Journal Article > Short ReportFull Text
Public Health Action. 2023 June 21; 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. 2023 June 21; 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. 2021 April 1; 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. 2021 April 1; 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.
Journal Article > ResearchFull Text
Euro Surveill. 2023 November 1; 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. 2023 November 1; 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.
Conference Material > Poster
Sikder E, del Barrio BV, Firuz W, Khatoon R, Opstrup A, et al.
MSF Scientific Days UK 2019: Research. 2019 April 29; DOI:10.7490/f1000research.1116684.1
Journal Article > CommentaryFull Text
Ann Fam Med. 2020 March 1; Volume 18 (Issue 2); 176-178.; DOI:10.1370/afm.2521
Asgary R
Ann Fam Med. 2020 March 1; Volume 18 (Issue 2); 176-178.; DOI:10.1370/afm.2521
Hundreds of thousands of Rohingya refugees arrived in Bangladesh within weeks in fall 2017, quickly forming large settlements without any basic support. Humanitarian first responders provided basic necessities including food, shelter, water, sanitation, and health care. However, the challenge before them—a vast camp ravaged by diphtheria and measles superimposed on a myriad of common pathologies—was disproportionate to the resources. The needs were endless, resources finite, inadequacies abundant, and premature death inevitable. While such confines force unimaginable choices in resource allocation, they do not define the humanitarian purpose—to alleviate suffering and not allow such moral violations to become devoid of their horrifying meaning. As humanitarian workers, we maintain humanity when we care, commit, and respond to moral injustices. This refusal to abandon others in desperate situations is an attempt to rectify injustices through witnessing and solidarity. When people are left behind, we must not leave them alone.
Conference Material > Abstract
Juma H, Worku DT, Evboumwan PE, Katuala Y, Mbuyi Y, et al.
MSF Paediatric Days 2024. 2024 May 3; 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.
Journal Article > ReviewFull Text
Int J Infect Dis. 2018 June 8; Volume 71; DOI:10.1016/j.ijid.2018.05.002
Blumberg LH, Prieto MA, Diaz JV, Blanco MJ, Valle B, et al.
Int J Infect Dis. 2018 June 8; Volume 71; DOI:10.1016/j.ijid.2018.05.002
Conference Material > Poster
Usman K, Suwaid SA, Fix M, Evbuomwan PE, Worku DT, et al.
MSF Paediatric Days 2024. 2024 May 3; DOI:10.57740/kX6Njdggl
Journal Article > ResearchFull Text
Clin Infect Dis. 2021 October 5; Volume 73 (Issue 7); e1713-e1718.; DOI:10.1093/cid/ciaa1718
Eisenberg N, Panunzi I, Wolz A, Burzio C, Cilliers A, et al.
Clin Infect Dis. 2021 October 5; Volume 73 (Issue 7); e1713-e1718.; DOI:10.1093/cid/ciaa1718
BACKGROUND
Diphtheria has re-emerged over the past several years. There is a paucity of data on the administration and safety of diphtheria antitoxin (DAT), the standard treatment for diphtheria. The 2017-2018 outbreak among Rohingya refugees in Bangladesh was the largest in decades. We determined the outcomes of DAT-treated patients and describe the occurrence and risk factors associated with adverse reactions to DAT.
METHODS
We conducted a retrospective study at the Médecins Sans Frontières Rubber Garden Diphtheria Treatment Center from December 2017-September 2018. Diphtheria was diagnosed based on the World Health Organization clinical case criteria. High-acuity patients were eligible for DAT. Safety precautions were meticulously maintained. We calculated the presence of adverse events by age, duration of illness, and DAT dosage using bivariate comparisons.
RESULTS
We treated 709 patients with DAT; 98% (n = 696) recovered and were discharged. One-fourth (n = 170) had at least 1 adverse reaction. Common reactions included cough (n = 115, 16%), rash (n = 66, 9%), and itching (n = 37, 5%). Three percent (n = 18) had severe hypersensitivity reactions. Five patients died during their DAT infusion or soon afterwards, but no deaths were attributed to DAT.
CONCLUSIONS
Outcomes for DAT-treated patients were excellent; mortality was <1%. Adverse reactions occurred in one-quarter of all patients, but most reactions were mild and resolved quickly. DAT can be safely administered in a setting with basic critical care, provided there is continuous patient monitoring during the infusion, staff training on management of adverse effects, and attention to safety precautions.
Diphtheria has re-emerged over the past several years. There is a paucity of data on the administration and safety of diphtheria antitoxin (DAT), the standard treatment for diphtheria. The 2017-2018 outbreak among Rohingya refugees in Bangladesh was the largest in decades. We determined the outcomes of DAT-treated patients and describe the occurrence and risk factors associated with adverse reactions to DAT.
METHODS
We conducted a retrospective study at the Médecins Sans Frontières Rubber Garden Diphtheria Treatment Center from December 2017-September 2018. Diphtheria was diagnosed based on the World Health Organization clinical case criteria. High-acuity patients were eligible for DAT. Safety precautions were meticulously maintained. We calculated the presence of adverse events by age, duration of illness, and DAT dosage using bivariate comparisons.
RESULTS
We treated 709 patients with DAT; 98% (n = 696) recovered and were discharged. One-fourth (n = 170) had at least 1 adverse reaction. Common reactions included cough (n = 115, 16%), rash (n = 66, 9%), and itching (n = 37, 5%). Three percent (n = 18) had severe hypersensitivity reactions. Five patients died during their DAT infusion or soon afterwards, but no deaths were attributed to DAT.
CONCLUSIONS
Outcomes for DAT-treated patients were excellent; mortality was <1%. Adverse reactions occurred in one-quarter of all patients, but most reactions were mild and resolved quickly. DAT can be safely administered in a setting with basic critical care, provided there is continuous patient monitoring during the infusion, staff training on management of adverse effects, and attention to safety precautions.
Journal Article > ReviewFull Text
Clin Infect Dis. 2019 August 19; Volume 71 (Issue 1); 89-97.; DOI:10.1093/cid/ciz808
Truelove SA, Keegan LT, Moss WJ, Chaisson LH, Macher E, et al.
Clin Infect Dis. 2019 August 19; Volume 71 (Issue 1); 89-97.; DOI:10.1093/cid/ciz808
BACKGROUND
Diphtheria, once a major cause of childhood morbidity and mortality, all but disappeared following introduction of diphtheria vaccine. Recent outbreaks highlight the risk diphtheria poses when civil unrest interrupts vaccination and healthcare access. Lack of interest over the last century resulted in knowledge gaps about diphtheria’s epidemiology, transmission, and control.
METHODS
We conducted 9 distinct systematic reviews on PubMed and Scopus (March–May 2018). We pooled and analyzed extracted data to fill in these key knowledge gaps.
RESULTS
We identified 6934 articles, reviewed 781 full texts, and included 266. From this, we estimate that the median incubation period is 1.4 days. On average, untreated cases are colonized for 18.5 days (95% credible interval [CrI], 17.7–19.4 days), and 95% clear Corynebacterium diphtheriae within 48 days (95% CrI, 46–51 days). Asymptomatic carriers cause 76% (95% confidence interval, 59%–87%) fewer cases over the course of infection than symptomatic cases. The basic reproductive number is 1.7–4.3. Receipt of 3 doses of diphtheria toxoid vaccine is 87% (95% CrI, 68%–97%) effective against symptomatic disease and reduces transmission by 60% (95% CrI, 51%–68%). Vaccinated individuals can become colonized and transmit; consequently, vaccination alone can only interrupt transmission in 28% of outbreak settings, making isolation and antibiotics essential. While antibiotics reduce the duration of infection, they must be paired with diphtheria antitoxin to limit morbidity.
CONCLUSIONS
Appropriate tools to confront diphtheria exist; however, accurate understanding of the unique characteristics is crucial and lifesaving treatments must be made widely available. This comprehensive update provides clinical and public health guidance for diphtheria-specific preparedness and response.
Diphtheria, once a major cause of childhood morbidity and mortality, all but disappeared following introduction of diphtheria vaccine. Recent outbreaks highlight the risk diphtheria poses when civil unrest interrupts vaccination and healthcare access. Lack of interest over the last century resulted in knowledge gaps about diphtheria’s epidemiology, transmission, and control.
METHODS
We conducted 9 distinct systematic reviews on PubMed and Scopus (March–May 2018). We pooled and analyzed extracted data to fill in these key knowledge gaps.
RESULTS
We identified 6934 articles, reviewed 781 full texts, and included 266. From this, we estimate that the median incubation period is 1.4 days. On average, untreated cases are colonized for 18.5 days (95% credible interval [CrI], 17.7–19.4 days), and 95% clear Corynebacterium diphtheriae within 48 days (95% CrI, 46–51 days). Asymptomatic carriers cause 76% (95% confidence interval, 59%–87%) fewer cases over the course of infection than symptomatic cases. The basic reproductive number is 1.7–4.3. Receipt of 3 doses of diphtheria toxoid vaccine is 87% (95% CrI, 68%–97%) effective against symptomatic disease and reduces transmission by 60% (95% CrI, 51%–68%). Vaccinated individuals can become colonized and transmit; consequently, vaccination alone can only interrupt transmission in 28% of outbreak settings, making isolation and antibiotics essential. While antibiotics reduce the duration of infection, they must be paired with diphtheria antitoxin to limit morbidity.
CONCLUSIONS
Appropriate tools to confront diphtheria exist; however, accurate understanding of the unique characteristics is crucial and lifesaving treatments must be made widely available. This comprehensive update provides clinical and public health guidance for diphtheria-specific preparedness and response.