Immunity to diphtheria and tetanus in Australia: a national serosurvey

Clinical outcomes and healthcare costs of inpatients with tetanus in Korea, 2011-2019

Background

Tetanus is a rare, vaccine-preventable but extremely serious disease. We investigated the recent trend of the clinical outcomes and medical costs for inpatients with tetanus in South Korea over 10 years.

Methods

We conducted a retrospective review to determine the clinical factors and medical costs associated with tetanus at two national university hospitals in South Korea between January 2011 and October 2019.

Results

Forty-nine patients were admitted for tetanus (mean age, 67.0 years [range, 53.0–80.0 years]; 32 women [57.1%]). All the patients had generalized tetanus, and 5 (10.2%) died during hospitalization. The median duration from symptom onset to hospital admission was 4 days. Trismus (85.7%) was the most common symptom, and the median hospital stay was 39 days. Thirty-two patients (65.3%) required mechanical ventilation, and 20 (40.8%) developed aspiration pneumonia. The median total healthcare cost per patient was US $18,011. After discharge, 35 patients (71.4%) recovered sufficiently to walk without disability.

Conclusions

Tetanus requires long hospital stays and high medical expenditures in South Korea; however, the vaccination completion rate is low. Medical staff should therefore promote medical advice and policies on the management of tetanus to the general South Korean population.

Fatal respiratory diphtheria caused by β-lactam-resistant Corynebacterium diphtheriae

BACKGROUND

Diphtheria is a potentially fatal respiratory disease caused by toxigenic Corynebacterium diphtheriae. Although resistance to erythromycin has been recognised, β-lactam resistance in toxigenic diphtheria has not been described. Here, we report a case of fatal respiratory diphtheria caused by toxigenic C. diphtheriae resistant to penicillin and all other β-lactam antibiotics and describe a novel mechanism of inducible carbapenem resistance associated with the acquisition of a mobile resistance element.

METHODS

Long-read whole genome sequencing was performed using Pacific Biosciences SMRT sequencing to determine the genome sequence of C. diphtheriae BQ11 and mechanism of β-lactam resistance. To investigate phenotypic inducibility of meropenem resistance, short read sequencing was performed using an Illumina NextSeq500 sequencer on the strain with and without exposure to meropenem.

RESULTS

BQ11 demonstrated high-level resistance to penicillin (benzylpenicillin MIC ≥ 256 μg/ml), β-lactam/β-lactamase inhibitors and cephalosporins (amoxicillin/clavulanic acid MIC ≥ 256 μg/mL; ceftriaxone MIC ≥ 8 μg/L). Genomic analysis of BQ11 identified acquisition of a novel transposon carrying the penicillin binding protein Pbp2c, responsible for resistance to penicillin and cephalosporins. When strain BQ11 was exposed to meropenem, selective pressure drove amplification of the transposon in a tandem array and led to a corresponding change from a low level to high level meropenem resistant phenotype.

CONCLUSIONS

We have identified a novel mechanism of inducible antibiotic resistance whereby isolates that appear to be carbapenem susceptible on initial testing can develop in vivo resistance to carbapenems with repeated exposure. This phenomenon could have significant implications for treatment of C. diphtheriae infection and may lead to clinical failure.

Corynebacterium diphtheriae-infective endocarditis in a patient with an atrial septal defect closure device

An 18-year-old woman presented to our institution with fever, bilateral flank pain, headache and photophobia. She had a previous atrial septal defect (ASD) closure device inserted at the age of 9 years. Blood cultures on admission were positive for Corynebacterium diphtheriae, and transoesophageal echocardiogram (TOE) revealed an echodensity associated with the ASD closure device, most consistent with a vegetation. She was treated for infective endocarditis with 6 weeks of intravenous benzylpenicillin, and follow-up TOE showed resolution of the echodensity. To our knowledge, no cases of C. diphtheriaeendocarditis of an ASD closure device have previously been reported.

Tetanus Immunity among Women Aged 15 to 39 Years in Cambodia: a National Population-Based Serosurvey, 2012

To monitor progress toward maternal and neonatal tetanus elimination (MNTE) in Cambodia, we conducted a nationwide serosurvey of tetanus immunity in 2012. Multistage cluster sampling was used to select 2,154 women aged 15 to 39 years. Tetanus toxoid antibodies in serum samples were measured by gold-standard double-antigen enzyme-linked immunosorbent assay (DAE) and a novel multiplex bead assay (MBA). Antibody concentrations of ≥0.01 IU/ml by DAE or the equivalent for MBA were considered seroprotective. Estimated tetanus seroprotection was 88% (95% confidence interval [CI], 86 to 89%); 64% (95% CI, 61 to 67%) of women had antibody levels of ≥1.0 IU/ml. Seroprotection was significantly lower (P < 0.001) among women aged 15 to 19 years (63%) and 20 to 24 years (87%) than among those aged ≥25 years (96%), among nulliparous women than among parous women (71 versus 97%), and among those living in the western region than among those living in other regions (82 versus 89%). The MBA showed high sensitivity (99% [95% CI, 98 to 99%]) and specificity (92% [95% CI, 88 to 95%]) compared with DAE. Findings were compatible with MNTE in Cambodia (≥80% protection). Tetanus immunity gaps should be addressed through strengthened routine immunization and targeted vaccination campaigns. Incorporating tetanus testing in national serosurveys using MBAs, which can measure immunity to multiple pathogens simultaneously, may be beneficial for monitoring MNTE.

Immunity to Diphtheria and Tetanus in Army Personnel and Adult Civilians in Mashhad, Iran

This study aimed to investigate serologic immunity to diphtheria and tetanus in army personnel and a sample population of adult civilians in Mashhad, Iran. Army personnel (n = 180) and civilians (n = 83) who presented at Mashhad army hospital participated in this study. Diphtheria and tetanus antitoxin levels were determined by enzyme-linked immunosorbent assay. Approximately 77% and 94% of army personnel aged 18-34 years had at least basic protection against diphtheria (antitoxin level ≥0.1 IU/mL) and tetanus (antitoxin level >0.1 IU/mL), respectively. For civilians in this age group, the proportions were 76% for both diseases. Antitoxin levels waned with age. Thus, participants older than 50 years had lower immunity; this decrease in immunity was more pronounced for tetanus than for diphtheria in both army personnel and civilians. For both diseases, geometric mean antitoxin titers and the proportion of participants with at least basic protection were higher in subjects with a history of vaccination in the last 10 years (P < 0.001), higher in men than women, and in army personnel than civilians in each age group. Young army personnel and civilians (18-34 years old) had adequate immunity to diphtheria and tetanus. However, the large number of susceptible older adults (>50 years old) calls for improved booster vaccination protocols.

Adolescent vaccines: Need special focus in India

WHO defines adolescence age between 10 to 19 years. In India, there are 243 million adolescents which constitute 21 per cent of the total population. The global burden of disease in adolescents (2011) reports that the total number of disability adjusted life years (DALYs) worldwide among adolescents were 230 million which constitutes 15.5% of total DALYs. The immunization is one of the most important, most beneficial and cost-effective disease prevention measures that can be provided for adolescents. The adolescent vaccination protects most of the world's adolescents from a number of infectious diseases that previously claimed millions of lives each year. In India, thousands of adolescents die and thousands are hospitalized every year due to communicable diseases that could have been prevented by vaccination. Main aims of adolescent vaccinations are: to boost immunity status that is waning after completion of primary immunization or absence of "natural" boosting due exposure to the particular disease. The recommendations for the immunization of adolescents are to improve vaccination coverage among them. The adolescent vaccinations also help in accelerate disease control or elimination effort. Improvement in adolescent immunization coverage in India, will require strengthening of health care delivery system and also require significant improvements in the health care functionaries ability and willingness to provide and deliver vaccines to adolescents.

Seroepidemiology of tetanus in Korean adults and adolescents in 2012

This seroepidemiologic study was performed to evaluate the immune status against tetanus in Korean adolescents and adults and to provide evidence to develop strategies for tetanus prevention. Between July 2012 and December 2012, serum samples were collected from adults and adolescents 11 years of age and older, and serum anti-tetanus IgG titers were determined using a commercial ELISA kit. Subjects were divided into six age groups: 11-20 years, 21-30 years, 31-40 years, 41-50 years, 51-60 years, and ≥61 years. The mean anti-tetanus IgG titers and tetanus seroprevalence of the age groups were compared. A total of 1193 adults and adolescents were enrolled. Mean anti-tetanus IgG titer and tetanus seroprevalence of all subjects were 1.20 ± 3.58 IU/mL and 56.4%, respectively. The mean anti-tetanus IgG titer decreased with an increase in age (p < 0.001). Tetanus seroprevalence increased from 92.0% in the 11-20 year age group to 95.7% in the 21-30 year age group, and then decreased with a further increase in age (p < 0.001). These results reflected an appropriate Td booster vaccine coverage at 11-12 years of age. However, the tetanus seroprevalence of adults older than 41 years was as low as the levels in previous studies: therefore, adults should be more encouraged to acquire decennial Td booster vaccinations recommended by the National Immunization Program.

Corynebacterium diphtheriae and the returned tropical traveler

BACKGROUND

In Western countries, nontoxigenic Corynebacterium diphtheriae is known to cause skin and soft tissue infections (SSIs), upper respiratory tract infections, and occasionally invasive disease. Its role as a skin pathogen in returned travelers from tropical destinations where the organism is endemic is often forgotten. A retrospective analysis of a large Australian private pathology laboratory's experience with C. diphtheriae was performed to identify how frequently overseas travel was associated with C. diptheriae infection/colonization.

METHODS

All C. diphtheriae isolates cultured from 2002 to 2012 were reviewed. Recorded clinical information regarding recent travel, country, and cause of infection was assessed. Antibiotic susceptibility was verified on all isolates.

RESULTS

In all there were 72 patients who had C. diphtheriae isolated on clinical specimens, and information about prior travel was available for 63. Seventy percent of these were healthy individuals with an SSI and history of recent travel to a tropical nation. Ninety-seven percent had associated copathogens. Two isolates were penicillin resistant. There was uniform susceptibility to cephalothin, clindamycin, erythromycin, and vancomycin, with 14% resistance to trimethoprim/sulfamethoxazole and 4% resistance to tetracycline. Only one isolate was a toxigenic strain.

CONCLUSION

The majority of C. diphtheriae isolated were from SSIs in otherwise healthy travelers returning from tropical destinations, rather than classical risk groups. Clinicians and laboratories need to be aware of this potential source of C. diphtheriae infection due to rare toxigenic strains.

Tetanus in Italy 2001-2010: a continuing threat in older adults

Despite being a completely preventable disease, tetanus cases continue to occur in Italy and notification and hospitalization rates have been reported to be higher with respect to European and other industrialized countries. We examined statutory notification, hospitalization, mortality and seroprevalence data to describe tetanus epidemiology in Italy from 2001 to 2010. A total of 594 tetanus cases were notified, with an average annual incidence of 1.0/1,000,000 population. Most cases were unvaccinated or incompletely vaccinated. Eighty percent of cases occurred in subjects aged >64 years and a higher proportion of females with respect to males were reported in this age group. The annual number of hospital admissions was 1.4-1.7 times greater than the number of notifications in the same year. The mean annual number of reported deaths was 21. Seroprevalence data show progressively higher susceptibility levels with increasing age. Over 50% of persons aged 45-64 years and over two thirds of subjects ≥65 years had tetanus antibody levels <0.01 IU/ml. Results show that tetanus is a continuing problem in Italy and, as in other countries, most cases occur in older adults, especially elderly women. The observed differences in notification and hospitalization rates suggest underreporting by physicians. In recent years, Italy has accounted for most cases reported annually in the European Union (EU) but different case definitions are used. In Italy, a confirmed case is one that meets the clinical case definition while the EU case definition classifies confirmed cases as those with laboratory confirmation of disease. The incidence of clinical tetanus in Italy is ten-fold higher than in other industrialized countries, like Australia and Canada, likely due to higher susceptibility levels in Italy. In view of the low prevalence of tetanus antibodies in adults ≥45 years, strategies to improve vaccine uptake in this population group need to be implemented.

The genus corynebacterium and other medically relevant coryneform-like bacteria

Catalase-positive Gram-positive bacilli, commonly called "diphtheroids" or "coryneform" bacteria were historically nearly always dismissed as contaminants when recovered from patients, but increasingly have been implicated as the cause of significant infections. These taxa have been underreported, and the taxa were taxonomically confusing. The mechanisms of pathogenesis, especially for newly described taxa, were rarely studied. Antibiotic susceptibility data were relatively scant. In this minireview, clinical relevance, phenotypic and genetic identification methods, matrix-assisted laser desorption ionization-time of flight (MALDI-TOF) evaluations, and antimicrobial susceptibility testing involving species in the genus Corynebacterium and other medically relevant Gram-positive rods, collectively called coryneforms, are described.

Multilocus sequence typing identifies evidence for recombination and two distinct lineages of Corynebacterium diphtheriae

We describe the development of a multilocus sequence typing (MLST) scheme for Corynebacterium diphtheriae, the causative agent of the potentially fatal upper respiratory disease diphtheria. Global changes in diphtheria epidemiology are highlighted by the recent epidemic in the former Soviet Union (FSU) and also by the emergence of nontoxigenic strains causing atypical disease. Although numerous techniques have been developed to characterize C. diphtheriae, their use is hindered by limited portability and, in some instances, poor reproducibility. One hundred fifty isolates from 18 countries and encompassing a period of 50 years were analyzed by multilocus sequence typing (MLST). Strain discrimination was in accordance with previous ribotyping data, and clonal complexes associated with disease outbreaks were clearly identified by MLST. The data produced are portable, reproducible, and unambiguous. The MLST scheme described provides a valuable tool for monitoring and characterizing endemic and epidemic C. diphtheriae strains. Furthermore, multilocus sequence analysis of the nucleotide data reveals two distinct lineages within the population of C. diphtheriae examined, one of which is composed exclusively of biotype belfanti isolates and the other of multiple biotypes.

Decline of tetanus antitoxin level with age in taiwan

BACKGROUND/PURPOSE

Tetanus is caused by Clostridium tetani, and is a vaccine-preventable infectious disease. The purpose of this study was to investigate the degree of protective tetanus immunity among adolescents and adults in Taiwan, which may provide valuable information for recommendations for tetanus vaccination strategy.

METHODS

Individuals aged 16 years or older who were visiting a local hospital for health examinations were invited to participate in the study. Participants' serum levels of tetanus antitoxin were measured. A standard questionnaire was used to collect demographic data and information about risk factors. The prevalence of protective tetanus immunity in various age groups was described and sociodemographic factors that potentially influenced the degree of tetanus immunity were analyzed.

RESULTS

Overall, 326 persons were included. Of these, 217 (67%) had never received a toxoid booster, while 109 (33%) had received a booster at least once. Among all participants, 95% had protective tetanus antitoxin levels (> or = 0.11 IU/mL), and 60% had protective antitoxin levels without the need of an immediate booster, i.e. > or = 0.51 IU/mL. Among 70 participants aged > 60 years, 89% had protective antitoxin levels > or = 0.11 IU/mL, and 31% had protective antitoxin levels > or = 0.51 IU/mL. Tetanus antitoxin levels declined with age. Male gender, birth after 1955, and prior receipt of toxoid booster(s) were independently associated with protective tetanus immunity (> or = 0.51 IU/mL) by multivariate analysis. Compared with those without tetanus toxoid boosters, individuals with a prior booster had higher antitoxin levels. The percentage of people with protective immunity declined if the interval between the last toxoid booster increased.

CONCLUSION

Waning immunity to tetanus was observed after primary tetanus vaccination or toxoid booster. The public health policy that one dose of toxoid booster after primary vaccination should be emphasized for continuing protection against tetanus.

Primary vaccination of adults with reduced antigen-content diphtheria-tetanus-acellular pertussis or dTpa-inactivated poliovirus vaccines compared to diphtheria-tetanus-toxoid vaccines

OBJECTIVE

To evaluate immunogenicity and reactogenicity of primary vaccination with reduced-antigen-content diphtheria-tetanus-acellular pertussis (dTpa) or dTpa-inactivated poliovirus (dTpa-IPV) vaccine compared to diphtheria-tetanus-toxoid vaccines (Td) in adults > or = 40 years of age without diphtheria or tetanus vaccination for 20 years or with an unknown vaccination history.

RESEARCH DESIGN AND METHODS

Double-blind, randomized, controlled clinical trial. Primary vaccination with either three doses of dTpa, one dose of dTpa-IPV followed by two doses of Td, or three doses of Td vaccine (control) administered in a 0-1-6-month schedule.

MAIN OUTCOME MEASURES

Blood samples were collected before commencement and 1 month after each dose. Local and general symptoms were solicited for 15 days after each dose.

RESULTS

A total of 460 adults were enrolled, of whom over 48% did not have protective antibody concentrations against diphtheria and tetanus. One month after dose 3 > 99% had seroprotective anti-diphtheria and tetanus antibodies. Three doses were required to maximize anti-diphtheria seroprotection rates. A vaccine response to pertussis antigens was observed in > 92% of dTpa and dTpa-IPV recipients after dose 1. One month after dTpa-IPV, > 98.4% had seroprotective anti-polio titres. No statistically significant differences in local or general symptoms between groups were observed.

CONCLUSIONS

dTpa and dTpa-IPV can provide primary vaccination of adults. Combinations of dTpa or dTpa-IPV can be used to replace Td and provide booster vaccination against pertussis and polio simultaneously with diphtheria and tetanus, even in situations where the primary vaccination history is unknown.

The seroepidemiology of tetanus in Catalonia, Spain

Titres of anti-tetanus toxin antibodies > or = 0.1 IU/ml were determined using an enzyme linked immunosorbent assay in representative samples of the juvenile and adult population of Catalonia. The prevalence obtained in 1,316 juveniles and 1,296 adults was 99.4 and 68.3%, respectively. In adults, the prevalence in males (76.5%) was higher (P < 0.001) than in females (61.7%), fell with increasing age and was higher in subjects born in Catalonia (72.5%) than in those born outside Catalonia (57.9%) (P < 0.001). These results show that routine vaccination of children is successful. In adults aged > or = 45 years, the prevalence is inadequate and efforts should be made to increase vaccination.

Tetanus in the elderly—An important preventable disease in Australia

Notification trends from countries with well-established immunisation programs show increasing tetanus cases among the elderly, corresponding to seroepidemiologic data showing declining immunity with advanced age. We examined Australian trends in tetanus to review the likely value of routine funded immunisation at 65 years. Since 1993, 62% (36/58) of notifications, 44% (67/151) of hospitalisations and 83% (10/12) of deaths were in people aged over 65 years. Taking into account higher vaccine coverage at 65 years, versus the current recommended age in Australia of 50 years, we estimate that routine funded tetanus vaccine would prevent 9% more hospitalisations and 28% more deaths than the most favourable outcome from the current unfunded recommendation at 50 years. This is likely to be applicable to other industrialised countries.

Measurement of tetanus antitoxin in oral fluid: a tool to conduct serosurveys

BACKGROUND

Serosurveys that measure tetanus antitoxin can complement immunization coverage surveys to allow evaluation of immunization services in developing countries. Measurement of IgG tetanus antitoxin in oral fluid was investigated as a practical and noninvasive alternative to and correlate of serum antibodies.

METHODS

Serum and oral fluid were collected from Malian infants, toddlers and adults (males without a history of tetanus vaccination). Specific IgG tetanus antitoxin was measured by enzyme-linked immunosorbent assay in serum (S-ELISA) and oral fluid (OF-ELISA).

RESULTS

One hundred forty-two pairs of serum and oral fluid samples were collected from infants, 35 pairs from toddlers and 35 pairs from adults. IgG tetanus antitoxin titers measured by OF-ELISA were 100-fold lower than those measured by S-ELISA but they correlated strongly (r = 0.90, P < 0.001). All 35 toddlers who had received 2 or 3 doses of diphtheria-tetanus-pertussis (DTP) vaccine (100%) had serum tetanus antitoxin levels >or=0.15 IU/mL and 28 of 35 (80%) had oral fluid values >or=0.0015 IU/mL. Among adults lacking a history of tetanus immunization, only 6 of 35 (17.1%) had serum titers >or=0.15 IU/mL and 4 of 35 (11%) had oral fluid titers >or=0.0015 IU/mL in oral fluid.

CONCLUSIONS

IgG tetanus antitoxin in oral fluid correlates well with levels in serum. OF-ELISA values >or=0.0015 IU/mL constitute protection against tetanus and in subjects >12 months of age imply multiple prior contacts with immunization services. IgG tetanus antitoxin measured by OF-ELISA provides a logistically practical alternative for performing seroprevalence surveys.