Materiały źródłowe

• #1 Diphtheria: Background, Pathophysiology, Epidemiology

  https://emedicine.medscape.com/article/782051-overview

  Since the introduction and widespread use of diphtheria toxoid in the 1920s, respiratory diphtheria has been well controlled, with an incidence of approximately 1000 cases reported annually. Before vaccination, at least 200,000 cases occurred annually in the United States. […] Diphtheria remained endemic in some states through the 1970s, with reported incidence rates of greater than 1.0 per million population in Alaska, Arizona, Montana, New Mexico, South Dakota, and Washington. Most of these infections were attributed to incomplete vaccination. […] In the United States, diphtheria currently occurs sporadically, mostly among the Native American population, homeless people, lower socioeconomic groups, and alcoholics. Immigrants and travelers from regions with ongoing epidemics are also at risk.

• #2 Diphtheria – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK560911/

  Since the implementation of the vaccine, the incidence of the disease has witnessed a rapid decline. Before 1920, the US reported approximately 200,000 annually. However, this number has drastically decreased following the introduction of widespread immunization programs, with only around 1000 cases reported annually. Most cases are observed in individuals with low socioeconomic status, living in overcrowded conditions, lacking immunizations, with a travel history from endemic regions, and having comorbid conditions. These numbers remain higher in certain global regions, particularly Southeast Asia and Africa. Regarding mortality in the US, the figures have decreased from 100 to 200 cases to 0.001 per 100,000 population since the advent of vaccinations. […] Reports from the World Health Organization (WHO) suggest that diphtheria epidemics continue to pose a health risk in developing countries. India has experienced a higher incidence of diphtheria, primarily attributed to challenges in implementing widespread vaccination efforts. A significant proportion of the global burden of diphtheria is concentrated in India.

• #3 Diphtheria: Background, Pathophysiology, Epidemiology

  https://emedicine.medscape.com/article/782051-overview

  According to the World Health Organization (WHO), diphtheria epidemics remain a health threat in developing nations. […] The largest epidemic recorded since widespread implementation of vaccine programs was in 1990-1995, when a diphtheria epidemic emerged in the Russian Federation, rapidly spreading to involve all Newly Independent States (NIS) and Baltic States. This epidemic caused more than 157,000 cases and 5000 deaths according to WHO reports. […] From 1993-2003, a decade long epidemic in Latvia resulted in 1359 reported cases of diphtheria with 101 deaths. […] Overall rates of infection have decreased in Europe from 2000 to 2009, according to the Diphtheria Surveillance Network. This has been attributed to improved vaccination rates creating herd immunity. However, issues with vaccinations still occur, especially in eastern European countries and Russia, and are thought to contribute to the ongoing outbreaks.

• #4

  https://pmc.ncbi.nlm.nih.gov/articles/PMC6759252/

  In 2017, a total of 8,819 cases of diphtheria were reported worldwide, the most since 2004. However, recent diphtheria epidemiology has not been well described. We analyzed incidence data and data from the literature to describe diphtheria epidemiology. World Health Organization surveillance data were 81% complete; completeness varied by region, indicating underreporting. As national diphtheriatetanuspertussis (DTP) 3 coverage increased, the proportion of case-patients 15 years of age decreased, indicating increased protection of young children. In countries with higher case counts, 66% of case-patients were unvaccinated and 63% were 15 years of age. In countries with sporadic cases, 32% of case-patients were unvaccinated and 66% were 15 years of age, consistent with waning vaccine immunity. Global DTP3 coverage is suboptimal. Attaining high DTP3 coverage and implementing recommended booster doses are necessary to decrease diphtheria incidence. Collection and use of data on subnational and booster dose coverage, enhanced laboratory capacity, and case-based surveillance would improve data quality.

• #5 Global Epidemiology Of Diphtheria In The 21st Century – MMGH Consulting

  https://www.mmglobalhealth.org/publications/global-epidemiology-of-diphtheria-in-the-21st-century/

  In 2017, a total of 8,819 cases of diphtheria were reported worldwide, the most since 2004. […] However, recent diphtheria epidemiology has not been well described. […] World Health Organisation surveillance data were 81% complete; completeness varied by region, indicating under-reporting. […] As national diphtheriatetanuspertussis (DTP) 3 coverage increased, the proportion of case-patients 15 years of age decreased, indicating increased protection of young children. […] In countries with higher case counts, 66% of case-patients were unvaccinated and 63% were 15 years of age, consistent with waning vaccine immunity. […] Global DTP3 coverage is suboptimal. […] Attaining high DTP3 coverage and implementing recommended booster doses are necessary to decrease diphtheria incidence. […] Collection and use of data on subnational and booster dose coverage, enhanced laboratory capacity, and case-based surveillance would improve data quality.

• #6

  https://pmc.ncbi.nlm.nih.gov/articles/PMC6759252/

  In 2017, a total of 8,819 cases of diphtheria were reported worldwide, the most since 2004. However, recent diphtheria epidemiology has not been well described. We analyzed incidence data and data from the literature to describe diphtheria epidemiology. World Health Organization surveillance data were 81% complete; completeness varied by region, indicating underreporting. As national diphtheriatetanuspertussis (DTP) 3 coverage increased, the proportion of case-patients 15 years of age decreased, indicating increased protection of young children. In countries with higher case counts, 66% of case-patients were unvaccinated and 63% were 15 years of age. In countries with sporadic cases, 32% of case-patients were unvaccinated and 66% were 15 years of age, consistent with waning vaccine immunity. Global DTP3 coverage is suboptimal. Attaining high DTP3 coverage and implementing recommended booster doses are necessary to decrease diphtheria incidence. Collection and use of data on subnational and booster dose coverage, enhanced laboratory capacity, and case-based surveillance would improve data quality.

• #7 Diphtheria | Nature Reviews Disease Primers

  https://www.nature.com/articles/s41572-019-0131-y

  Diphtheria is a potentially fatal infection mostly caused by toxigenic Corynebacterium diphtheriae strains and occasionally by toxigenic C. ulcerans and C. pseudotuberculosis strains. […] Changes in the epidemiology of diphtheria have been reported worldwide. The prevalence of toxigenic Corynebacterium spp. highlights the need for proper clinical and epidemiological investigations to quickly identify and treat affected individuals, along with public health measures to prevent and contain the spread of this disease. […] Thousands of diphtheria cases are still reported annually from several countries in Asia and Africa, along with many outbreaks.

• #8 Diphtheria – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK560911/

  Since the implementation of the vaccine, the incidence of the disease has witnessed a rapid decline. Before 1920, the US reported approximately 200,000 annually. However, this number has drastically decreased following the introduction of widespread immunization programs, with only around 1000 cases reported annually. Most cases are observed in individuals with low socioeconomic status, living in overcrowded conditions, lacking immunizations, with a travel history from endemic regions, and having comorbid conditions. These numbers remain higher in certain global regions, particularly Southeast Asia and Africa. Regarding mortality in the US, the figures have decreased from 100 to 200 cases to 0.001 per 100,000 population since the advent of vaccinations. […] Reports from the World Health Organization (WHO) suggest that diphtheria epidemics continue to pose a health risk in developing countries. India has experienced a higher incidence of diphtheria, primarily attributed to challenges in implementing widespread vaccination efforts. A significant proportion of the global burden of diphtheria is concentrated in India.

• #9 Diphtheria – Wikipedia

  https://en.wikipedia.org/wiki/Diphtheria

  Diphtheria is fatal in 5-10% of cases. In children under five years and adults over 40 years, the fatality rate may be as much as 20%. […] In 2013, it resulted in 3,300 deaths, down from 8,000 deaths in 1990. Better standards of living, mass immunization, improved diagnosis, prompt treatment, and more effective health care have led to a decrease in cases worldwide. […] In 2015, 4,500 cases were officially reported worldwide, down from nearly 100,000 in 1980. Diphtheria currently occurs most often in sub-Saharan Africa, South Asia, and Indonesia. […] In areas where it is still common, children are most affected. It is rare in the developed world due to widespread vaccination, but can re-emerge if vaccination rates decrease. […] In 2017, outbreaks occurred in a Rohingya refugee camp in Bangladesh, and amongst children unvaccinated due to the Yemeni Civil War. […] In December 2023 there was an outbreak at a school in Luton, in the United Kingdom. UK Health Security Agency (UKHSA) issued a statement saying specialists have been providing public health support following confirmation of the diphtheria case at a primary school in Luton.

• #10 Diphtheria – Wikipedia

  https://en.wikipedia.org/wiki/Diphtheria

  Diphtheria is fatal in 5-10% of cases. In children under five years and adults over 40 years, the fatality rate may be as much as 20%. […] In 2013, it resulted in 3,300 deaths, down from 8,000 deaths in 1990. Better standards of living, mass immunization, improved diagnosis, prompt treatment, and more effective health care have led to a decrease in cases worldwide. […] In 2015, 4,500 cases were officially reported worldwide, down from nearly 100,000 in 1980. Diphtheria currently occurs most often in sub-Saharan Africa, South Asia, and Indonesia. […] In areas where it is still common, children are most affected. It is rare in the developed world due to widespread vaccination, but can re-emerge if vaccination rates decrease. […] In 2017, outbreaks occurred in a Rohingya refugee camp in Bangladesh, and amongst children unvaccinated due to the Yemeni Civil War. […] In December 2023 there was an outbreak at a school in Luton, in the United Kingdom. UK Health Security Agency (UKHSA) issued a statement saying specialists have been providing public health support following confirmation of the diphtheria case at a primary school in Luton.

• #11 Diphtheria – Wikipedia

  https://en.wikipedia.org/wiki/Diphtheria

  Diphtheria is fatal in 5-10% of cases. In children under five years and adults over 40 years, the fatality rate may be as much as 20%. […] In 2013, it resulted in 3,300 deaths, down from 8,000 deaths in 1990. Better standards of living, mass immunization, improved diagnosis, prompt treatment, and more effective health care have led to a decrease in cases worldwide. […] In 2015, 4,500 cases were officially reported worldwide, down from nearly 100,000 in 1980. Diphtheria currently occurs most often in sub-Saharan Africa, South Asia, and Indonesia. […] In areas where it is still common, children are most affected. It is rare in the developed world due to widespread vaccination, but can re-emerge if vaccination rates decrease. […] In 2017, outbreaks occurred in a Rohingya refugee camp in Bangladesh, and amongst children unvaccinated due to the Yemeni Civil War. […] In December 2023 there was an outbreak at a school in Luton, in the United Kingdom. UK Health Security Agency (UKHSA) issued a statement saying specialists have been providing public health support following confirmation of the diphtheria case at a primary school in Luton.

• #12 Diphtheria – Wikipedia

  https://en.wikipedia.org/wiki/Diphtheria

  Diphtheria is fatal in 5-10% of cases. In children under five years and adults over 40 years, the fatality rate may be as much as 20%. […] In 2013, it resulted in 3,300 deaths, down from 8,000 deaths in 1990. Better standards of living, mass immunization, improved diagnosis, prompt treatment, and more effective health care have led to a decrease in cases worldwide. […] In 2015, 4,500 cases were officially reported worldwide, down from nearly 100,000 in 1980. Diphtheria currently occurs most often in sub-Saharan Africa, South Asia, and Indonesia. […] In areas where it is still common, children are most affected. It is rare in the developed world due to widespread vaccination, but can re-emerge if vaccination rates decrease. […] In 2017, outbreaks occurred in a Rohingya refugee camp in Bangladesh, and amongst children unvaccinated due to the Yemeni Civil War. […] In December 2023 there was an outbreak at a school in Luton, in the United Kingdom. UK Health Security Agency (UKHSA) issued a statement saying specialists have been providing public health support following confirmation of the diphtheria case at a primary school in Luton.

• #13 Diphtheria – Wikipedia

  https://en.wikipedia.org/wiki/Diphtheria

  Diphtheria is fatal in 5-10% of cases. In children under five years and adults over 40 years, the fatality rate may be as much as 20%. […] In 2013, it resulted in 3,300 deaths, down from 8,000 deaths in 1990. Better standards of living, mass immunization, improved diagnosis, prompt treatment, and more effective health care have led to a decrease in cases worldwide. […] In 2015, 4,500 cases were officially reported worldwide, down from nearly 100,000 in 1980. Diphtheria currently occurs most often in sub-Saharan Africa, South Asia, and Indonesia. […] In areas where it is still common, children are most affected. It is rare in the developed world due to widespread vaccination, but can re-emerge if vaccination rates decrease. […] In 2017, outbreaks occurred in a Rohingya refugee camp in Bangladesh, and amongst children unvaccinated due to the Yemeni Civil War. […] In December 2023 there was an outbreak at a school in Luton, in the United Kingdom. UK Health Security Agency (UKHSA) issued a statement saying specialists have been providing public health support following confirmation of the diphtheria case at a primary school in Luton.

• #14

  https://pmc.ncbi.nlm.nih.gov/articles/PMC6759252/

  Although several comprehensive reviews were published after that outbreak peaked, only sporadic documentation of diphtheria outbreaks has been published since, and no examination of global epidemiologic trends has been published. During 2016-2019, diphtheria outbreaks were reported in multiple countries, including Bangladesh, Yemen, and Venezuela. Several outbreaks were among vulnerable populations or in areas of social disruption and conflict. […] The diphtheria data reported annually to WHO and UNICEF on the JRF have substantial limitations in terms of quality and reflect opportunities to improve disease surveillance. We found these data to be incomplete when cross-referenced with the literature, indicating a likely underestimate of incidence worldwide and a decreased understanding of the burden of disease. However, in some countries with lower laboratory capacity, only a small proportion of cases are laboratory confirmed, which could result in overreporting in some settings. The ability to use aggregate data for action is limited by the lack of key variables, including vaccination status, age, and subnational location. […] Implementation of case-based surveillance for diphtheria, combined with availability of subnational coverage data, would result in improved understanding of diphtheria epidemiology and enhanced capability to prevent and respond to outbreaks.

• #15

  https://pmc.ncbi.nlm.nih.gov/articles/PMC6759252/

  Although several comprehensive reviews were published after that outbreak peaked, only sporadic documentation of diphtheria outbreaks has been published since, and no examination of global epidemiologic trends has been published. During 2016-2019, diphtheria outbreaks were reported in multiple countries, including Bangladesh, Yemen, and Venezuela. Several outbreaks were among vulnerable populations or in areas of social disruption and conflict. […] The diphtheria data reported annually to WHO and UNICEF on the JRF have substantial limitations in terms of quality and reflect opportunities to improve disease surveillance. We found these data to be incomplete when cross-referenced with the literature, indicating a likely underestimate of incidence worldwide and a decreased understanding of the burden of disease. However, in some countries with lower laboratory capacity, only a small proportion of cases are laboratory confirmed, which could result in overreporting in some settings. The ability to use aggregate data for action is limited by the lack of key variables, including vaccination status, age, and subnational location. […] Implementation of case-based surveillance for diphtheria, combined with availability of subnational coverage data, would result in improved understanding of diphtheria epidemiology and enhanced capability to prevent and respond to outbreaks.

• #16 Diphtheria: Background, Pathophysiology, Epidemiology

  https://emedicine.medscape.com/article/782051-overview

  According to the World Health Organization (WHO), diphtheria epidemics remain a health threat in developing nations. […] The largest epidemic recorded since widespread implementation of vaccine programs was in 1990-1995, when a diphtheria epidemic emerged in the Russian Federation, rapidly spreading to involve all Newly Independent States (NIS) and Baltic States. This epidemic caused more than 157,000 cases and 5000 deaths according to WHO reports. […] From 1993-2003, a decade long epidemic in Latvia resulted in 1359 reported cases of diphtheria with 101 deaths. […] Overall rates of infection have decreased in Europe from 2000 to 2009, according to the Diphtheria Surveillance Network. This has been attributed to improved vaccination rates creating herd immunity. However, issues with vaccinations still occur, especially in eastern European countries and Russia, and are thought to contribute to the ongoing outbreaks.

• #17 Diphtheria: Background, Pathophysiology, Epidemiology

  https://emedicine.medscape.com/article/782051-overview

  According to the World Health Organization (WHO), diphtheria epidemics remain a health threat in developing nations. […] The largest epidemic recorded since widespread implementation of vaccine programs was in 1990-1995, when a diphtheria epidemic emerged in the Russian Federation, rapidly spreading to involve all Newly Independent States (NIS) and Baltic States. This epidemic caused more than 157,000 cases and 5000 deaths according to WHO reports. […] From 1993-2003, a decade long epidemic in Latvia resulted in 1359 reported cases of diphtheria with 101 deaths. […] Overall rates of infection have decreased in Europe from 2000 to 2009, according to the Diphtheria Surveillance Network. This has been attributed to improved vaccination rates creating herd immunity. However, issues with vaccinations still occur, especially in eastern European countries and Russia, and are thought to contribute to the ongoing outbreaks.

• #18 Diphtheria – Wikipedia

  https://en.wikipedia.org/wiki/Diphtheria

  Diphtheria is fatal in 5-10% of cases. In children under five years and adults over 40 years, the fatality rate may be as much as 20%. […] In 2013, it resulted in 3,300 deaths, down from 8,000 deaths in 1990. Better standards of living, mass immunization, improved diagnosis, prompt treatment, and more effective health care have led to a decrease in cases worldwide. […] In 2015, 4,500 cases were officially reported worldwide, down from nearly 100,000 in 1980. Diphtheria currently occurs most often in sub-Saharan Africa, South Asia, and Indonesia. […] In areas where it is still common, children are most affected. It is rare in the developed world due to widespread vaccination, but can re-emerge if vaccination rates decrease. […] In 2017, outbreaks occurred in a Rohingya refugee camp in Bangladesh, and amongst children unvaccinated due to the Yemeni Civil War. […] In December 2023 there was an outbreak at a school in Luton, in the United Kingdom. UK Health Security Agency (UKHSA) issued a statement saying specialists have been providing public health support following confirmation of the diphtheria case at a primary school in Luton.

• #19 Diphtheria – Wikipedia

  https://en.wikipedia.org/wiki/Diphtheria

  Diphtheria is fatal in 5-10% of cases. In children under five years and adults over 40 years, the fatality rate may be as much as 20%. […] In 2013, it resulted in 3,300 deaths, down from 8,000 deaths in 1990. Better standards of living, mass immunization, improved diagnosis, prompt treatment, and more effective health care have led to a decrease in cases worldwide. […] In 2015, 4,500 cases were officially reported worldwide, down from nearly 100,000 in 1980. Diphtheria currently occurs most often in sub-Saharan Africa, South Asia, and Indonesia. […] In areas where it is still common, children are most affected. It is rare in the developed world due to widespread vaccination, but can re-emerge if vaccination rates decrease. […] In 2017, outbreaks occurred in a Rohingya refugee camp in Bangladesh, and amongst children unvaccinated due to the Yemeni Civil War. […] In December 2023 there was an outbreak at a school in Luton, in the United Kingdom. UK Health Security Agency (UKHSA) issued a statement saying specialists have been providing public health support following confirmation of the diphtheria case at a primary school in Luton.

• #20 JMIR Public Health and Surveillance – Epidemiology of Diphtheria in Yemen, 2017-2018: Surveillance Data Analysis

  https://publichealth.jmir.org/2021/6/e27590/

  Background: As a consequence of war and the collapse of the health system in Yemen, which prevented many people from accessing health facilities to obtain primary health care, vaccination coverage was affected, leading to a deadly diphtheria epidemic at the end of 2017. […] Objective: This study aimed to describe the epidemiology of diphtheria in Yemen and determine its incidence and case fatality rate. […] A total of 2243 cases were reported during the period between July 2017 and August 2018. […] The overall incidence of diphtheria was 8 per 100,000 population. […] The overall case fatality rate among all age groups was 5%, and it was higher (10%) in the age group 5 years. […] Five governorates that were difficult to access (Raymah, Abyan, Sa’ada, Lahj, and Al Jawf) had a very high case fatality rate (22%).

• #21 Nigeria Centre for Disease Control and Prevention

  https://ncdc.gov.ng/news/489/official-statement-following-the-first-reported-confirmed-case-of-diphtheria-in-fct-abuja

  The Nigeria Centre for Disease Control and Prevention (NCDC) is aware of the death in June 2023 of a four-year-old with diphtheria in the Federal Capital Territory (FCT), Abuja. The NCDC, since December 2022, has reported multiple diphtheria outbreaks in different states across the country. As of June 30th, 2023, there have been 798 confirmed diphtheria cases from 33 Local Government Areas (LGAs) in eight (8) States including the FCT. […] The majority (71.7%) of the 798 confirmed cases occurred among children aged 2 14 years. […] So far, a total of 80 deaths have been recorded among all confirmed cases (case fatality rate of 10.0%). […] Despite the availability of a safe and cost-effective vaccine in the country, the majority i.e., 654 (82%) of 798 confirmed diphtheria cases in this ongoing outbreak were unvaccinated.

• #22

  https://www.actamedindones.org/index.php/ijim/article/view/1077

  Background: in recent years, diphtheria has reemerged in several countries including Venezuela, Yemen, Bangladesh, and Haiti. Similarly, Indonesia also showed an increased number of diphtheria cases in 2010-2017 despite the Diphteria, Tetanus, Pertussis (DTP) immunization program applied in Indonesia for children. This study aimed to evaluate the epidemiology of diphtheria cases which occurred in Indonesia during 2010-2017. […] Results: the number of diphtheria cases in Indonesia were distributed across 30 provinces with a total of 811 cases in 2011; 1,192 cases in 2012; 296 cases in 2014; and 939 cases in 2017. Based on age group, the highest number of case fatality rate were in age group of 5-9 years old. Diphtheria immunization coverage in Indonesia among children was fluctuated, reported as 67.7 % in 2007, 61.9 % in 2010, 75.6% in 2013 and 61.3% in 2018.

• #23 Eleven-Year Report of High Number of Diphtheria Cases in Children in East Java Province, Indonesia

  https://www.mdpi.com/2414-6366/9/9/204

  A high incidence of diphtheria cases in children in East Java province, Indonesia, has been observed since the beginning of this century. […] This study aims to explain the high incidence of diphtheria in children in East Java province since 2013. […] Surveillance of vaccine-preventable diseases such as diphtheria is crucial as part of the government’s and society’s efforts to address the problem. […] This study shows that diphtheria cases in children and adolescents in East Java have consistently been high, and low immunization coverage might still be the leading cause. […] The eleven-year case fatality rate (CFR) was 2.36% (69/2921). […] The high number of diphtheria cases in East Java province has reemerged since 2005 in Madura Island, one of the areas with many outbreaks in recent years.

• #24 Diphtheria: Background, Pathophysiology, Epidemiology

  https://emedicine.medscape.com/article/782051-overview

  Since the introduction and widespread use of diphtheria toxoid in the 1920s, respiratory diphtheria has been well controlled, with an incidence of approximately 1000 cases reported annually. Before vaccination, at least 200,000 cases occurred annually in the United States. […] Diphtheria remained endemic in some states through the 1970s, with reported incidence rates of greater than 1.0 per million population in Alaska, Arizona, Montana, New Mexico, South Dakota, and Washington. Most of these infections were attributed to incomplete vaccination. […] In the United States, diphtheria currently occurs sporadically, mostly among the Native American population, homeless people, lower socioeconomic groups, and alcoholics. Immigrants and travelers from regions with ongoing epidemics are also at risk.

• #25 Diphtheria Surveillance and Trends | Diphtheria | CDC

  https://www.cdc.gov/diphtheria/php/surveillance/index.html

  CDC tracks diphtheria cases using a national surveillance system. […] Diphtheria is now an uncommon disease in the United States. […] CDC collects national information about diphtheria cases through the National Notifiable Diseases Surveillance System (NNDSS). […] CDC also identifies cases by DAT requests. […] Now diphtheria is well controlled. The last U.S. case of confirmed respiratory diphtheria was in 1997. A small number of cutaneous cases associated with international travel have been reported since then. […] The Council of State and Territorial Epidemiologists (CSTE) released the most recent case definition for diphtheria in 2019.

• #26 Surveillance of diphtheria in the Netherlands between 2000–2021: cutaneous diphtheria supersedes the respiratory form | BMC Infectious Diseases | Full Text

  https://bmcinfectdis.biomedcentral.com/articles/10.1186/s12879-023-08388-5

  The low numbers of diphtheria cases in the Netherlands are mainly attributed to the ongoing vaccination program that started in 1953. […] Based on the public health act (WPG), toxigenic diphtheria is a notifiable disease in The Netherlands. […] Between 2000-2021, human-to-human transmission of C. diphtheriae has only rarely been described in Europe. […] The low incidence of diphtheria in The Netherlands and Europe is likely explained by the high vaccination coverage. […] Nevertheless, the current increase (fall 2022) in diphtheria among immigrants, mainly from countries with poor immunisation programs, in Europe and The Netherlands, does put these populations at risk. […] Based on this study and the reviewed literature, we conclude that the risk of human-to-human transmission of C. diphtheriae is minimal in the Netherlands, a country with a high vaccination coverage.

• #27 Diphtheria – Annual Epidemiological Report for 2022

  https://www.ecdc.europa.eu/en/publications-data/diphtheria-annual-epidemiological-report-2022

  In 2022, 359 cases of diphtheria due to toxigenic Corynebacterium diphtheriae (n=318) or C. ulcerans (n=11) were reported to ECDC. […] Since the second half of 2022, an increase of diphtheria among migrants was reported in several EU/EEA countries, with peaking case numbers in September to December. […] The highest proportion of C. diphtheriae cases was among 15- to 44-year-old males. C. ulcerans cases were more common in adults aged 65 years and above. […] Among C. diphtheriae cases with importation status available, 62% were reported as imported (having been outside the country of notification during the incubation period with no links to local transmission), with 78% of the imported cases presenting with a cutaneous infection. […] Vaccination status was available for 39% of all cases. Seventy-five percent of the cases with known vaccination status were not vaccinated or were vaccinated with an unknown number of doses. […] Vaccination with the diphtheria toxoid vaccine is the only effective method of preventing the toxin-mediated disease. Achieving and sustaining high vaccination coverage in the population is critical for preventing toxigenic diphtheria from causing serious or fatal illness.

• #28 Diphtheria – Annual Epidemiological Report for 2022

  https://www.ecdc.europa.eu/en/publications-data/diphtheria-annual-epidemiological-report-2022

  In 2022, 359 cases of diphtheria due to toxigenic Corynebacterium diphtheriae (n=318) or C. ulcerans (n=11) were reported to ECDC. […] Since the second half of 2022, an increase of diphtheria among migrants was reported in several EU/EEA countries, with peaking case numbers in September to December. […] The highest proportion of C. diphtheriae cases was among 15- to 44-year-old males. C. ulcerans cases were more common in adults aged 65 years and above. […] Among C. diphtheriae cases with importation status available, 62% were reported as imported (having been outside the country of notification during the incubation period with no links to local transmission), with 78% of the imported cases presenting with a cutaneous infection. […] Vaccination status was available for 39% of all cases. Seventy-five percent of the cases with known vaccination status were not vaccinated or were vaccinated with an unknown number of doses. […] Vaccination with the diphtheria toxoid vaccine is the only effective method of preventing the toxin-mediated disease. Achieving and sustaining high vaccination coverage in the population is critical for preventing toxigenic diphtheria from causing serious or fatal illness.

• #29 Diphtheria: Background, Pathophysiology, Epidemiology

  https://emedicine.medscape.com/article/782051-overview

  C diphtheria is responsible for both endemic and epidemic diseases, and it was first described in the 5th century BC by Hippocrates. Diphtheria manifests as either an upper respiratory tract or cutaneous infection and is caused by the aerobic gram-positive bacteria, Corynebacterium diphtheria. The infection usually occurs in the spring or winter months. It is communicable for 2-6 weeks without antibiotic treatment. […] People who are most susceptible to infection are those who are not completely immunized or have low antitoxin antibody levels and have been exposed to a carrier or diseased individual. A carrier is someone whose cultures are positive for the diphtheria species but does not exhibit signs and symptoms. As the number of asymptomatic carriers decrease, the number of diphtheria cases consequently decline.

• #30 Diphtheria: Background, Pathophysiology, Epidemiology

  https://emedicine.medscape.com/article/782051-overview

  C diphtheria is responsible for both endemic and epidemic diseases, and it was first described in the 5th century BC by Hippocrates. Diphtheria manifests as either an upper respiratory tract or cutaneous infection and is caused by the aerobic gram-positive bacteria, Corynebacterium diphtheria. The infection usually occurs in the spring or winter months. It is communicable for 2-6 weeks without antibiotic treatment. […] People who are most susceptible to infection are those who are not completely immunized or have low antitoxin antibody levels and have been exposed to a carrier or diseased individual. A carrier is someone whose cultures are positive for the diphtheria species but does not exhibit signs and symptoms. As the number of asymptomatic carriers decrease, the number of diphtheria cases consequently decline.

• #31

  https://pmc.ncbi.nlm.nih.gov/articles/PMC6759252/

  In 2017, a total of 8,819 cases of diphtheria were reported worldwide, the most since 2004. However, recent diphtheria epidemiology has not been well described. We analyzed incidence data and data from the literature to describe diphtheria epidemiology. World Health Organization surveillance data were 81% complete; completeness varied by region, indicating underreporting. As national diphtheriatetanuspertussis (DTP) 3 coverage increased, the proportion of case-patients 15 years of age decreased, indicating increased protection of young children. In countries with higher case counts, 66% of case-patients were unvaccinated and 63% were 15 years of age. In countries with sporadic cases, 32% of case-patients were unvaccinated and 66% were 15 years of age, consistent with waning vaccine immunity. Global DTP3 coverage is suboptimal. Attaining high DTP3 coverage and implementing recommended booster doses are necessary to decrease diphtheria incidence. Collection and use of data on subnational and booster dose coverage, enhanced laboratory capacity, and case-based surveillance would improve data quality.

• #32

  https://pmc.ncbi.nlm.nih.gov/articles/PMC6759252/

  In 2017, a total of 8,819 cases of diphtheria were reported worldwide, the most since 2004. However, recent diphtheria epidemiology has not been well described. We analyzed incidence data and data from the literature to describe diphtheria epidemiology. World Health Organization surveillance data were 81% complete; completeness varied by region, indicating underreporting. As national diphtheriatetanuspertussis (DTP) 3 coverage increased, the proportion of case-patients 15 years of age decreased, indicating increased protection of young children. In countries with higher case counts, 66% of case-patients were unvaccinated and 63% were 15 years of age. In countries with sporadic cases, 32% of case-patients were unvaccinated and 66% were 15 years of age, consistent with waning vaccine immunity. Global DTP3 coverage is suboptimal. Attaining high DTP3 coverage and implementing recommended booster doses are necessary to decrease diphtheria incidence. Collection and use of data on subnational and booster dose coverage, enhanced laboratory capacity, and case-based surveillance would improve data quality.

• #33

  https://pmc.ncbi.nlm.nih.gov/articles/PMC6759252/

  In 2017, a total of 8,819 cases of diphtheria were reported worldwide, the most since 2004. However, recent diphtheria epidemiology has not been well described. We analyzed incidence data and data from the literature to describe diphtheria epidemiology. World Health Organization surveillance data were 81% complete; completeness varied by region, indicating underreporting. As national diphtheriatetanuspertussis (DTP) 3 coverage increased, the proportion of case-patients 15 years of age decreased, indicating increased protection of young children. In countries with higher case counts, 66% of case-patients were unvaccinated and 63% were 15 years of age. In countries with sporadic cases, 32% of case-patients were unvaccinated and 66% were 15 years of age, consistent with waning vaccine immunity. Global DTP3 coverage is suboptimal. Attaining high DTP3 coverage and implementing recommended booster doses are necessary to decrease diphtheria incidence. Collection and use of data on subnational and booster dose coverage, enhanced laboratory capacity, and case-based surveillance would improve data quality.

• #34

  https://pmc.ncbi.nlm.nih.gov/articles/PMC6759252/

  In 2017, a total of 8,819 cases of diphtheria were reported worldwide, the most since 2004. However, recent diphtheria epidemiology has not been well described. We analyzed incidence data and data from the literature to describe diphtheria epidemiology. World Health Organization surveillance data were 81% complete; completeness varied by region, indicating underreporting. As national diphtheriatetanuspertussis (DTP) 3 coverage increased, the proportion of case-patients 15 years of age decreased, indicating increased protection of young children. In countries with higher case counts, 66% of case-patients were unvaccinated and 63% were 15 years of age. In countries with sporadic cases, 32% of case-patients were unvaccinated and 66% were 15 years of age, consistent with waning vaccine immunity. Global DTP3 coverage is suboptimal. Attaining high DTP3 coverage and implementing recommended booster doses are necessary to decrease diphtheria incidence. Collection and use of data on subnational and booster dose coverage, enhanced laboratory capacity, and case-based surveillance would improve data quality.

• #35 Diphtheria: Background, Pathophysiology, Epidemiology

  https://emedicine.medscape.com/article/1204017-overview

  According to the World Health Organization (WHO), diphtheria epidemics remain a health threat in developing nations. […] The largest epidemic recorded since widespread implementation of vaccine programs was in 1990-1995, when a diphtheria epidemic emerged in the Russian Federation, rapidly spreading to involve all Newly Independent States (NIS) and Baltic States. […] Overall rates of infection have decreased in Europe from 2000 to 2009, according to the Diphtheria Surveillance Network. This has been attributed to improved vaccination rates creating herd immunity. […] Many case reports in the literature describe epidemics in sub-Saharan Africa, France, India, and the United States. […] The most widely quoted diphtheria mortality rate is 5-10%. […] Mortality rates have not changed significantly over the past few decades. […] Historically, diphtheria has been primarily a disease of childhood, affecting populations younger than 12 years. […] Recently, however, diphtheria has shifted into the adolescent and adult population, most notably those in ages 40 and older accounting for most new cases.

• #36 Diphtheria – Annual Epidemiological Report for 2022

  https://www.ecdc.europa.eu/en/publications-data/diphtheria-annual-epidemiological-report-2022

  In 2022, 359 cases of diphtheria due to toxigenic Corynebacterium diphtheriae (n=318) or C. ulcerans (n=11) were reported to ECDC. […] Since the second half of 2022, an increase of diphtheria among migrants was reported in several EU/EEA countries, with peaking case numbers in September to December. […] The highest proportion of C. diphtheriae cases was among 15- to 44-year-old males. C. ulcerans cases were more common in adults aged 65 years and above. […] Among C. diphtheriae cases with importation status available, 62% were reported as imported (having been outside the country of notification during the incubation period with no links to local transmission), with 78% of the imported cases presenting with a cutaneous infection. […] Vaccination status was available for 39% of all cases. Seventy-five percent of the cases with known vaccination status were not vaccinated or were vaccinated with an unknown number of doses. […] Vaccination with the diphtheria toxoid vaccine is the only effective method of preventing the toxin-mediated disease. Achieving and sustaining high vaccination coverage in the population is critical for preventing toxigenic diphtheria from causing serious or fatal illness.

• #37 WHO EMRO | Disease surveillance | Diphtheria | Health topics

  https://www.emro.who.int/health-topics/diphtheria/disease-surveillance.html

  A probable case of diptheria is a case that meets the clinical description of an illness characterized by laryngitis or pharyngitis or tonsillitis, and by an adherent membrane of the tonsils, pharynx and/or nose. […] A confirmed case is a probable case that is laboratory confirmed or linked epidemiologically to a laboratory-confirmed case of isolation of Corynebacterium diphtheriae from a clinical specimen, or fourfold or greater rise in serum antibody (but only if both serum samples were obtained before the administration of diphtheria toxoid or antitoxin). […] Surveillance of diphtheria consists of a routine monthly report of probable or confirmed diphtheria cases; and immediate investigation of all diphtheria outbreaks with collection of case-based data. Monitoring the number of infants who have received the third dose of diphtheria toxoid-containing vaccine (DPT3) is also important. In countries with low incidence (usually where coverage is 85%90%) immediate reporting of case-based data of probable or confirmed cases is recommended from peripheral level to intermediate and central levels.

• #38 WHO EMRO | Disease surveillance | Diphtheria | Health topics

  https://www.emro.who.int/health-topics/diphtheria/disease-surveillance.html

  A probable case of diptheria is a case that meets the clinical description of an illness characterized by laryngitis or pharyngitis or tonsillitis, and by an adherent membrane of the tonsils, pharynx and/or nose. […] A confirmed case is a probable case that is laboratory confirmed or linked epidemiologically to a laboratory-confirmed case of isolation of Corynebacterium diphtheriae from a clinical specimen, or fourfold or greater rise in serum antibody (but only if both serum samples were obtained before the administration of diphtheria toxoid or antitoxin). […] Surveillance of diphtheria consists of a routine monthly report of probable or confirmed diphtheria cases; and immediate investigation of all diphtheria outbreaks with collection of case-based data. Monitoring the number of infants who have received the third dose of diphtheria toxoid-containing vaccine (DPT3) is also important. In countries with low incidence (usually where coverage is 85%90%) immediate reporting of case-based data of probable or confirmed cases is recommended from peripheral level to intermediate and central levels.

• #39 WHO EMRO | Disease surveillance | Diphtheria | Health topics

  https://www.emro.who.int/health-topics/diphtheria/disease-surveillance.html

  A probable case of diptheria is a case that meets the clinical description of an illness characterized by laryngitis or pharyngitis or tonsillitis, and by an adherent membrane of the tonsils, pharynx and/or nose. […] A confirmed case is a probable case that is laboratory confirmed or linked epidemiologically to a laboratory-confirmed case of isolation of Corynebacterium diphtheriae from a clinical specimen, or fourfold or greater rise in serum antibody (but only if both serum samples were obtained before the administration of diphtheria toxoid or antitoxin). […] Surveillance of diphtheria consists of a routine monthly report of probable or confirmed diphtheria cases; and immediate investigation of all diphtheria outbreaks with collection of case-based data. Monitoring the number of infants who have received the third dose of diphtheria toxoid-containing vaccine (DPT3) is also important. In countries with low incidence (usually where coverage is 85%90%) immediate reporting of case-based data of probable or confirmed cases is recommended from peripheral level to intermediate and central levels.

• #40 WHO EMRO | Disease surveillance | Diphtheria | Health topics

  https://www.emro.who.int/health-topics/diphtheria/disease-surveillance.html

  A probable case of diptheria is a case that meets the clinical description of an illness characterized by laryngitis or pharyngitis or tonsillitis, and by an adherent membrane of the tonsils, pharynx and/or nose. […] A confirmed case is a probable case that is laboratory confirmed or linked epidemiologically to a laboratory-confirmed case of isolation of Corynebacterium diphtheriae from a clinical specimen, or fourfold or greater rise in serum antibody (but only if both serum samples were obtained before the administration of diphtheria toxoid or antitoxin). […] Surveillance of diphtheria consists of a routine monthly report of probable or confirmed diphtheria cases; and immediate investigation of all diphtheria outbreaks with collection of case-based data. Monitoring the number of infants who have received the third dose of diphtheria toxoid-containing vaccine (DPT3) is also important. In countries with low incidence (usually where coverage is 85%90%) immediate reporting of case-based data of probable or confirmed cases is recommended from peripheral level to intermediate and central levels.

• #41 Diphtheria Surveillance and Trends | Diphtheria | CDC

  https://www.cdc.gov/diphtheria/php/surveillance/index.html

  CDC tracks diphtheria cases using a national surveillance system. […] Diphtheria is now an uncommon disease in the United States. […] CDC collects national information about diphtheria cases through the National Notifiable Diseases Surveillance System (NNDSS). […] CDC also identifies cases by DAT requests. […] Now diphtheria is well controlled. The last U.S. case of confirmed respiratory diphtheria was in 1997. A small number of cutaneous cases associated with international travel have been reported since then. […] The Council of State and Territorial Epidemiologists (CSTE) released the most recent case definition for diphtheria in 2019.

• #42 Chapter 1: Diphtheria | Manual for the Surveillance of Vaccine-Preventable Diseases | CDC

  https://www.cdc.gov/surv-manual/php/table-of-contents/chapter-1-diphtheria.html

  This chapter provides general guidance for vaccine-preventable disease surveillance, describing the disease background/epidemiology, case investigation and reporting/notification, disease case definitions, and activities for enhancing surveillance, case investigation, and outbreak control for diphtheria. […] Diphtheria is now rarely reported in the United States; however, in the pre-vaccine era, the disease was one of the most common and feared causes of illness and death among children. […] Prior to 2019, an upper respiratory infection caused by any C. diphtheriae, irrespective of toxigenicity, was reportable to CDC’s National Notifiable Diseases Surveillance System (NNDSS). […] Over the last decade, nonrespiratory (most commonly cutaneous) diphtheria has been increasingly detected in the United States and elsewhere.

• #43 Chapter 1: Diphtheria | Manual for the Surveillance of Vaccine-Preventable Diseases | CDC

  https://www.cdc.gov/surv-manual/php/table-of-contents/chapter-1-diphtheria.html

  Given that cutaneous and other forms of nonrespiratory diphtheria can be transmitted and cause respiratory diphtheria, the US case definition was revised in 2019 to include disease caused by toxin-producing C. diphtheriae from any site, including cutaneous sites. […] Diphtheria remains endemic in countries with low routine immunization coverage. […] Among countries that have achieved high childhood vaccination coverage with diphtheria- and tetanus toxoids- and pertussis-containing vaccines (DTP/DTaP), overall incidence is low. […] Prompt recognition and reporting of respiratory diphtheria are important to ensure early, appropriate treatment with diphtheria antitoxin (DAT) and antibiotics. […] Surveillance, vaccination, prompt treatment of diphtheria patients, and investigation of close contacts help to halt the spread of diphtheria.

• #44 Diphtheria Surveillance and Trends | Diphtheria | CDC

  https://www.cdc.gov/diphtheria/php/surveillance/index.html

  CDC tracks diphtheria cases using a national surveillance system. […] Diphtheria is now an uncommon disease in the United States. […] CDC collects national information about diphtheria cases through the National Notifiable Diseases Surveillance System (NNDSS). […] CDC also identifies cases by DAT requests. […] Now diphtheria is well controlled. The last U.S. case of confirmed respiratory diphtheria was in 1997. A small number of cutaneous cases associated with international travel have been reported since then. […] The Council of State and Territorial Epidemiologists (CSTE) released the most recent case definition for diphtheria in 2019.

• #45 Surveillance and updates for diphtheria

  https://www.ecdc.europa.eu/en/diphtheria/surveillance-and-disease-data

  ECDCs annual epidemiological reports provide a wealth of epidemiological data to support decision-making at the national level. […] All reports on this page are based data retrieved from TESSy. Countries participating in disease surveillance submitted their data electronically. […] Surveillance report […] Diphtheria – Annual Epidemiological Report for 2022 […] Diphtheria – Annual Epidemiological Report for 2021 […] Diphtheria – Annual Epidemiological Report for 2018 […] Diphtheria – Annual Epidemiological Report for 2017 […] Diphtheria – Annual Epidemiological Report for 2016 […] See the latest surveillance data […] ECDC coordinates and supports the various disease and reference laboratory networks in Europe.

• #46 Diphtheria: Surveillance – Canada.ca

  https://www.canada.ca/en/public-health/services/immunization/vaccine-preventable-diseases/diphtheria/surveillance.html

  As a nationally reportable disease in Canada, surveillance of diphtheria is conducted by public health professionals in provinces and territories. They report cases to the Public Health Agency of Canada through the Canadian Notifiable Disease Surveillance System (CNDSS). […] Cases are reported by health care providers to public health units if: […] For more information on diphtheria epidemiology, transmission, prevention and control, refer to information for Health Professionals.

• #47

  https://www.gov.uk/government/collections/diphtheria-guidance-data-and-analysis

  Diphtheria is an acute infectious disease of humans that affects the upper respiratory tract and occasionally the skin, caused by the action of diphtheria toxin produced by toxigenic Corynebacterium diphtheriae or by Corynebacterium ulcerans. […] It is a notifiable disease in England and Wales. Health professionals must inform local health protection teams of suspected cases. […] UK Health Security Agency supports the European Diphtheria Surveillance Network (EDSN) as a surveillance network across Europe. […] Immunisation coverage: completed primary courses at 2 years of age in England and Wales from 1966 to 1977, England only from 1978 onwards. […] Diphtheria: notifications, deaths and laboratory isolates data.

• #48

  https://www.gov.uk/government/collections/diphtheria-guidance-data-and-analysis

  Diphtheria is an acute infectious disease of humans that affects the upper respiratory tract and occasionally the skin, caused by the action of diphtheria toxin produced by toxigenic Corynebacterium diphtheriae or by Corynebacterium ulcerans. […] It is a notifiable disease in England and Wales. Health professionals must inform local health protection teams of suspected cases. […] UK Health Security Agency supports the European Diphtheria Surveillance Network (EDSN) as a surveillance network across Europe. […] Immunisation coverage: completed primary courses at 2 years of age in England and Wales from 1966 to 1977, England only from 1978 onwards. […] Diphtheria: notifications, deaths and laboratory isolates data.

• #49 Diphtheria | Surveillance | CDC

  http://medbox.iiab.me/modules/en-cdc/www.cdc.gov/diphtheria/surveillance.html

  Although diphtheria is now rarely reported in the United States, the disease was one of the most common causes of illness and death among children before a vaccine was available. Since the introduction and widespread use of diphtheria vaccines, which began in the 1920s and 1930s, and universal childhood immunization in the late 1940s, diphtheria has been well-controlled in the United States. […] Suspected diphtheria cases should be reported promptly by telephone to the CDC Emergency Operations Center (770-488-7100) so that diphtheria antitoxin can be obtained for the patient. […] Healthcare professionals should notify their state health department promptly so that an epidemiologic investigation can be initiated. Reports of probable and confirmed cases should be forwarded by the state health department to the National Notifiable Disease Surveillance System. Reporting should not be delayed because of incomplete information or lack of laboratory confirmation.

• #50

  https://pmc.ncbi.nlm.nih.gov/articles/PMC6759252/

  In 2017, a total of 8,819 cases of diphtheria were reported worldwide, the most since 2004. However, recent diphtheria epidemiology has not been well described. We analyzed incidence data and data from the literature to describe diphtheria epidemiology. World Health Organization surveillance data were 81% complete; completeness varied by region, indicating underreporting. As national diphtheriatetanuspertussis (DTP) 3 coverage increased, the proportion of case-patients 15 years of age decreased, indicating increased protection of young children. In countries with higher case counts, 66% of case-patients were unvaccinated and 63% were 15 years of age. In countries with sporadic cases, 32% of case-patients were unvaccinated and 66% were 15 years of age, consistent with waning vaccine immunity. Global DTP3 coverage is suboptimal. Attaining high DTP3 coverage and implementing recommended booster doses are necessary to decrease diphtheria incidence. Collection and use of data on subnational and booster dose coverage, enhanced laboratory capacity, and case-based surveillance would improve data quality.

• #51

  https://pmc.ncbi.nlm.nih.gov/articles/PMC6759252/

  Although several comprehensive reviews were published after that outbreak peaked, only sporadic documentation of diphtheria outbreaks has been published since, and no examination of global epidemiologic trends has been published. During 2016-2019, diphtheria outbreaks were reported in multiple countries, including Bangladesh, Yemen, and Venezuela. Several outbreaks were among vulnerable populations or in areas of social disruption and conflict. […] The diphtheria data reported annually to WHO and UNICEF on the JRF have substantial limitations in terms of quality and reflect opportunities to improve disease surveillance. We found these data to be incomplete when cross-referenced with the literature, indicating a likely underestimate of incidence worldwide and a decreased understanding of the burden of disease. However, in some countries with lower laboratory capacity, only a small proportion of cases are laboratory confirmed, which could result in overreporting in some settings. The ability to use aggregate data for action is limited by the lack of key variables, including vaccination status, age, and subnational location. […] Implementation of case-based surveillance for diphtheria, combined with availability of subnational coverage data, would result in improved understanding of diphtheria epidemiology and enhanced capability to prevent and respond to outbreaks.

• #52

  https://pmc.ncbi.nlm.nih.gov/articles/PMC6759252/

  Although several comprehensive reviews were published after that outbreak peaked, only sporadic documentation of diphtheria outbreaks has been published since, and no examination of global epidemiologic trends has been published. During 2016-2019, diphtheria outbreaks were reported in multiple countries, including Bangladesh, Yemen, and Venezuela. Several outbreaks were among vulnerable populations or in areas of social disruption and conflict. […] The diphtheria data reported annually to WHO and UNICEF on the JRF have substantial limitations in terms of quality and reflect opportunities to improve disease surveillance. We found these data to be incomplete when cross-referenced with the literature, indicating a likely underestimate of incidence worldwide and a decreased understanding of the burden of disease. However, in some countries with lower laboratory capacity, only a small proportion of cases are laboratory confirmed, which could result in overreporting in some settings. The ability to use aggregate data for action is limited by the lack of key variables, including vaccination status, age, and subnational location. […] Implementation of case-based surveillance for diphtheria, combined with availability of subnational coverage data, would result in improved understanding of diphtheria epidemiology and enhanced capability to prevent and respond to outbreaks.

• #53 Diphtheria Surveillance | SpringerLink

  https://link.springer.com/chapter/10.1007/978-94-007-7624-1_10

  Diphtheria is uncommon in developed countries but when cases do arise they are often severe with high mortality. This disease has demonstrated its potential to re-emerge to epidemic proportions in areas where it was previously thought to be under control. Ongoing monitoring and surveillance is therefore essential and in general follows the principles of surveillance utilised for most other vaccine preventable infections, but with some specific adaptations relevant to a disease that is close to elimination. Surveillance across countries and regions is complicated by a number of factors including the use of different case definitions and the variation in laboratory policy and expertise. International networks have been valuable in improving knowledge and skills in this area. […] Population coverage of approximately 85% is required for elimination, based on a basic reproductive number (R0; the average number of secondary cases produced by one primary case in a wholly susceptible population) of 67 (Fine 1993). […] The sero-epidemiology of diphtheria in Western Europe.

• #54

  https://pmc.ncbi.nlm.nih.gov/articles/PMC6759252/

  Although several comprehensive reviews were published after that outbreak peaked, only sporadic documentation of diphtheria outbreaks has been published since, and no examination of global epidemiologic trends has been published. During 2016-2019, diphtheria outbreaks were reported in multiple countries, including Bangladesh, Yemen, and Venezuela. Several outbreaks were among vulnerable populations or in areas of social disruption and conflict. […] The diphtheria data reported annually to WHO and UNICEF on the JRF have substantial limitations in terms of quality and reflect opportunities to improve disease surveillance. We found these data to be incomplete when cross-referenced with the literature, indicating a likely underestimate of incidence worldwide and a decreased understanding of the burden of disease. However, in some countries with lower laboratory capacity, only a small proportion of cases are laboratory confirmed, which could result in overreporting in some settings. The ability to use aggregate data for action is limited by the lack of key variables, including vaccination status, age, and subnational location. […] Implementation of case-based surveillance for diphtheria, combined with availability of subnational coverage data, would result in improved understanding of diphtheria epidemiology and enhanced capability to prevent and respond to outbreaks.

• #55 Epidemiology and pathophysiology of diphtheria – UpToDate

  https://www.uptodate.com/contents/epidemiology-and-pathophysiology-of-diphtheria

  Transmission — The primary modes of spread consist of close contact with infectious material from respiratory secretions (direct or via airborne droplet) or from skin lesions. Humans are believed to be the only known reservoir for C. diphtheriae, although rare cases of disease in animals have been reported. Infection may occur throughout the year with a peak incidence in the colder months.

• #56 Epidemiology and pathophysiology of diphtheria – UpToDate

  https://www.uptodate.com/contents/epidemiology-and-pathophysiology-of-diphtheria

  Transmission — The primary modes of spread consist of close contact with infectious material from respiratory secretions (direct or via airborne droplet) or from skin lesions. Humans are believed to be the only known reservoir for C. diphtheriae, although rare cases of disease in animals have been reported. Infection may occur throughout the year with a peak incidence in the colder months.

• #57

  https://www.who.int/publications/m/item/vaccine-preventable-diseases-surveillance-standards-diphtheria

  Diphtheria is caused by Corynebacterium species, mostly by toxin-producing Corynebacterium diphtheriae and rarely by toxin-producing strains of C. ulcerans and C. pseudotuberculosis. […] C. diphtheriae is transmitted from person to person by intimate respiratory and direct contact; in contrast, C. ulcerans and C. pseudotuberculosis are zoonotic infections, not transmitted person-to-person. […] A person is infectious as long as virulent bacteria are present in respiratory secretions, usually two weeks without antibiotics, and seldom more than six weeks.

• #58 Epidemiology and pathophysiology of diphtheria – UpToDate

  https://www.uptodate.com/contents/epidemiology-and-pathophysiology-of-diphtheria

  Epidemiology and pathophysiology of diphtheria […] The epidemiology and pathophysiology of diphtheria will be reviewed here. […] EPIDEMIOLOGY […] Biotypes causing disease — There are at least four biotypes or biovars of C. diphtheriae: gravis, intermedius, mitis, and belfanti. All biotypes have been associated with both endemic and epidemic diphtheria. However, belfanti is rarely described as toxigenic, whereas the other biotypes are named for their association with disease severity: gravis (serious), intermedius (intermediate), and mitis (mild). […] C. ulcerans is a rare cause of respiratory illness that resembles diphtheria. It has been reported predominantly in industrialized countries, which may be due in part to detection bias. Isolated cases of diphtheria-like illness due to C. ulcerans were reported in the United States in 2008 and 2010. Like C. diphtheriae, C. ulcerans can produce diphtheria toxin and lead to life-threatening disease that requires urgent treatment with diphtheria antitoxin and macrolide antibiotics. However, unlike C. diphtheriae, C. ulcerans is a zoonotic illness; evidence for human-to-human transmission is limited.

• #59

  https://www.who.int/publications/m/item/vaccine-preventable-diseases-surveillance-standards-diphtheria

  Diphtheria is caused by Corynebacterium species, mostly by toxin-producing Corynebacterium diphtheriae and rarely by toxin-producing strains of C. ulcerans and C. pseudotuberculosis. […] C. diphtheriae is transmitted from person to person by intimate respiratory and direct contact; in contrast, C. ulcerans and C. pseudotuberculosis are zoonotic infections, not transmitted person-to-person. […] A person is infectious as long as virulent bacteria are present in respiratory secretions, usually two weeks without antibiotics, and seldom more than six weeks.

• #60 Epidemiology and pathophysiology of diphtheria – UpToDate

  https://www.uptodate.com/contents/epidemiology-and-pathophysiology-of-diphtheria

  Transmission — The primary modes of spread consist of close contact with infectious material from respiratory secretions (direct or via airborne droplet) or from skin lesions. Humans are believed to be the only known reservoir for C. diphtheriae, although rare cases of disease in animals have been reported. Infection may occur throughout the year with a peak incidence in the colder months.

• #61

  https://pmc.ncbi.nlm.nih.gov/articles/PMC6759252/

  In 2017, a total of 8,819 cases of diphtheria were reported worldwide, the most since 2004. However, recent diphtheria epidemiology has not been well described. We analyzed incidence data and data from the literature to describe diphtheria epidemiology. World Health Organization surveillance data were 81% complete; completeness varied by region, indicating underreporting. As national diphtheriatetanuspertussis (DTP) 3 coverage increased, the proportion of case-patients 15 years of age decreased, indicating increased protection of young children. In countries with higher case counts, 66% of case-patients were unvaccinated and 63% were 15 years of age. In countries with sporadic cases, 32% of case-patients were unvaccinated and 66% were 15 years of age, consistent with waning vaccine immunity. Global DTP3 coverage is suboptimal. Attaining high DTP3 coverage and implementing recommended booster doses are necessary to decrease diphtheria incidence. Collection and use of data on subnational and booster dose coverage, enhanced laboratory capacity, and case-based surveillance would improve data quality.

• #62 Global Epidemiology Of Diphtheria In The 21st Century – MMGH Consulting

  https://www.mmglobalhealth.org/publications/global-epidemiology-of-diphtheria-in-the-21st-century/

  In 2017, a total of 8,819 cases of diphtheria were reported worldwide, the most since 2004. […] However, recent diphtheria epidemiology has not been well described. […] World Health Organisation surveillance data were 81% complete; completeness varied by region, indicating under-reporting. […] As national diphtheriatetanuspertussis (DTP) 3 coverage increased, the proportion of case-patients 15 years of age decreased, indicating increased protection of young children. […] In countries with higher case counts, 66% of case-patients were unvaccinated and 63% were 15 years of age, consistent with waning vaccine immunity. […] Global DTP3 coverage is suboptimal. […] Attaining high DTP3 coverage and implementing recommended booster doses are necessary to decrease diphtheria incidence. […] Collection and use of data on subnational and booster dose coverage, enhanced laboratory capacity, and case-based surveillance would improve data quality.

• #63 Clinical and Epidemiological Aspects of Diphtheria: A Systematic Review and Pooled Analysis | IDD

  https://www.iddynamics.jhsph.edu/clinical-and-epidemiological-aspects-diphtheria-systematic-review-and-pooled-analysis

  Diphtheria, once a major cause of childhood morbidity and mortality, all but disappeared following introduction of diphtheria vaccine. […] Recent outbreaks highlight the risk diphtheria poses when civil unrest interrupts vaccination and healthcare access. […] Lack of interest over the last century resulted in knowledge gaps about diphtheria’s epidemiology, transmission, and control. […] Asymptomatic carriers cause 76% (95% confidence interval, 59%-87%) fewer cases over the course of infection than symptomatic cases. […] The basic reproductive number is 1.7-4.3. […] Receipt of 3 doses of diphtheria toxoid vaccine is 87% (95% CrI, 68%-97%) effective against symptomatic disease and reduces transmission by 60% (95% CrI, 51%-68%). […] Vaccinated individuals can become colonized and transmit; consequently, vaccination alone can only interrupt transmission in 28% of outbreak settings, making isolation and antibiotics essential. […] While antibiotics reduce the duration of infection, they must be paired with diphtheria antitoxin to limit morbidity.

• #64 Clinical and Epidemiological Aspects of Diphtheria: A Systematic Review and Pooled Analysis | IDD

  https://www.iddynamics.jhsph.edu/clinical-and-epidemiological-aspects-diphtheria-systematic-review-and-pooled-analysis

  Diphtheria, once a major cause of childhood morbidity and mortality, all but disappeared following introduction of diphtheria vaccine. […] Recent outbreaks highlight the risk diphtheria poses when civil unrest interrupts vaccination and healthcare access. […] Lack of interest over the last century resulted in knowledge gaps about diphtheria’s epidemiology, transmission, and control. […] Asymptomatic carriers cause 76% (95% confidence interval, 59%-87%) fewer cases over the course of infection than symptomatic cases. […] The basic reproductive number is 1.7-4.3. […] Receipt of 3 doses of diphtheria toxoid vaccine is 87% (95% CrI, 68%-97%) effective against symptomatic disease and reduces transmission by 60% (95% CrI, 51%-68%). […] Vaccinated individuals can become colonized and transmit; consequently, vaccination alone can only interrupt transmission in 28% of outbreak settings, making isolation and antibiotics essential. […] While antibiotics reduce the duration of infection, they must be paired with diphtheria antitoxin to limit morbidity.

• #65 Clinical and Epidemiological Aspects of Diphtheria: A Systematic Review and Pooled Analysis | IDD

  https://www.iddynamics.jhsph.edu/clinical-and-epidemiological-aspects-diphtheria-systematic-review-and-pooled-analysis

  Diphtheria, once a major cause of childhood morbidity and mortality, all but disappeared following introduction of diphtheria vaccine. […] Recent outbreaks highlight the risk diphtheria poses when civil unrest interrupts vaccination and healthcare access. […] Lack of interest over the last century resulted in knowledge gaps about diphtheria’s epidemiology, transmission, and control. […] Asymptomatic carriers cause 76% (95% confidence interval, 59%-87%) fewer cases over the course of infection than symptomatic cases. […] The basic reproductive number is 1.7-4.3. […] Receipt of 3 doses of diphtheria toxoid vaccine is 87% (95% CrI, 68%-97%) effective against symptomatic disease and reduces transmission by 60% (95% CrI, 51%-68%). […] Vaccinated individuals can become colonized and transmit; consequently, vaccination alone can only interrupt transmission in 28% of outbreak settings, making isolation and antibiotics essential. […] While antibiotics reduce the duration of infection, they must be paired with diphtheria antitoxin to limit morbidity.

• #66 Diphtheria: Background, Pathophysiology, Epidemiology

  https://emedicine.medscape.com/article/782051-overview

  Many case reports in the literature describe epidemics in sub-Saharan Africa, France, India, and the United States. […] Before the introduction of vaccine in the 1920s, the incidence of respiratory disease was 100-200 cases per 100,000 population in the United States and has decreased to approximately 0.001 cases per 100,000 population. […] The most widely quoted diphtheria mortality rate is 5-10%. It may reach higher than 20% in children younger than 5 years and adults older than 40 years. Mortality rates have not changed significantly over the past few decades. Most deaths occur on days 3-4 secondary to asphyxia with a pharyngeal membrane or due to myocarditis.

• #67 Diphtheria: For Health Professionals – Canada.ca

  https://www.canada.ca/en/public-health/services/immunization/vaccine-preventable-diseases/diphtheria/health-professionals.html

  Diphtheria became nationally notifiable in 1924. That year 9,057 cases were reported, the highest annual number of cases ever recorded in Canada. […] The diphtheria vaccine was introduced in 1926. Routine immunization in infancy and childhood has been widely practiced in Canada since 1930. By the mid-1950s, routine immunization had resulted in a remarkable decline in the morbidity and mortality of the disease. […] A small number of toxigenic strains of diphtheria bacilli continue to be detected each year, although classic diphtheria is rare. Since 1993, a total of 19 cases have been reported with a range of 0 to 4 cases annually. […] The last death due to diphtheria in Canada was reported in 2010.

• #68 Diphtheria – Taiwan Centers for Disease Control

  https://www.cdc.gov.tw/En/Category/ListContent/bg0g_VU_Ysrgkes_KRUDgQ?uaid=9GTlSWUmUE40xA_W9ZTWmA

  Diphtheria can involve almost any mucous membrane. Taiwan Centers for Disease Control (Taiwan CDC) had listed diphtheria as the second category of notifiable infectious disease, and all people are the monitoring subjects. The medical institutes have to inform cases within 24 hours in accordance with the provision. Whenever the diphtheria is isolated from the pseudomembranous lesions in the throat, larynx and nasal mucosa from suspected cases, the notification should be done as soon as possible. The isolates have to send to Taiwan CDC for further identification to determine the infection cases. […] Diphtheria once was a major cause of illness and death among children who were under 15 of years. Taiwan has recorded 2,186 cases of diphtheria in 1957, and then has dropped to 4 cases till 1980. There has been no confirmed case after 1981. However, the disease continues to play a role globally. The cases of diphtheria were reported worldwide to the World Health Organization (WHO), but many more cases likely go unreported. […] Diphtheria toxoid was introduced to Taiwan in 1948. DPT vaccination for 6 to 24 month-old infants was implemented in 1955. The incidence was 126 cases per 10,000 people in 1957, and dropped to 0.02 cases per 10,000 people by 1980. There was no more confirmed case after 1981.

• #69 Diphtheria is back in Australia, here’s why – and how vaccines can prevent its spread | NCIRS

  https://ncirs.org.au/diphtheria-back-australia-heres-why-and-how-vaccines-can-prevent-its-spread

  An unvaccinated toddler from the far north coast of New South Wales is in intensive care after catching respiratory diphtheria (diphtheria of the throat). A six-year-old close family contact is also infected. […] These are the first cases of respiratory diphtheria in children seen in Australia since 1992. […] Diphtheria vaccination rates in Australian children have been high at over 90% since 2000 and are currently around 95%. […] Diphtheria vaccination prevents disease but doesn’t fully prevent people carrying the bacteria in the back of their throat without symptoms. It is possible for fully vaccinated people to spread the bacteria to unvaccinated contacts, including when they return from overseas travel. […] Increases in diphtheria are a now a real risk as vaccination rates have declined globally.

• #70 JMIR Public Health and Surveillance – Epidemiology of Diphtheria in Yemen, 2017-2018: Surveillance Data Analysis

  https://publichealth.jmir.org/2021/6/e27590/

  Diphtheria affected a large number of people in Yemen in 2017-2018. […] The majority of patients were partially or not vaccinated. […] To control the diphtheria epidemic in Yemen, it is recommended to increase routine vaccination coverage and booster immunizations, and strengthen the surveillance system for early detection and immediate response.

• #71 Diphtheria – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK560911/

  Diphtheria does not exhibit any racial or sexual preference. While diphtheria is commonly recognized as a childhood disease, predominantly affecting those below 12 years, individuals around the age of 40 and those with comorbid conditions are also susceptible to infection. As immunity against the bacteria naturally wanes, the risk of infection rises for individuals not currently receiving immunizations and booster doses.

• #72 Diphtheria – Wikipedia

  https://en.wikipedia.org/wiki/Diphtheria

  Diphtheria is fatal in 5-10% of cases. In children under five years and adults over 40 years, the fatality rate may be as much as 20%. […] In 2013, it resulted in 3,300 deaths, down from 8,000 deaths in 1990. Better standards of living, mass immunization, improved diagnosis, prompt treatment, and more effective health care have led to a decrease in cases worldwide. […] In 2015, 4,500 cases were officially reported worldwide, down from nearly 100,000 in 1980. Diphtheria currently occurs most often in sub-Saharan Africa, South Asia, and Indonesia. […] In areas where it is still common, children are most affected. It is rare in the developed world due to widespread vaccination, but can re-emerge if vaccination rates decrease. […] In 2017, outbreaks occurred in a Rohingya refugee camp in Bangladesh, and amongst children unvaccinated due to the Yemeni Civil War. […] In December 2023 there was an outbreak at a school in Luton, in the United Kingdom. UK Health Security Agency (UKHSA) issued a statement saying specialists have been providing public health support following confirmation of the diphtheria case at a primary school in Luton.

• #73

  https://link.springer.com/article/10.1186/s12982-024-00352-1

  Comprehensive global standards that highlight the value of vaccination, bolster the healthcare system, and implement measures to encourage vaccine uptake are required to address these issues. […] Long-term policies including boosting funding for immunization programs, improving disease surveillance, and building collaborations are expedient. […] The COVID-19 pandemic has further disrupted vaccination campaigns, contributing to the recent resurgence of diphtheria in developing countries. […] The WHO South-East Asia area is especially concerning because it regularly reports the bulk of the annual global incidence of diphtheria. […] The pandemic’s impact on healthcare systems, vaccine supply chains, and immunization campaigns has exacerbated the situation, leaving populations more vulnerable to diphtheria and other preventable diseases.

• #74 Circulation of pertussis and poor protection against diphtheria among middle-aged adults in 18 European countries | Nature Communications

  https://www.nature.com/articles/s41467-021-23114-y

  Reported incidence of pertussis in the European Union (EU) and the European Economic Area (EEA) varies and may not reflect the real situation, while vaccine-induced protection against diphtheria and tetanus seems sufficient. […] For diphtheria the proportion of sera lacking the protective level (0.1 IU/mL) varied between 22.8-82.0%. […] Here, we report that the seroprevalence of pertussis in these age groups indicates circulation of B. pertussis across EU/EEA while the lack of vaccine-induced seroprotection against diphtheria is of concern and deserves further attention. […] In contrast to pertussis, the incidence of diphtheria and tetanus according to the data reported to ECDC has been very low in the last decade across EU/EEA countries, due to the longstanding vaccination programmes and high coverage, indicating that these vaccines seem to confer better protection than the pertussis vaccines.

• #75 Circulation of pertussis and poor protection against diphtheria among middle-aged adults in 18 European countries | Nature Communications

  https://www.nature.com/articles/s41467-021-23114-y

  The aim of this study was to determine the seroprevalence levels of IgG-PT, IgG-Dt and IgG-TT within two specific age groups (i.e. 40-49 and 50-59 years of age) in EU/EEA countries to explore the proportion of sera indicative for a recent exposure to pertussis to determine the circulation of B. pertussis, and the persistence of vaccine-induced protection against diphtheria and tetanus in EU/EEA. […] The proportion of sera with Dt antibody levels below the basic immunity level of 0.01 IU/mL varied between 4% (Finland) and 43% (Greece) and for the protective level of 0.1 IU/mL from 23% for Finland up to around 80% for Greece, Ireland, Romania and United Kingdom. […] The high proportion of sera with unprotected levels for diphtheria is of concern, leaving at least a quarter up to over three-quarters of the middle-aged adult population sampled not well protected against diphtheria. […] Overall, the protection against diphtheria in EU/EEA in the older age groups is suboptimal and certainly not sufficient, and might indicate a need for boosting immunity.

• #76 Diphtheria: Background, Pathophysiology, Epidemiology

  https://emedicine.medscape.com/article/782051-overview

  Many case reports in the literature describe epidemics in sub-Saharan Africa, France, India, and the United States. […] Before the introduction of vaccine in the 1920s, the incidence of respiratory disease was 100-200 cases per 100,000 population in the United States and has decreased to approximately 0.001 cases per 100,000 population. […] The most widely quoted diphtheria mortality rate is 5-10%. It may reach higher than 20% in children younger than 5 years and adults older than 40 years. Mortality rates have not changed significantly over the past few decades. Most deaths occur on days 3-4 secondary to asphyxia with a pharyngeal membrane or due to myocarditis.

• #77 Diphtheria – Wikipedia

  https://en.wikipedia.org/wiki/Diphtheria

  Diphtheria is fatal in 5-10% of cases. In children under five years and adults over 40 years, the fatality rate may be as much as 20%. […] In 2013, it resulted in 3,300 deaths, down from 8,000 deaths in 1990. Better standards of living, mass immunization, improved diagnosis, prompt treatment, and more effective health care have led to a decrease in cases worldwide. […] In 2015, 4,500 cases were officially reported worldwide, down from nearly 100,000 in 1980. Diphtheria currently occurs most often in sub-Saharan Africa, South Asia, and Indonesia. […] In areas where it is still common, children are most affected. It is rare in the developed world due to widespread vaccination, but can re-emerge if vaccination rates decrease. […] In 2017, outbreaks occurred in a Rohingya refugee camp in Bangladesh, and amongst children unvaccinated due to the Yemeni Civil War. […] In December 2023 there was an outbreak at a school in Luton, in the United Kingdom. UK Health Security Agency (UKHSA) issued a statement saying specialists have been providing public health support following confirmation of the diphtheria case at a primary school in Luton.

• #78 Diphtheria | Health & Human Services

  https://hhs.iowa.gov/center-acute-disease-epidemiology/epi-manual/reportable-diseases/diphtheria

  Infection can occur in immunized, partially immunized and unimmunized persons, but it is usually less severe in those who are partially or fully immunized. […] Diphtheria is endemic in many parts of the world, including countries of the Caribbean and Latin America. The incidence of respiratory diphtheria is greatest in the fall and winter. During the last few years, large epidemics of respiratory diphtheria, primarily in adolescents and adults, have occurred in the former Soviet Union, Algeria, and Ecuador. In the states of the former Soviet Union (including Russia, the Ukraine and Central Asian Republics), more than 150,000 cases and 5,000 deaths from diphtheria occurred between 1990 and 1997. In recent epidemics in the former Soviet Union, the case fatality rate has ranged from 3% to 23%. In 2011, 4,887 cases of diphtheria were reported worldwide to the World Health Organization (WHO), but many more cases likely go unreported. […] The last reported case in Iowa occurred in 1967. It is estimated that more than 40% of US adults lack protective levels of circulating antitoxin.

• #79 JMIR Public Health and Surveillance – Epidemiology of Diphtheria in Yemen, 2017-2018: Surveillance Data Analysis

  https://publichealth.jmir.org/2021/6/e27590/

  Background: As a consequence of war and the collapse of the health system in Yemen, which prevented many people from accessing health facilities to obtain primary health care, vaccination coverage was affected, leading to a deadly diphtheria epidemic at the end of 2017. […] Objective: This study aimed to describe the epidemiology of diphtheria in Yemen and determine its incidence and case fatality rate. […] A total of 2243 cases were reported during the period between July 2017 and August 2018. […] The overall incidence of diphtheria was 8 per 100,000 population. […] The overall case fatality rate among all age groups was 5%, and it was higher (10%) in the age group 5 years. […] Five governorates that were difficult to access (Raymah, Abyan, Sa’ada, Lahj, and Al Jawf) had a very high case fatality rate (22%).

• #80 Nigeria Centre for Disease Control and Prevention

  https://ncdc.gov.ng/news/489/official-statement-following-the-first-reported-confirmed-case-of-diphtheria-in-fct-abuja

  The Nigeria Centre for Disease Control and Prevention (NCDC) is aware of the death in June 2023 of a four-year-old with diphtheria in the Federal Capital Territory (FCT), Abuja. The NCDC, since December 2022, has reported multiple diphtheria outbreaks in different states across the country. As of June 30th, 2023, there have been 798 confirmed diphtheria cases from 33 Local Government Areas (LGAs) in eight (8) States including the FCT. […] The majority (71.7%) of the 798 confirmed cases occurred among children aged 2 14 years. […] So far, a total of 80 deaths have been recorded among all confirmed cases (case fatality rate of 10.0%). […] Despite the availability of a safe and cost-effective vaccine in the country, the majority i.e., 654 (82%) of 798 confirmed diphtheria cases in this ongoing outbreak were unvaccinated.

• #81 Eleven-Year Report of High Number of Diphtheria Cases in Children in East Java Province, Indonesia

  https://www.mdpi.com/2414-6366/9/9/204

  A high incidence of diphtheria cases in children in East Java province, Indonesia, has been observed since the beginning of this century. […] This study aims to explain the high incidence of diphtheria in children in East Java province since 2013. […] Surveillance of vaccine-preventable diseases such as diphtheria is crucial as part of the government’s and society’s efforts to address the problem. […] This study shows that diphtheria cases in children and adolescents in East Java have consistently been high, and low immunization coverage might still be the leading cause. […] The eleven-year case fatality rate (CFR) was 2.36% (69/2921). […] The high number of diphtheria cases in East Java province has reemerged since 2005 in Madura Island, one of the areas with many outbreaks in recent years.

• #82 Diphtheria: Background, Pathophysiology, Epidemiology

  https://emedicine.medscape.com/article/1204017-overview

  According to the World Health Organization (WHO), diphtheria epidemics remain a health threat in developing nations. […] The largest epidemic recorded since widespread implementation of vaccine programs was in 1990-1995, when a diphtheria epidemic emerged in the Russian Federation, rapidly spreading to involve all Newly Independent States (NIS) and Baltic States. […] Overall rates of infection have decreased in Europe from 2000 to 2009, according to the Diphtheria Surveillance Network. This has been attributed to improved vaccination rates creating herd immunity. […] Many case reports in the literature describe epidemics in sub-Saharan Africa, France, India, and the United States. […] The most widely quoted diphtheria mortality rate is 5-10%. […] Mortality rates have not changed significantly over the past few decades. […] Historically, diphtheria has been primarily a disease of childhood, affecting populations younger than 12 years. […] Recently, however, diphtheria has shifted into the adolescent and adult population, most notably those in ages 40 and older accounting for most new cases.

• #83 Diphtheria: Background, Pathophysiology, Epidemiology

  https://emedicine.medscape.com/article/782051-overview

  Many case reports in the literature describe epidemics in sub-Saharan Africa, France, India, and the United States. […] Before the introduction of vaccine in the 1920s, the incidence of respiratory disease was 100-200 cases per 100,000 population in the United States and has decreased to approximately 0.001 cases per 100,000 population. […] The most widely quoted diphtheria mortality rate is 5-10%. It may reach higher than 20% in children younger than 5 years and adults older than 40 years. Mortality rates have not changed significantly over the past few decades. Most deaths occur on days 3-4 secondary to asphyxia with a pharyngeal membrane or due to myocarditis.

• #84 Chapter 1: Diphtheria | Manual for the Surveillance of Vaccine-Preventable Diseases | CDC

  https://www.cdc.gov/surv-manual/php/table-of-contents/chapter-1-diphtheria.html

  Given that cutaneous and other forms of nonrespiratory diphtheria can be transmitted and cause respiratory diphtheria, the US case definition was revised in 2019 to include disease caused by toxin-producing C. diphtheriae from any site, including cutaneous sites. […] Diphtheria remains endemic in countries with low routine immunization coverage. […] Among countries that have achieved high childhood vaccination coverage with diphtheria- and tetanus toxoids- and pertussis-containing vaccines (DTP/DTaP), overall incidence is low. […] Prompt recognition and reporting of respiratory diphtheria are important to ensure early, appropriate treatment with diphtheria antitoxin (DAT) and antibiotics. […] Surveillance, vaccination, prompt treatment of diphtheria patients, and investigation of close contacts help to halt the spread of diphtheria.

• #85 Chapter 1: Diphtheria | Manual for the Surveillance of Vaccine-Preventable Diseases | CDC

  https://www.cdc.gov/surv-manual/php/table-of-contents/chapter-1-diphtheria.html

  Given that cutaneous and other forms of nonrespiratory diphtheria can be transmitted and cause respiratory diphtheria, the US case definition was revised in 2019 to include disease caused by toxin-producing C. diphtheriae from any site, including cutaneous sites. […] Diphtheria remains endemic in countries with low routine immunization coverage. […] Among countries that have achieved high childhood vaccination coverage with diphtheria- and tetanus toxoids- and pertussis-containing vaccines (DTP/DTaP), overall incidence is low. […] Prompt recognition and reporting of respiratory diphtheria are important to ensure early, appropriate treatment with diphtheria antitoxin (DAT) and antibiotics. […] Surveillance, vaccination, prompt treatment of diphtheria patients, and investigation of close contacts help to halt the spread of diphtheria.

• #86 Chapter 1: Diphtheria | Manual for the Surveillance of Vaccine-Preventable Diseases | CDC

  https://www.cdc.gov/surv-manual/php/table-of-contents/chapter-1-diphtheria.html

  This chapter provides general guidance for vaccine-preventable disease surveillance, describing the disease background/epidemiology, case investigation and reporting/notification, disease case definitions, and activities for enhancing surveillance, case investigation, and outbreak control for diphtheria. […] Diphtheria is now rarely reported in the United States; however, in the pre-vaccine era, the disease was one of the most common and feared causes of illness and death among children. […] Prior to 2019, an upper respiratory infection caused by any C. diphtheriae, irrespective of toxigenicity, was reportable to CDC’s National Notifiable Diseases Surveillance System (NNDSS). […] Over the last decade, nonrespiratory (most commonly cutaneous) diphtheria has been increasingly detected in the United States and elsewhere.

• #87 Chapter 1: Diphtheria | Manual for the Surveillance of Vaccine-Preventable Diseases | CDC

  https://www.cdc.gov/surv-manual/php/table-of-contents/chapter-1-diphtheria.html

  Given that cutaneous and other forms of nonrespiratory diphtheria can be transmitted and cause respiratory diphtheria, the US case definition was revised in 2019 to include disease caused by toxin-producing C. diphtheriae from any site, including cutaneous sites. […] Diphtheria remains endemic in countries with low routine immunization coverage. […] Among countries that have achieved high childhood vaccination coverage with diphtheria- and tetanus toxoids- and pertussis-containing vaccines (DTP/DTaP), overall incidence is low. […] Prompt recognition and reporting of respiratory diphtheria are important to ensure early, appropriate treatment with diphtheria antitoxin (DAT) and antibiotics. […] Surveillance, vaccination, prompt treatment of diphtheria patients, and investigation of close contacts help to halt the spread of diphtheria.

• #88 Surveillance of diphtheria in the Netherlands between 2000–2021: cutaneous diphtheria supersedes the respiratory form | BMC Infectious Diseases | Full Text

  https://bmcinfectdis.biomedcentral.com/articles/10.1186/s12879-023-08388-5

  Diphtheria is a severe respiratory or cutaneous infectious disease, caused by exotoxin producing Corynebacterium diphtheriae, C. ulcerans and C. pseudotuberculosis. Diphtheria is once again prevalent due to breakdown of immunisation programmes, social disruption and unrest. […] This study describes the notified diphtheria cases in the Netherlands between 2000-2021 and isolates that were sent to the National Institute for Public Health and the Environment (RIVM). […] Eighteen diphtheria notifications were made with confirmed toxigenic C. diphtheriae (n=9) or ulcerans (n=9) between 2000 and 2021. Seventeen (94.4%) presented with a cutaneous infection. […] Both human-to-human transmission of C. diphtheriae and animal-to-human transmission of C. ulcerans rarely occurs in the Netherlands. Cases mainly present with a cutaneous infection. Travel-related cases remain a risk for transmission to populations with low vaccination coverage, highlighting the importance of immunization and diphtheria control measures.

• #89 Diphtheria – Annual Epidemiological Report for 2022

  https://www.ecdc.europa.eu/en/publications-data/diphtheria-annual-epidemiological-report-2022

  In 2022, 359 cases of diphtheria due to toxigenic Corynebacterium diphtheriae (n=318) or C. ulcerans (n=11) were reported to ECDC. […] Since the second half of 2022, an increase of diphtheria among migrants was reported in several EU/EEA countries, with peaking case numbers in September to December. […] The highest proportion of C. diphtheriae cases was among 15- to 44-year-old males. C. ulcerans cases were more common in adults aged 65 years and above. […] Among C. diphtheriae cases with importation status available, 62% were reported as imported (having been outside the country of notification during the incubation period with no links to local transmission), with 78% of the imported cases presenting with a cutaneous infection. […] Vaccination status was available for 39% of all cases. Seventy-five percent of the cases with known vaccination status were not vaccinated or were vaccinated with an unknown number of doses. […] Vaccination with the diphtheria toxoid vaccine is the only effective method of preventing the toxin-mediated disease. Achieving and sustaining high vaccination coverage in the population is critical for preventing toxigenic diphtheria from causing serious or fatal illness.

• #90 Diphtheria – Annual Epidemiological Report for 2022

  https://www.ecdc.europa.eu/en/publications-data/diphtheria-annual-epidemiological-report-2022

  In 2022, 359 cases of diphtheria due to toxigenic Corynebacterium diphtheriae (n=318) or C. ulcerans (n=11) were reported to ECDC. […] Since the second half of 2022, an increase of diphtheria among migrants was reported in several EU/EEA countries, with peaking case numbers in September to December. […] The highest proportion of C. diphtheriae cases was among 15- to 44-year-old males. C. ulcerans cases were more common in adults aged 65 years and above. […] Among C. diphtheriae cases with importation status available, 62% were reported as imported (having been outside the country of notification during the incubation period with no links to local transmission), with 78% of the imported cases presenting with a cutaneous infection. […] Vaccination status was available for 39% of all cases. Seventy-five percent of the cases with known vaccination status were not vaccinated or were vaccinated with an unknown number of doses. […] Vaccination with the diphtheria toxoid vaccine is the only effective method of preventing the toxin-mediated disease. Achieving and sustaining high vaccination coverage in the population is critical for preventing toxigenic diphtheria from causing serious or fatal illness.

• #91 Global Epidemiology Of Diphtheria In The 21st Century – MMGH Consulting

  https://www.mmglobalhealth.org/publications/global-epidemiology-of-diphtheria-in-the-21st-century/

  In 2017, a total of 8,819 cases of diphtheria were reported worldwide, the most since 2004. […] However, recent diphtheria epidemiology has not been well described. […] World Health Organisation surveillance data were 81% complete; completeness varied by region, indicating under-reporting. […] As national diphtheriatetanuspertussis (DTP) 3 coverage increased, the proportion of case-patients 15 years of age decreased, indicating increased protection of young children. […] In countries with higher case counts, 66% of case-patients were unvaccinated and 63% were 15 years of age, consistent with waning vaccine immunity. […] Global DTP3 coverage is suboptimal. […] Attaining high DTP3 coverage and implementing recommended booster doses are necessary to decrease diphtheria incidence. […] Collection and use of data on subnational and booster dose coverage, enhanced laboratory capacity, and case-based surveillance would improve data quality.

• #92 Chapter 1: Diphtheria | Manual for the Surveillance of Vaccine-Preventable Diseases | CDC

  https://www.cdc.gov/surv-manual/php/table-of-contents/chapter-1-diphtheria.html

  Given that cutaneous and other forms of nonrespiratory diphtheria can be transmitted and cause respiratory diphtheria, the US case definition was revised in 2019 to include disease caused by toxin-producing C. diphtheriae from any site, including cutaneous sites. […] Diphtheria remains endemic in countries with low routine immunization coverage. […] Among countries that have achieved high childhood vaccination coverage with diphtheria- and tetanus toxoids- and pertussis-containing vaccines (DTP/DTaP), overall incidence is low. […] Prompt recognition and reporting of respiratory diphtheria are important to ensure early, appropriate treatment with diphtheria antitoxin (DAT) and antibiotics. […] Surveillance, vaccination, prompt treatment of diphtheria patients, and investigation of close contacts help to halt the spread of diphtheria.

• #93 Chapter 1: Diphtheria | Manual for the Surveillance of Vaccine-Preventable Diseases | CDC

  https://www.cdc.gov/surv-manual/php/table-of-contents/chapter-1-diphtheria.html

  Given that cutaneous and other forms of nonrespiratory diphtheria can be transmitted and cause respiratory diphtheria, the US case definition was revised in 2019 to include disease caused by toxin-producing C. diphtheriae from any site, including cutaneous sites. […] Diphtheria remains endemic in countries with low routine immunization coverage. […] Among countries that have achieved high childhood vaccination coverage with diphtheria- and tetanus toxoids- and pertussis-containing vaccines (DTP/DTaP), overall incidence is low. […] Prompt recognition and reporting of respiratory diphtheria are important to ensure early, appropriate treatment with diphtheria antitoxin (DAT) and antibiotics. […] Surveillance, vaccination, prompt treatment of diphtheria patients, and investigation of close contacts help to halt the spread of diphtheria.

• #94 Global Epidemiology Of Diphtheria In The 21st Century – MMGH Consulting

  https://www.mmglobalhealth.org/publications/global-epidemiology-of-diphtheria-in-the-21st-century/

  In 2017, a total of 8,819 cases of diphtheria were reported worldwide, the most since 2004. […] However, recent diphtheria epidemiology has not been well described. […] World Health Organisation surveillance data were 81% complete; completeness varied by region, indicating under-reporting. […] As national diphtheriatetanuspertussis (DTP) 3 coverage increased, the proportion of case-patients 15 years of age decreased, indicating increased protection of young children. […] In countries with higher case counts, 66% of case-patients were unvaccinated and 63% were 15 years of age, consistent with waning vaccine immunity. […] Global DTP3 coverage is suboptimal. […] Attaining high DTP3 coverage and implementing recommended booster doses are necessary to decrease diphtheria incidence. […] Collection and use of data on subnational and booster dose coverage, enhanced laboratory capacity, and case-based surveillance would improve data quality.

• #95 Diphtheria Surveillance | SpringerLink

  https://link.springer.com/chapter/10.1007/978-94-007-7624-1_10

  Diphtheria is uncommon in developed countries but when cases do arise they are often severe with high mortality. This disease has demonstrated its potential to re-emerge to epidemic proportions in areas where it was previously thought to be under control. Ongoing monitoring and surveillance is therefore essential and in general follows the principles of surveillance utilised for most other vaccine preventable infections, but with some specific adaptations relevant to a disease that is close to elimination. Surveillance across countries and regions is complicated by a number of factors including the use of different case definitions and the variation in laboratory policy and expertise. International networks have been valuable in improving knowledge and skills in this area. […] Population coverage of approximately 85% is required for elimination, based on a basic reproductive number (R0; the average number of secondary cases produced by one primary case in a wholly susceptible population) of 67 (Fine 1993). […] The sero-epidemiology of diphtheria in Western Europe.

• #96 Nigeria Centre for Disease Control and Prevention

  https://ncdc.gov.ng/news/489/official-statement-following-the-first-reported-confirmed-case-of-diphtheria-in-fct-abuja

  Historical sub-optimal vaccination coverage is the main driver of the outbreak given the most affected age group (2-14-year-olds) observed, and a national survey of diphtheria immunity that found less than half (41.7%) of children under 15 years old are fully protected from diphtheria. […] In response to the outbreak in December 2022, NCDC activated a multi-sectoral national Diphtheria Emergency Operations Centre as a mechanism for coordinating surveillance and response activities across the country. […] The response activities include coordination, surveillance, laboratory investigation, risk communication, case management and immunisation activities. […] Development and dissemination of surveillance tools across the country case definition, case investigation form (CIF), line listing template, etc.

• #97 Nigeria Centre for Disease Control and Prevention

  https://ncdc.gov.ng/news/489/official-statement-following-the-first-reported-confirmed-case-of-diphtheria-in-fct-abuja

  Historical sub-optimal vaccination coverage is the main driver of the outbreak given the most affected age group (2-14-year-olds) observed, and a national survey of diphtheria immunity that found less than half (41.7%) of children under 15 years old are fully protected from diphtheria. […] In response to the outbreak in December 2022, NCDC activated a multi-sectoral national Diphtheria Emergency Operations Centre as a mechanism for coordinating surveillance and response activities across the country. […] The response activities include coordination, surveillance, laboratory investigation, risk communication, case management and immunisation activities. […] Development and dissemination of surveillance tools across the country case definition, case investigation form (CIF), line listing template, etc.

• #98

  https://journals.lww.com/ijph/fulltext/2021/65010/trend,_morbidity_profile_and_immunization_status.12.aspx

  Hospital-based surveillance and hospital records play a crucial role in identifying current diphtheria epidemiology. […] The present study revealed that 27.4% of the patients suffered from diphtheria despite being fully immunized, whereas 44.4% of affected patients were partially immunized. […] The present study clearly indicated that female diphtheria cases outnumbered males. […] Admission trend over the last 5 years also showed repeated sharp incline in number of female cases during 2016 and 2019, whereas admission among males did not show any sharp rise. […] The present study indicated that diphtheria was also prevalent among immunized adolescents and adults, in addition to partially immunized and nonimmunized individuals, probably due to waning of immunity with age. […] Proper implementation of VPD surveillance throughout the country will be helpful to combat diphtheria-related problems.

• #99

  https://pmc.ncbi.nlm.nih.gov/articles/PMC6759252/

  Although several comprehensive reviews were published after that outbreak peaked, only sporadic documentation of diphtheria outbreaks has been published since, and no examination of global epidemiologic trends has been published. During 2016-2019, diphtheria outbreaks were reported in multiple countries, including Bangladesh, Yemen, and Venezuela. Several outbreaks were among vulnerable populations or in areas of social disruption and conflict. […] The diphtheria data reported annually to WHO and UNICEF on the JRF have substantial limitations in terms of quality and reflect opportunities to improve disease surveillance. We found these data to be incomplete when cross-referenced with the literature, indicating a likely underestimate of incidence worldwide and a decreased understanding of the burden of disease. However, in some countries with lower laboratory capacity, only a small proportion of cases are laboratory confirmed, which could result in overreporting in some settings. The ability to use aggregate data for action is limited by the lack of key variables, including vaccination status, age, and subnational location. […] Implementation of case-based surveillance for diphtheria, combined with availability of subnational coverage data, would result in improved understanding of diphtheria epidemiology and enhanced capability to prevent and respond to outbreaks.

• #100 Global Epidemiology Of Diphtheria In The 21st Century – MMGH Consulting

  https://www.mmglobalhealth.org/publications/global-epidemiology-of-diphtheria-in-the-21st-century/

  In 2017, a total of 8,819 cases of diphtheria were reported worldwide, the most since 2004. […] However, recent diphtheria epidemiology has not been well described. […] World Health Organisation surveillance data were 81% complete; completeness varied by region, indicating under-reporting. […] As national diphtheriatetanuspertussis (DTP) 3 coverage increased, the proportion of case-patients 15 years of age decreased, indicating increased protection of young children. […] In countries with higher case counts, 66% of case-patients were unvaccinated and 63% were 15 years of age, consistent with waning vaccine immunity. […] Global DTP3 coverage is suboptimal. […] Attaining high DTP3 coverage and implementing recommended booster doses are necessary to decrease diphtheria incidence. […] Collection and use of data on subnational and booster dose coverage, enhanced laboratory capacity, and case-based surveillance would improve data quality.

• #101 Preventing the preventable through effective surveillance: the case of diphtheria in a rural district of Maharashtra, India | BMC Public Health | Full Text

  https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-13-317

  Epidemic diphtheria is still poorly understood and continues to challenge both developing and developed countries. […] Investigating each outbreak to understand the epidemiology of the disease and its current status in the country is therefore necessary. […] The outbreak raises several concerns regarding the epidemiology of diphtheria in Dhule. […] Given the persistence of multiple foci in all regions of the country there is indeed a heightened risk of re-emergence of the disease in epidemic forms. […] An improved understanding of the nature of each outbreak is therefore mandated to generate a pool of evidence regarding the current disease status in India. […] The outbreak confirms the upward trend in median age of diphtheria incidence observed in other states of India. […] Reasons for the shift only to adolescents despite consistent poor immunization coverage and a sufficient pool of susceptible adults – remain unclear. […] Monitoring disease trends, clinical progression, emerging strains and mutations, alongside drug resistance through robust and effective surveillance is the pragmatic way forward.

• #102

  https://journals.lww.com/ijph/fulltext/2021/65010/trend,_morbidity_profile_and_immunization_status.12.aspx

  Hospital-based surveillance and hospital records play a crucial role in identifying current diphtheria epidemiology. […] The present study revealed that 27.4% of the patients suffered from diphtheria despite being fully immunized, whereas 44.4% of affected patients were partially immunized. […] The present study clearly indicated that female diphtheria cases outnumbered males. […] Admission trend over the last 5 years also showed repeated sharp incline in number of female cases during 2016 and 2019, whereas admission among males did not show any sharp rise. […] The present study indicated that diphtheria was also prevalent among immunized adolescents and adults, in addition to partially immunized and nonimmunized individuals, probably due to waning of immunity with age. […] Proper implementation of VPD surveillance throughout the country will be helpful to combat diphtheria-related problems.

• #103 Diphtheria Outbreak in Africa: Strengthening Response Capacities – Africa CDC

  https://africacdc.org/news-item/diphtheria-outbreak-in-africa-strengthening-response-capacities/

  Africa is facing recurrent infectious disease outbreaks, with diphtheria re-emerging in four African Union Member States: Algeria, Guinea, Niger, and Nigeria. […] Over 65% of reported diphtheria cases in Africa have no vaccination history, and over 60% are under 15. […] All four (4) Member States are conducting emergency coordination meetings, risk communication, community engagement, mass vaccinations, case management, and surveillance activities. […] Africa CDC is also facilitating cross-border collaborations and strengthening surveillance and information exchange among Member States. […] Member States are urged to enhance surveillance of other vaccine-preventable diseases and promote vaccine access and uptake.

• #104 Preventing the preventable through effective surveillance: the case of diphtheria in a rural district of Maharashtra, India | BMC Public Health | Full Text

  https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-13-317

  Epidemic diphtheria is still poorly understood and continues to challenge both developing and developed countries. […] Investigating each outbreak to understand the epidemiology of the disease and its current status in the country is therefore necessary. […] The outbreak raises several concerns regarding the epidemiology of diphtheria in Dhule. […] Given the persistence of multiple foci in all regions of the country there is indeed a heightened risk of re-emergence of the disease in epidemic forms. […] An improved understanding of the nature of each outbreak is therefore mandated to generate a pool of evidence regarding the current disease status in India. […] The outbreak confirms the upward trend in median age of diphtheria incidence observed in other states of India. […] Reasons for the shift only to adolescents despite consistent poor immunization coverage and a sufficient pool of susceptible adults – remain unclear. […] Monitoring disease trends, clinical progression, emerging strains and mutations, alongside drug resistance through robust and effective surveillance is the pragmatic way forward.

• #105 Preventing the preventable through effective surveillance: the case of diphtheria in a rural district of Maharashtra, India | BMC Public Health | Full Text

  https://bmcpublichealth.biomedcentral.com/articles/10.1186/1471-2458-13-317

  Epidemic diphtheria is still poorly understood and continues to challenge both developing and developed countries. […] Investigating each outbreak to understand the epidemiology of the disease and its current status in the country is therefore necessary. […] The outbreak raises several concerns regarding the epidemiology of diphtheria in Dhule. […] Given the persistence of multiple foci in all regions of the country there is indeed a heightened risk of re-emergence of the disease in epidemic forms. […] An improved understanding of the nature of each outbreak is therefore mandated to generate a pool of evidence regarding the current disease status in India. […] The outbreak confirms the upward trend in median age of diphtheria incidence observed in other states of India. […] Reasons for the shift only to adolescents despite consistent poor immunization coverage and a sufficient pool of susceptible adults – remain unclear. […] Monitoring disease trends, clinical progression, emerging strains and mutations, alongside drug resistance through robust and effective surveillance is the pragmatic way forward.

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