DIPHTHERIADIPHTHERIAThe Past, Present & the Future The Past, Present & the Future

Dr Cummings HenryDr Cummings HenryConsultant PaediatricianConsultant Paediatrician

DELSUTHDELSUTH

PRE TESTPRE TEST

1.1. Diphtheria has been eradicatedDiphtheria has been eradicated

2.2. The is a resurgence of diphtheria The is a resurgence of diphtheria

3.3. The mainstay of treatment is antibioticsThe mainstay of treatment is antibiotics

4.4. Vaccination remain the most effective control Vaccination remain the most effective control measure. measure.

OutlineOutlineThe PastThe Past

The PresentThe Present

The futureThe future

Diphtheria, The Past:Diphtheria, The Past: IntroductionIntroduction EpidemiologyEpidemiology Aetio-pathogenesisAetio-pathogenesis ImmunologyImmunology Clinical PresentationClinical Presentation ComplicationsComplications DifferentialsDifferentials InvestigationsInvestigations TreatmentTreatment PrognosisPrognosis PreventionPrevention

IntroductionIntroduction An ancient disease described by Hippocrates in the An ancient disease described by Hippocrates in the

55thth century BC century BC

Plagued Europe & the American colonies in the 18Plagued Europe & the American colonies in the 18 thth centurycentury

Diphtheria is an acute toxic infectious diseaseDiphtheria is an acute toxic infectious disease

A localized infection of mucous membrane &/or A localized infection of mucous membrane &/or skinskin

May have systemic complications/manifestationsMay have systemic complications/manifestations

EpidemiologyEpidemiology ReservoirReservoir - Exclusively in humans- Exclusively in humans - Skin infection and skin carriage constitute - Skin infection and skin carriage constitute

silent reservoirsilent reservoir

Mode of spreadMode of spread * primarily by airborne respiratory droplets* primarily by airborne respiratory droplets * direct contact with;* direct contact with; -respiratory secretions of infected individuals-respiratory secretions of infected individuals -exudates from infected skin lesions-exudates from infected skin lesions

Epidemiology contd.Epidemiology contd. In the U.S In the U.S

- Pre-vaccination era(1920s) > 115,000 cases and - Pre-vaccination era(1920s) > 115,000 cases and 10,000 deaths reported annually10,000 deaths reported annually

- Recently, < 5 cases are reported annually- Recently, < 5 cases are reported annually In NigeriaIn Nigeria

- 5,039 cases reported in 1989- 5,039 cases reported in 1989

- 3,995 cases in 2000- 3,995 cases in 2000

- 2,468 cases in 2001- 2,468 cases in 2001

- 312 cases in 2006 (7.8% of global report) - 312 cases in 2006 (7.8% of global report)

Epidemiology contd.Epidemiology contd. Carriers are important in transmission Carriers are important in transmission

- constitute 3-5% of healthy individuals in - constitute 3-5% of healthy individuals in endemic region endemic region

Estimated mortality ratesEstimated mortality rates→→5-10% 5-10%

(up to 20% in <5yrs, & > 40yrs)(up to 20% in <5yrs, & > 40yrs)

Epidemiology contd.Epidemiology contd. SexSex

No significant difference in the incidence in No significant difference in the incidence in males & females of similar immunization males & females of similar immunization statusstatus

AgeAge

- Commoner in 6month-12yrs - Commoner in 6month-12yrs

(esp. in the pre-vaccination era)(esp. in the pre-vaccination era)

Risk factorsRisk factors Incomplete or absent immunizationIncomplete or absent immunization Low herd immunityLow herd immunity Travel to endemic areas or regions with Travel to endemic areas or regions with

current epidemiccurrent epidemic Immunocompromised states e.g. Immunocompromised states e.g.

HIV/AIDSHIV/AIDS Low socio-economic statusLow socio-economic status Poor health care facilitiesPoor health care facilities OvercrowdingOvercrowding

Aetio-pathogenesisAetio-pathogenesis Caused by toxigenic Corynebacterium Caused by toxigenic Corynebacterium

diphtheriaediphtheriae TypesTypes - Corynebacterium diphtheriae- Corynebacterium diphtheriae * mitis* mitis * intermedius* intermedius * belfanti* belfanti * gravis* gravis - Corynebacterium ulcerans- causes cutaneous - Corynebacterium ulcerans- causes cutaneous

diseasedisease

CharacteristicsCharacteristics Gram positiveGram positive Club-shaped bacillusClub-shaped bacillus AerobicAerobic Non-motileNon-motile Non-encapsulatedNon-encapsulated About 2-4About 2-4μμm in lengthm in length Assume L &/or V configuration to each otherAssume L &/or V configuration to each other Form a Chinese lettering patternForm a Chinese lettering pattern

Corynebacterium diphtheriaCorynebacterium diphtheria

Corynebacterium diphtheriaCorynebacterium diphtheria

Gram stainGram stain Methylene blue stainMethylene blue stain

VirulenceVirulence Depends on the ability to produce the Depends on the ability to produce the

diphtheria toxin-an exotoxindiphtheria toxin-an exotoxin

Toxigenicity depends on the presence of a Toxigenicity depends on the presence of a lysogenic bacteriophagelysogenic bacteriophage

Non-toxigenic strain can become Non-toxigenic strain can become toxigenic by coming in contact with toxigenic by coming in contact with toxigenic strainstoxigenic strains

B-phage that carries the tox gene B-phage that carries the tox gene that encodes the diphtheria toxinthat encodes the diphtheria toxin

The ExotoxinThe Exotoxin A 62,000 dalton polypeptideA 62,000 dalton polypeptide Composed of 2 joined major segments Composed of 2 joined major segments

(A and B)(A and B)

Actions of the ToxinActions of the Toxin Segment B bind receptors on Segment B bind receptors on

susceptible cells and facilitate entrance susceptible cells and facilitate entrance of segment Aof segment A

Segment A mediates toxic actions:Segment A mediates toxic actions: - inactivates RNA translocase- inactivates RNA translocase - inhibits protein synthesis- inhibits protein synthesis - causing tissue necrosis- causing tissue necrosis

Actions of The Toxin contd.Actions of The Toxin contd. Formation ofFormation of pseudomembranepseudomembrane

* a dense necrotic coagulum of organism, * a dense necrotic coagulum of organism, epithelial cells, fibrin, leucocytes & RBCsepithelial cells, fibrin, leucocytes & RBCs

* grayish-white or brown in colour* grayish-white or brown in colour

The PseudomembraneThe Pseudomembrane

HistologicalHistological GrossGross

Other effects of the toxinOther effects of the toxin Paralysis of palate & hypopharynxParalysis of palate & hypopharynx Systemic absorption:Systemic absorption: - renal tubules necrosis- renal tubules necrosis - thrombocytopenia- thrombocytopenia - cardiomyopathy- cardiomyopathy - demyelination of nerves- demyelination of nerves - paralysis of the diaphragm- paralysis of the diaphragm The toxin is converted to toxoid (for The toxin is converted to toxoid (for

vaccination) when treated with formalinvaccination) when treated with formalin

ImmunologyImmunology Organisms invasion usually remain localizedOrganisms invasion usually remain localized

The main immune response is to the exotoxinThe main immune response is to the exotoxin Immune response is antibody-mediatedImmune response is antibody-mediated The antibody is of the IgG type – AntitoxinThe antibody is of the IgG type – Antitoxin

Immunity does not prevent colonization rather Immunity does not prevent colonization rather it protects against the effects of the toxinit protects against the effects of the toxin

Immunology Contd.Immunology Contd. Active antibodies production may be Active antibodies production may be

induced by:induced by: - active disease- active disease - carrier state- carrier state - vaccination with the toxoid- vaccination with the toxoid Passive immunity –transplacentally Passive immunity –transplacentally

transferredtransferred Immunity was previously thought to be Immunity was previously thought to be

life longlife long

Assessment of immunityAssessment of immunity The Schick test:The Schick test:

- Intradermal injection of 0.1ml 1:50 dilution of - Intradermal injection of 0.1ml 1:50 dilution of toxintoxin

- positive result: inflammation appearing after - positive result: inflammation appearing after 24-36hrs & persisting for 24-36hrs & persisting for ≥ 4≥ 4days – no days – no antitoxin – no immunityantitoxin – no immunity

- negative result – has antitoxin - immune- negative result – has antitoxin - immune

Immunity assessment contd.Immunity assessment contd. Assay of serum level of antitoxinAssay of serum level of antitoxin

- full protection: - full protection: ≥0.1IU/mL≥0.1IU/mL

- basic protection: - basic protection: ≥0.01- <0.1IU/mL≥0.01- <0.1IU/mL

- no protection : < 0.01IU/mL- no protection : < 0.01IU/mL

N.BN.B: Epidemic outbreak is likely when > : Epidemic outbreak is likely when > 90% of the population has < 0.01IU/mL 90% of the population has < 0.01IU/mL of antitoxinof antitoxin

Clinical PresentationClinical Presentation Incubation: usually 2-4days with a Incubation: usually 2-4days with a

range of 1-7daysrange of 1-7days

Classified into:Classified into:

- Respiratory Tract Diphtheria- Respiratory Tract Diphtheria

- Non-Respiratory Tract disease- Non-Respiratory Tract disease

- Complicated disease- Complicated disease

Respiratory tract diphtheriaRespiratory tract diphtheria Nasal DiphtheriaNasal Diphtheria

- commoner in infants- commoner in infants

- little or no constitutional symptoms- little or no constitutional symptoms

- serosanguineous nasal discharge- serosanguineous nasal discharge

- epistaxis- epistaxis

Nasal Diphtheria contd.Nasal Diphtheria contd.- - purulent foul smelling discharge- purulent foul smelling discharge

- shallow ulcers +/- pseudomembrane- shallow ulcers +/- pseudomembrane

- unilateral or bilateral- unilateral or bilateral

- may persist for several weeks- may persist for several weeks

- major source of transmission- major source of transmission

Tonsilo-PharyngealTonsilo-Pharyngeal Most common (90% of cases)Most common (90% of cases) MalaiseMalaise Fever – mild to moderateFever – mild to moderate Sore throat – drooling, odynophagia +/- Sore throat – drooling, odynophagia +/-

dysphagiadysphagia Bull-neck appearanceBull-neck appearance Pseudomembrane of variable extentPseudomembrane of variable extent

Bull-Neck appearanceBull-Neck appearance

PseudomenbranePseudomenbrane

Laryngeal DiphtheriaLaryngeal Diphtheria Usually an extension of pharyngeal Usually an extension of pharyngeal

diseasedisease

Hoarseness of voiceHoarseness of voice

CoughCough

Inspiratory stridorInspiratory stridor

Laryngeal Diphtheria contd.Laryngeal Diphtheria contd. Suprasternal, substernal & subcostal Suprasternal, substernal & subcostal

recessionsrecessions

Symptoms & signs of sudden airway Symptoms & signs of sudden airway obstructionobstruction

Sudden deathSudden death

May require intubation/tracheotomyMay require intubation/tracheotomy

Tracheo-bronchial diphtheriaTracheo-bronchial diphtheria Usually an extension from pharynx & Usually an extension from pharynx &

larynxlarynx

Diphtheria pneumonia – hemorrhagicDiphtheria pneumonia – hemorrhagic

Bronchiolar pseudomembraneBronchiolar pseudomembrane

Airway obstruction/sudden deathAirway obstruction/sudden death

Diphtheria PneumoniaDiphtheria Pneumonia

Non-Respiratory diseaseNon-Respiratory disease

Cutaneous diphtheriaCutaneous diphtheria

Cutaneous diphtheria Cutaneous diphtheria superficial, non-healing ulcerssuperficial, non-healing ulcers well defined marginswell defined margins pseudomembrane on floor of ulcerpseudomembrane on floor of ulcer erythema & tenderness of surrounding erythema & tenderness of surrounding

skinskin important in transmission in the important in transmission in the

communitycommunity

Cutaneous diphtheria contd.Cutaneous diphtheria contd. Predisposing factors:Predisposing factors:

- pre-existing dermatoses- pre-existing dermatoses

- laceration- laceration

- burns- burns

- bites - bites

- impetigo- impetigo

Other non-respiratory diseaseOther non-respiratory disease

Ear- otitis externaEar- otitis externa Eye – purulent and ulcerative Eye – purulent and ulcerative

conjunctivitisconjunctivitis Genital tract – purulent and ulcerative Genital tract – purulent and ulcerative

vulvo-vaginitisvulvo-vaginitis Rarely septicaemiaRarely septicaemia

ComplicationsComplications Toxic CardiomyopathyToxic Cardiomyopathy - commonly myocarditis, rarely endocarditis- commonly myocarditis, rarely endocarditis - usually occurs at the end of 2- usually occurs at the end of 2ndnd wk of illness wk of illness - tachycardia out of proportion to fever- tachycardia out of proportion to fever - arrhythmias- arrhythmias - symptoms & signs of CCF- symptoms & signs of CCF - occurs in 10-25% of patients- occurs in 10-25% of patients - accounts for 50-60% of deaths- accounts for 50-60% of deaths

Toxic Cardiomyopathy contd.Toxic Cardiomyopathy contd. ECG findings:ECG findings: - prolonged PR interval- prolonged PR interval - ST segment elevation- ST segment elevation - 1- 1stst, 2, 2ndnd, or 3, or 3rdrd degree heart block degree heart block

Echocardiogram:Echocardiogram: - dilated cardiomyopathy- dilated cardiomyopathy - hypertrophic cardiomyopathy- hypertrophic cardiomyopathy - vegetations- vegetations

Toxic Neuropathy Toxic Neuropathy Usually occurs at 3-4wks Usually occurs at 3-4wks

Affects mainly motor functionsAffects mainly motor functions

Paralysis of soft palate &pharyngeal wallParalysis of soft palate &pharyngeal wall

- nasal voice- nasal voice

- difficulty in swallowing (esp. fluids)- difficulty in swallowing (esp. fluids)

Toxic Neuropathy contd.Toxic Neuropathy contd. Occulomotor N. & cillary paralysisOcculomotor N. & cillary paralysis

- strabismus &/or blurred vision- strabismus &/or blurred vision

Peripheral neuritis – diminished DTR & Peripheral neuritis – diminished DTR & paralysisparalysis

- occasionally glove & stockings neuropathy - occasionally glove & stockings neuropathy ( like GBS)( like GBS)

Paralysis of the diaphragmParalysis of the diaphragm

Airway obstructionAirway obstruction Commoner in laryngeal diseaseCommoner in laryngeal disease

May be suddenMay be sudden

Usually due to dislodgement of Usually due to dislodgement of PseudomembranePseudomembrane

May require intubation/tracheotomy & May require intubation/tracheotomy & mechanical ventilationmechanical ventilation

DifferentialsDifferentials Tonsillo-PharyngitisTonsillo-Pharyngitis Viral CroupViral Croup EpiglottitisEpiglottitis Peritonsilar abscessPeritonsilar abscess AngioedemaAngioedema Myocarditis (other causes)Myocarditis (other causes) Peripheral neuropathy 2Peripheral neuropathy 2o o GBSGBS

Laboratory StudiesLaboratory Studies Methylene blue &/or gram stainingMethylene blue &/or gram staining

Culture using tellurite-Loeffler mediaCulture using tellurite-Loeffler media

Toxigenicity test:Toxigenicity test: - Elek test- Elek test - PCR- PCR

Laboratory studies contd.Laboratory studies contd. FBC – moderate leucocytosisFBC – moderate leucocytosis

Urinalysis – transient proteinuriaUrinalysis – transient proteinuria

Serum assay of antibodies – immunitySerum assay of antibodies – immunity

Serum assay of troponin 1 – myocarditisSerum assay of troponin 1 – myocarditis

Radiological studiesRadiological studies Echocardiogram & ECG findingsEchocardiogram & ECG findings Neck soft tissue X-ray – prevertebral soft Neck soft tissue X-ray – prevertebral soft

tissue swellingtissue swelling::

TreatmentTreatment Diphtheria AntitoxinDiphtheria Antitoxin

- mainstay of treatment- mainstay of treatment

- give at clinical diagnosis- give at clinical diagnosis

- can only neutralize free toxins- can only neutralize free toxins

- efficacy diminishes with delay- efficacy diminishes with delay

- only available from CDC/WHO- only available from CDC/WHO

- preferably given IV- preferably given IV

- dosage depends on site involved & duration - dosage depends on site involved & duration of illness of illness

Dosage of Antitoxin (units)Dosage of Antitoxin (units) Site and extent of lesion illness<72hrs illness >72hrsSite and extent of lesion illness<72hrs illness >72hrs Nasal 10,000-20,000 10,000-20,000Nasal 10,000-20,000 10,000-20,000 One tonsil 20,000 20,000-40,000One tonsil 20,000 20,000-40,000 Both tonsils+/-Both tonsils+/- Pharyngeal 20,000-40,000 40,000-60,000Pharyngeal 20,000-40,000 40,000-60,000 Laryngeal or Laryngeal or Combined types 40,000-80,000 60,000-80,000Combined types 40,000-80,000 60,000-80,000 Very extensive Very extensive Disease 60,000-80,000 80,000-100,000 Disease 60,000-80,000 80,000-100,000

• N.B. Test for sensitivity before administration and desensitized if necessary

Testing for SensitivityTesting for Sensitivity Skin test:Skin test:

- Intradermal injection of 0.1mL of 1:10 - Intradermal injection of 0.1mL of 1:10 dilution of antiserum in salinedilution of antiserum in saline

- read in 20mins - read in 20mins

- a wheal - a wheal ≥ 1cm – positive – sensitive≥ 1cm – positive – sensitive Conjunctiva test:Conjunctiva test:

- conjunctivitis & lacrimation – positive - conjunctivitis & lacrimation – positive Caution! Ensure adrenalin is availableCaution! Ensure adrenalin is available

DesensitizingDesensitizing 0.1ml of a 1:20 dilution subcut. - wait 20mins0.1ml of a 1:20 dilution subcut. - wait 20mins 0.1ml of a 1:10 dilution subcut. - wait 20mins0.1ml of a 1:10 dilution subcut. - wait 20mins 0.1 ml undiluted subcut. - wait 20mins0.1 ml undiluted subcut. - wait 20mins 0.3ml undiluted IM - wait 20mins0.3ml undiluted IM - wait 20mins 0.5ml undiluted IM - wait 20mins0.5ml undiluted IM - wait 20mins

If no reaction has occurred the rest of the dose If no reaction has occurred the rest of the dose can be given IM can be given IM

Antimicrobial therapyAntimicrobial therapy Role:Role:

- halt toxin production- halt toxin production

- treat localized infection- treat localized infection

- prevent transmission- prevent transmission Drugs/dosageDrugs/dosage

- IV/IM penicillin- IV/IM penicillin

* iv xtapen 100,000/kg/day in 6hrly dosing* iv xtapen 100,000/kg/day in 6hrly dosing

* im procaine pen. 25,000iu/kg/day, 12hrly * im procaine pen. 25,000iu/kg/day, 12hrly

- Oral erythromycin, 40mg/kg/day 6hrly- Oral erythromycin, 40mg/kg/day 6hrly

Antimicrobial contd.Antimicrobial contd. Other drugs that can be used:Other drugs that can be used:

- Clindamycin- Clindamycin

- Tetracycline- Tetracycline

Give for 10 – 14 daysGive for 10 – 14 days

Elimination of organism should be confirmed Elimination of organism should be confirmed by at least 2 successive negative culture by at least 2 successive negative culture obtained 24hrs apartobtained 24hrs apart..

Treatment contd.Treatment contd. IsolationIsolation - respiratory isolation for respiratory disease- respiratory isolation for respiratory disease - contact isolation for cutaneous disease- contact isolation for cutaneous disease

Bed restBed rest

Secure airway if necessarySecure airway if necessary

NG tube feeding – palatal/pharyngeal paralysisNG tube feeding – palatal/pharyngeal paralysis

Treatment contd.Treatment contd. IV fluid administration if neededIV fluid administration if needed

Vaccinate – 1Vaccinate – 10 0 series &/or boostersseries &/or boosters

Disease notificationDisease notification

Contact tracingContact tracing

Contact tracing & CareContact tracing & Care The risk of developing the disease after The risk of developing the disease after

household exposure to a case is household exposure to a case is ≈ 2%≈ 2%

The risk of disease after exposure to a carrier The risk of disease after exposure to a carrier

is ≈ 0.3%is ≈ 0.3%

Types of contacts:Types of contacts:

- asymptomatic case contact- asymptomatic case contact

- carrier- carrier

Asymptomatic case contactAsymptomatic case contact monitor for illness monitor for illness cultureculture Antimicrobial prophylaxis Antimicrobial prophylaxis VaccinateVaccinate

primary schedule.primary schedule.booster dose booster dose

CarrierCarrier The reported rate of carriage in The reported rate of carriage in

household contacts of case patients is household contacts of case patients is 0-25%0-25%

Antimicrobial prophylaxis x 7daysAntimicrobial prophylaxis x 7days IsolationIsolation MonitorMonitor Vaccination Vaccination

PrognosisPrognosisDepends on:Depends on: Virulence of the organism. Gravis has the Virulence of the organism. Gravis has the

highest fatality followed by intermedius highest fatality followed by intermedius and the least is mitis.and the least is mitis.

Age; higher mortality rates in individuals Age; higher mortality rates in individuals < 5yrs and those > 40yrs.< 5yrs and those > 40yrs.

Immunization status: worse in the Immunization status: worse in the unimmunizedunimmunized

Prognosis (contd.)Prognosis (contd.) Site of infection/involvement; mortality occur Site of infection/involvement; mortality occur

in: in: < 1% of cutaneous disease< 1% of cutaneous disease ≈ ≈ 10% of uncomplicated respiratory disease 10% of uncomplicated respiratory disease 30 – 40% of bacteremic disease30 – 40% of bacteremic disease 60 - 90% of those with cardiac involvement.60 - 90% of those with cardiac involvement.

Speed of administration of antitoxin; worse Speed of administration of antitoxin; worse with delaywith delay

PreventionPrevention Immunization is the mainstay of preventionImmunization is the mainstay of prevention

Given as DPTGiven as DPT

Immunization schedule (NPI) Immunization schedule (NPI)

- DPT1 – 6wks- DPT1 – 6wks

- DPT2 – 10wks- DPT2 – 10wks

- DPT3 – 14wks- DPT3 – 14wks

The PresentThe Present

Emerging IssuesEmerging Issues Changing epidemiologyChanging epidemiology

- recent re-emergence in some - recent re-emergence in some developed and developing countriesdeveloped and developing countries

- Shifting of the disease into the older - Shifting of the disease into the older populationpopulation

Immunity wanes over timeImmunity wanes over time

Other Epidemiological issuesOther Epidemiological issues Questionable Notification from NigeriaQuestionable Notification from Nigeria Erratic values:Erratic values:

- In 1996 reported 2016 cases- In 1996 reported 2016 cases - In 1997 ,, 31cases- In 1997 ,, 31cases

*DPT3 coverage in 1996 – 30%*DPT3 coverage in 1996 – 30%

Inconsistent figuresInconsistent figures In 2003 & 2004 – no case reportedIn 2003 & 2004 – no case reported

* In 2003 Nigeria had the worst immunization * In 2003 Nigeria had the worst immunization coverage in the worldcoverage in the world

DPT1 coverage – 43.2%DPT1 coverage – 43.2%

DPT3 coverage – 24.8%DPT3 coverage – 24.8%

Only 12.8% were fully immunized Only 12.8% were fully immunized

Latest Immunization CoverageLatest Immunization Coverage Global: 79% estimated DPT3 coverage Global: 79% estimated DPT3 coverage

Current coverage in Nigeria:Current coverage in Nigeria:

- DPT1 is - DPT1 is ≈ 65%≈ 65%

- DPT3 is ≈ 77%- DPT3 is ≈ 77%

WHO proposed coverage is ≥ 90%WHO proposed coverage is ≥ 90%

Changes In Immunization strategiesChanges In Immunization strategies Effect of passive immunity on 1Effect of passive immunity on 100 series series

Commencing 1Commencing 1O O series later e.g.series later e.g. - In the US- In the US

DPT1 – 2mthDPT1 – 2mth

DPT2 – 4mthDPT2 – 4mth

DPT2 – 6mthDPT2 – 6mth

New Immunization Strategies contd.New Immunization Strategies contd.

Boosters:Boosters:

- Given at- Given at

*18mths*18mths

*5yrs*5yrs

*adolescence*adolescence

*every 10yrs thereafter*every 10yrs thereafter

New Formulations of the ToxoidNew Formulations of the Toxoid TdTd - tetanus toxoid with lower dose of diphtheria - tetanus toxoid with lower dose of diphtheria

toxoidtoxoid - adult type- adult type *for adolescence & beyond*for adolescence & beyond - less side effects- less side effects TdapTdap - tetanus toxoid + smaller dose diphtheria + - tetanus toxoid + smaller dose diphtheria +

acellular pertusis vaccineacellular pertusis vaccine - may be used for pregnant women- may be used for pregnant women

Other Emerging IssuesOther Emerging Issues

Antitoxin for Carriers:Antitoxin for Carriers:

* To give or not to give ?* To give or not to give ?

The need for vaccination of pregnant The need for vaccination of pregnant womenwomen

The FutureThe Future

Recommendations Recommendations Improve coverage of 1Improve coverage of 100 schedule to schedule to

90% at least90% at least

44thth & 5 & 5thth DPT doses at 18mths & 5yrs DPT doses at 18mths & 5yrs respectivelyrespectively

Improve disease Surveillance and Improve disease Surveillance and notificationnotification

Recommendations contd.Recommendations contd. Research to evaluate the need toResearch to evaluate the need to

- delay commencement of the primary - delay commencement of the primary seriesseries

- give booster doses at adolescence & - give booster doses at adolescence & thereafter every 10yrs, using Tdthereafter every 10yrs, using Td

- give Td or Tdap to pregnant women- give Td or Tdap to pregnant women

ConclusionConclusion The global goal is to eradicate diphtheria. The global goal is to eradicate diphtheria.

This may only be achieved by not only This may only be achieved by not only making the right policies but also making the right policies but also ensuring that these policies are ensuring that these policies are completely and effectively implemented.completely and effectively implemented.

THANK YOUTHANK YOU