By-Dr. Samarjeet Kaur JR-II BRD Med.

College GKP

Diphtheria is an acute infectious disease caused by toxigenic strains of

Corynebacterium diphtheriae.

Three major clinical types are : - anterior nasal - faucial - laryngeal

The bacilli multiply locally, usually in the throat, and elaborate a powerful exotoxin which is responsible for: - the formation of a psedomembrane over tonsils, pharynx or larynx. - marked congestion, oedema or local tissue destruction - enlargement of the regional lymph nodes; - signs and symptoms of toxaemia. Fatality rate on the average is about 10 per cent in untreated cases, and about 5 per cent in treated cases .

Agent factors : AGENT : - C. diphtheriae is a gram-positive, non-motile organism. - It has no invasive power, but produces a powerful exotoxin. - Three types of diphtheria bacilli are differentiated - gravis, - mitis, - intermedius, - A non-toxigenic strain may become toxigenic when exposed to a particular bacteriophage the beta phage carrying the gene for toxin production .

SOURCE OF INFECTION:

(i) CASE:

Carriers are common sources of infection, their ratio is estimated to be 95 carriers for 5 clinical cases . Incidence of carrier varies from 0.1 5%. Immunization does not prevent carrier state.

(ii) CARRIER: -Temporary or chronic -Nasal or throat

- subclinical - clinical

INFECTIVE MATERIAL : Nasopharyngeal secretions, discharges from skin lesions, contaminated fomites and infected dust, PERIOD OF INFECTIVITY : - varies from 14-28 days from the onset of d/s -A case or carrier may be considered noncommunicable, when at least 2 cultures properly obtained from nose and throat, 24 hours apart, are negative for diphtheria bacilli.

AGE: Diphtheria particularly affects children aged 1 to 5. In countries where widespread immunization is practised, a shift in age incidence has been observed from preschool to school age. SEX: Both sexes are affected, IMMUNITY: Infants born of immune mothers are relatively immune during the first few weeks or months of life. A large proportion of population in developing countries acquire active immunity through inapparent infection. Schick test surveys in India have shown that about 70 per cent of children over the age of 3 years, and 99 per cent over the age of 5 years are already immune. A herd immunity of over 70 per cent is considered necessary to prevent epidemic spread, but some believe that the critical level may be as high as 90 %

Cases of diphtheria occur in all seasons, although winter months favour its spread. In Kolkata, the highest incidence was reported in August; in Mumbai in the winter months; and in Delhi, during August to October .

The disease is spread mainly by droplet infection. It can also be transmitted directly to susceptible persons from infected cutaneous lesions. Transmission by objects (e.g., cups, thermometers, toys, pencils), contaminated by the nasopharyngeal secretions of the patient is possible, but for only short periods.

Portal of entry :

The portal of entry sometimes may be the skin where cuts, wounds and ulcers not properly attended to, may get infected with diphtheria bacilli, and so is the umbilicus in the newborn. Occasionally, the site of implantation may be the eye, genitalia or middle ear. Incubation period : 2-6 days.

(a) RESPIRATORY ROUTE (b) NON-RESPIRATORY ROUTES:

Respiratory tract forms of diphtheria: - pharyngotonsillar - laryngotracheal, - nasal, Patients with pharyngotonsillar diphtheria usually have a sore throat, difficulty in swallowing, and low grade fever at presentation. Examination of the throat may show only mild erythema, localized exudate, or a membrane. Attempts to remove the membrane result in bleeding. Patients with severe disease may have marked oedema of the submandibular area and the anterior portion of the neck, along with lymphadenopathy, giving a characteristic "bullnecked" appearance.

Laryngotracheal diphtheria: most often is preceded by pharyngotonsillar disease, usually is associated with hoarseness and croupy cough at presentation, and, if the infection extends into bronchial tree, is the most severe form of disease. Initially it may be clinically indistinguishable from viral croup or epiglottitis. Nasal diphtheria: the mildest form of respiratory diphtheria, usually is localized to the septum or turbinates of one side of the nose.

Cutaneous diphtheria: - Is common in tropical areas. -It often appears as a secondary infection of a previous skin abrasion or infection. -The presenting lesion, often an ulcer, may be surrounded by erythema and covered with a membrane.

CASES AND CARRIERS (a) Early detection : An active search for cases and carriers should start immediately amongst family and school contacts . Carriers can be detected only by cultural method. (b) Isolation: All cases, suspected cases and carriers should be promptly isolated, preferably in a hospital, for at least 14 days or until proved free of infection. At least 2 consecutive nose and throat swabs, taken 24 hours apart, should be negative before terminating isolation. (c) Treatment : (i) CASES: When diphtheria is suspected, diphtheria antitoxin should be given without delay, 1M or IV, in doses ranging from 10,000 to 80,000 units or more, depending upon the severity of the case, after a preliminary test dose of 0.2 ml subcutaneously to detect sensitization to horse serum. In addition to antitoxin, every case should be treated with penicillin (2.5 lakh units every 6 hours) or erythromycin (250 mg every 6 hrs.) for 5 to 6 days to clear the throat of C. diptheriae and thereby decrease toxin production, (ii) CARRIERS: The carriers should be treated with 10 day course of oral erythromycin, which is the most effective drug for the treatment of carriers.

CONTACTS : They should be throat swabbed and their immunity status determined. Different situations pose different options : (a) where primary immunization or booster dose was received within the previous 2 years, no further action would be needed (b) where primary course or booster dose of diphtheria toxoid was received more than 2 years before, only a booster dose of diphtheria toxoid need be given (c) non-immunized close contact should receive prophylactic penicillin or erythromycin. They should be given 1000-2000 units of diphtheria antitoxin and actively immunized against diphtheria. Contacts should be placed under medical surveillance and examined daily for evidence of diphtheria for at least a week after exposure . The bacteriological surveillance of close contacts should be continued for several weeks by repeated swabbing at approximately weekly intervals .

COMMUNITY The only effective control is by active immunization with diphtheria toxoid of all infants as early in life as possible, as scheduled, with subsequent booster doses every 10 years thereafter . The aim should be to immunize before the infant loses his maternally derived immunity so that there will be continuous protection from birth without any gap in immunity to natural disease . The vaccine being a toxoid is not directed against organisms. Therefore immunization does not prevent the carrier state; consequently, the nonimmune individuals are not protected by a high level of population immunity . This implies that immunization rate must be maintained at a high level