Diphtheria

Source: Wikipedia, the free encyclopedia.
"Diphthera" redirects here. For the genus of moth, see Diphthera (moth).

Diphtheria
tracheostomy[2]
Prognosis5–10% risk of death
Frequency4,500 (reported 2015)[3]
Deaths2,100 (2015)[4]

Diphtheria is an

abnormal heart rate), inflammation of nerves (which can result in paralysis), kidney problems, and bleeding problems due to low levels of platelets.[2]

Diphtheria is usually spread between people by direct contact,

through the air, or through contact with contaminated objects.[2][5] Asymptomatic transmission and chronic infection are also possible.[2] Different strains of C. diphtheriae are the main cause in the variability of lethality,[2] as the lethality and symptoms themselves are caused by the exotoxin produced by the bacteria.[1] Diagnosis can often be made based on the appearance of the throat with confirmation by microbiological culture.[1] Previous infection may not protect against reinfection.[1]

A

antibiotics erythromycin or benzylpenicillin.[2]In severe cases a tracheotomy is sometimes needed to open the airway.[1]

In 2015, 4,500 cases were officially reported worldwide, down from nearly 100,000 in 1980.

developed world due to widespread vaccination, but can re-emerge if vaccination rates decrease.[1][8] In the United States, 57 cases were reported between 1980 and 2004.[2] Death occurs in 5–10% of those diagnosed.[2] The disease was first described in the 5th century BC by Hippocrates.[2] The bacterium was identified in 1882 by Edwin Klebs.[2]

Signs and symptoms

Diphtheria can cause a swollen neck, sometimes referred to as a bull neck.[2]
A diphtheria skin lesion on the leg

The symptoms of diphtheria usually begin two to seven days after infection. They include fever of 38 °C (100.4 °F) or above; chills;

cranial and peripheral nerve palsies.[12]

Diphtheritic croup

Laryngeal diphtheria can lead to a characteristic swollen neck and throat, or "bull neck." The swollen throat is often accompanied by a serious respiratory condition, characterized by a brassy or "barking" cough,

diphtheria vaccination is customary. As a result, the term "croup" nowadays most often refers to an unrelated viral illness that produces similar but milder respiratory symptoms.[17]

Transmission

Human-to-human transmission of diphtheria typically occurs through the air when an infected individual coughs or sneezes. Breathing in particles released from the infected individual leads to infection.[18] Contact with any lesions on the skin can also lead to transmission of diphtheria, but this is uncommon.[19] Indirect infections can occur, as well. If an infected individual touches a surface or object, the bacteria can be left behind and remain viable. Also, some evidence indicates diphtheria has the potential to be zoonotic, but this has yet to be confirmed. Corynebacterium ulcerans has been found in some animals, which would suggest zoonotic potential.[20]

Mechanism

Diphtheria toxin (DT) is produced only by C. diphtheriae infected with a certain type of bacteriophage.[21][22] Toxinogenicity is determined by phage conversion (also called lysogenic conversion); i.e., the ability of the bacterium to make DT changes as a consequence of infection by a particular phage. DT is encoded by the tox gene. Strains of corynephage are either tox+ (e.g., corynephage β) or tox− (e.g., corynephage γ). The tox gene becomes integrated into the bacterial genome.[23] The chromosome of C. diphtheriae has two different but functionally equivalent bacterial attachment sites (attB) for integration of β prophage into the chromosome.

The diphtheria toxin precursor is a

disulfide bond.[23] DT-B is a recognition subunit that gains entry of DT into the host cell by binding to the EGF-like domain of heparin-binding EGF-like growth factor on the cell surface. This signals the cell to internalize the toxin within an endosome via receptor-mediated endocytosis. Inside the endosome, DT is split by a trypsin-like protease into DT-A and DT-B. The acidity of the endosome causes DT-B to create pores in the endosome membrane, thereby catalysing the release of DT-A into the cytoplasm.[23]

Fragment A inhibits the synthesis of new proteins in the affected cell by catalyzing

tRNA from the A-site to the P-site of the ribosome during protein translation, ADP-ribosylation of EF-2 prevents protein synthesis.[24]

ADP-ribosylation of EF-2 is reversed by giving high doses of nicotinamide (a form of vitamin B3), since this is one of the reaction's end products, and high amounts drive the reaction in the opposite direction.[25]

Diagnosis

The current clinical case definition of diphtheria used by the United States' Centers for Disease Control and Prevention is based on both laboratory and clinical criteria.

Laboratory criteria

  • Isolation of C. diphtheriae from a Gram stain or throat culture from a clinical specimen.[10]
  • Histopathologic diagnosis of diphtheria by Albert's stain.

Toxin demonstration

  • In vivo tests (guinea pig inoculation): Subcutaneous and intracutaneous tests.[citation needed]
  • In vitro test: Elek's gel precipitation test, detection of tox gene by PCR, ELISA, ICA.

Clinical criteria

  • Upper respiratory tract illness with sore throat.
  • Low-grade fever (above 39 °C (102 °F) is rare).
  • An adherent, dense, grey pseudomembrane covering the posterior aspect of the pharynx; in severe cases, it can extend to cover the entire tracheobronchial tree.

Case classification

  • Probable: a clinically compatible case that is not laboratory-confirmed, and is not epidemiologically linked to a laboratory-confirmed case.
  • Confirmed: a clinically compatible case that is either laboratory-confirmed or epidemiologically linked to a laboratory-confirmed case.

Empirical treatment should generally be started in a patient in whom suspicion of diphtheria is high.

Prevention

Main article: Diphtheria vaccine

Vaccination against diphtheria is commonly done in infants, and delivered as a combination vaccine, such as a

developing countries by organizations such as UNICEF.[26]

Treatment

The disease may remain manageable, but in more severe cases,

antibodies isolated from the serum of horses that have been challenged with diphtheria toxin).[27] Since antitoxin does not neutralize toxin that is already bound to tissues, delaying its administration increases risk of death. Therefore, the decision to administer diphtheria antitoxin is based on clinical diagnosis, and should not await laboratory confirmation.[28]

Antibiotics have not been demonstrated to effect healing of local infection in diphtheria patients treated with antitoxin. Antibiotics are used in patients or carriers to eradicate C. diphtheriae, and prevent its transmission to others. The Centers for Disease Control and Prevention (CDC) recommends[29] either:

In cases that progress beyond a throat infection, diphtheria toxin spreads through the blood, and can lead to potentially life-threatening complications that affect other organs, such as the heart and kidneys. Damage to the heart caused by the toxin affects the heart's ability to pump blood, or the kidneys' ability to clear wastes. It can also cause nerve damage, eventually leading to paralysis. About 40–50% of those left untreated can die.[citation needed][30]

Epidemiology

Disability-adjusted life year for diphtheria per 100,000 inhabitants in 2004:
  no data
  ≤ 1
  1–2
  2–3
  3–4
  4–5
  5–6
  6–7
  7–9
  9–10
  10–15
  15–50
  ≥ 50
Diphtheria cases reported to the World Health Organization between 1997 and 2006:
  no data
  1–49 reported cases
  Between 50–99 reported cases
  Over 100 reported cases

Diphtheria is fatal in 5–10% of cases. In children under five years and adults over 40 years, the fatality rate may be as much as 20%.[28] In 2013, it resulted in 3,300 deaths, down from 8,000 deaths in 1990.[7] Better standards of living, mass immunization, improved diagnosis, prompt treatment, and more effective health care have led to a decrease in cases worldwide.[31]

History

In 1613, Spain experienced an epidemic of diphtheria, referred to as El Año de los Garrotillos (The Year of Strangulations).[31]

In 1705, the Mariana Islands experienced an epidemic of diphtheria and typhus simultaneously, reducing the population to about 5,000 people.[32]

In 1735, a diphtheria epidemic swept through New England.[33]

Before 1826, diphtheria was known by different names across the world. In England, it was known as "Boulogne sore throat," as the illness had spread from France. In 1826, Pierre Bretonneau gave the disease the name diphthérite (from Greek διφθέρα, diphthera 'leather'), describing the appearance of pseudomembrane in the throat.[34][35]

In 1856,

California.[36]

In 1878, Princess Alice (Queen Victoria's second daughter) and her family became infected with diphtheria; Princess Alice and her four-year-old daughter, Princess Marie, both died.[37][self-published source]

In 1883, Edwin Klebs identified the bacterium causing diphtheria,[38] and named it Klebs–Loeffler bacterium. The club shape of this bacterium helped Edwin to differentiate it from other bacteria. Over time, it has been called Microsporon diphtheriticum, Bacillus diphtheriae, and Mycobacterium diphtheriae. Current nomenclature is Corynebacterium diphtheriae.[39]

In 1884, German bacteriologist Friedrich Loeffler became the first person to cultivate C. diphtheriae.[40] He used Koch's postulates to prove association between C. diphtheriae and diphtheria. He also showed that the bacillus produces an exotoxin.[citation needed]

A diphtheria immunisation scheme in London (1941)

In 1885, Joseph P. O'Dwyer introduced the O'Dwyer tube for laryngeal intubation in patients with an obstructed larynx. It soon replaced tracheostomy as the emergency diphtheric intubation method.[41]

In 1888,

Emile Roux and Alexandre Yersin showed that a substance produced by C. diphtheriae caused symptoms of diphtheria in animals.[42][43]

In 1890, Shibasaburō Kitasato and Emil von Behring immunized guinea pigs with heat-treated diphtheria toxin.[44] They also immunized goats and horses in the same way, and showed that an "antitoxin" made from serum of immunized animals could cure the disease in non-immunized animals. Behring used this antitoxin (now known to consist of antibodies that neutralize the toxin produced by C. diphtheriae) for human trials in 1891, but they were unsuccessful. Successful treatment of human patients with horse-derived antitoxin began in 1894, after production and quantification of antitoxin had been optimized.[45][27] In 1901, Von Behring won the first Nobel Prize in medicine for his work on diphtheria.[46]

In 1895, H. K. Mulford Company of Philadelphia started production and testing of diphtheria antitoxin in the United States.[47] Park and Biggs described the method for producing serum from horses for use in diphtheria treatment.[citation needed]

In 1897, Paul Ehrlich developed a standardized unit of measure for diphtheria antitoxin. This was the first ever standardization of a biological product, and played an important role in future developmental work on sera and vaccines.[48]

In 1901, 10 of 11 inoculated St. Louis children died from contaminated diphtheria antitoxin. The horse from which the antitoxin was derived died of tetanus. This incident, coupled with a tetanus outbreak in Camden, New Jersey,[49] played an important part in initiating federal regulation of biologic products.[50]

On 7 January 1904,

Frances Folsom.[citation needed
]

In 1905, Franklin Royer, from Philadelphia's Municipal Hospital, published a paper urging timely treatment for diphtheria and adequate doses of antitoxin.

Clemens Pirquet and Béla Schick described serum sickness in children receiving large quantities of horse-derived antitoxin.[52]

Between 1910 and 1911, Béla Schick developed the

Metropolitan Life Insurance Company, with an appeal to parents to "Save your child from diphtheria." A vaccine was developed in the next decade, and deaths began declining significantly in 1924.[53]

A poster from the United Kingdom advertising diphtheria immunization (published prior to 1962)

In 1919, in

Mulford Company of Philadelphia, paid damages in every case.[54]

During the 1920s, an annual estimate of 100,000 to 200,000 diphtheria cases and 13,000 to 15,000 deaths occurred in the United States.[28] Children represented a large majority of these cases and fatalities. One of the most infamous outbreaks of diphtheria occurred in 1925, in Nome, Alaska; the "Great Race of Mercy" to deliver diphtheria antitoxin is now celebrated by the Iditarod Trail Sled Dog Race.[55]

In 1926, Alexander Thomas Glenny increased the effectiveness of diphtheria toxoid (a modified version of the toxin used for vaccination) by treating it with aluminum salts.[56] Vaccination with toxoid was not widely used until the early 1930s.[57] In 1939, Dr. Nora Wattie, who was the Principal Medical Officer (Maternity and Child Welfare) of Glasgow between 1934– 1964,[58] introduced immunisation clinics across Glasgow, and promoted mother and child health education, resulting in virtual eradication of the infection in the city.[59]

Widespread vaccination pushed cases in the United States down from 4.4 per 100,000 inhabitants in 1932 to 2.0 in 1937. In Nazi Germany, where authorities preferred treatment and isolation over vaccination (until about 1939–1941), cases rose over the same period from 6.1 to 9.6 per 100,000 inhabitants.[60]

Between June 1942 and February 1943, 714 cases of diphtheria were recorded at Sham Shui Po Barracks, resulting in 112 deaths because the Imperial Japanese Army did not release supplies of anti-diphtheria serum.[61]

In 1943, diphtheria outbreaks accompanied war and disruption in

Europe. The 1 million cases in Europe resulted in 50,000 deaths.[citation needed
]

During 1948 in Kyoto, 68 of 606 children died after diphtheria immunization due to improper manufacture of aluminum phosphate toxoid.[62]

In 1974, the

Expanded Programme on Immunization for developing countries.[63][64]

In 1975, an outbreak of cutaneous diphtheria in Seattle, Washington, was reported.[65]

After the breakup of the former Soviet Union in 1991, vaccination rates in its constituent countries fell so low that an explosion of diphtheria cases occurred. In 1991, 2,000 cases of diphtheria occurred in the USSR. Between 1991 and 1998, as many as 200,000 cases were reported in the Commonwealth of Independent States, and resulted in 5,000 deaths.[31] In 1994, the Russian Federation had 39,703 diphtheria cases. By contrast, in 1990, only 1,211 cases were reported.[66]

In early May 2010, a case of diphtheria was diagnosed in Port-au-Prince, Haiti, after the devastating 2010 Haiti earthquake. The 15-year-old male patient died while workers searched for antitoxin.[67]

In 2013, three children died of diphtheria in

Hyderabad, India.[68]

In early June 2015, a case of diphtheria was diagnosed at

opposition to vaccination.[69] It was the first case of diphtheria in the country since 1986, as reported by the Spanish daily newspaper El Mundo,[70] or from 1998, as reported by the WHO.[71]

In March 2016, a three-year-old girl died of diphtheria in the University Hospital of Antwerp, Belgium.[72]

In June 2016, a three-year-old, five-year-old, and seven-year-old girl died of diphtheria in Kedah, Malacca, and Sabah, Malaysia.[73]

In January 2017, more than 300 cases were recorded in Venezuela.[74][75]

In 2017, outbreaks occurred in a

Yemeni Civil War.[76]

In November and December 2017, an outbreak of diphtheria occurred in Indonesia, with more than 600 cases found and 38 fatalities.[77]

In November 2019, two cases of diphtheria occurred in the Lothian area of Scotland.[78] Additionally, in November 2019, an unvaccinated 8-year-old boy died of diphtheria in Athens, Greece.[79]

In July 2022, two cases of diphtheria occurred in northern New South Wales, Australia.[80]

In October 2022, there was an outbreak of diphtheria at the former

asylum seeker processing centre. The capacity of the processing centre was 1,000 people, although about 3,000 were living at the site, with some accommodated in tents. The Home Office, the government department responsible for asylum seekers, refused to confirm the number of cases.[81]

In December 2023 there was an outbreak at a school in Luton, in the United Kingdom. UK Health Security Agency (UKHSA) issued a statement saying specialists have been providing public health support following confirmation of the diphtheria case at a primary school in Luton. The agency said it is working closely with local and national partners "to ensure all necessary public health measures are implemented" following the discovery of the new case. The statement added: "We have conducted a risk assessment and close contacts of the case have been identified and where appropriate, vaccination and advice will be given to prevent the spread of the infection."[82]

References

  1. ^
    PMID 16671240. Archived
    (PDF) from the original on 6 June 2015.
  2. ^
    ISBN 9780983263135. Archived
    from the original on 15 September 2016.
  3. ^ a b "Diphtheria". who.int. 3 September 2014. Archived from the original on 2 April 2015. Retrieved 27 March 2015.
  4. ^
    PMID 27733281
    .
  5. ISBN 9781439821961. Archived
    from the original on 21 December 2016.
  6. ISBN 9780323263733. Archived
    from the original on 21 December 2016.
  7. ^
    PMID 25530442
    .
  8. PMID 30698523
    .
  9. ^ "Diphtheria—Symptoms—NHS Choices". Archived from the original on 28 June 2015. Retrieved 28 June 2015.
  10. ^ a b MedlinePlus Encyclopedia: Diphtheria
  11. ^ "Diphtheria Symptoms". www.cdc.gov. 10 April 2017. Retrieved 26 October 2017.
  12. ^ "Diphtheria". The Lecturio Medical Concept Library. 4 August 2020. Retrieved 12 July 2021.
  13. doi:10.1001/jama.1895.02430400011001d. Archived
    from the original on 4 July 2014. Retrieved 16 April 2014.
  14. PMID 20747853
    .
  15. PMID 20747854
    .
  16. ^ Beard, George Miller (1875). Our Home Physician: A New and Popular Guide to the Art of Preserving Health and Treating Disease. New York: E. B. Treat. pp. 560–564. Retrieved 15 April 2014.
  17. ^ Vanderpool, Patricia (December 2012). "Recognizing croup and stridor in children". American Nurse Today. 7 (12). Archived from the original on 16 April 2014. Retrieved 15 April 2014.
  18. ^ Diphtheria Causes and Transmission Archived 13 April 2014 at the Wayback Machine. U.S. Center for Disease Control and Prevention (2016).
  19. PMID 1521987
    .
  20. S2CID 8726176
    .
  21. PMID 14850426
    .
  22. PMID 14927573
    .
  23. ^
    PMID 10657208
    .
  24. ^ "Entrez Gene: EEF2 eukaryotic translation elongation factor 2".
  25. PMID 164179
    .
  26. ^ "Immunisation and Pentavalent Vaccine". UNICEF. Archived from the original on 29 July 2014.
  27. ^ a b "Horses and the Diphtheria Antitoxin". Academic Medicine. April 2000.
  28. ^ a b c Atkinson W, Hamborsky J, McIntyre L, Wolfe S, eds. (2007). "Diphtheria" (PDF). Epidemiology and Prevention of Vaccine-Preventable Diseases (The Pink Book) (10 ed.). Washington, D.C.: Public Health Foundation. pp. 59–70. Archived (PDF) from the original on 27 September 2007.
  29. public domain resource
    .
  30. ^ "Diagnosis, Treatment, and Complications". Centers for Disease Control and Prevention. 9 September 2022. Retrieved 7 March 2023.
  31. ^
    PMID 16462970
    .
  32. ISBN 978-0-8248-3334-3
    .
  33. S2CID 245183270
    .
  34. ^ Bretonneau, Pierre (1826) Des inflammations spéciales du tissu muqueux, et en particulier de la diphtérite, ou inflammation pelliculaire, connue sous le nom de croup, d'angine maligne, d'angine gangréneuse, etc. [Special inflammations of mucous tissue, and in particular diphtheria or skin inflammation, known by the name of croup, malignant throat infection, gangrenous throat infection, etc.] Paris, France: Crevot.
    A condensed version of this work is available in: P. Bretonneau (1826) "Extrait du traité de la diphthérite, angine maligne, ou croup épidémique" (Extract from the treatise on diphtheria, malignant throat infection, or epidemic croup), Archives générales de médecine, series 1, 11 : 219–254. From p. 230: " … M. Bretonneau a cru convenable de l'appeler diphthérite, dérivé de ΔΙΦθΕΡΑ, … " ( … Mr. Bretonneau thought it appropriate to call it diphtheria, derived from ΔΙΦθΕΡΑ [diphthera], … )
  35. ^ "Diphtheria". Online Etymology Dictionary. Archived from the original on 13 January 2013. Retrieved 29 November 2012.
  36. OCLC 11760038.[page needed
    ]
  37. ^ "Diaries and Letters – Princess Alice of Hesse and by Rhine".
  38. ^ Klebs, E. (1883) "III. Sitzung: Ueber Diphtherie" (Third session: On diphtheria), Verhandlungen des Congresses für innere Medicin. Zweiter Congress gehalten zu Wiesbaden, 18.-23. April 1883 Archived 22 May 2016 at the Wayback Machine (Proceedings of the Congress on Internal Medicine. Second congress held at Wiesbaden, 18–23 April 1883), 2 : 139–154.
  39. ^ "Corynebacterium diphtheriae". NCBI Taxonomy browser.
  40. ^ Loeffler, F. (1884) "Untersuchungen über die Bedeutung der Mikroorganismen für die Entstehung der Diphtherie, beim Menschen, bei der Taube und beim Kalbe" (Investigations into the significance of microorganisms in the development of diphtheria among humans, pigeons, and calves), Mitteilungen aus der Kaiserlichen Gesundheitsamte (Communications from the Imperial Office of Health), 2 : 421–499.
  41. S2CID 37108037
    .
  42. ^ Roux, E. and Yersin, A. (December 1888) "Contribution à l'étude de la diphthérte" Archived 15 March 2016 at the Wayback Machine (Contribution to the study of diphtheria), Annales de l'Institute Pasteur, 2 : 629–661.
  43. ^ Parish, Henry (1965). A history of immunization. E. & S. Livingstone. p. 120.
  44. ^ Behring, E. and Kitasato, S. (1890) "Ueber das Zustandekommen der Diphtherie-Immunitat und der Tetanus-Immunitat bei Thieren" Archived 20 December 2016 at the Wayback Machine (On the realization of diphtheria immunity and tetanus immunity among animals), Deutsche medizinsche Wochenschrift, 16 : 1113–1114.
  45. PMID 28246359
    .
  46. ^ Emil von Behring Serum Therapy in Therapeutics and Medical Science. Nobel Lecture, 12 December 1901. nobelprize.org
  47. ^ H. K. Mulford Company (1903). Diphtheria Antitoxin. The Company.
  48. ^ "Difference Between Serums & Vaccines | What is - YTread". youtuberead.com. Retrieved 2 April 2023.
  49. doi:10.1001/jama.1901.02470490037010
    .
  50. S2CID 30767303
    .
  51. ^ Royer, Franklin (1905). "The Antitoxin Treatment of Diphtheria, with a Plea for Rational Dosage in Treatment and in Immunizing". The Therapeutic Gazette.
  52. S2CID 7001068
    .
  53. ^ "United States mortality rate from measles, scarlet fever, typhoid, whooping cough, and diphtheria from 1900–1965". HealthSentinel.com. Archived from the original on 14 May 2008. Retrieved 30 June 2008.
  54. ISBN 9780485263190
    .
  55. ^ "Iditarod: Celebrating the "Great Race of Mercy" to Stop Diphtheria Outbreak in Alaska | About | CDC". www.cdc.gov. 11 July 2018. Retrieved 5 March 2019.
  56. ^ "Timeline". History of Vaccines. 1926 — Glenny Develops Adjuvant. Archived from the original on 1 July 2014. Retrieved 28 October 2013.
  57. ^ Immunology and Vaccine-Preventable Diseases – Pink Book – Diphtheria, CDC
  58. ^ "Nora Isabel Wattie". MacTutor. University of St Andrews. March 2021. Archived from the original on 3 September 2023. Retrieved 2 September 2023.
  59. ^ Mackie, Elizabeth M; Scott Wilson, T. (12 November 1994). "Obituary N.I.Wattie". British Medical Journal. 309: 1297.
  60. S2CID 36431705
    .
  61. ISBN 9781848845503
    .
  62. ISBN 978-0-309-04895-8
    .
  63. ^ "Immunization, Vaccines and Biologicals". World Health Organization. Archived from the original on 8 December 2013. Retrieved 10 May 2020.
  64. PMID 3176515
    .
  65. PMID 2472081
    .
  66. PMID 10657219
    .
  67. ^ "CNN's Anderson Cooper talks with Sean Penn and Dr. Sanjay Gupta about the threat of diphtheria in Haiti". CNN. 10 May 2010. Archived from the original on 20 December 2016.
  68. ^ "Three kids die of diphtheria". The Hindu. 28 August 2013. Archived from the original on 20 December 2016.
  69. ^ "Parents of diphtheria-stricken boy feel "tricked" by anti-vaccination groups". El Pais. 5 June 2015. Archived from the original on 7 June 2015.
  70. ^ "Primer caso de difteria en España en casi 30 años". El Mundo. 2 June 2015. Archived from the original on 2 June 2015.
  71. ^ "WHO – Diphtheria reported cases". Archived from the original on 12 June 2015. Retrieved 11 June 2015.
  72. ^ "Meisje (3) overlijdt aan difterie in ziekenhuis". De Standaard. 17 March 2016. Archived from the original on 19 March 2016.
  73. ^ Murali, R.S.N. (21 June 2016). "Malacca Health Dept works to contain diptheria after seven-year-old dies". thestar.com.my. Archived from the original on 24 June 2016.
  74. ^ "Infant mortality and malaria soar in Venezuela, according to government data". Reuters. 9 May 2017. Archived from the original on 24 May 2017. Retrieved 3 June 2017.
  75. ^ "Diphtheria Reemerges as Venezuela Remains on the Brink of Economic Collapse | HealthMap". www.healthmap.org. Archived from the original on 12 July 2017. Retrieved 3 June 2017.
  76. ^ Diphtheria: What Exactly Is It ... And Why Is It Back?
  77. ^ Nugraha, Indra Komara. "IDI: 38 Anak Meninggal karena Difteri". detiknews. Retrieved 18 December 2017.
  78. ^ BBC (9 November 2019). "Two cases of deadly diphtheria detected in Lothian area". BBC News.
  79. ^ "Οκτάχρονος πέθανε από διφθερίτιδα στην Αθήνα - Δεν είχε εμβολιαστεί". ΑμεΑ Care (in Greek). 28 November 2019. Retrieved 28 November 2019.
  80. ^ "Two children diagnosed with first cases of diphtheria of the throat in NSW this century". Retrieved 21 July 2022.
  81. ^ Taylor, Diane (20 October 2022). "Diphtheria outbreak confirmed at asylum seeker centre in Kent". The Guardian. Archived from the original on 20 October 2022. Retrieved 21 October 2022.
  82. ^ "UKHSA issues statement as case of rare infectious disease confirmed at UK primary school". The Manchester Evening News. 13 December 2023. Retrieved 14 December 2023.

Further reading

External links

Wikimedia Commons has media related to Diphtheria.
Retrieved from "https://en.wikipedia.org/w/index.php?title=Diphtheria&oldid=1220177054"