2. INTRODUCTION
Acute infectious diseasecaused
by toxigenic strains of Coryne
bacteriumdiphtheriae.
3 major clinicaltypes-anterior
nasal, faucial, laryngeal
Skin, conjunctiva, vulvaand
other parts may beaffected.
Bacilli multiply locally inthroat
and produce powerfulexotoxin.
2Kuldeep Vyas M.Sc. CHN
3. HISTORY
Took its name from greek word “diphthera”meaning
leather.
Named in 1826 by French physician PierreBretonneau.
In the past, disease was called as general disease or
killerdisease because therewas no treatmentand was
the cause of high mortality inchildren.
Itwas said that thedisease killed as manyas 80% of
the children below 10yrs.
3Kuldeep Vyas M.Sc. CHN
5. WORLD
Developed countries
rare disease dueto
routine child
vaccination
Developing countries
endemic due to lackof
adequate widespread
immunization
Reported cases in 2010- 4187
Epidemics are largely due to decreasing immunization coverage
among infants and children, waning immunity to diphtheria in
adults, movements of large groups of populations in the last few
years and irregular supplyof vaccines.
5Kuldeep Vyas M.Sc. CHN
6. INDIA
Endemic disease
Declining trend of diphtheria due toincreasing
coverage of child population by immunization.
Reported cases
1987- 12952
2011- 4286
112 deathsshowing acase fatality rateof about 2.61
6Kuldeep Vyas M.Sc. CHN
7. AGENT
Agent Corynebacterium diphtheria
Gram positive motileorganism
No invasivepower but producepowerful exotoxinafter
multiplication locally in the throat responsible for:
1. Formation of false membrane over tonsils, pharynx or larynx, with
well defined edgesand membranecannot bewiped away.
2. Marked congestion, edema, local tissuedestruction
3. Enlargement of lymph nodes
4. Toxaemic signs andsymptoms
7Kuldeep Vyas M.Sc. CHN
8. 4 types -Gravis
Mitis
Belfanti
Intermedius
Sensitive topenicillinand readily killed by heatand
chemical agents
Affects heart- myocarditis
nerves- paralysis
Gravis more
severe than
mitis infection
8Kuldeep Vyas M.Sc. CHN
9. SOURCE OF INFECTION
Cases-
ranges from sub clinical toclinical
mild orsilent infections mayexhibit not more
than a mere running noseorsore throat
Carriers-
common source of infection
may be temperoryorchronic;nasal or throatcarriers
Nasal- dangerous( frequent shedding into
environment)
Temperory- lasts for 1 month
Chronic- last for 1 yearuntil thepatient is treated
9Kuldeep Vyas M.Sc. CHN
11. PERIOD OF INFECTIVITY
14 – 28 days from theonsetof disease butcarriers may
remain infective for much longerperiods.
A case or carrier may be considered non-
communicablewhen atleast 2 culturesobtained from
nose or throat, 24 hours apart are negative for
diphtheria bacilli.
11Kuldeep Vyas M.Sc. CHN
12. AGE
Children upto
1-5 yrs
HOST FACTORS
SEX
both
IMMUNITY
Infants borne of immune
mothers are immune for
first fewweeks or monthsof
life.
12Kuldeep Vyas M.Sc. CHN
14. MODE OF TRANSMISSION
Droplet infections
Can also be transmitted directly tosusceptiblepersons
from infected cutaneouslesions.
Transmission by objects contaminated by naso-
pharyngeal secretionsof patients isalso possible.
14Kuldeep Vyas M.Sc. CHN
15. PORTAL OF ENTRY
Respiratory route- respiratory tract
Non-respiratory route-
Portal of entry may be skin wherecuts, ulcersand
wounds not properly attended to or through
umbilicus of new born.
Siteof implantation may be eyes, genitalia or
middleear.
15Kuldeep Vyas M.Sc. CHN
20. Laryngo-tracheal diphtheria
• Preceeded by pharyngotonsillar
diphtheria
• Fever, hoarseness and croupy
cough
• Dyspnoea
• necrosis in heart
muscles, liver, kidneys
and adrenals
• vision difficulties,
speech, swallowing or
movements of armsor
legs
• paralysis of softpalate,
eye muscle or
extremities
Toxindamage
• parenchymatous
degeneration
20Kuldeep Vyas M.Sc. CHN
21. Nasal diphtheria
• Mildest form
• Localized in septum or turbinatesof one
side of nose
• Conjunctiva and genitals also sources of
infection
• Membrane extends topharynx.
21Kuldeep Vyas M.Sc. CHN
22. Cutaneous diphtheria
• Common in tropicalareas
• Secondary infection of
previous infection orskin
abrasion
• Presenting lesion-an ulcer
surrounded by erythema
and covered with
membrane.
22Kuldeep Vyas M.Sc. CHN
24. SCHICK’S TEST
Intra dermal test
Tests – presence of antitoxin(immunity status)and
state of hypersensitivity to diphtheriatoxin.
Inject 0.2ml of Schick test toxin intradermallyinto
skin of forearm, while into opposite arm- control
(Schick toxin inactivated by heat) isinjected.
24Kuldeep Vyas M.Sc. CHN
25. Negative reactions
if the person is immune, no reaction of any kind.
Positive reaction
In testarm, acircumscribed red flush of 10-50mm
diameter appears within 24-36 hours reaching
maximum development by 4th – 7th day.
This slowly fades intoa brown patch and skin
desquamates.
Control arm shows nochange.
The person is susceptible todiphtheria.
25Kuldeep Vyas M.Sc. CHN
26. Pseudo-positive reactions
A red flush develops equally on both
arms, much less circumscribed than
true +vereactions.
Fades by 4th day.
allergic reaction found in certain
individuals
Schick negative
Combined reactions
Control arm shows pseudo positive
reaction and test armshows positive
reaction.
The person is susceptibleto
diphtheria.
26Kuldeep Vyas M.Sc. CHN
28. • Start active search
immediately fromfamily
and school contacts.
• Carriers can bedetected
by culture methods.
(swabs taken from nose
and throat)
CASES & CARRIERS
Early detection Isolation
all cases, suspectedcases
and carriers should be
isolated, preferably in a
hospital for atleast 14
days or until proved free
of infection.
2 consecutive throat swabs taken 24 hours apart
should be negative before terminating isolation.
28Kuldeep Vyas M.Sc. CHN
29. Treatment-
Cases
• Preliminary test dose of 0.2 ml
subcutaneouslytodetectsensitization to
horseserum.
• Followed bydip: antitoxin IM or IV in doses
ranging from 20,000-40,000 units or more
depending on severity ofcases.
• Mild early pharyngeal or laryngeal:20,000-
40,000 units
• Moderate naso pharyngeal: 40,000-60,000
units
• Severe, extensive or latedisease: 80,000-
100,000 units.
• Addition to antitoxin, penicillinor
erythromycin for 5-6 days toclearthroat.
Carriers
• Should betreated
in 10 days course
of oral
erythromycin
29Kuldeep Vyas M.Sc. CHN
30. CONTACTS
Should be throat swabbed and immunityshould be
determined.
Where primary immunization was received withinthe
previous 2 years- no furtheraction needed.
Where primary course or booster dose of diphtheria
toxoid was received more than 2 years before, only a
booster dose of dip: toxoid need begiven.
Non-immunized close contacts shouldreceive
prophylatic penicilin orerythromycin.
They should be given 1000-2000 unitsof antitoxinand
actively immunized againstdiphtheria.
30Kuldeep Vyas M.Sc. CHN
31. COMMUNITY
Active immunization with diphtheria toxoid of all
infants as early in life as possible with subsequent
boosterdoseevery 10 years thereafter.
Immunization rate must be maintained athigh level.
31Kuldeep Vyas M.Sc. CHN
34. DPT -VACCINE
For immunization of infants.
Pertussis component enhances diphtheriatoxoid.
Types- plain and adsorbed
Adsorption-carried out on a mineral carrier likealuminium
phosphate orhydroxide.
STORAGE
should not be frozen
Stored in refrigerator at 2-8 degreecelsius
Will loose potency if keptat room temperature fora long
time.
34Kuldeep Vyas M.Sc. CHN
35. Optimum age-
Global Advisory Group of EPI recommended that DPTan
be safelyadministered as earlyas 6 weeks after birth.
Doses-
3 doses of DPT each is0.5ml.
Mode of admn-
All vaccines containing mineral carriers should beinjected
intramuscular.
DPT given in upperand outerquadrantsof gluteal region.
35Kuldeep Vyas M.Sc. CHN
37. Reactions-
Fever and mild local reactions
2-6% develop feverof 39 degree or higher.
5-10% experience swelling and induration.
Neurological- encephalitis, prolonged convulsions,
infantile spasms, Reye’ssyndrome.
Contra indications-
Seriously ill children orwho need hospitalizationare not
vaccinated.
Should not be repeated if a severe reaction occurred after
a previousdose.
In case of DPT, subsequent DTimmunization.
37Kuldeep Vyas M.Sc. CHN
38. For children over the age of 5 years who have not
received DPT- 2 doses of DT vaccine, 4 weeksapart,
with a boosterdose 6 months to 1 year later.
Thosechildren who received primary courseof DPT
earlier, should receive DT as boosterat 5-6 years.
For immunizing children over 12 years of age and
adults, preparation –dT (adult typediphtheria tetanus
vaccine).
Contains no more than 2 Lf diphtheria toxoidper
dose.
Admn:- 2 doses at interval of 4-6 weeks, followedby
booster 6-12 months after seconddose.
38Kuldeep Vyas M.Sc. CHN
39. SINGLE VACCINES
Less frequentlyused.
Good immunizing agents.
APT- hardly used; prone togive rise tosevere
infections.
Each doseof theseantigens generallycontain 25
loeffler(lf) units of DT.
39Kuldeep Vyas M.Sc. CHN
40. ANTI-SERA
main stayof passiveprophylaxis and also for treatment
in diphtheria.
diphtheria antitoxin prepared in horseserum.
40Kuldeep Vyas M.Sc. CHN