Diphtheria

‘ भ्यागुते रोग ’

Abhinandan Shrestha
Abhishek kharel
 Introduction
• Is a acute infectious disease caused by toxigenic
strain of Corynebacterium diphtheriae ,a gram-
positive bacillus.
• Derived from Greek word diphthera  leather.
• Primarily infects the throat and upper airways by
producing a toxin.
• The diphtheria exotoxin causes a membrane of dead
tissue to build up over the throat and tonsils, making
breathing and swallowing difficult.
Dense adherent pseudomembrane

Bull necked appearance

 History
• 1st described by Hippocrates in 5th century BC
• Between 1735 to 1740  epidemic in English colonies.
• In 1883 C. diphtheriae 1st described by  Theoder Klebs
• In 1884 Fredrich loffler Isolated and proved it as
causative agent of diphtheria.
• In 1890s Emil Von Behring developed Antitoxin
neutralizing Diphtheria toxin.
↓
Recipient of 1st Nobel Prize in field of medicine
 Global scenario

• Rare in most of the developed countries.

• Even in developing ones with satisfactory
vaccination schemes no longer a public health
concern.
• Just about 4490 cases reported globally during
the year 2012. (down from 100,000 in 1980)
• Currently, sub-Saharan Africa, India, Indonesia
and Philppines.
 National scenario
• Expanded program on Immunization (EPI) including
BCG and DPT vaccines in Nepal started in 1979 in
three districts (Bara, Kaski and Bhaktapur)
• Expanded to all 75 districts by 1989.
• Due to this significant reduction in number of cases
of Diphtheria, just 3 or 4 reported annually.
Immunization coverage
 Coverage by region
• Fiscal year 2070/2071 BS
Development region % coverage
Eastern development region 99
Central development region 90
Western development region 96
Mid western development region 81
Far western development region 87

National 92
 Epidemiological traid
Agent
Corynebacterium
diphtheriae.

Host
Environment
Children < 5yrs
Winter
old
 Agent
Causative agent: Corynebacterium diphtheriae.

• Non-motile, noncapsulated, club

shaped Gram positive bacilli
• No invasive power
• Powerful exotoxin
• 4 sub specis : gravis, mitis, belfanti,
intermedius ,all pathogenic to man
 Agent
Source of infection:
– Cases
– Carriers (more common)

Infective material:
– Nasopharyngeal secretions
– Discharges from skin lesions
– Contaminated fomites

Portal of Entry:
– Respiratory route
– Non respiratory route
 Host
• Age: Children 1 to 5 yrs but shift in age been
observed from preschool to school.

• Sex: Both sexes are affected

• Immunity:
– Infants born of immune mothers relatively immune
during first few weeks or months.
(It is generally true that diphtheria occurs only in person
who posses no anti toxin.)
 Environment
• All seasons but more in winter
• Over crowded conditions
• Poor sanitation.
Mode of transmission:
– Mainly, Droplet infection.
– Infected cutaneous lesions.
– Objects contaminated with nasopharyngeal secretions.
(eg: toys, pencils, cups etc)

Incubation period: 2 to 6 days

 Pathogenesis:
Entry of toxigenic Bacilli

Tissue invasion & Colonization

Release Exotoxin that inhibits cellular protein synthesis

Necrosis of epithelium + discharge of sero-fibrinous materials

Local tissue destruction + greyish white pseodo-membrane is

formed
 Diphtheria : Clinical features
• Respiratory tract forms:-
 Pharyngotonsillar type
 Laryngotracheal type
 Nasal type
• Non respiratory :-
Skin
Conjunctiva
 Genitals
 Pharyngotonsillar type
• Sore throat,
difficulty in swallowing ,
low grade fever.

• Mild erythema,
localised exudate ,
pseudo membrane.

• Severe forms :“Bull necked” appearance

 Laryngotracheal type
• fever
• Hoarseness of voice
• Croupy cough
• Most severe form
• Obstruction by
membrane leading to
prostration and dyspnoea
 Nasal type
• Mildest form
• Localized to septum / turbinates
• Nasal carriers are dangerous than throat carriers
 Non respiratory
• Skin: on fingers &
back of the hands,
punched out ulcers

• Ocular: conjunctival, corneal damage

• Intestinal: Dysphagia & bloody diarrhoea
• Genital
 Immunization
Available prophylactics
1. Combined or mixed vaccine
eg. DPT
2. Single vaccine
eg. Formal-toxoid
3. Antisera
eg. Diphtheria antitoxin
Immunization
 National immunization program
Immunization Schedule
Type of Vaccine Number of Doses Recommended
Age

DPT - Hep B-Hib 3 6, 10, and 14

weeks of age
 National immunization program

Immunization coverage by antigens doses FY 2070/71

Antigens % achieved
DPT-Hep B Hib 1 90.3

DPT-Hep B Hib 2 88.6

DPT-Hep B Hib 3 91.7
 Prevention and control
1. Cases and carriers
• Early detection
• Isolation
• Treatment
2. contact
3. community
 Prevention and control
• Cases and carriers
Early detection: active search should start immediately
amongst friends and family
throat and nose swab ;culture for organism
Isolation: suspected cases and carriers must be promptly
isolated
Treatment: Diphtheria antitoxins for cases without
delay, Oral erythromycin for 10 days for carriers
 Prevention and control
• Contacts
If immunized previously with in 2 year – no action
needed
If immunized long back ( more than 2 years)- DT
booster dose
If not immunized at all- prophylactic penicillin and
erythromycin + 1000-2000 unit antitoxin + active
immunization
 Prevention and control
• Community
Active immunization with diphtheria toxoid of all the
infants as early in life as possible as scheduled with
subsequent booster dose every 10 yrs thereafter
Thank you!!!!!!!