Clinical spectrum and outcomes of the 2019-2020 pediatric diphtheria outbreak in Yemen
Abstract
Background Diphtheria is an acute bacterial infectious disease characterized by serious morbidity and mortality. Outbreaks continue to occur in developing countries despite national vaccination programs. Vaccination, early recognition the disease, and adequate intervention are needed to avoid devastating outcomes.
Objective To describe the clinical spectrum of childhood diphtheria and its association to outcomes during the 2019-2020 diphtheria outberak in Yemen.
Methods This was a retrospective study to assess the demographic, clinical features, and outcomes of paediatric respiratory diphtheria in patients with diphtheria during the outbreak from September 2019 until May 2020 admitted at Mukalla Maternity and Children Hospital. We used SPSS 22 version for data analysis.
Results There were 34 culture-confirmed diphtheria cases included in this study, their age ranged from 13 months to 15 years old. Most of the cases (76.5%) happened to children at more than 5 years old. There was no gender difference. Of these 34-positive diphtheria, 79.4% from Hadramout and 17.6% from Shabwa governorate. Most of the cases (35.3%) were admitted in December. More than half of the patients (52.9%) were unimmunized. Fever, sore throat, and enlarged tonsils were presented in all patients, dysphagia (82.4 %), pseudomembrane (91.7%), bull neck (52.9%), and stridor (8.8%) were also found in some patients. Complications included acute renal failure (20.6%), disseminated intravascular coagulation (DIC), shock (17.6%), and myocarditis (8.8%). Significant poor outcome (P< 0.05) was associated with bull neck, myocarditis, acute renal failure, DIC, and shock. The case fatality rate (CFR) was 20.6%.
Conclusion Fever, sore throat, tonsillitis, pseudomembrane, and bull neck are high index suspicion of diphtheria and anticipation of ominous outcome. The shifting of occurrence of diphtheria to older age group indicates the need for booster(s) diphtheria toxoid vaccine in addition to improving and strengthening the current immunization program.
References
2. Franklin HT, Wehrle PF. Communicable and infectious diseases. 9th ed. St. Louis: Mosby; 1981.
3. Basavaraja GV, Chebbi PG, Joshi S. Resurgence of diphtheria: clinical profile and outcome – a retrospective observational study. Int J Contemp Pediatr. 2016;3:60-3. DOI: https://doi.org/10.18203/2349-3291.ijcp20160058
4. Galazka AM, Robertson SE. Diphtheria: changing patterns in the developing world and the industrialized world. Eur J Epidemiol. 1995;11:107-17. DOI: https://doi.org/10.1007/BF01719955
5. World Health Organization. Vaccine preventable disease: monitoring system 2016 global summary. Updated March 3, 2017. [cited 2022 June 20]. Available from: https://immunizationdata.who.int/pages/incidence/diphtheria.html.
6. Sardar JC, Saren AB, Haldar D, Chatterjee K, Biswas S, Chatterjee T, et al. Obstinate diphtheria needs innovation in immunization. Int J Contemp Pediatr. 2016;3:902-9. DOI: https://doi.org/10.18203/2349-3291.ijcp20162363
7. Clarke K, MacNeil A, Hadler S, Scott C, Tiwari T, Cherian T. Global epidemiology of diphtheria, 2000–2017. Emerg Infect Dis. 2019;25:1834-42. DOI: https://doi.org/10.3201/eid2510.190271
8. Murakami H, Phuong NM, Thang HV, Giao PN, Tho ND. Endemic diphtheria in Ho Chi Minh City; Viet Nam: A matched case-control study to identify risk factors incidence. Vaccine. 2010;28:8141-6. DOI: https://doi.org/10.1016/j.vaccine.2010.09.088
9. Hsan K , Misti JM, Gozal D, Griffiths MD, Mamun MA. Diphtheria outbreak among the Rohingya refugees in Bangladesh: What strategies should be utilized for prevention and control? Travel Med Infec Dis. 2020;34:101591. DOI: https://doi.org/10.1016/j.tmaid.2020.101591
10. Jones EE, Kim-Farley RJ, Algunaid M, Parvez MA, Ballad YA, Hightower AW, Orenstein WA, Broome CV. Diphtheria: a possible foodborne outbreak in Hodeida, Yemen Arab Republic. Bull World Health Organ. 1985;63:287-93. PMID: 3874714.
11. Dureab F, Al-Sakkaf M, Ismail O, Kuunibe N, Krisam J, Müller O, Jahn A. Diphtheria outbreak in Yemen: the impact of conflict on a fragile health system. Confl Health. 2019;13:1-7. DOI: https://doi.org/10.1186/S13031-019-0204-2
12. Bisgard KM, Rhodes P, Hardy IR, Litkina IL, Filatov NN, Monisov AA, et al. Diphtheria toxoid vaccine effectiveness: a case-control study in Russia. J Infect Dis. 2000;181Suppl:1 S184-7. DOI: https://doi.org/10.1086/315562
13. Nanthavong N, Black AP, Nouanthong P, Souvannaso C, Vilivong K, Muller CP, et al. Diphtheria in Lao PDR: Insufficient Coverage or Ineffective Vaccine? PLoS One. 2015;10:e0121749. DOI: https://doi.org/10.1371/journal.pone.0121749.
14. Murhekar MV, Bitragunta S. Persistence of diphtheria in India. Indian J Community Med. 2011; 36:164-5. DOI: https://doi.org/10.4103/0970-0218.84141
15. World Health Organization. Diphtheria vaccines: WHO position paper – August 2017. Weekly Epidemiological Record. 2017; 92:417–6. [cited 2022 June 20]. Available from: https://www.who.int/publications/i/item/who-wer9231.
16. Begg N and World Health Organization. Regional Office for Europe. Manual for the management and control of diphtheria in the European region. Copenhagen: WHO; 1994. [cited 2022 June 20]. Available from: http://www.who.int/iris/handle/10665/108107.
17. Boyer NH, Weinstein L. Diphtheritic myocarditis. N Engl J Med. 1948; 239:913-9. DOI: https://doi.org/10.1056/NEJM194812092392403.
18. Ledbetter MK, Cannon AB, Costa AF. The electrocardiogram in diphtheritic myocarditis. Am Heart J. 1964; 68:599-611. DOI: https://doi.org/10.1016/0002-8703(64)90268-6
19. Wehrle PF. Diphtheria. In: Evans AS, Brachman PS, eds. Bacterial infections of humans. 2nd ed. New York: Plenum Medical Book Company, 1991. p.227–37.
20. Khan MH, Aurakzai AA, Irshad M, Ullah H. Complications and outcome of diphtheria in admitted pediatric patients at a tertiary care setting in Peshawar. J Postgrad Med Inst. 2018; 32: 242-5.
21. Nawing HD, Pelupessy NM, Alimadong H, Albar H. Clinical spectrum and outcomes of pediatric diphtheria. Paediatr Indones. 2019;59:38-43. DOI: https://doi.org/10.14238/pi59.1.2019.38-43
22. Gundam BR, Sudarsi RK, Gundam A. Study of cardiac involvement in diphtheria. J Evid Based Med Health. 2016;3:3309-19. DOI: https://doi.org/10.18410/jebmh/2016/715
23. Clarke KEN and Center for Disease Control and Prevention. Review of the Epidemiology of diphtheria 2000-2016. [cited 2022 June 20]. Available from: https://terrance.who.int/mediacentre/data/sage/SAGE_Docs_Ppt_Apr2017/10_session_diptheria/Apr2017_session10_diphtheria_2000-2016.pdf.
24. Mattos-Guaraldi AL, Moreira LO, Damasco PV, Hirata Júnior R. Diphtheria remains a threat to health in the developing world – An overview. Mem Inst Oswaldo Cruz. 2003;98:987-93. DOI: https://doi.org/10.1590/S0074-02762003000800001
25. World Health Organization. Diphtheria vaccine: WHO position paper-August 2017. Geneva: The Organization; 2017. Available at: https://www.who.int/immunization/policy/position_papers/ diphtheria.
26. Vitek CR, Brennan MB, Gotway CA, Bragina VY, Govorukina NV, Kravtsova ON, et al. Risk of diphtheria among school children in the Russian Federation in relation to time since last vaccination. The Lancet. 1999;353:355-8. DOI: https://doi.org/10.1016/S0140-6736(98)03488-6
27. Ba’amer AA. Coverage of and barriers to routine child vaccination in Mukalla district, Hadramout governorate, Yemen. East Mediterr Health J. 2010;16 :223-7. PMID: 20799579.
28. Khuri-Bulos N, Hamzah Y, Sammerrai SM, Shehabi A, Hamed R, Arnaout MA, et al. The changing epidemiology of diphtheria in Jordan. Bull World Health Organ. 1988;66:65-8. PMID: 3260143.
29. Pelupessy JM, Macmur R, Daud D. Bull-neck, electrocardiographic changes and creatine phosphokinase blood levels in patients with diphtheria. Paediatr Indones. 1991; 31:303- 11. PMID: 1845655.
30. Meshram RM, Patil A. Clinical profile and outcome of diphtheria in central India: a retrospective observational study. Int J Contemp Pediatr. 2018;5:1600-1605. DOI: https://doi.org/10.18203/2349-3291.ijcp20182572
31. Khadirova R, Kartoglu HU, Strebel PM. Clinical characteristics and management of 676 hospitalized diphtheria cases, Kyrgyz Republic, 1995. J Infect Dis. 2000;181Suppl:S110–5. DOI: https://doi.org/10.1086/315549
32. Ramos AC, Elias PR, Barrucand L, Da Silva JA. The Protective Effect of Carnitine in Human Diphtheric Myocarditis. Pediatr Res. 1984;18:815-9. DOI: https://doi.org/10.1203/00006450-198409000-00001
33. Chang MP, Baldwin RL, Bruce C, Wisnieski BJ. Second cytotoxic pathway of diphtheria suggested by nuclease activity. Science. 1989; 246:1165-1168. DOI: https://doi.org/10.1126/science.2531465
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Accepted 2024-02-22
Published 2024-02-26
