Volume 5, Number 2—April 1999
Diphtheria in Eastern Nepal
To the Editor: Diphtheria, caused by Corynebacterium diphtheriae, was a major childhood killer until the advent of the Expanded Program on Immunization when diphtheria, pertussis, and tetanus (DPT) vaccination was greatly increased; diphtheria gradually declined in many countries. We report two cases of diphtheria identified at the B.P. Koirala Institute of Health Sciences Hospital, Dharan, Nepal.
During April 1996, a 6-year-old patient had fever (for 5 days), difficulty in swallowing and breathing, and change of voice (for 4 days). Throat examination showed a grayish-white membrane over the right tonsil, uvula, and adjacent soft palate. The membrane could not be removed, and the larynx could not be examined. Swabs were taken from the membrane area and sent to the laboratory, where smears were made and stained by Gram and Albert stains. Gram-stained smears showed a large number of gram-positive bacilli with the appearance of Chinese letters, and Albert stain showed bacilli with numerous metachromatic granules. A diagnosis of faucial diphtheria, with a strong possibility of laryngeal diphtheria, was made. The patient was treated with parenteral penicillin and diphtheria antitoxin. His condition improved after 6 days of therapy.
In December 1996, a 9-year-old patient sought treatment for chronic pain and discharge in the left ear. On examination, he had mucopurulent discharge, antral perforation, and mastoid tenderness. Throat examination showed bilateral tonsilitis. A provisional diagnosis of acute mastoiditis associated with acute septic tonsillitis was made. Throat swabs were collected and sent to the laboratory; smear findings showed typical organisms morphologically resembling C. diphtheriae. Culture done on 10% defibrinated sheep blood agar and Loefflers serum slope grew colonies consistent with C. diphtheriae. In addition to local antibiotic to the ear, the patient was given parenteral penicillin, gentamicin, and metronidazole. Because the patient had no features of systemic toxicity, no antidiphtheria serum was administered. The patient became well and was discharged on day 4.
In the first case, a throat culture could not be done because the patient had already received local antiseptic paint. However, the diagnosis was clinically consistent with classic diphtheria with features of toxicity. In the second case, diphtheria was suspected only after bacteriologic examination. Unlike patient 1, patient 2 had no evident features of systemic toxicity. Hence the isolate could be nontoxigenic. Localized diphtheria due to nontoxigenic C. diphtheriae is known to occur (1).
The two patients did not give a complete history of immunization and may not have been vaccinated (or may have been partially vaccinated) with DPT. On the Indian subcontinent, DPT vaccination coverage is reported to be 80%. However, it may not be so in all areas, and immunization may have decreased to approximately 50% in certain areas of Southeast Asia (2). This may also be true in certain areas of eastern Nepal. An immunization status survey done in midwestern Nepal from 1989 to 1990 showed that DPT coverage was unsatisfactory (3). Lack of sustained immunization may even result in outbreaks. The recent epidemics of diphtheria in the Ukraine, Russian Federation, and other countries of the former Soviet Union are examples of resurgence due to ineffectively maintained immunization programs (4,5).
Diphtheria, still occasionally seen in many Southeast Asian countries including India and Nepal, is thought to be declining in these areas. However, accurate data have not been recently available, particularly from Nepal, because reporting is infrequent, laboratory confirmation is not available, and the extent of carriers is not clearly known (2).
These two cases show the persistence of diphtheria in a population in Nepal immunized with DPT and underscore the need for careful surveillance, laboratory documentation of clinical diphtheria, and increased immunization of children in this area.
- Dixon JMS, Noble WC, Smith GR. Diphtheria, other mycobacterial, and corynebacterial and coryneform infections. In: Topley and Wilson's principle of bacteriology, virology and immunology. Vol 3. 8th ed. London: Edwards Arnold; 1990. p. 55-79.
- Srinivasa H. Immunizing children in Southeast Asia: a critical appraisal of current EPI status and future prospects. In: Immunizing agents for tropics: success, failure and some practical issues (BPKIHS Monograph Series 1). B.P. Koirala Institute of Health Sciences (BPKIHS) Hospital, Dharan, Nepal; 1997. p. 1-8.
- Shrestha IB. Immunization status in mid-western region of Nepal. In: Health Research Abstract 1991-1994. Nepal Research Council 1995. Proceedings of Second National Seminar on Health Research in Nepal at Kathmandu, Nepal. 1994 Dec 20-22.
- The World Health Reports. Fighting disease, fostering development. Report of the Director General, World Health Organization, Geneva; 1996.
- Begg N, Balraj B. Diphtheria: are we ready for it? Archives of Childhood 1995:568-92.