Diphtheria levels in India are at a thirty year high. Does this point towards failings in India’s vaccination efforts against the disease?
Diphtheria is a potentially fatal infection of the respiratory tract, caused by the bacterium Corynebacterium diphtheriae. It is typically seen among children or those over the age of 25. However, India is seeing a trend of rising diphtheria cases among young adults.
The state-run Ronald Ross Institute of Tropical and Communicable Diseases in Hyderabad -, known to the locals as Fever Hospital – is reporting that increasing number of cases are being seen among young adults. Around half a dozen cases a day have been diagnosed within the hospital, which is the only hospital in Hyderabad that provides treatment for diphtheria.
Diphtheria is predominantly a disease of the airways, throat and mouth. As such it is easily spread through coughing and sneezing. An untreated individual can spread the disease for around a month, though antibiotics can remove the ability to spread the disease within 48 hours.
Diphtheria, while typically non-lethal, is thought to be fatal in around five to ten percent of cases. Fatalities are most common in children under five. The bacteria incubates within the person’s airways and throat, gradually producing a toxin that creates a thick, grey membrane. This membrane is one of the hallmark symptoms and is often used to diagnose the disease. However, it may go unnoticed by the patient
The toxin can eventually spread to other organs, potentially resulting in death. The typically affected organs include the heart and nerve system. The complications that result from this are derived from inflammation. Inflammation caused to muscles in the heart can potentially be lethal, or result in cardiac arrhythmias, inflammation to nervous tissue, especially in the throat can cause difficulty swallowing or breathing.
The disease is, however, vaccine-preventable. The diphtheria vaccine is covered under India’s Universal Immunisation Programme (UIP) with booster shots being provided at ages 16-24 months with additional shots provided between five and six years old.
It is recommended that booster shots are provided every ten years in order to maintain immunity. The World Health Organization (WHO) recommends follow-up shots between the ages of nine and fifteen. However, under the UIP, this is not provided. As such by the age of fifteen immunity levels in previously vaccinated individuals may have fallen to such an extent that they are again vulnerable to infection. This may in part explain India’s current situation with young adults becoming infected with diphtheria.
Shankar, superintendent of the Ronald Ross Institute, has blamed a lack of awareness of the availability of these booster shots. Education regarding the disease may be key to averting this, as many will be under the impression that, if their child has been vaccinated once, they are immune to the disease indefinitely.
For levels of diphtheria to hit a thirty year-high, despite the implementation of the UIP in 1985, clear issues must be present in the way in which diphtheria is being handled. By 2014, around 65 percent of children were said to have been vaccinated for the conditions covered under the scheme. While this is an improvement, it falls far short of the expected upwards of ninety percent expected to drastically reduce disease incidence.
This left 35 percent of India’s child population not immunised. Taking this into account – combined with the diminishing levels of immunity resulting from a lack of follow up booster shots throughout a child’s teenage years – it is understandable that diphtheria cases would rise in young adults.
One initiative began in December 2014, called Mission Indradhanush. The goal of Mission Indradhanush is full immunisation with all available vaccines for children up to two years of age and pregnant women. A second programme, known as Rashtriya Bal Swasthya Karyakram (RSBK), aims to put in place child health screening and early intervention services to compliment the vaccination drives.
However, in all these cases the drives target newborns or very young children. As a result a lack of emphasis has been placed on continuation of vaccination throughout childhood and into the teenage years. This has caused diseases like diphtheria, which require the follow up shots, to fall through gaps in the system.