Lessons from Diphtheria Outbreak

Rumah Ginjal - The declaration of the current diphtheria outbreak as an “extraordinary occurrence” is quite worrying. According to the latest newspaper reports, the extraordinary occurrence of diphtheria has been declared in at least 20 provinces.

The Health Ministry has recorded 561 cases of diphtheria and 32 deaths from the disease as of November. This disease is quite dangerous, because it is a serious bacterial infection that causes respiratory problems and myocarditis (inflammation of the heart muscle).

Patients may suffer paralysis or damage to the cranial nerves (sensory nerves) and peripheral nerves in the brain. Diphtheria can also affect the joints, bones and the kidneys. Anyone who has not been immunized or vaccinated is at high risk of contracting diphtheria.

This can happen anywhere in the world, even in developed countries. The difference is that in developed countries, the fatality rate can be easily controlled because they are supported by better standards of living, mass immunization, better diagnosis, the possibility of immediate treatment, and more effective treatment.

Indications of problems

Why has this happened? In fact, according to Health Ministry data, the disease had been eliminated in 1990, but it reemerged in 2009. In 2013, another outbreak was kept under control.

The emergence of the diphtheria extraordinary occurrence could indicate a problem in containing the disease in the affected areas. So, improvements to our health policy are needed.

Such problems include, but are not limited to, poor immunization coverage, disease surveillance systems, and limited access to health facilities. Is the immunization program ineffective?

From observation alone, the immunization program may not be effective enough. This could be due to a lack of preparedness and capacity of local leaders in running the immunization program, such as issues related to accurate vaccine dosage, as well as distribution and absorption, the targeted population, vaccination schedules, campaign strategies, and criteria.

It is difficult to accept this, considering that the immunization program has been carried out as part of the activities of integrated health services posts (Posyandu) in each community. Professionalism should be a priority, and an upgrading program for competency should be run every year.

The other possibility is the biological nature of diphtheria itself: that its transmission can never been completely stopped and that isolated outbreaks will continue to occur throughout the year, especially among children, and the fact that the disease has low-level endemicity in some areas.

At certain times, after several years of declining public health services, including a decline in diphtheria-tetanus-pertussis (DTP) immunization coverage for children, a rise in diphtheria cases is usually seen, especially in urban areas.

We should therefore be able to develop a road map to contain outbreaks of diphtheria. An outbreak is likely to begin among children from areas with inadequate immunization programs, and then spread rapidly to adults who are not adequately protected.

Role of vaccination

In Ukraine a diphtheria epidemic reoccurred in 1991, several decades after the country had controlled the disease with fewer than 40 sporadic cases reported each year. The outbreak began in three provinces. Two years later, the epidemic spread to half the country, and two years after that, all 27 provinces were affected. The outbreak reached its peak in 1995, with about 5,000 cases reported and more than 200 people dying of the disease.

The same thing occurred in the former Soviet Union. In early 1990, a decline in the country’s vaccination program caused an outbreak of diphtheria. A year later, the outbreak spread further, with at least 2,000 cases reported. The disease then spread to other parts of Europe, including Belgium, Finland, Poland and Germany. The epidemic was due to the large number of unvaccinated children.

It is clear that a lack of vaccination greatly contributes to spread of diphtheria. With the widespread use of vaccines, cases of diphtheria have dropped rapidly since the 1920s. This analysis shows a close connection between the biological nature of the disease and immunization programs for preventing diphtheria. The right steps must be found to combat the diphtheria outbreak.

However, it should be remembered that a road map for eliminating the disease cannot be effectively implemented if inadequate financial support is provided for running the programs. The decentralization of public health systems, under which each region has a different system, can also hamper the central government’s efforts to manage the spread of the disease.

Preventive measures

To ensure the success of the diphtheria-free road map, it is important to pay attention to personal hygiene. This is because diphtheria is transmitted from person to person, usually through respiratory droplets from coughing or sneezing, or through physical contact with contaminated household or personal items.

Parents should also be taught the symptoms of the disease, such as fever, sore throat and swollen glands, so that they are aware of the disease and know when they should take their children to the doctor.

The Health Ministry also needs to work hand-in-hand with the Indonesian Ulema Council (MUI) on the possibility of issuing a fatwa that obliges parents to vaccinate their children.

In addition, a government policy that requires school to reject unvaccinated children from enrollment (which may be debatable) can also be considered. The government should thus initiate a program to strengthen the immunization program among vulnerable children and adults, especially in endemic areas. If possible, a mass immunization program could be undertaken in an effort to minimize the exponential rise of an epidemic.

Another point is the need to immediately launch a mass immunization campaign and introduce regular DTP vaccination for children, followed by a higher dose of the diphtheria-tetanus toxoids (DT) vaccine for children and the tetanus-diphtheria toxoids (Td) vaccine for adolescents and adults.

The current diphtheria outbreak could have been prevented if the universal immunization program for infants and children was implemented properly. However, it is already too late, as “the rice has already turned into porridge”. Let us all support the diphtheria-free program so this mistake will not be repeated.


Professor in the Medical Faculty of Airlangga University

Source: https://kompas.id/baca/english/2017/12/14/lessons-from-diphtheria-outbreak/

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