Dr KK Aggarwal
Recently in a meeting, young
doctors of Federation of Resident Doctors Association (FORDA) expressed
their concern about the resurgence of diphtheria in Delhi. They are the first
point of contact with the patients and can talk about real-life situations they
come across.
Last week Delhi reported its
first death as per an Indian Express report. It is unfortunate that as doctors
we get this information from the media. It is the duty of the public health
detective in the National Centre for Disease Control (NCDC) to report and
issue an alert.
Source of the first case
should be traced and surrounding areas issued an alert.
Despite the introduction of mass
immunization, diphtheria continues to play a major role as a potentially lethal
infectious disease in many countries and 4530 cases were reported worldwide in
2015. Unfortunately, 2365 (52.2%) of these were from India.
Remember, diphtheria is
an infectious disease and the primary modes of spread are close contact with
infectious material from respiratory secretions (direct or via airborne
droplet) or from skin lesions.
Humans are the only known
reservoir for Corynebacterium
diphtheriae. Therefore, asymptomatic carriers are important in diphtheria
transmission. Immunity (either via natural infection or vaccine induced) does
not prevent carriage. In areas of endemicity, up to 5% of healthy individuals
may have positive pharyngeal cultures.
The WHO Vaccine Preventable
Diseases Monitoring System has also reported periodic resurgence in India. The
number of cases has been 39231 in 1980, 1326 in 1997, 8465 in 2004, 2525 in
2012, 6094 in 2014 and 2365 in 2015. Again in 2016, 2017 and 2018, the numbers
rose successively to 3,380, 5,293 and 8,788.
As per Central Bureau of
Health Intelligence, during 2005-2014, India reported 41,672 cases of
diphtheria (average 4,167 per year) with 897 deaths (case fatality ratio
2.2%). Ten of the states (Andhra Pradesh, Assam, Delhi, Gujarat,
Haryana, Karnataka, Nagaland, Maharashtra, Rajasthan, and West Bengal)
accounted for 84% of the cases reported across the country.
According to successive
National Family Health Survey reports, the coverage of 3 primary doses of DPT vaccine
has been significantly lower than the desired goal of >90%; 51.7% in 1993,
55% in 1999, 55.3% in 2006 and 78.4% in 2016.
After the advent of widespread
vaccination against diphtheria, circulation of toxigenic strains has reduced,
resulting in decline in immunity in older age groups and increased
susceptibility. This age shift has been demonstrated in studies from West
Bengal, Southern India, and Delhi.
Reasons for high case fatality
include inconsistent and restricted availability of antitoxin and delay in
diagnosis.
Delay in the specific therapy
of diphtheria may result in death and, therefore, accurate diagnosis of
diphtheria is imperative.
A study carried out at NCDC has shown persistence of
toxigenic C. diphtheriae in our community indicating the possibility of
inadequate immunization coverage.
What should be done?
Resurgence of infectious
diseases such as diphtheria is a reflection of our public systems. Instead of
adding more Dunmore vaccines under pressure from GAVI, one
should ensure full coverage of the traditional ones as a
starter. Gavi currently supports 13 life-saving vaccines.
Dr KK Aggarwal
Padma Shri Awardee
President Elect Confederation of
Medical Associations in Asia and Oceania
(CMAAO)
Group Editor-in-Chief IJCP Publications
President Heart Care Foundation of
India
Past National President
IMA
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