Six-Year Surveillance of Diphtheria Outbreak in Indonesia

Abstract

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.

The Effect of Diphtheria AntiToxin (DAT) to Decrease Degrees of Diphtheria Severity

“…In the Husada (2017) study, in 2011-2016 outbreaks in East Java, the proportion of men suffering from diphtheria was 53.4%, a slight difference with women [20]. In the Bottiger study (1998), sex diphtheria immunity showed diphtheria immunity in men based on age were higher than female immunity (CI = 95%, p-value <0.005).…”

“…The theory of Nuzirwan Acang in the Internal Medicine Faculty textbook at the University of Indonesia (2006) states that the most common age for diphtheria is 2-10 years, rarely at the age of 6 months and the age of 15 years [19]. Results of the Husada study (2017), in diphtheria outbreaks that occurred in East Java, the largest age group infected with diphtheria was at the age of 15 years and under (69.4%) but the trend showed an increase in the proportion of adolescents and adults [20].…”

Impact of a three-dose diphtheria outbreak response immunization in East Java, Indonesia, 6 months after completion

“… 25 , 26 There are also several pockets with very low coverage for various reasons including religious objection, fear of side effects, and lack of understanding. 9 , 27 Most outbreaks in East Java occur in the northern and eastern regions. Most people living in those areas are members of the Madura tribe.…”

“…The percentage of culture positive clinical diphtheria in East Java has never been more than 10% since 2011. 9 Improvements in the quality and number of reference laboratories may succeed in closing the gap. Both mitis and gravis biotype cultures were found in this study.…”

“…The outbreaks continue despite clinical and community interventions implemented by the Ministry of Health. 9 , 10…”