Conference Material > Abstract
Amevoin Y, Ale F
Epicentre Scientific Day 2024. 23 May 2024
BACKGROUND
Diphtheria is an infection of the upper respiratory tract characterized by the production of an extracellular toxin. Individuals with incomplete immunization or low levels of antitoxin antibodies are particularly susceptible to infection. Specific treatment relies on Diphtheria Anti-Toxin (DAT) and the disease is preventable by active immunization. Since 2019, large outbreaks have been reported in WHO African Region, but 2023 has seen an unprecedented surge in diphtheria cases in West Africa, mainly Kano State, Nigeria.
METHODS
Médecins Sans Frontières (MSF) and Epicentre have been involved in response efforts but have faced several challenges due to limited hospital capacity and a global shortage of DAT. This led to the implementation of new solutions such as home-based care, adaptation of DAT dosage and strategic allocation of DAT stocks. Preliminary descriptive analysis shows the key figures from the 2023 diphtheria outbreak and summarizes critical insights from one year of MSF intervention in Kano.
RESULTS
MSF treated around 23 thousand individuals across 14 sites in five countries. Nearly half of these patients required hospitalization, with an overall case fatality rate (CFR) of 6%. The majority of patients were under 15 years of age, and most were female.
In Kano State, Nigeria, specifically, three main centres were established at the peak of the outbreak. MSF used adaptive strategies to deal with the constraints of the response, which were phased according to the number of cases and the availability of drugs. Centralised case management was used for severe cases, while a decentralised care model, including home-based care, was used for mild and close contacts. The primary centre, which remains operational, has received approximately 9 thousand patients.
Data indicate that the prompt administration of diphtheria antitoxin (DAT) may influence patient outcomes. Furthermore, an early immunization campaign could have potentially reduced the overall mortality rate associated with the epidemic.
CONCLUSION
The surge of diphtheria in West Africa highlighted numerous challenges in combating the disease in low-resource settings, particularly concerning the availability of diphtheria antitoxin (DAT). Further analyses are required to accurately assess the impact of home-based care and DAT dosage strategies. Scaling up global DAT production and enhancing routine vaccination programs could be crucial in preventing future outbreaks.
Diphtheria is an infection of the upper respiratory tract characterized by the production of an extracellular toxin. Individuals with incomplete immunization or low levels of antitoxin antibodies are particularly susceptible to infection. Specific treatment relies on Diphtheria Anti-Toxin (DAT) and the disease is preventable by active immunization. Since 2019, large outbreaks have been reported in WHO African Region, but 2023 has seen an unprecedented surge in diphtheria cases in West Africa, mainly Kano State, Nigeria.
METHODS
Médecins Sans Frontières (MSF) and Epicentre have been involved in response efforts but have faced several challenges due to limited hospital capacity and a global shortage of DAT. This led to the implementation of new solutions such as home-based care, adaptation of DAT dosage and strategic allocation of DAT stocks. Preliminary descriptive analysis shows the key figures from the 2023 diphtheria outbreak and summarizes critical insights from one year of MSF intervention in Kano.
RESULTS
MSF treated around 23 thousand individuals across 14 sites in five countries. Nearly half of these patients required hospitalization, with an overall case fatality rate (CFR) of 6%. The majority of patients were under 15 years of age, and most were female.
In Kano State, Nigeria, specifically, three main centres were established at the peak of the outbreak. MSF used adaptive strategies to deal with the constraints of the response, which were phased according to the number of cases and the availability of drugs. Centralised case management was used for severe cases, while a decentralised care model, including home-based care, was used for mild and close contacts. The primary centre, which remains operational, has received approximately 9 thousand patients.
Data indicate that the prompt administration of diphtheria antitoxin (DAT) may influence patient outcomes. Furthermore, an early immunization campaign could have potentially reduced the overall mortality rate associated with the epidemic.
CONCLUSION
The surge of diphtheria in West Africa highlighted numerous challenges in combating the disease in low-resource settings, particularly concerning the availability of diphtheria antitoxin (DAT). Further analyses are required to accurately assess the impact of home-based care and DAT dosage strategies. Scaling up global DAT production and enhancing routine vaccination programs could be crucial in preventing future outbreaks.
Conference Material > Video
Usman K, Suwaid SA, Fix M, Evbuomwan PE, Worku DT, et al.
MSF Paediatric Days 2024. 3 May 2024
Conference Material > Video
Juma H
MSF Paediatric Days 2024. 3 May 2024
English
Français
Conference Material > Abstract
Juma H, Worku DT, Evboumwan PE, Katuala Y, Mbuyi Y, et al.
MSF Paediatric Days 2024. 3 May 2024; DOI:10.57740/Sh2BIQ8FOl
BACKGROUND AND OBJECTIVES
Diphtheria is a vaccine preventable disease caused by toxicogenic Corynebacterium diphtheriae. Since declaration of an outbreak in Nigeria in December 2022, Kano state has been its epicentre, with 77% of the 12,581 confirmed cases nationally. In response, a Decentralised Model of Care (DMC) for delivering proximal, fast, and easily accessible curative and preventive community-based health care was introduced in Kano. Here, we describe implementation of this DMC and assess its impact in reducing mortality from diphtheria during this outbreak.
METHODS
Components of DMC:
• OPD for the triaging and management of mild cases
• Contact clinic (mobile and fixed) to improve access to preventative care for close contacts
Main packages of DMC:
• Health and Infection Prevention and Control promotion
• Chemoprophylaxis and vaccination for close contacts
• Identification and management of simple cases
• Referral of complicated cases
• Training of health workers
DMC was implemented within existing public health facilities for outpatient services, and in the community for the management of close contacts. The selection of facilities was guided by epidemiological data analysis and mapping.
Chi-square testing was used for analysing statistical significance on mortality before and after the implementation of DMC.
RESULTS
Between weeks 2 and 48 of 2023, the health facilities included in this study managed a total of 12,662 suspected diphtheria cases. From this, 1,987 cases (136 deaths; CFR 6.84%) were managed before implementation of DMC (before week 34), and 10,675 cases (611 deaths; CFR 5.72%) were managed after its implementation (from week 34 to 48). One-tailed Chi-square testing showed a statistically significant difference in mortality before and after implementation (p-value 0.02).
CONCLUSIONS
DMC may have contributed to the reduction of mortality in healthcare facilities. Upon in-depth analysis of the impact of DMC, it may be recommended for implementation in large outbreaks. Further studies, however, need to be conducted to assess the role of DMC in improving patients’ access to healthcare and reducing the burden on healthcare facilities during massive outbreaks.
Diphtheria is a vaccine preventable disease caused by toxicogenic Corynebacterium diphtheriae. Since declaration of an outbreak in Nigeria in December 2022, Kano state has been its epicentre, with 77% of the 12,581 confirmed cases nationally. In response, a Decentralised Model of Care (DMC) for delivering proximal, fast, and easily accessible curative and preventive community-based health care was introduced in Kano. Here, we describe implementation of this DMC and assess its impact in reducing mortality from diphtheria during this outbreak.
METHODS
Components of DMC:
• OPD for the triaging and management of mild cases
• Contact clinic (mobile and fixed) to improve access to preventative care for close contacts
Main packages of DMC:
• Health and Infection Prevention and Control promotion
• Chemoprophylaxis and vaccination for close contacts
• Identification and management of simple cases
• Referral of complicated cases
• Training of health workers
DMC was implemented within existing public health facilities for outpatient services, and in the community for the management of close contacts. The selection of facilities was guided by epidemiological data analysis and mapping.
Chi-square testing was used for analysing statistical significance on mortality before and after the implementation of DMC.
RESULTS
Between weeks 2 and 48 of 2023, the health facilities included in this study managed a total of 12,662 suspected diphtheria cases. From this, 1,987 cases (136 deaths; CFR 6.84%) were managed before implementation of DMC (before week 34), and 10,675 cases (611 deaths; CFR 5.72%) were managed after its implementation (from week 34 to 48). One-tailed Chi-square testing showed a statistically significant difference in mortality before and after implementation (p-value 0.02).
CONCLUSIONS
DMC may have contributed to the reduction of mortality in healthcare facilities. Upon in-depth analysis of the impact of DMC, it may be recommended for implementation in large outbreaks. Further studies, however, need to be conducted to assess the role of DMC in improving patients’ access to healthcare and reducing the burden on healthcare facilities during massive outbreaks.
Conference Material > Poster
Usman K, Suwaid SA, Fix M, Evbuomwan PE, Worku DT, et al.
MSF Paediatric Days 2024. 3 May 2024; DOI:10.57740/kX6Njdggl
Conference Material > Poster
Suwaid SA, Mustapha A, Reid M, Muhammad A, Muhammad R, et al.
MSF Paediatric Days 2024. 3 May 2024; DOI:10.57740/RIbxNO7
Conference Material > Slide Presentation
Juma H
MSF Paediatric Days 2024. 3 May 2024; DOI:10.57740/k5Ve82Tjh
Journal Article > ResearchFull Text
Euro Surveill. 1 November 2023; Volume 28 (Issue 44); 2300130.; DOI:10.2807/1560-7917.ES.2023.28.44.2300130
Jacquinet S, Martini H, Mangion JP, Neusy S, Detollenaere A, et al.
Euro Surveill. 1 November 2023; Volume 28 (Issue 44); 2300130.; DOI:10.2807/1560-7917.ES.2023.28.44.2300130
Since 2022, European countries have been facing an outbreak of mainly cutaneous diphtheria caused by toxigenic Corynebacterium diphtheriae among asylum seekers. In Belgium, between 1 March and 31 December 2022, 25 cases of toxigenic C. diphtheriae infection were confirmed among asylum seekers, mostly among young males from Afghanistan. Multi-locus sequence typing showed that most isolates belonged to sequence types 574 or 377, similar to the majority of cases in other European countries. The investigation and management of the outbreak, with many asylum seekers without shelter, required adjustments to case finding, contact tracing and treatment procedures. A test-and-treat centre was organised by non-governmental organisations, the duration of the antimicrobial treatment was shortened to increase compliance, and isolation and contact tracing of cases was not possible. A vaccination centre was opened, and mobile vaccination campaigns were organised to vaccinate a maximum of asylum seekers. No more cases were detected between end December 2022 and May 2023. Unfortunately, though, three cases of respiratory diphtheria, including one death, were reported at the end of June 2023. To prevent future outbreaks, specific attention and sufficient resources should be allocated to this vulnerable population, in Belgium and at international level.
Journal Article > Short ReportFull Text
Public Health Action. 21 June 2023; Volume 13 (Issue 2); 31-33.; DOI:10.5588/pha.23.0011
Mangion JP, Mancini S, Bachy C, de Weggheleire A, Zamatto F
Public Health Action. 21 June 2023; Volume 13 (Issue 2); 31-33.; DOI:10.5588/pha.23.0011
English
Français
A rising number of diphtheria cases were recorded in Europe in 2022, including in Belgium, within the newly arriving young migrant population. In October 2022, Médecins Sans Frontières (MSF) opened a temporary roadside container-clinic offering free medical consultations. Over 3 months of activity, the temporary clinic detected 147 suspected cases of cutaneous diphtheria with 8 laboratory-confirmed cases growing toxigenic Corynebacterium diphtheriae. This was followed by a mobile vaccination campaign, during which 433 individuals living rough in squats and informal shelters were vaccinated. This intervention has shown how even in Europe’s capital, access to preventive and curative medical services remains difficult for those who need it the most. Appropriate access to health services, including routine vaccination, are crucial to improve the health status among migrants.
Journal Article > ResearchFull Text
PLOS Med. 1 April 2021; Volume 18 (Issue 4); e1003587.; DOI:10.1371/journal.pmed.1003587
Polonsky JA, Ivey M, Mazhar KA, Rahman Z, le Polain de Waroux O, et al.
PLOS Med. 1 April 2021; Volume 18 (Issue 4); e1003587.; DOI:10.1371/journal.pmed.1003587
BACKGROUND
Unrest in Myanmar in August 2017 resulted in the movement of over 700,000 Rohingya refugees to overcrowded camps in Cox's Bazar, Bangladesh. A large outbreak of diphtheria subsequently began in this population.
METHODS AND FINDINGS
Data were collected during mass vaccination campaigns (MVCs), contact tracing activities, and from 9 Diphtheria Treatment Centers (DTCs) operated by national and international organizations. These data were used to describe the epidemiological and clinical features and the control measures to prevent transmission, during the first 2 years of the outbreak. Between November 10, 2017 and November 9, 2019, 7,064 cases were reported: 285 (4.0%) laboratory-confirmed, 3,610 (51.1%) probable, and 3,169 (44.9%) suspected cases. The crude attack rate was 51.5 cases per 10,000 person-years, and epidemic doubling time was 4.4 days (95% confidence interval [CI] 4.2-4.7) during the exponential growth phase. The median age was 10 years (range 0-85), and 3,126 (44.3%) were male. The typical symptoms were sore throat (93.5%), fever (86.0%), pseudomembrane (34.7%), and gross cervical lymphadenopathy (GCL; 30.6%). Diphtheria antitoxin (DAT) was administered to 1,062 (89.0%) out of 1,193 eligible patients, with adverse reactions following among 229 (21.6%). There were 45 deaths (case fatality ratio [CFR] 0.6%). Household contacts for 5,702 (80.7%) of 7,064 cases were successfully traced. A total of 41,452 contacts were identified, of whom 40,364 (97.4%) consented to begin chemoprophylaxis; adherence was 55.0% (N = 22,218) at 3-day follow-up. Unvaccinated household contacts were vaccinated with 3 doses (with 4-week interval), while a booster dose was administered if the primary vaccination schedule had been completed. The proportion of contacts vaccinated was 64.7% overall. Three MVC rounds were conducted, with administrative coverage varying between 88.5% and 110.4%. Pentavalent vaccine was administered to those aged 6 weeks to 6 years, while tetanus and diphtheria (Td) vaccine was administered to those aged 7 years and older. Lack of adequate diagnostic capacity to confirm cases was the main limitation, with a majority of cases unconfirmed and the proportion of true diphtheria cases unknown.
CONCLUSIONS
To our knowledge, this is the largest reported diphtheria outbreak in refugee settings. We observed that high population density, poor living conditions, and fast growth rate were associated with explosive expansion of the outbreak during the initial exponential growth phase. Three rounds of mass vaccinations targeting those aged 6 weeks to 14 years were associated with only modestly reduced transmission, and additional public health measures were necessary to end the outbreak. This outbreak has a long-lasting tail, with Rt oscillating at around 1 for an extended period. An adequate global DAT stockpile needs to be maintained. All populations must have access to health services and routine vaccination, and this access must be maintained during humanitarian crises.
Unrest in Myanmar in August 2017 resulted in the movement of over 700,000 Rohingya refugees to overcrowded camps in Cox's Bazar, Bangladesh. A large outbreak of diphtheria subsequently began in this population.
METHODS AND FINDINGS
Data were collected during mass vaccination campaigns (MVCs), contact tracing activities, and from 9 Diphtheria Treatment Centers (DTCs) operated by national and international organizations. These data were used to describe the epidemiological and clinical features and the control measures to prevent transmission, during the first 2 years of the outbreak. Between November 10, 2017 and November 9, 2019, 7,064 cases were reported: 285 (4.0%) laboratory-confirmed, 3,610 (51.1%) probable, and 3,169 (44.9%) suspected cases. The crude attack rate was 51.5 cases per 10,000 person-years, and epidemic doubling time was 4.4 days (95% confidence interval [CI] 4.2-4.7) during the exponential growth phase. The median age was 10 years (range 0-85), and 3,126 (44.3%) were male. The typical symptoms were sore throat (93.5%), fever (86.0%), pseudomembrane (34.7%), and gross cervical lymphadenopathy (GCL; 30.6%). Diphtheria antitoxin (DAT) was administered to 1,062 (89.0%) out of 1,193 eligible patients, with adverse reactions following among 229 (21.6%). There were 45 deaths (case fatality ratio [CFR] 0.6%). Household contacts for 5,702 (80.7%) of 7,064 cases were successfully traced. A total of 41,452 contacts were identified, of whom 40,364 (97.4%) consented to begin chemoprophylaxis; adherence was 55.0% (N = 22,218) at 3-day follow-up. Unvaccinated household contacts were vaccinated with 3 doses (with 4-week interval), while a booster dose was administered if the primary vaccination schedule had been completed. The proportion of contacts vaccinated was 64.7% overall. Three MVC rounds were conducted, with administrative coverage varying between 88.5% and 110.4%. Pentavalent vaccine was administered to those aged 6 weeks to 6 years, while tetanus and diphtheria (Td) vaccine was administered to those aged 7 years and older. Lack of adequate diagnostic capacity to confirm cases was the main limitation, with a majority of cases unconfirmed and the proportion of true diphtheria cases unknown.
CONCLUSIONS
To our knowledge, this is the largest reported diphtheria outbreak in refugee settings. We observed that high population density, poor living conditions, and fast growth rate were associated with explosive expansion of the outbreak during the initial exponential growth phase. Three rounds of mass vaccinations targeting those aged 6 weeks to 14 years were associated with only modestly reduced transmission, and additional public health measures were necessary to end the outbreak. This outbreak has a long-lasting tail, with Rt oscillating at around 1 for an extended period. An adequate global DAT stockpile needs to be maintained. All populations must have access to health services and routine vaccination, and this access must be maintained during humanitarian crises.