BackgroundDiphtheria has been reported as an outbreak in some regions in Indonesia, most especially in East Java Province. Resistance to penicillin, erythromycin, and other antibiotics, single or multiple, has been reported in several studies. This study aims to evaluate the first-line antibiotic susceptibility pattern of toxigenic Corynebacterium diphtheriae isolates.MethodsThis descriptive observational study was performed from August to November 2018. C. diphtheriae isolates were collected from diphtheria patients and carriers in East Java from 2012 to 2017 and kept at the Balai Besar Laboratorium Kesehatan Daerah Surabaya or the Public Health Laboratory of Surabaya. Sample selection was done by random cluster sampling. The sensitivity test by E-test®of the five antibiotics (penicillin, oxacillin, erythromycin, azithromycin, and clarithromycin) was done to determine the minimum inhibitory concentration (MIC). The Clinical and Laboratory Standards Institute M45A (2015) Corynebacterium spp. for penicillin and erythromycin was used as standard.ResultsFrom 114 targeted isolates, 108 were viable and toxigenic. The E-test was performed on the viable isolates. The majority of the hosts were male (58.3%), with median (range) age of 6.5 (1–14) years. Half of the samples were from the 1 to 5-year-old age group. The isolates were acquired much more from patients (78.7%) than carriers (21.3%) and from pharyngeal swab (74.1%). Most of these isolates were from Madura Island (47.2%) and the northern and eastern parts of the province (horseshoe area). Mitis isolates were the major variant (76.9%). The susceptibility pattern of C. diphtheriae to erythromycin was better than that to penicillin. The E-test result for penicillin was 68.52% susceptible, 31.48% intermediate, and 0% resistant (MIC range, < 0.016 to 2 μg/L) and for erythromycin (MIC range, < 0.016 to > 256 μg/L) was 85.2% susceptible, 12% intermediate, and 2.8% resistant The MIC range for oxacillin was 1 to 96 μg/L, while for both azithromycin and clarithromycin were <  0.016 to > 256 μg/L.ConclusionThe susceptibility rate of C. diphtheriae to erythromycin is higher than that to penicillin. The regular update of antibiotic selection to the national guidelines is recommended. The MIC reference standard to azithromycin and clarithromycin is also needed.

BackgroundDiphtheria outbreak has become a major problem in Indonesia since 2011. East Java province in Java Island, with 35 millions population, is the most severely affected area contributing approximately 80% of the total cases in the country. The objective of this study is to present a 6-year (2011–2016) surveillance report of diphtheria outbreak in East Java IndonesiaMethodsThis study was based on surveillance data collected (actively and passively) at East Java Provincial Health Office from all districts since January 2011 until December 2016. The data came from the district and provincial hospitals, the health officers, the patients and families, and also the contacts. Microbiology cultures were performed at an international standard diphtheria laboratory in Surabaya.ResultsFor six years period since 2011, there were 3,353 cases reported from 35 among 38 districts (92.1%), with the peak at 2012 (955 cases). This number was the second rank in the world after India. The case fatality rate was 3.3% (110 patients). Male (1,790, 53.4%) slightly outnumbered female. Although most patients were below 15 years old (2,343, 69.4%), the trend showed the increasing proportion of adolescents and adults. The largest proportion was on below 10 years of age. Based on the immunization status, the percentage of unimmunized patients, partially immunized, and completely immunized by age were 39%, 49.3%, and 11.7%, respectively. The youngest and oldest age among those deceased were 11 month and 70 year old. Only 197 nasal and throat swab specimens were positive for toxigenic Corynebacterium diphtheriae. Among serotypes, mitis was the most followed by gravis. There was only one case of intermedius. Most of the belfanti serotypes were non toxigenic. Despite many efforts such as multiple outbreak response immunization (ORI) especially in 2011–2013 this outbreak could not be stopped.ConclusionFor six years (2011–2016) there have been a diphtheria outbreak in East Java Indonesia. The highest number of patient was recorded in 2012. Most of the patients affected were not completely immunized. Each year, the positivity rate of throat and nasal swab culture were low. Until today, many efforts in severely affected area could not stop the high incidence of diphtheria cases.Disclosures All authors: No reported disclosures.

Background: An increase in diphtheria cases has occurred in East Java Province since 2011. The resistance level to diphtheria is considered as the most important cause. Purpose: The study aims analyzed the immunity level immunity to diphtheria in adolescents aged 16-18 years old in Bangkalan and Kediri Districts. Methods: This study was a cross-sectional study, conducted on students in eleven grade of senior high schools (SMAN) from both districts. The inclusion criteria included being 16-18 years old and students in eleven grades of senior high schools in Bangkalan and Kediri. This study was approved by their parents/guardians. The exclusion criteria included immunocompromised students and those who have a history of diphtheria infection. The data were obtained from 204 samples, 89 samples in Bangkalan, and 115 samples in Kediri. The antidiphtheria antibodies examination was carried out by the Vero cell method. The antibodies levels were grouped according to WHO standard, consist of vulnerable, basic, full, and long-term. Further analysis was done with 2 tiers of immunity, consist of immune and vulnerable. Results: The immunization coverage for basic and booster diphtheria vaccine is better in Kediri than in Bangkalan. In contrast, levels of antibodies samples in Bangkalan District is better. The participants who were immune in Bangkalan were higher than those in Kediri (91% vs. 44.3%). Conclusion: The immunity adolescents of Bangkalan is higher than in adolescent Kediri District. The adolescents in Kediri have a greater risk to get infected by the disease

Background: Measles is a recurrent health problem in both advanced and developed countries. The World Health Organization (WHO) recommends anti-measles immunoglobulin M (Ig M) as the standard method of detecting the virus; however, many areas still present the inability to perform a serology test of anti-measles IgM. Therefore, a typical clinical feature is necessary to establish the diagnosis of measles. The objective of this study was to evaluate hyperpigmented rash and other clinical features as the diagnostic tools with respect to measles, especially in an outbreak setting. Methods: In this observational diagnostic study, the inclusion criteria were as follows: between 6 and 144 months of age, fever, maculopapular rash for 3 days or more, accompanied by a cough, or coryza, or conjunctivitis. Those with a prior history of measles vaccination (1-6 weeks) were excluded, in addition to those with histories of corticosteroid for 2 weeks or more and immunocompromised conditions. The samples were taken from Dr. Soetomo General Academic Hospital in Surabaya, Indonesia. We evaluated the sensitivity, specificity, the positive predictive value, and the negative predictive value of such clinical features. Hyperpigmented rash was validated using Kappa and Mc Nemar tests. Anti-measles Ig M was considered as the gold standard. Results: This study gathered 82 participants. The clinical manifestations of all subjects included fever, cough, coryza, conjunctivitis, Koplik spots, and maculopapular rash (which turns into hyperpigmented rash along the course of the illness). Most maculopapular rashes turn out to be hyperpigmented (89%). Sensitivity, specificity, positive predictive value, and negative predictive values of the combination of fever, maculopapular rash, and hyperpigmented rash were found to be at 90.7, 28.6, 93.2, and 22.2%, respectively. The Mc Nemar and Kappa tests showed p values of 0.774 and 0.119, respectively. Conclusion: The combination of fever, maculopapular rash, and hyperpigmented rash can be used as a screening tool regarding measles infection in an outbreak setting, which can then be confirmed by anti-measles Ig M. Cough, coryza, and Koplik's spot can be added to this combination, albeit with a slight reduction of sensitivity value.

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