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Indian Journal of Community Medicine

A Retrospective Study of Diphtheria Cases, Rajkot, Gujarat

Author(s): U.V. Patel1, B.H. Patel1, B.S. Bhavsar1, H.M. Dabhi1, S.K. Doshi2

Vol. 29, No. 4 (2004-10 - 2004-12)

Abstract

Objectives: (1) To study trend of Diphtheria morbidity and mortality (2) To study epidemiological characteristics of Diphtheria cases treated in a children hospital.

Study Design: Retrospective - analysis of hospital records.

Settings: A teaching hospital attached to Medical College, Rajkot, Gujarat.

Study variables: Morbidity trend (per 1000 admissions), mortality trend (CFR %), seasonal index, age, sex, and immunization status of affected children.

Statistical analysis: Proportions, X2 test and Z test.

Results: Retrospective analysis of hospital records revealed decline in diphtheria morbidity from 1985 to 1997 and an increase thereafter. Case fatality rate has reduced over time period and now it is around 20%. Cases were found more during August to October months. Children less than five years accounted for 61.9% of total cases. The overall male to female case ratio was 1.06:1. Mortality was significantly higher in under five year age group. 70 (65.42%) children had not received a single dose of DPT vaccine.

Introduction

Most of the vaccine preventable diseases showed a decline after inroduction of Expanded Programme of Immunization in 1978 and Universal Immunization Programme in 1985. The reported incidence of diphtheria in the country during 1987 was about 12,952 whereas during the year 1999, there were only 2,725 cases showing a decline of about 79%1. It is still endemic in our country2. The last decade has seen resurgence of diphtheria in both developed and developing countries where it was previously well controlled3. Resurgence of diphtheria cases was also noticed at a major tertiary care hospital of North India3.

Rajkot district, which is one of the 25 districts of Gujarat, is located centrally in Saurashtra region. Children hospital, which is one of the teaching hospitals attached to Medical College, Rajkot has a facility of 160 beds, one operation theatre and surgical ward, neo-natal ward with 30 beds, and isolation ward. The hospital bears a good reputation, which is reflected in its daily work load of 800 (new and old) patients in outdoor and 55 indoor admission. The indoor general mortality of this hospital, which was 11% in 1988, reduced to 6% in 1993 and remained constant at this level thereafter. This reflects the quality of medical care of hospital. This hospital caters to the medical needs of people of Rajkot and surrounding districts.

It was learnt that a good number of diphtheria cases are treated at this hospital. It was therefore, decided to analyze the recorded information and to bring out various, aspects of diphtheria cases treated in the hospital.

Material and Method

The present study on diphtheria is based on the restrospective analysis of the record of K.T. Children Hospital of Rajkot. It was intended to bring out the clinico-epidemiological profile of diphtheria cases admitted in the hospital from 1985 to December 2002, subject to the limitation of the availability of data. Cases from and around Rajkot District are referred to this hospital. Total number of indoor admissions sand deaths during the above period were also recorded. The diagnosis of diphtheria was made mainly on clinical findings, microbiological confirmation was available in only 12% of cases. Detail analysis was possible only in 126 cases that were admitted during the period from Oct. 1999 to Dec. 2002.

Results

Analysis of the record showed the following features of diphtheria cases treated in children hospital in Rajkot City.

Morbidity and Mortality

Annual hospital admissions, number of diphtheria cases admitted per 1000 admission and case fatality rate of diphtheria from the year 1985 to 2002 is shown in Table - I.

Diphtheria case rate, which was above 6 per 1000 admissions before 1989 reduced to less than 1 per 1000 admissions during 1993-97. However, 1989 and thereafter it increased from 2.8 in 1998 to 4.8 per 1,000 admissions in the year 2001. Case fatality rate of diphtheria varied from 0.0% (1994-95) to 42.9% (1993) and now it is 18.6% in the year 2002. (Table - I)

Table I: Hospital Admission, Diphtheria Cases and Deaths - Year Wise From 1985 to 2002

year Number of Admissions Diptheria Cases Deaths Due to Diptheria
Number of Cases per 1,000 admissions Number Case Fatality Rate (%)
1985 10,729 77 7.2 29 37.7
1986 9,052 104 11.5 31 29.8
1987 10,096 89 8.8 22 24.7
1988 10,211 61 6.0 23 37.7
1989 9,389 28 3.0 06 21.4
1990 8,954 17 2.0 05 29.4
1991 10,447 23 2.2 08 34.8
1992 11,173 15 1.3 04 26.7
1993 10917 07 0.6 03 42.9
1994 11,542 04 0.3 00 0.0
1995 10,192 02 0.2 00 0.0
1996 10,005 05 0.5 01 20.0
1997 10,221 05 0.5 02 40.0
1998 10,640 30 2.8 10 33.3
1999 10,675 27 2.5 05 18.5
2000 10,266 29 2.8 05 17.2
2001 11,308 54 4.8 16 29.6
2002 11,392 43 3.8 08 18.6

Seasonal Variation

There were 188 cases of diphtheria that were treated in the hospital during January 1997 and December 2002. Year and month wise occurrence of these cases per 1,000 admissions is shown in the Table -II, which also shows seasonal index calculated by simple average method. The maximum number of cases was treated in the month of August to October.

Table II : Month Wise Diphtheria Cases Per 1000 Admission From Year 1997 to 2002

Month Diptheria Cases per 1,000 Admissions Seasonal Indices*
1997 1998 1999 2000 2001 2002
January 1.58 6.3 1.45 1.42 1.40 7.63 89.27
February 0.0 1.55 9.76 0.00 0.00 0.00 57.47
March 0.0 1.12 5.71 2.13 2.39 3.52 82.75
April 0.0 1.07 2.4 2.6 0.00 3.04 50.95
May 0.0 0.86 1.11 1.35 1.38 0.00 25.28
June 0.0 0.00 2.46 0.00 1.31 1.27 25.28
July 0.0 0.00 3.01 2.36 2.84 1.78 63.30
August 1.9 2.14 4.9 5.24 9.54 5.79 216.85
September 1.09 7.57 0.00 5.14 10.78 6.31 216.85
October 0.0 2.19 0.00 8.09 8.10 9.16 185.05
November 0.0 4.21 0.00 2.13 5.86 2.14 95.78
December 1.38 8.19 0.00 0.00 4.83 2.68 89.27
Total 0.50 2.80 2.50 2.80 4.80 3.80 1200.0

* Seasonal Index = (Average no. of cases of any particular month/Average of average of all months) X 100

Age and Sex

A total of 126 cases of diphtheria were treated in the hospital duirng October 1999 and December 2002. Children less than five year accounted for 61.9%, while the children of school going age (above 5 years) formed 38.1%. Male children predominated in under five, while female children predominated above five years age groups. The overall male to female case ratio was 1.06 : 1 (Table - III). Per 1,000 admissions, diphtheria case rate was significantly higher for females (4.74) than that for males (2.81) (z = 9.19, p<0.01).

Out of 126 cases of diphtheria, outcome was known in 116 cases, of which 29 died giving a case fatality rate of 25%. Mortality was significantly higher in children under five years of age (31.50%) as compared to children above 5 years of age (13.95%, p<0.05) (Table - III)

Table III: Age and Sex Wise Distribution of Diptheria Cases*

Age Group  (Yrs.) Males Cases (%) Females Cases (%) Male/Female Case Ratio Total Cases (%) CFR (%)
0 <1 02 (03.07) 00 (00.00) NA 02 (01.59) 50.0
1 - 5 42 (64.61) 34 (55.73) 1.23:1 76 (60.31) 30.98
6 - 10 19 (29.23) 24 (39.34) 0.79:1 43 (34.13) 15.78
11 - 15 02 (03.07) 03 (04.91) 0.66:1 05 (03.97) 00.00
Total 65 (100.00) 61 (100.00) 1.06:1 126 (100.00) 25.00

* Data was recorded from October 1999 to December 2002

Out of 126 cases, 78 (61.9%) cases were from Rajkot district, while 48 (38.1%) cases came for medical care from six surrounding districts of Rajkot and one union territory Diu.

Immunization Status Out of 107 cases of diphtheria whose information on immunization status was available, 4 (3.73%) were fully immunized against diphtheria, 33 (30.84%) were partially immunized, while 70 (65.42%) children did not receive a single dose of DPT vaccine. Mortality was 21.42% among partially immunized and 28.12% among unimmunized. The difference in mortality, however, was not significant (p<0.05) Table- IV.

Table IV : Diphtheria Cases According to Sex and Immunization Status*

Immunization Status Males Females Male Female Case Ratio Total Cases (%) CFR (%)
Fully Immunized 02 03.63 02 03.84 1:1 04 03.73 00.00
Partially Immunized 14 25.45 19 36.53 0.73:1 33 30.84 21.42
Un-Immunized 39 70.90 31 59.61 1.25:1 70 65.42 28.12
Total 55 100.00 52 100.00 1.05:1 107 100.00 26.08

Discussion

Diphtheria morbidity and mortality continues to be high in several developing countries. It is still a public health problem in under developed countries including India. The true number of diphtheria cases and deaths are unknown because of incomplete/lack of reporting from the area where the disease occur2.

Study presents the retrospective analysis of diphtheria cases treated between January 1985 and December 2002 in children hospital attached to Government Medical College, Rajkot with detail information of 126 cases treated between Oct. 1999 and Dec. 2002. In the present study diphtheria was diagnosed mainly on clinical findings and microbiological confirmation was available in 12% of cases. Ray et al (1998) in their study in rural medical college hospital, near Kolkotta also observed the low microbiological confirmation rate and giving reasons for the same stated that clinical diagnosis of diphtheria should be given due consideration4.

It was observed that diphtheria cases declined from 1985 to 1997 and an increase was seen thereafter. Resurgence of diphtheria cases was also noticed at a major tertiary care hospital of North India3. It was observed that the maximum number of cases were treated in the month of August to October. Several studies4-10 carried out over last 30 years at different places in this country also reported that diphtheria occur more frequently during the month of August to November.

Approximately 60% of the cases treated between Oct. 1999 and Dec. 2002 were less than 5 years of age. Nearly 2/3 of attached children did not receive any dose of DPT vaccine and 30.84% of children could not complete their DPT immunization schedule. This probably indicates the unsatifactory immunization coverage with DPT vaccine in the area. NFHS (1998-99) showed DPT - 3 coverage in Gujarat among children of 12-23 months of age group to be 64.1%. As per UNICEF (2000) DPT-3 coverage among one year old children was 73% in India12. Inspite of high DPT coverage, no discernible impact on diphtheria incidence was observed in Rural Kolkota and some South Indian Districts4,13.

Official figures from Governmnet of India, indicating approximately 90% achievement of target with DPT-3 coverage from the year 1991-92 to 1997-98. But marked reduction of DT booster coverage was reported, i.e., 81-4% in the year 1990-91 to only 60.8% in the year 1997-9814. The drop could be attributed to lack of awareness, misconception, avoiding immunization for trivial reasons, migration, declining enthusiasm regarding routine immunization due to repetition of pulse polio immunization capaign. Also, though not documented, many families may accept pulse polio immunization as a substitute for routine immunization.

It was observed that 4 (3.73%) children who completed DPT vaccination schedule, developed diphtheria and both survived. This may be because duration of immunity after primary immunization is limited15. Moreover, disease in previously immunized children is milder and less likely to be fatal16-17. Overall male to female case ratio was 1.06 : 1. But for every 1000 hospital admissions diphtheria rate was significantly higher for female (4.74) compared to male children (2.81). This is in confirmation with the findings of other studies18,19. While Laha and Mishra (1956) reported that among diphtheria cases proporation was higher for male children than females5. No sex difference in diphtheria cases was observed in a study carried out in a rural medical college near Kolkota4. Case fatality rate was reduced from 37.7% (1985) to around 20% since last four years. Case fatality rate was significantly higher in children less than five years. This is in confirmation with the other studies18,19.

Conclusion

Diphtheria still remains confined to children under five years. Low or declining routine immunization coverage, as well as naturally waning of immunity against diphtheria are major factors for endemicity or even resurgence of diphtheria. This is a matter of concerned for all public health professionals. Recognize diphtheria suspects as early as possible and referring them timely to higher medical care facility may help reducing mortality. High and sustained vaccination coverage with DPT-3, its booster doses and preventon/ reduction of drop out rate are essential measures to keep diphtheria under control. At the same time it is also essential to establish a good surveillance system to detect possible outbreak of diphtheria as earlier as possible.

References

  1. Government of India, Annual Report 1999-2000. Ministry of Health
  2. Park K. Park's Text Book of Preventive and Social Medicine. 16th Edition, 2000; 125-128.
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  4. Ray SK, Gupta SD and Saha I. A report of Diphtheria surveillance from a rual Medical College, Hospital. Journal of Indian Medical Association 1998 ; 96 (8) : 236-238.
  5. Laha PN and Mishra PN. Diphtheria - a comparative study. Indian Pediatrics, 1956 ; 23 : 354.
  6. Bhargava HS and Bhatta AN. A study of 275 cases of Diphtheria. Journal of Indian Medical Association 1960 ; 35 : 243.
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  11. Health Monitor 1999. Foundation for Research in Health Systems. Immunization coverage 1998-99, 1999 ; 100-101.
  12. UNICEF 2000. The State of the world's Children. Percentage of fully immunized 1995-98, 2000;92-93.
  13. Havaldar PV. Diphtheria in the eighties. Experience in a south Indian District Hospital. Journal of Indian Medical Association, 1992;90:155-156.
  14. Government of India. Annual Report 1998-99. Ministry of Health and Family Welfare, New Delhi, 1999; 63-71.
  15. Galazka AM, Robertson SE. Immunization against Diphtheria with special emphasis on immunization of adults. Vaccine, 1996; 14: 845-857.
  16. Eskola J, Lumino J, Vuopia - Varkila J. Resurgence of Diphtheria are we safe? British Medical Bulletin, 1998; 54:635-645.
  17. Vitek CR, Brennan MB, Gotway CA, Bragia VY, Govorukina NV, Kravtsova ON, et al. Risk of Diphtheria among school children in Russian Federation in relation to time since last vaccination. Lancet, 1999; 353 : 355-358.
  18. Chakroborty AK, Das KB and Bose R, Trend of Diphtheria in Calcutta. Indian Journal of Public Health, 1986 : XXX (4) 187-192.
  19. Vasundhra MK and Shrinivasan BS. A retrospective study of Diphtheria cases. Indian Journal of Community Medicine, 1983; VIII (2): 9-12.

1. Department of Community Medicine,Government Medical College, Rajkot, Gujarat
2. Department of Paediatrics Government Medical College, Rajkot, Gujarat.

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