Download Fatal case of diphtheria in an unvaccinated infant

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Eurosurveillance Weekly: Thursday 24 January 2002. Volume 6, Issue 4
Contents:
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4.
Fatal case of diphtheria in an unvaccinated infant, Finland 2001
Toxigenic Corynebacterium diphtheriae var mitis isolated from a child from north west England
A case of typhoid in a student community and subsequent public health measures
Immunisation against meningococcal meningitis for haj and Umrah
Fatal case of diphtheria in an unvaccinated infant, Finland 2001
In November 2001, a 3 month old, previously healthy, unvaccinated infant died of diphtheria in south
eastern Finland. The illness began with laryngeal cough and low grade fever, and progressed in one
week to severe respiratory distress requiring mechanical ventilation. The child died of toxic illness despite
intensive care and antimicrobial and antitoxin treatment. The clinical presentation was bacterial tracheitis;
a pseudomembrane around the epiglottis was detected only during intubation. Corynebacterium
diphtheriae var mitis was grown on culture; the strain tested positive for toxigenicity by polymerase chain
reaction. During necropsy, an extensive pseudomembrane in the trachea extending to the bronchi was
observed.
In cultures of close contacts, a 7 year old sister of the patient was identified as an asymptomatic carrier of
C. diphtheriae. She had received a full course of diphtheria, tetanus, and pertussis (DTP) vaccines. All
other cultures from close contacts of both the patient and his sister were negative. Many of the people
with whom the patient and his sister had been in contact before the onset of illness had recently visited
Russia. According to DNA typing results, the bacterial strain appeared similar to C. diphtheriae var mitis
strains recently detected circulating in Russia.
Routine DTP vaccinations in Finland are given at 3, 4, 5, and 20-24 months of age, and a booster dose is
given at 11-13 years. The patient had not yet started his vaccination series. According to serological
studies done in 1995-96, young adults in Finland have good protection against diphtheria (1). Among
persons aged under 40 years, 90% have antibody concentrations of at least 0.01 IU/ml. The antibody
concentrations wane with increasing age, however, and are substantially lower in middle aged and older
age groups. Among persons aged 40 years or above, a higher proportion of men have protective antibody
concentrations than women. The higher seroprevalence in men is related to booster doses received
during military service.
From 1995 to 2001, eight cases of microbiologically confirmed diphtheria were reported in Finland
through routine surveillance with varying clinical presentations; all had a link to Russia. According to
recent unofficial reports, cases of diphtheria in areas of Russia bordering Finland, particularly in St
Petersburg, seem to be increasing. The official reported total annual number of cases from Russia was
771 in 2000 and 642 from January to September 2001. The peak of the outbreak was in 1995 at nearly
50 000 cases. The small number of diphtheria cases identified in Finland in recent years despite
extensive traffic across the border implies that the overall immunity of the population is comparatively
good. Adults, however, particularly women, should ensure that they have received a full series of three
doses of diphtheria vaccine and booster doses every 10 years, especially when travelling to Russia or the
Baltic states.
The molecular typing of the isolate was carried out by the Finnish representative of the European
Laboratory Working Group on Diphtheria (ELWGD) at the National Diphtheria Reference Laboratory,
KTL. The ELWGD was established in 1993 at the request of the World Health Organization (WHO)
Regional Office for Europe in response to the diphtheria epidemics in the Newly Independent States of
the former Soviet Union (2) (http://www.phls.co.uk/International/diphtheria/diphtheria.htm). The network
comprises representatives from 35 diphtheria reference laboratories and facilities in all European Union
(EU) member states, and some associated countries and other countries in all WHO regions. It is
coordinated by the Public Health Laboratory Service (PHLS) in the United Kingdom (UK).
This network is currently being enhanced by a programme funded by the EU Directorate General Health
and Consumer Protection of the European Commission (DG SANCO) (122/SID/2001) and led by the
PHLS in the UK. This feasibility study started on 1 December 2001. It aims to encompass and integrate
microbiological and public health aspects in developing a diphtheria surveillance network covering all
European states.
References:
1.
2.
Edmunds WJ, Pebody RG, Aggerback H, Baron S, Berbers G, Conyn-van Spaendonck MA, et al. The sero-epidemiology
of diphtheria in Western Europe. Epidemiol Infect 2000; 125: 113-25. (http://uk.cambridge.org/journals/hyg/)
Efstratiou A, Roure C, and members of the European Laboratory Working Group on Diphtheria. The European Laboratory
Working Group on Diphtheria: a global microbiologic network. J Infect Dis 2000; 181 (Suppl. 1): S145-51.
Reported by Pekka Nuorti ([email protected]), Department of Infectious Disease Epidemiology, National
Public Health Institute (KTL), Helsinki, Finland; Pekka Suomalainen, Etelä-Karjala Central Hospital,
Lappeenranta, Finland; Tarja Heiskanen-Kosma, Department of Infectious Disease Epidemiology, KTL,
and Jaana Vuopio-Varkila, Department of Microbiology, KTL; Androulla Efstratiou
([email protected]), PHLS Central Public Health Laboratory, London, England; Natasha Crowcroft
([email protected]), and Joanne White ([email protected]), PHLS Communicable Disease
Surveillance Centre, London, England.
Toxigenic Corynebacterium diphtheriae var mitis isolated from a child from north
west England
A toxigenic strain of Corynebacterium diphtheriae var mitis was isolated on 14 January from a throat
swab from an 11 year old boy from a religious community in Salford, north west England (1). The child
had developed a sore throat on 5 January, six days after returning from a one week holiday with four
members of his family in Jerusalem, Israel. The throat swab was taken on 7 January. A seven day course
of antibiotic treatment (azithromycin) was started as soon as the isolation of a toxigenic strain of C.
diphtheriae var mitis was reported. The boy has been excluded from school until throat swabs after
treatment are negative. The organism was detected because throat swabs are routinely screened for
corynebacteria (2). The child remained well and did not develop any signs or symptoms of diphtheria.
Close contacts of the child were identified as household members, two relatives in London and two
household relatives in Israel, with whom the carrier had stayed overnight in the previous seven days.
Nose and throat swabs were taken from all family members in Salford, and a three day course of
azithromycin was prescribed. All child contacts were excluded from school for three days until they had
completed treatment (3). Immunisation histories showed that all the family had received appropriate age
specific vaccinations, and, in line with current guidance, a booster dose was given. Nose and throat
swabs were also taken from the London contacts, and they received antibiotics and a booster dose of
vaccine. All swabs taken from the Salford and London contacts were negative for C. diphtheriae.
The contacts in Jerusalem were informed of the microbiological findings by the Salford family. Their local
doctor in Jerusalem has taken throat cultures and given antibiotic prophylaxis.
Genotyping (ribotyping) is currently being undertaken by the Public Health Laboratory Service Respiratory
and Systemic Infection Laboratory in London. Preliminary findings indicate that this is an uncommon
ribotype that has not been seen in the European region for more than a decade. C. diphtheriae strains
can be readily reintroduced into a population as shown by the re-emergence of diphtheria in Russia and
the former Soviet Union during the 1990s (4). This incident further emphasises the importance of
ensuring and maintaining high levels of diphtheria vaccination in the population.
References:
1.
2.
3.
4.
CDSC. Toxigenic Corynebacterium diphtheriae var mitis isolated from a child from Salford. Comm Dis Rep CDR Weekly
2002 12(4). (http://www.phls.co.uk/publications/CDR%20Weekly/index.html)
Efstratiou A, George R. Laboratory guidelines for the diagnosis of infections caused by Corynebacterium diphtheriae and
C. ulcerans. Commun Dis Public Health 1999; 2: 250-7. (http://www.phls.co.uk/publications/cdph.htm)
Bonnet JM, Begg NT. Control of diphtheria: guidance for consultants in communicable disease control. Commun Dis
Public health 1999; 2: 242-9. (http://www.phls.co.uk/publications/cdph.htm)
Galazka A. The changing epidemiology of diphtheria in the vaccine era. J Infect Dis 2000; 181 (Suppl. 1): S2-9.
(http://www.journals.uchicago.edu/JID/journal/contents/v181nS1.html)
Reported by Rosemary McCann ([email protected]), Salford and Trafford
Health Authority, England.
A case of typhoid in a student community and subsequent public health
measures
Timely public health measures and close collaboration between the health authorities, physicians, the
patient, and contacts can limit infection transmission, as the following report from Germany’s surveillance
bulletin shows (1).
A 23 year old Indian man arrived on 1 October 2001 in a small town in southern Germany to start a
course of studies at a college for higher education. He shared his room with another Indian man; the
other five rooms in the residence were occupied by 10 fellow students from different countries who
attended one of two colleges.
Ten days after his arrival the man became ill with fever, shivers, headaches, and constipation. Without
consulting a general practitioner he went to hospital and was admitted with a continuing high temperature,
on 16 October, where typhoid fever was confirmed on blood culture. The case was reported to the health
authorities on 22 October 2001.
The health authorities informed the two colleges about the risk of transmission and instigated contact
tracing. The number of people with potential exposure was small as the patient had not been in Germany
very long, and had spent his time mainly with the people sharing his residence.
On 23 October a health officer visited the residence and informed the landlady and fellow students that
they were at risk because of close contact in the living and study areas. One of the flatmates was
immunosuppressed after a kidney transplant. All were invited to attend an information event at the health
office on the following day, where English language information leaflets were handed out. The contacts
were put under observation, and protection measures were implemented to comply with legal
requirements (contacts are not to use community venues such as public baths, saunas, event halls; they
have to report changes in residence, disinfect toilets after use, may not work in the food sector or
children’s institutions, seek medical advice immediately on developing symptoms, and report to the health
authorities). They were given containers for stool specimens and disinfectant. It was particularly stressed
that washing and adequate disinfection of hands is the main way to prevent transmission.
The two colleges allocated a toilet, equipped with disinfectant and signage, so that the students could
continue their course. They did not visit the student refectory and reported only sporadic contacts with
other students. The patient himself was treated with ciprofloxacin and discharged from hospital on 16
November after two stool specimens had tested negative. A third specimen, however, tested positive for
typhoid bacteria, and the patient was moved into a single room with a separate bathroom. He was put on
a ciprofloxacin regimen for four weeks. Observation of the contacts was discontinued after three stool
specimens each tested negative, and their toilet was then allocated to the patient so that he could
continue his studies.
Close cooperation between the patient, his contacts, the health authorities, the colleges, and doctors
helped to contain this infection risk. The students did not have to interrupt their studies for more than
three days.
Reference:
1.
Robert Koch-Institut. Erfahrungsbericht: Massnahmen bei einer Typhuserkrankung in einer Gemeinschaft.
Epidemiologisches Bulletin 2002; 1: 4-5. (http://www.rki.de/INFEKT/EPIBULL/EPI.HTM)
Reported by Rainer Nusser, Gesundheitsamt Villingen-Schwenningen, and Wolfgang Kiehl, Robert KochInstitut, Berlin ([email protected]). Translated and adapted from reference 1 by Birte Twisselmann
([email protected]), Eurosurveillance editorial office.
Immunisation against meningococcal meningitis for haj and Umrah
This year’s recommendations by the Department of Health (DH) for England for immunisation against
meningococcal meningitis for pilgrims planning to travel to Mecca on haj or Umrah were reported in last
week’s Communicable Disease Report (1). An outbreak of meningococcal serogroup A infection occurred
among pilgrims on the haj pilgrimage of 1987, resulting in outbreaks in other countries including the
United Kingdom (UK). There were 18 primary cases among pilgrims returning to UK and 15 subsequent
cases among Muslims over the following 19 months. The strains were shown to be of the same clone as
the strains from the Mecca outbreak and had been encountered in England only rarely before this
outbreak (2). Saudi Arabia’s authorities required that, for the 1988 haj, pilgrims should produce proof of
vaccination with meningococcal serogroup A vaccine.
This was the first time that meningococcal immunisation was required as a condition of travel. Although
this requirement went beyond the International Health Regulations (IHR,
http://www.who.int/emc/IHR/int_regs.html), it was a response that attempted to prevent further outbreaks.
The meningococcal vaccine (containing groups A and C) was not at that time widely available for
travellers or licensed in the UK. The requirement at first resulted in some inconvenience for those seeking
immunisation and a challenge for those administering it. During the 1990s, however, the requirement
became established, the vaccine became licensed and more easily available, and pilgrims received the
vaccine routinely. The Saudi authorities stipulated that the vaccine should be received at least two weeks
before travel and originally was acceptable only within two years of travel, a requirement that was later
extended to three years.
An outbreak of serogroup W135 meningococcal infection occurred among pilgrims on haj in 2000, and
cases associated with those returning were reported from many countries including Finland, France,
Germany, Iran, Kuwait, Morocco, the Netherlands, Oman, Singapore, Spain, UK, and the United States,
in addition to those reported in Saudi Arabia (3). In the UK there were 45 cases in 2000 and 52 in 2001,
including pilgrims, contacts of pilgrims, and also to some with no known contacts. The European
Commission’s Directorate-General V (now DG SANCO) set up a rapid reporting system for meningitis
W135: 2a:P1.2, 5 in 2000 in response to the outbreak. (4)
After this outbreak, the DH recommended immunisation with vaccine that included serogroup W135. The
quadrivalent vaccine (ACWY) had not been widely available in the UK up to that time, being used only for
contacts of this hitherto unusual strain. Coverage among pilgrims was low (5). Further cases of serogroup
W135 were reported as associated with the 2001 pilgrimage and the DH launched a campaign to
increase vaccine uptake for haj in 2002. The quadrivalent vaccine is now widely available.
The dates for haj vary annually; in 2002 it is expected to take place in the last week of February or early
March. Umrah is performed outside of the period of haj, and some pilgrims will have left the UK for that
purpose in November.
Pilgrims going on haj should be further reminded about immunisation requirements. The Saudi Arabian
authorities now require proof of vaccination with the quadrivalent vaccine when a visa for haj or Umrah is
issued. The proof of vaccination is valid for three years. Details of immunising children below the age of
two years can be found in CDR Weekly (6).
An international certificate of vaccination against yellow fever is required for entry to Saudi Arabia from
countries with infected areas. This does not affect those travelling directly from Europe.
References:
1.
2.
3.
4.
5.
6.
7.
CDSC. Immunisation against meningococcal meningitis for Hajj and Umrah. Commun Dis Rep CDR Wkly 2002; 12(3).
(http://www.phls.co.uk/publications/CDR%20Weekly/index.html)
Jones DM, Sutcliffe EM. Group A meningococcal disease in England associated with the Hajj. J Infect 1990; 21: 21-5.
Samuelsson S, Handysides S, Ramsay M, Lyytikäinen O, Nygård K, Perrocheau A, et al. Meningococcal infection in
pilgrims returning from the haj: update from Europe and beyond. Eurosurveillance Weekly 2000; 4: 000427.
(http://www.eurosurv.org/2000/000427.htm)
Henderson B, Handford S, Ramsay M. Rapid reporting system for meningitis W135: 2a:P1.2, 5 prompted by haj outbreak.
Eurosurveillance Weekly 2000; 4: 001116. (http://www.eurosurv.org/2000/001116.htm)
Hahne SJM, Aguilera J-F, Crowcroft NS, Gray SJ, Kaczmarski EB, Nichols T, et al. W135 meningococcal disease in
England and Wales associated with the Hajj 2000 and 2001. Lancet. In press 2002.
CDSC. Quadrivalent meningococcal immunisation required for pilgrims to Saudi Arabia. Commun Dis Rep CDR Weekly
2001 11(45): news. (www.phls.org.uk/publications/CDR%20Weekly/archive/news/news4501.html#Pilgrims)
Department of Health. Health advice for travellers. Guard against meningitis and save lives at Hajj or Umrah this year.
London: Department of Health, 2 January 2002. (http://www.doh.gov.uk/traveladvice/hajj.htm)
Reported by Gil Lea ([email protected]) and Susan Hahné ([email protected]), Public Health
Laboratory Service Communicable Disease Surveillance Centre, London, England.