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• W2108583693 abstract "For several years, diphtheria was nearly forgotten in most European countries, as it had been eliminated following the implementation of the generalized vaccination of children. In this encouraging context the recent occurrence of a massive epidemic in the Newly Independent States (NIS) of the former Soviet Union was unexpected. How will that epidemic, which is actually not yet controlled, develop. Is it threatening for other European countries? Can these countries be considered to be sufficiently protected against a return of diphtheria? Such are the questions raised today about the immediate future of diphtheria in Europe. Over the last half-century, diphtheria dramatically declined in Europe. In the past, until World War II, during which an upsurge of morbidity was observed, this severe respiratory disease due to toxigenic Corynebacterium diphtheriae organisms was endemic in most countries, including European ones, affecting mainly children, particularly those of pre-school age [1Galazka AM Robertson S. Diphtheria: changing patterns in the developing world and the industrialized world.Eur J Epidemiol. 1995; 11: 107-117Crossref PubMed Scopus (135) Google Scholar]. At least 5% of people suffered on any given day from clinical diphtheria; among them, 5 to 10% died, while the rest of the population was naturally immunized by asymptomatic infection. The generalized vaccination of young children with diphtheria toxoid was implemented in industrialized countries in the late 1940s and during the 1950s. Subsequendy, endemic diphtheria progressively declined, and even disappeared during the 1970s and 1980s, in most European countries, as in other well-vaccinated industrialized countries. However, limited outbreaks occurred as happened in Sweden in 1984-86. While the circulation of toxigenic strains of C. diphtheriae seemed to be eliminated by the antitoxin vaccination, non-toxigenic strains were still circulating, causing sporadic cases of septicemia, endocarditis and arthritis, mainly in adults living in very poor socio-economic conditions [2Groupe dʼnétude sur les infections àC. diphtheriae. Situation de C. diphtheriae en France (1987-95).Bull Epidemiol Hebd (Paris). 1996; 17: 78-79Google Scholar]. Moreover, a dramatic change in the antitoxin immunity of the general population appeared, according to several serosurveys carried out in different industrialized countries. These surveys showed in adults a partial and progressive waning of the immune protection according to age, which could be explained by the absence of recommended vaccine boosters, and the lack of natural contacts with toxigenic C. diphtheriae, resulting in an increasing susceptibility of the adult population [1Galazka AM Robertson S. Diphtheria: changing patterns in the developing world and the industrialized world.Eur J Epidemiol. 1995; 11: 107-117Crossref PubMed Scopus (135) Google Scholar, 3Maple PA Efstratiou A George FC Adrens NJ Sesardic D. Diphtheria immunity in UK blood donors.Lancet. 1995; 345: 963-965Abstract PubMed Google Scholar, 4Vincent-Ballereau F Schrive I Fisch A et al.Immunité antidiphtérique de la population française adulte, dʼnaprés une enquête sérologique multicentrique.Bull Epidemiol Hebd (Paris). 1995; 15: 65-66Google Scholar]. Women were generally found to be even more susceptible than men, who were probably reimmunized by compulsory vaccination during military service. So, while most children were fully protected, provided that the majority of them were properly vaccinated, about 50% of the European adult population was not, and is presently partially or totally susceptible to diphtheria. In the Soviet Union, endemic diphtheria dramatically decreased following the general vaccination of children, but did not totally disappear, and was controlled at a low level in the 1970s [5Galazka AM Robertson S Oblapenko GP. Resurgence of diphtheria.Eur J Epidemiol. 1995; 11: 95-105Crossref PubMed Scopus (170) Google Scholar]. Then its incidence, which began to slightly increase in the 1980s, sharply rose after 1990, reaching 19,462 cases in 1993, and culminating in 1994 and 1995 with, respectively, 47,808 and 50,412 cases. Case-fatality rates ranged from 2-3% (Russia, Ukraine) to more than 20% (Georgia, Azerbaijan, Turkmenistan). Starting in Russia, mainly in Moscow and St Petersburg (where the attack rate exceeded 50 per 100,000 in 1993), the epidemic then spread to other states and to the Ukraine, Belarus and the Baltic Republics, Moldavia, the Caucasus and the Asiatic NIS. In 1995 the epidemic seemed to be stabilized in the European part of Russia, following the implementation of a strengthened control program, including vaccination, but was still increasing in the Ukraine and in some Asiatic Republics. This epidemic was first characterized by a shift in the age distribution of cases from children to adults: 60% to 80% of Russian or Ukrainian patients were >15 years old. On the other hand, children remain most affected in the Asiatic Republics. The biotype gravis was predominant. Several ribotypes were identified, but ribotypes 1 and 2 were more frequent in the European part of the former Soviet Union. The massive resurgence of diphtheria in that part of the world could be explained by [5Galazka AM Robertson S Oblapenko GP. Resurgence of diphtheria.Eur J Epidemiol. 1995; 11: 95-105Crossref PubMed Scopus (170) Google Scholar, 6Dittman S Roure C. Plan of action for the prevention and control of diphtheria in the European Region of WHO (1994-1995). World Health Organization, Copenhagen1994Google Scholar]: (a)A dramatic decrease of vaccine coverage in young children, which fell to around 50% or less in some urban areas of Russia and in the Ukraine; this fall was attributed to a loss of confidence in vaccines, which suffered from some negative propaganda in the media, to an excessive list of contraindications, and furthermore to irregular supplies of vaccine.(b)Gap in immunity among adults, due to the lack of boosters in school-age children and in adults. This was already known, from serosurveys carried out in Russia prior to the epidemic, showing a very low protection rate in adults (lower than 40% in individuals above 15 years of age in Moscow, 1984).(c)The disorganization of health services associated with the political upheaval, resulting in a shortage of resources for diagnosis and management of cases, prevention of secondary cases in contacts, and for control of the spread of the epidemic by vaccination.(d)Large movements of the civil population, facilitating the spread of infection throughout the NIS, as well as the high morbidity and mobility of military personnel. The emergence of some new virulent strains cannot be excluded. On the other hand, the vaccine potency was not implicated, as three doses have induced 82% of protective efficacy in Kiev, and 96% in Moscow. Several cases were imported from the NIS into some neighboring European countries (Finland, Poland, Germany, Bulgaria, Norway) by visitors or returning travelers. Two cases were observed in US citizens staying in or visiting Russia and the Ukraine. In Turkey the incidence rate markedly increased in 1993-94, and then fell to nearly zero. What about the risk of reintroducing diphtheria into well-vaccinated European populations? Regarding the growing circulation of people between eastern and western European countries, the importation, from the NIS as well as from any endemo-epidemic country in the world, of toxigenic strains of C. diphtheriae by a traveler or a visitor (either an asymptomatic carrier or a not-recognized patient) is possible - and has already occurred. However, in a population among which adults are now partially susceptible, what is the risk of occurrence of secondary cases and even of a local outbreak? Furthermore, what is the risk of reintroduction of diphtheria and of its epidemic spread? Until now, no secondary cases have been observed around the few imported cases in European countries. Another reassuring argument is that the health structures and resources of these countries are capable of rapidly controlling a threat of outbreak, in groups at risk or in the general population. In any case, European countries which formerly succeeded in eliminating diphtheria should draw lessons from and take advantage of the present alert, in improving their protection against the risk of reintroduction of respiratory diphtheria and strengthening control measures such as the following [6Dittman S Roure C. Plan of action for the prevention and control of diphtheria in the European Region of WHO (1994-1995). World Health Organization, Copenhagen1994Google Scholar, 7Popovic T Wharton M Wenger JD McIntyre C Wachsmuth IK. Are we ready for diphtheria? A report from the Diphtheria Diagnostic Workshop, Atlanta 11-12 July 1994.J Infect Dis. 1995; 17: 1765-1767Google Scholar]: (a)Surveillance, clinical and biological. If we consider that most practicing physicians and biologists have never seen a single case of clinical diphtheria and have never isolated the C. diphtheriae organism, education of the health profession seems to be necessary. The investigation and laboratory examination of sore throats, particularly membranous pharyngitis, should be developed again. In addition, all isolated strains of C. diphtheriae should be sent to a reference laboratory, national or regional, for evaluation of toxin production, and typing. Molecular typing, like ribotyping or pulse gel electrophoresis, is essential to identify the provenance of the strains and to follow their movements throughout the countries [4Vincent-Ballereau F Schrive I Fisch A et al.Immunité antidiphtérique de la population française adulte, dʼnaprés une enquête sérologique multicentrique.Bull Epidemiol Hebd (Paris). 1995; 15: 65-66Google Scholar, 6Dittman S Roure C. Plan of action for the prevention and control of diphtheria in the European Region of WHO (1994-1995). World Health Organization, Copenhagen1994Google Scholar].(a)To restore and maintain the immune protection of the adult population. In countries at higher risk, mass vaccination compaigns, particularly targeted on the adult population, could be considered, as carried out in Finland in 1993-94. In all countries routine immunization programs should be reinforced in adults. In order to attenuate the risk of clinical reaction after revaccination, a low dose of highly purified diphtheria toxoid should be used, combined with a full dose of tetanus toxoid (Td). Diphtheria vaccination or booster is already advised for travelers going to endemoepidemic countries, and could be recommended to some occupational groups at risk, including healthcare workers, teachers, and personnel working in contact with young children. A decennial booster of Td could be recommended for the general population, following the example of the USA; however, as the feasibility of this recommendation is questionable, it has been suggested to replace the use of monovalent tetanus toxoid by the general use of Td, whenever Td is indicated, e.g. for tetanus prevention in the wounded. However, the priority is obviously to rapidly end the current epidemic. It is not only a concern of the NIS, but also a regional, if not a global, concern. For their own safety, European countries are interested in helping the NIS to better control such epidemics. The WHO Regional Office for Europe (Copenhagen) played an important part [6Dittman S Roure C. Plan of action for the prevention and control of diphtheria in the European Region of WHO (1994-1995). World Health Organization, Copenhagen1994Google Scholar] in coordinating the international cooperation and planning control activities, such as: (a) the large-scale vaccination of all the population at risk, possibly by mass campaigns; (b) the proper management of diphtheria cases, including their prompt recognition and confirmation by laboratory examination, and their prompt treatment by antibiotics and serum; (c) the identification, chemoprophylaxis and surveillance of close contacts; and (d) the reinforcement of epidemiologic surveillance. Thanks are due to O. Patey (Hospital of Villeneuve St Georges) and P Vincent-Ballereau (School of Phar- macy, Nantes) for their invaluable collaboration." @default.
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• W2108583693 title "Resurgence of diphtheria in Europe" @default.
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