In response to recent outbreak in Malaysia which till today 24th june 2016 takes 2 lives of innocent children. This slides is prepared for staff's CME by Dr Nurdalila Klinik Kesihatan Kg Gial Perlis. Based on cased investigation and outbreak managment for health care professional by MOH Malaysia

1. DIPHTHERIA
ICD 10 A36
DR NURDALILA SAHIDAN
KK KG GIAL
JUNE 2016

2. WHAT IS?
• Bacterial Infections- affecting nose and throat
• Corynaebacterium diphtheria-produce toxin
• Highly contagious
• Is prevented with vaccination
• Can also affecting skin- cutaneous diphtheria- action by c.diphtheria and
occasionaly by c. ulcerans*

3. THE BACTERIA
• nonsporulating, unencapslated, non motile gram positive bacteria
• It has 4 subspecies ( for now)-c.d gravis ,c.d. mitis, c.d. intermedius, and c.d belfanti
• It can be toxigenic= diphtheria ( alter protein fx in the host,inactivate elongation
factor EF-2)**
• It can be nontoxigenic-mild sorethroat, rarely membranous pharyngitis*
• Host can be carrier without sx
• Humans are the only natural host

6. HOW IT IS SPREAD
• Droplets
• Close physical contact
• Direct contact with nasopharyngeal secretion of an infected person
• Skin abrasion

7. • (i) the catarrhal form (erythema of pharynx, no membranes)
• (ii) the follicular form (patches of exudates over pharynx and the tonsils)
• (iii) the spreading form (membranes covering the tonsils and posterior
pharynx)
• (iv) the combined form (more than one anatomical site involved, for
example throat and skin)

8. INCUBATION PERIOD
• 2 to 7 days or longer
• Respiratory dipththeria usually occur after 5 days
• Onset is slow from moderate fever and mild exudative pharyngitis
• Severe case- develop pseudomembrane

9. WHO CAN BE INFECTED?
• Immunised person
• Partially immunised
• Unimmunised
Less severe

10. HISTORY
• 1613- epidemic in spain- the year of strangulation
• 1735- epidemic in New England
• 1826- pseudomembrane was described by Pierre Bretonneou
• 1856- epidemic in California
• 1878- Queen Victoria’s daughter Princess Alice infected. 2 royal family dead
• 1883-Edwin Klebs identified the bacteria
• 1888-1926- trials anti toxin, n thousand of deaths around the globe
• 1946- outbreak after war in Europe. 1 million case, 50000 death
• 1994-39703 in Russia
• 2010- 1 case during Haiti earth quake
• 2013- 3 children died in India
• 2015- 1 case in Spain. First case after 1986
• 2016- 2 children died in Malaysia- Malacca n Kedah

11. HOW ABOUT MALAYSIA?

12. SIGNS AND SYMPTOMS
• Respiratory
• Cutaneous

13. Airway
obstruction

16. Cutaneous
• caused by either toxigenic or nontoxigenic strains
• is usually mild, typically consisting of nondistinctive sore or shallow ulcers
• rarely involving toxic complications (1- 2% of infections with toxigenic
strains).

18. Complications
• paralysis due to demyelinating peripheral neuritis
• Myocarditis
• Airway Obstruction
• Renal insufficient
• Toxaemia
• Death

19. LAB DIAGNOSIS
• Swab from nose and throat ( or wound and skin)
• Use polyester, nylon or rayon swab
• Place in transport media such as Amies/ stuart and sent to lab with ice pack
• Dry swabs should be submitted in silica gel satchet
• Pseudo membrane tissue- put in sterile saline and sent with ice packs

20. TREATMENT
• Antibitotic
• Anti-toxin

21. Antibiotic Dose Route Duration of treatment
Erythromycin Parentally: 40 to 50 mg / kg / day,
maximum2 g / day When patient can
swallow, take orally in 4 divided doses
(or oral penicillin) 125 to 250 mg, 4
times a day
14 days
Aqueous crystalline Penicillin IM; 100,000 to 150,000 U/kg/day, in 4
divided doses
14 days
Aqueous Procaine Penicillin IM: Children: 25,000 to 50,000
U/kg/day, maximum 1.2 million U, in
four divided doses Adults: 1.2 million U
daily
14 days

22. No Types of diphtheria Dose (units) route
1 Nasal 10,000 – 20,000 i/m
2 Tonsillar 15,000 – 25,000 i/m or i/v
3 Pharyngeal or laryngeal 20,000 – 40,000 i/m or i/v
4 Combined types or delay diagnosis 40,000 – 60,000 i/v
5 Extensive disease of > 3 days
duration and/or severe swelling of
neck (bull-neck)
80,000 – 100,000 i/v or part i/v and part
i/m
Anti-Toxin

23. • Resolved= two successive pairs of nose and throat cultures (and cultures of
skin lesions in cutaneous diphtheriae) obtained ≥ 2 weeks after completion
of abx therapy and ≥ 24 hours apart are negative

24. Important Points
• Case definition:An illness of the upper respiratory tract characterised by laryngitis or
pharyngitis or tonsilitis and adherent membrane of the tonsils, pharynx and/or nose
• Cutaneous diphtheriae alone need not be reported
• Close contacts are defined as those who sleep in the same house or who share food,
drink or eating / drinking utensils with the case. Definition includes health workers in
contact with the case’s oral or respiratory secretions.
• Anyone who has been in close contact with a case of diphtheria caused by toxigenic C.
diphtheriae or C. ulcerans (whatever the clinical presentation) in the previous seven days
should be considered as potentially at risk
• Treatment for close contact: EES for 7 to 10 days (1 gram a day for adults, 40 mg/kg
day in divided doses for children).
• Flow chart

25. • Flow Chart
• Missed Vaccine

26. Vaccine save lives, fear endangers them. It’s a simple
message parents need to keep hearing.
Those who ignore the history are doomed to repeat it