What You Should Know about the Recent Diphtheria Outbreak?
Indonesia’s Ministry of Health has confirmed the recent outbreak of Diphtheria. Based on their data, there are 95 regions and cities from 20 provinces that have reported cases. From January until November, in total there were 622 cases, 32 of which were fatal cases.
Diphtheria is a very contagious and infectious disease. Complications caused by diphtheria infection may cause death due obstruction of the airways (the larynx and pharynx) and infection of the heart muscles (myocarditis). It is caused by a bacteria called Corynebacterium diphtheria
. It spreads through droplet infection (from cough, sneezing, saliva) from a sick patient or a carrier. Diphtheria mainly attacks the throat (pharynx, tonsils, larynx). Lately, there are also reports on diphtheria causing skin and nose infection. The bacteria also releases a toxin (called the diphtheria exotoxin) that causes a disturbance to the heart muscles, kidney failure, and circulatory failure (shock) which is deadly.
Diphtheria can spread through:
Signs and Symptoms
- Droplet transmission: sneezing, coughing, saliva
- Fomite transmission: a person may be infected when they share or touch an object that a patient may have been in contact with for instance toys, towels, utensils
- Rarely, people may be infected by touching a skin lesion or an open wound/sore
Diphtheria has an incubation period of 2-5 days, which means that the bacteria have colonized the body, but symptoms do not occur yet. However, the person may already be infectious and spread it to others. The bacteria gets into the body, attaches toe the respiratory system and produces and releases toxins. Signs and symptoms include:
Recent Outbreak and Vaccination
- A sore throat with a “pseudomembrane” on the tonsils and back of the throat. A pseudomembrane is a grey-whitish lining that covers the tonsils and throat. A pseudomembrane easily bleeds, especially when scraped. This pseudomembrane plus swollen tonsils causes airway obstruction, making it hard to breathe.
- Sore throat may come with enlarged lymph nodes in the neck called a “bullneck:.
- Runny nose. Initially a watery discharge, it may thicken after a few days, and may even contain blood.
- When the larynx or voice box is affected, it also causes a hoarse voice.
- Fever (usually around 38 degrees Celcius).
- May also cause skin problems with an open sore
There were no recorded outbreaks of diphtheria since the 1990s until 2009. Diphtheria is not a new disease, but rather a disease that has come back to haunt us. Before the enforcement of vaccinations, diphtheria was common and deadly, but since most of the population were immunized by vaccinations, diphtheria cases were almost down to zero.
Based on one of the regulations of Indonesia’s Ministry of Health (No. 1501/MENKES/PER/X/2010) regarding Specific Cases of Infectious Diseases, if there is 1 clinical case of diphtheria, it is already considered a “disease outbreak”. The first case was found in East Java, and since then has spread to 20 provinces in November 2017.
Diphtheria is easily prevented through active vaccinations. The vaccines (called DPT, which is combined with vaccines for pertussis and tetanus) is given 3x before the age of 12 months. In this period, recommendations by IDAI (Ikatan Dokter Anak Indonesia/Indonesia Pediatric Society), the DPT vaccine is also administered with the HiB Vaccine (for haemophilus influenza) and Hb vaccine (for hepatitis B)
Booster shots are given at 18 months and 5 years old. Two more boosters (Td vaccine, without tetanus or pertussis) is given at age 10-12 years old, and 18 years old.
The recent outbreak raises the question to why there is a return of diphtheria cases. According to IDAI, this may be caused by:
1. Immunizations of obligatory vaccinations did not reach its targetThe percentage of population that is vaccinated in Indonesia varies in different areas of the country.The result also varies depending on the survey collecting the data.Possible incomplete and inaccurate recording of vaccination history contributes to the potentially erroneous data.Simple things such as the patient’s parents forgetting where they put the vaccine history data contributes to this.There is an “immunity gap” in Indonesia, where there is a part of the population that is yet to be vaccinated and immunized.In some areas, there are campaigns that support unfounded negative claims of vaccinations, that vaccines may cause autism, that leads to people refusing to be vaccinated.
2. The vaccines fail to give maximal immunity to the childrenThe failure of the vaccines to work may be attributed to a few factors.For example, children may be vaccinated once or twice, instead of having a complete vaccine history, and/or not receive booster shots.It is also important to crosscheck the logistics and storage of the vaccines are up to standards such as proper storage temperature, expiry date etc.
Management of this diphtheria outbreak in Indonesia is to detect the disease early, proper medical therapy (antibiotic administration, patient isolation, anti-toxin administration), referral to a hospital. Management and prevention of diphtheria starts with the community, and not only healthcare workers. Actively seeking proper vaccinations will hopefully eradicate diphtheria, a contagious and potentially deadly disease.