo, Kabupaten Blitar, Kota Malang, and Kabupaten Malang. The eleven-year case fatality rate (CFR) was 2.36% (69/2921). This study shows that diphtheria cases in children and adolescents in East Java have consistently been high, and low immunization coverage might still be the leading cause. There has also been a shift in the district distribution. Diphtheria outbreaks require complete and sustainable efforts, not just outbreak response immunizations.

Determinants of mortality in relationship between clinical and laboratory characteristics with the outcomes of children with diphtheria: A cross-sectional study at a national hospital of Sumatra region in 2020- 2023

In 2017, diphtheria outbreaks occurred in several provinces in Indonesia; however, the epidemiological data in the country is limited. The aim of this study was to determine the association between clinical findings and laboratory parameters associated with mortality of children with diphtheria. A retrospective cohort study was conducted at Haji Adam Malik General Hospital, Medan, Indonesia, covering diphtheria patients from January 2020 to December 2023. All patients aged 1-18 years clinically diagnosed with diphtheria were considered eligible. The associations between demographic characteristics, clinical features, immunization status, complications, and laboratory profiles with mortality were determined using Fisher's exact test, and the odds ratio (OR) with a 95% confidence interval (95%CI) was calculated. Our data indicated that the clinical characteristics of myocarditis (p=0.005) and airway obstruction (p=0.003) were associated with mortality. There was also a significant association between thrombocytopenia (p=0.020) and mortality in diphtheria patients. Patients with airway obstruction were 13 times more likely to have an increase in mortality compared to patients without airway obstruction. This study highlights that clinical and laboratory characteristics could be associated with in-hospital mortality of diphtheria cases, and therefore, pediatricians should be aware of the presence of those characteristics to prevent the mortality of the patients.

Vaccine hesitancy within the Muslim community: Islamic faith and public health perspectives

Vaccine hesitancy is a growing public health concern that has fueled the resurgence of vaccine-preventable diseases in several Muslim-majority countries. Although multiple factors are associated with vaccine hesitancy, certain religious deliberations are significant in determining individuals' vaccine-related decisions and attitudes. In this review article, we summarize the literature on religious factors linked to vaccine hesitancy among Muslims, thoroughly discuss the Islamic law (sharia) viewpoint on vaccination and offer recommendations to address vaccine hesitancy in Muslim communities. Halal content/labeling and the influence of religious leaders were identified as major determinants of vaccination choices among Muslims. The core concepts of sharia, such as "preservation of life," "necessities permit prohibitions," and "empowering social responsibility for the greater public benefit" promote vaccination. Engaging religious leaders in immunization programs is crucial to enhance the uptake of vaccines among Muslims.

Genomic Epidemiology of Corynebacterium diphtheriae in New Caledonia

An increasing number of isolations of Corynebacterium diphtheriae has been observed in recent years in the archipelago of New Caledonia. We aimed to analyze the clinical and microbiological features of samples with C. diphtheriae. All C. diphtheriae isolates identified in New Caledonia from May 2015 to May 2019 were included. For each case, a retrospective consultation of the patient files was conducted. Antimicrobial susceptibility phenotypes, tox gene and diphtheria toxin expression, biovar, and the genomic sequence were determined. Core genome multilocus sequence typing (cgMLST), 7-gene MLST, and search of genes of interest were performed from genomic assemblies. Fifty-eight isolates were included, with a median age of patients of 28 years (range: 9 days to 78 years). Cutaneous origin accounted for 51 of 58 (87.9%) isolates, and C. diphtheriae was associated with Staphylococcus aureus and/or Streptococcus pyogenes in three-quarters of cases. Half of cases came either from the main city Noumea (24%, 14/58) or from the sparsely populated island of Lifou (26%, 15/58). Six tox-positive isolates were identified, associated with recent travel to Vanuatu; 5 of these cases were linked and cgMLST confirmed recent transmission. Two cases of endocarditis in young female patients with a history of rheumatic fever involved tox-negative isolates. The 58 isolates were mostly susceptible to commonly used antibiotics. In particular, no isolate was resistant to the first-line molecules amoxicillin or erythromycin. Resistance to tetracycline was found in a genomic cluster of 17 (29%) isolates, 16 of which carried the tetO gene. There were 13 cgMLST sublineages, most of which were also observed in the neighboring country Australia. Cutaneous infections may harbor nontoxigenic C. diphtheriae isolates, which circulate largely silently in nonspecific wounds. The possible introduction of tox-positive strains from a neighboring island illustrates that diphtheria surveillance should be maintained in New Caledonia, and that immunization in neighboring islands must be improved. Genomic sequencing uncovers how genotypes circulate locally and across neighboring countries. IMPORTANCE The analysis of C. diphtheriae from the tropical archipelago of New Caledonia revealed a high genetic diversity with sublineages that may be linked to Polynesia, Australia, or metropolitan France. Genomic typing allowed confirming or excluding suspected transmission events among cases and contacts. A highly prevalent tetracycline-resistant sublineage harboring the tetO gene was uncovered. Toxigenic isolates were observed from patients returning from Vanuatu, showing the importance of improving vaccination coverage in settings where it is insufficient. This study also illustrates the importance for diphtheria surveillance of the inclusion of isolates from cutaneous sources in addition to respiratory cases, in order to provide a more complete epidemiological picture of the diversity and transmission of C. diphtheriae.

Comparison of Immunogenicity and Safety of Diphtheria-Tetanus-Pertussis-Hepatitis B-Haemophilus influenza B (Bio Farma) with Pentabio® Vaccine Primed with Recombinant Hepatitis B at Birth (Using Different Source of Hepatitis B) in Indonesian Infants

Satisfying the needs of the national immunization program requires maintaining diphtheria-tetanus-pertussis (DTP)-hepatitis B (HB)-Haemophilus influenza B (Hib) production. Therefore, new hepatitis B sources are needed. This study aimed to evaluate the immunogenicity of the DTP-HB-Hib vaccine (Bio Farma) that used a different source of hepatitis B. A prospective randomized, double-blind, bridging study was conducted. Subjects were divided into two groups with different batch numbers. Healthy infants 6-11 weeks of age at enrollment were immunized with three doses of the DTP-HB-Hib vaccine after a birth dose of hepatitis B vaccine. Blood samples were obtained prior to vaccination and 28 days after the third dose. Adverse events were recorded until 28 days after each dose. Of the 220 subjects, 205 (93.2%) completed the study protocol. The proportion of infants with anti-diphtheria and anti-tetanus titers ≥ 0.01 IU/mL was 100%, with anti-HBsAg titers ≥ 10 mIU/mL was 100%, and with Polyribosylribitol Phosphate-Tetanus Conjugate (PRP-TT) titers > 0.15 µg/mL was 96.1%. The pertussis response rate was 84.9%. No serious adverse events related to the study vaccine occurred. The three-dose DTP-HB-Hib vaccine (Bio Farma) is immunogenic, well tolerated, and suitable to replace licensed-equivalent vaccines.

Waning rate of immunity and duration of protective immunity against diphtheria toxoid as a function of age and number of doses: Systematic review and quantitative data analysis

Although the burden of diphtheria has declined greatly since the introduction of vaccines, sporadic outbreaks continue to be reported. WHO recommends booster doses after a primary series, but questions remain about the optimal interval between these doses. We conducted a systematic review and quantitative data analysis to quantify the duration of protective immunity after different numbers of doses. Fifteen cross-sectional seroprevalence studies provided data on geometric mean concentration (GMC). Single-year age-stratified GMCs were analyzed using a mixed-effect linear regression model with a random intercept incorporating the between-country variability. GMC was estimated to decline to 0.1 IU/ml in 2.5 years (95% CI: 0.9-4.0), 10.3 years (95% CI: 7.1-13.6), and 25.1 years (95% CI: 7.6-42.6) after receiving three, four and five doses, respectively. The results drawn from cross-sectional data collected in countries with different epidemiologies, vaccines, and schedules had several limitations. However, these analyses contribute to the discussion of optimal timing between booster doses of diphtheria toxoid-containing vaccine.

Leveraging serology to titrate immunization program functionality for diphtheria in Madagascar

Diphtheria is a potentially devastating disease whose epidemiology remains poorly described in many settings, including Madagascar. Diphtheria vaccination is delivered in combination with pertussis and tetanus antigens and coverage of this vaccine is often used as a core measure of health system functioning. However, coverage is challenging to estimate due to the difficulty in translating numbers of doses delivered into numbers of children effectively immunised. Serology provides an alternative lens onto immunisation, but is complicated by challenges in discriminating between natural and vaccine-derived seropositivity. Here, we leverage known features of the serological profile of diphtheria to bound expectations for vaccine coverage for diphtheria, and further refine these using serology for pertussis. We measured diphtheria antibody titres in 185 children aged 6–11 months and 362 children aged 8–15 years and analysed them with pertussis antibody titres previously measured for each individual. Levels of diphtheria seronegativity varied among age groups (18.9% of children aged 6–11 months old and 11.3% of children aged 8–15 years old were seronegative) and also among the districts. We also find surprisingly elevated levels of individuals seropositive to diphtheria but not pertussis in the 6–11 month old age group suggesting that vaccination coverage or efficacy of the pertussis component of the DTP vaccine remains low or that natural infection of diphtheria may be playing a significant role in seropositivity in Madagascar.

Microbiological and Clinical Aspects of Diphtheria-Confirmed Cases from Capital City of Indonesia, Jakarta, and Surrounding Areas in 2017

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.

Epidemiology of Diphtheria in Yemen, 2017-2018: Surveillance Data Analysis

BACKGROUND

As a consequence of war and the collapse of the health system in Yemen, which prevented many people from accessing health facilities to obtain primary health care, vaccination coverage was affected, leading to a deadly diphtheria epidemic at the end of 2017.

OBJECTIVE

This study aimed to describe the epidemiology of diphtheria in Yemen and determine its incidence and case fatality rate.

METHODS

Data were obtained from the diphtheria surveillance program 2017-2018, using case definitions of the World Health Organization. A probable case was defined as a case involving a person having laryngitis, pharyngitis, or tonsillitis and an adherent membrane of the tonsils, pharynx, and/or nose. A confirmed case was defined as a probable case that was laboratory confirmed or linked epidemiologically to a laboratory-confirmed case. Data from the Central Statistical Organization was used to calculate the incidence per 100,000 population. A P value <.05 was considered significant.

RESULTS

A total of 2243 cases were reported during the period between July 2017 and August 2018. About 49% (1090/2243, 48.6%) of the cases were males. About 44% (978/2243, 43.6%) of the cases involved children aged 5 to 15 years. Respiratory tract infection was the predominant symptom (2044/2243, 91.1%), followed by pseudomembrane (1822/2243, 81.2%). Based on the vaccination status, the percentages of partially vaccinated, vaccinated, unvaccinated, and unknown status patients were 6.6% (148/2243), 30.8% (690/2243), 48.6% (10902243), and 14.0% (315/2243), respectively. The overall incidence of diphtheria was 8 per 100,000 population. The highest incidence was among the age group <15 years (11 per 100,000 population), and the lowest incidence was among the age group ≥15 years (5 per 100,000 population). The overall case fatality rate among all age groups was 5%, and it was higher (10%) in the age group <5 years. Five governorates that were difficult to access (Raymah, Abyan, Sa'ada, Lahj, and Al Jawf) had a very high case fatality rate (22%).

CONCLUSIONS

Diphtheria affected a large number of people in Yemen in 2017-2018. The majority of patients were partially or not vaccinated. Children aged ≤15 years were more affected, with higher fatality among children aged <5 years. Five governorates that were difficult to access had a case fatality rate twice that of the World Health Organization estimate (5%-10%). To control the diphtheria epidemic in Yemen, it is recommended to increase routine vaccination coverage and booster immunizations, increase public health awareness toward diphtheria, and strengthen the surveillance system for early detection and immediate response.

Toxin-associated infectious diseases: tetanus, botulism and diphtheria

PURPOSE OF REVIEW

The incidence rates of the toxin-related infectious diseases, tetanus, diphtheria and botulism declined dramatically over the past decades mainly because of the implementation of immunization programs also in low-and-middle-income countries (LAMICs) and by improving hygiene conditions. But still, single cases occur, and they need fastest possible recognition and management.

RECENT FINDINGS

Over the past 20 years, the incidence of neonatal tetanus has declined by more than 90%. This success was achieved by immunizing women in reproductive age in areas of high risk as sub-Saharan Africa and parts of Asia. Larger regional outbreaks of diphtheria have been reported from the former Soviet Union in the 1990s and from India in 2017. Botulism is still rare, mainly seen in infants and, in recent years, in intravenous drug abusers.

SUMMARY

Tetanus, diphtheria and botulism are rarities in high-income countries (HICs) with unlimited access to immunization programs and standard hygiene procedures. The diagnosis of all three diseases is still, even in the 21st century, based upon patient's history and clinical signs and symptoms. Neither biochemical bedside tests nor neuroradiological investigations help to confirm the diagnosis in an emergency situation.