Study of Immunization Status and Outcome of Diphtheria Patients

Transcription

1 Indian Medical Gazette MARCH Original Study Study of Immunization Status and Outcome of Diphtheria Patients Himanshu Rana, Associate Professor, Dept. of Medicine, Shubhangi Deshpande, Assistant Professor, Dept. of Medicine, Chirag Rathod, Assistant Professor, Dept. of Medicine, Amul Patel, Assistant Professor, Dept. of Community Medicine, Viren Patel, Assistant Professor, Dept. of Pathology GMERS Medical College, Gotri, Vadodara. Asha Shah, Professor & H.O.D, Dept. of Medicine, B. J. Medical College, AHD. Vijai Jhala, Medical Superintendent, Dept. of Medicine, Infectious Disease HOS. Neha Tuli, Junior Resident, Jyoti Ahuja, A.H.A GMERS Medical College, Gotri, Vadodara. Abstract Background: With advent of EPI and UIP, most of the vaccine preventable diseases have shown a decline; however, Diphtheria continues to remain an endemic disease and has also shown resurgence nationally as well as internationally. Aims and Objectives: To study Diphtheria morbidity and mortality trends. To note variation with respect to age, sex, immunization status, seasonal variation and outcome. Materials and Method: A retrospective analysis of hospital records over the period of 3 years from Jan/2008 to Dec/2010 obtained with permission of hospital superintendent Dr. Jhala from infectious disease hospital in Ahmedabad, Gujarat. Details of 247 cases regarding age, sex, immunization status were taken as per the hospital case records. Results: Of 247 cases, 114 were male (46%), 133 (54%) Females, 71 (29%) were under 5 Years, 103 (42%) were in 6 12 years and 35 (14%) were in 13-20yrs, 38 patients (15%) were noted within 21-60yrs group, a total of 73 (29.5%) patients were observed in adult and adolescent group. Mortality was 0.47%. Incidence was more in months of September to March. In the present study, 85 (34.4%) were completely immunized, 31 (12.55%) were partially immunized and for 18 (7.3%) vaccination status was unknown. 113 (45.75%) were not immunized. Conclusion: Diphtheria continues to remain a major public health concern in spite of being a vaccine preventable disease, though common in pediatric age it is increasingly common in adoloscent and adults. High level Address for correspondence: Dr Himanshu M Rana, Associate Professor, Dept. of Medicine, GMERS Medical College, Gotri, Vadodara. drhimanshurana@yahoo.com

2 96 Indian Medical Gazette MARCH 2013 of clinical suspicion needed to keep the mortality rates on lower side. A strict implementation of vaccination programmes with follow up booster dose is necessary which will increase the herd immunity, leading to decrease in diphtheria prevalence. Introduction Corynebectrium diphtheria is responsible for both the endemic and epidemic diseases. The DToxoid introduced in 1920s helped in controlling the disease to a large extent; however, due to incomplete vaccinations it remained a endemic in India. Since last decade or so it has shown a resurgence causing epidemics nationally and internationally. (10, 11 study in north India). Infectious disease hospital gets direct and referred patients from in and around Ahmedabad. Complicated patients requiring multispecialty approach are transferred to tertiary center in the city. Significant number of diphtheria patients was being treated in this hospital hence it was decided to analyze the hospital records to notice the epidemiological trends, variation related to age, sex, seasonal variation, immunization status and the outcome. Aims and Objectives To study Diphtheria morbidity and mortality trends. To note variation with respect to age, sex, immunization status, seasonal variation and outcome. Materials and Metods A retrospective analysis of hospital records was used as the base for this present study. Record of reported cases of diphtheria over a period of 3 yrs was obtained with due permission from hospital superintendent Dr. Jhala.All the details regarding patient information was obtained from same. Patients were diagnosed clinically keeping a high level of suspicion and subjected to microbiological examination. Smear examination was done in 224 patients, 23 pts were diagnosed only clinically. Since culture isolation facility was not available, it was sent to tertiary care centre for same. Culture was done in 157 patients; Diphtheria could be isolated from 30 patients. Albert stain was used for the staining the slide. Tellu rite medium alongside McLeod agar was used at the laboratory for the culture isolation. Results Heterogeneous results were seen on analysis of the records as follows. Age and sex: A total of 247 cases were treated in the 3 year period. 174 patients were below 12yrs with 71 (29%) patients under 5 yrs. 73(29.55%) patients were from age group 13yrs and above compromising the adolescent and adult population. As seen from Tables 1 and 2, it is clear that prevalence is more in the female population with 133 of

3 Indian Medical Gazette MARCH Fig. 1 Year and month wise distribution of diphtheria cases 247 patients being females (53.9%) while 114 (46.1%) were males. Immunization rates were also less in the female group, 64 females pts( 48.12%) were unimmunized as compared to 49 males (42.9%).The male to female case ratio was 0.67%. Final Outcome: Of 247 patients, 156 (63.15%)were declared cured and 76 (30.76%) patients had to be transferred to higher tertiary centre for multispecialty care as was the hospital policy. Death was reported only in 1 case. Seasonal Variation: Month wise distribution is seen in the following table in each of the studied 3 yrs. Though cases were reported all throughout the year majority was seem from months of September to March with noticeable peak in February. Discussion Diphtheria morbidity and mortality continues to be high in several developing countries including India. Due to implementation of various vaccination programmes, Diphtheria initially declined, however, showed resurgence nationally and internationally after ,3,4. Diphtheria incidence is affected by DTP3 coverage and booster doses. The decline in reported diphtheria case in 1980 s is consistent with reported increase in DTP3 coverage 8. True incidence of the disease is difficult to know because of incomplete reporting 1. This study reflects the retrospective analysis of 247 reported cases of Diphtheria in infectious disease hospital in Ahmedabad. The patients were diagnosed clinically and microbiological confirmation was available in patients. Maximum numbers of cases were seen in months of August to October in various other studies 2, 4, 5, in this study maximum numbers were seen from months of September to March. Historically diphtheria has been primarily a childhood disease, affecting populations younger than 12yrs of age.

4 98 Indian Medical Gazette MARCH (12.55%) partially immunized, 113(45.75%) unimmunized and immunization status of 18(7.29%)patients was not known. This indicates unsatisfactory immunization coverage with DPT vaccine in the area. In this study also maximum number of cases (174) was below 12yrs, but 73 patients (29.55%) were from adolescent-adult age group (13-60 and above). Incomplete immunization or not receiving a booster dose of DT vaccine is an important reason behind increasing incidence of diphtheria in this age group. According to immunologic studies, one must have an antitoxin levels of greater than 0.1IU/ml for adequate immunity 6. Additionally, adolescent and adults may exhibit atypical presentation of disease thus potentially obscuring diagnosis. Internationally immunization schedules have changed recently requiring a toxoid booster at 11-12yrs and every 10yrs thereafter 6,7. In the present study 85(34.45%)patients were fully immunized, The incidence in females 133(54%) and males was 114(46%).The females showed more incidence which is in confirmation with findings of other studies. However, one study from Kolkata showed equal incidences in males and female patients. In the present study, sex did not have any effect on the outcome of the disease. More number of female patients could be due to less percentage of immunization in females as compared to males. The most widely quoted diphtheria mortality rate is 5-10%and may reach higher than 20% in children younger than 5yrs. In present study; low mortality rate has been seen. The high clinical suspicion to early treatment in patients probably leading to low mortality rates. Conclusion Though a vaccine preventable disease, Diphtheria is still a matter of concern for the public health. It is common in children; however, its prevalence in adolescent and adults

5 Indian Medical Gazette MARCH is not insignificant, suggesting -need for high level of suspicion in treating this age group. Insistence on completing the immunization schedule beyond the basic vaccine doses which includes the booster doses is needed to create good herd immunity. Promotion of a booster every 10yrs after 11yrs of age along with that of tetanus is needed for the same reason. Public awareness regarding the need for regular booster needs to be created. Early recognition with high levels of suspicion and timely referrals will help in keeping the mortality rates on lower sides. Acknowledgement We are very much thankful to INDIAN MEDICAL GAZETTE for giving us an opportunity to submit our article. A special word of thanks to N.I.H.D, Infectious Disease Hospital, Jamalpur, Ahmedabd, especially Medical Superintendent Vijai Jhala whose immense help has been beyond words, he has been there to help us throughout following all official formalities. We are grateful to Dr. Asha N Shah, Professor & Head of Dept. of Medicine, B.J.Medical College, Ahmedabad whose guidance has helped us a lot and been our inspiration. A word of thanks to all the supportive staff members and last but not the list the patients without whom this study would not have gone beyond imagination.

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