Journal of Clinical and Diagnostic Research. 2023 Feb, Vol-17(2): SC17-SC20 17 17 DOI: 10.7860/JCDR/2023/59627.17548 Original Article Paediatrics Section Diphtheria Remains a Threat to the Health System Even in the Era of Vaccination: A Cross-sectional Observational Study from Karnataka, India LAXMI KAMATH 1 , L RAMITHA 2 , VINOD RATAGERI 3 INTRODUCTION Diphtheria is an upper respiratory tract infection involving anterior nasal, pharyngeal, tonsillar or laryngeal mucous membranes. The organisms are locally invasive and secrete soluble exotoxins, which can lead to fatal consequences mainly involving the heart muscle and nervous system. The mortality rate, which is generally 5-10%, may be as high as 20% in children below 5 years and adults over 40 years of age [1]. Incidence of the disease, which was more than a million per year during the first half of the 19 th century declined by over 95% during the past three decades due to widespread immunisation [2]. However, after this sharp decline in cases, there seems to be a plateau in the world incidence of the disease with India contributing as much as 78% of all cases between 2000-2017 [2,3]. Due to the vaccine-preventable nature of the disease and initial steady decline, not much attention has been given towards this disease which has not only continued over the past decade in India but has also been sixth in the list with highest mortality rate in India. Current statistics show that diphtheria has been re-emerging [3,4]. This re-emergence is despite a reported increase in coverage of the National Immunisation Programme (NIP). The recent national health profile reports about 11270 cases of diphtheria in India with a mortality rate of 2% [3]. Certainly, this information is a compilation of the data which is mostly limited to reports obtained from routine surveillance systems functioning in respective states and union territories in the country. Detailed literature on occurrence of diphtheria as cases or outbreaks has been very scanty. Literature that is available includes those cases and outbreaks in Vijayapura district of Karnataka and also mostly in northern India and also in Mumbai [5-7]. The present health statistics and data from the few studies that have been carried out suggest that the war with this disease is still going on and is far from being over in spite of the vaccine that’s freely available. At a global level there has been outbreaks of diphtheria in Rohingya refugees [8,9]. There have been recent outbreaks of this vaccine preventable disease in Venezuela, due to the tumbling economy and authoritarian rule prevailing in the country leading to a massive gap in immunisation coverage [10]. Similar outbreak has been noticed in Yemen with the ongoing civil war since March 2015, which has severely affected the country’s infrastructure including health services. Less than 50% of existing health facilities is fully functional and there is a serious shortage of staff, medicine and equipment, this in turn, has led to outbreaks of vaccine preventable diseases and arthropod borne diseases [11]. This research was taken up to study the clinical profile, vaccination status and predictors of mortality in the era of intensified routine immunisation in Hubballi, Dharwad district of Karnataka, India. Keywords: Arrhthymias, Immunisation, Partially immunised, Upper respiratory tract ABSTRACT Introduction: Diphtheria is an infectious disease caused by a gram-positive facultatively anaerobic bacilli, Corynebacterium (C.) diphtheriae. The present health statistics and data from the few studies that have been carried out suggest that our war with this disease is still going on and is far from being over in spite of the vaccine that’s freely available. Aim: To study clinical profile, complications, and outcome of diphtheria in karnataka population and to correlate with immunisation status. Materials and Methods: This was a hospital-based prospective cross-sectional observational study done in the Department of Paediatrics, Karnataka Institute of Medical Sciences, Hubballi, Karnataka, India, from January 2018 to November 2018. Patients admitted with history suggestive of diphtheria were enrolled and categorised into probable and confirmed cases. The age, sex, area of residence, religion, immunisation status, mean time of presentation to hospital from onset of illness, use of inotropes and mechanical ventilation were recorded in a predesigned proforma. Throat swab smear for C.diphtheria and culture, complete blood count, Renal Function Tests (RFT) with serum electrolytes, chest radiograph, Electrocardiogram (ECG) and 2-Dimensional (2D) Echocardiogram (ECHO) were also recorded. Results: Out of total 28 cases, 18 fulfilled the inclusion criteria. Male to female ratio was 2:1 and the mean age of presentation was 9.7 years. Highest incidence (n=14, 77.8%) was seen in the age group of 09-11 years. Most common clinical presentation was fever and sore-throat present in all 18 (100%), neck swelling in 13 (72.2%), dysphagia in 05 (27.7%). Examination revealed tonsillar hypertrophy and pseudomembrane in 17 (94.4%) patients, whereas one patient had laryngeal diphtheria, which was diagnosed when swab was sent while intubating in view of membranous laryngitis. Mean time of presentation to hospital after the onset of symptoms was 5.65 days. All children received appropriate antibiotics and Antidiphtheritic Serum (ADS). Total of seven patients were ventilated, of which 5 (27.7%) succumbed, and two were extubated. Four (22.2%) patients developed myocarditis in the second week, and all succumbed to resistant arrhythmias. One patient developed sepsis with ventilator dependency, and succumbed to inotrope resistant septic shock. On follow-up, 5 (27.7%) developed palatal palsy among which three had associated polyneuropathy; all these children recovered with only supportive care. Conclusion: Diphtheria is down but not out, the present study unmasks the fact that the disease is equally prevalent in immunised and older children with the changing epidemiology of diphtheria in the era of vaccines.