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PubMed2000

Diphtheria in the Russian Federation in the 1990s.

A resurgence of diphtheria spread throughout the Russian Federation in the early 1990s; diphtheria had been well controlled, but circulation of toxigenic strains of Corynebacterium diphtheriae had persisted since the implementation of universal childhood vaccination in the late 1950s. More than 115,000 cases and 3,000 deaths were reported from 1990 to 1997, and, in contrast to the situation in the prevaccine era, most of the cases and deaths occurred among adults. Contributing factors included the accumulation of susceptible individuals among both adults and children and probably the introduction of new strains of C. diphtheriae. Vaccine quality, vaccine supply, or access to vaccine providers did not significantly contribute to the epidemic. Mass vaccination of adults and improved childhood immunization controlled the epidemic. High levels of population immunity, especially among children, will be needed to prevent and control similar outbreaks in the future.

Adolescent↗

PubMed2000

Epidemic diphtheria in Ukraine, 1991-1997.

In 1991, Ukraine experienced a return of epidemic diphtheria after decades of control that had resulted in <40 sporadic cases reported every year. Increased incidence was first recorded in Kiev, Lviv, and Odessa. By 1993, the epidemic had spread to >50% of the oblasts (provinces) in the country, and by 1995, all regions were affected. In 1995, at the peak of the epidemic, >5,000 cases and >200 deaths were reported. As in Russia, >80% of these cases were diagnosed in persons 16-59 years old. In 1993, the government of Ukraine initiated a program of increased immunization among children and at-risk adults, and by 1995, a mass immunization strategy was adopted in an effort to arrest the epidemic, which was increasing exponentially. In 1996, the number of cases started to decrease, and data from 1998 indicate that the downward trend has continued. It is likely that the diphtheria epidemic in Ukraine started among children, who had been left vulnerable due to inadequate childhood immunizations, and then quickly spread to inadequately protected adults.

Adolescent↗

PubMed2000

Epidemiology and control of diphtheria in the Republic of Moldova, 1946-1996.

In 1994-1996, the Republic of Moldova was stricken with an epidemic of diphtheria after >30 years of routine diphtheria immunization and the near absence of the disease for nearly 20 years. The intensity of the epidemic gradually grew, reaching a peak in 1994-1995. The epidemiology of diphtheria in Moldova during this period is described along with laboratory findings and control measures. Pharyngeal diphtheria was the predominant clinical form of the disease (97% of cases), and it most often developed in a localized form (70%), with 20% in the toxic form. The clinical diagnosis of diphtheria was bacteriologically confirmed in 91% of cases: Of the cases tested for biotype, 91.3% were gravis, 8.5% were mitis, and 0. 2% were intermedius. Of 494 toxigenic isolates from cases and carriers at the beginning of the epidemic, 47% were nonphagotypeable strains, and 25.7% were phagotype VI strains. Aggressive population-based diphtheria control measures, a mass immunization campaign, rapid case identification, antibiotic prophylaxis and supplemental immunization of close contacts in clusters of infection, and high coverage with routine immunization rapidly controlled the epidemic within Moldova.

Adolescent↗

PubMed2000

Diphtheria in Lithuania, 1986-1996.

Diphtheria reappeared in Lithuania in 1986 and rose to epidemic levels by 1992. Between 1991 and 1996, 110 cases of diphtheria were registered, with an incidence of 0.03-1.15/100,000 population. Most cases (84%) and all 17 deaths occurred among persons >/=15 years, most of whom had never been vaccinated. Persons 40-49 years old had the highest average annual age-specific morbidity (1.70/100,000) and mortality (0.53/100,000) rates. Low levels of immunity among individuals 40-49 years old and migration to epidemic areas in Russia and Belarus contributed to the epidemic's occurrence. Between 1991 and 1995, toxigenic Corynebacterium diphtheriae strains were isolated from 84 of all registered patients (76%), and nontoxigenic strains were isolated from 13 (12%). By 1996, two mass vaccination campaigns, which provided one dose of vaccine to individuals 25-30 years old and three doses of vaccine to persons 31-60 years old, helped reduce the number of cases. The first campaign achieved 69% coverage; the second achieved 48% coverage.

Adult↗

PubMed2000

Diphtheria in Latvia, 1986-1996.

After nearly two decades without a diphtheria case in Latvia, the disease reappeared in 1986. From 1990 to 1996, case counts were highest among adults 40-49 years of age, school-aged children, and adolescents. Nonetheless, the average annualized incidence of disease was highest among infants and preschoolers. In August 1995, mass vaccination efforts began to provide adults 25-60 years of age with at least one dose of vaccine. By the end of the year, a 77% coverage rate was achieved, resulting in a decrease of reported diphtheria cases by 1996. From February to September 1997, special outreach efforts were focused on hard-to-reach populations; as a result, by June 1997, 55% of adults had received three doses of vaccine. While decreases in the incidence of and morbidity from diphtheria have occurred, additional efforts still need to be concentrated on improving vaccination coverage in adults and children <2 years of age and in reducing mortality from diphtheria.

Adolescent↗

PubMed2000

Diphtheria in Estonia, 1991-1996.

Clinical diphtheria reappeared in Estonia in 1991. Between 1991 and 1996, 61 cases and 5 deaths occurred; 19 cases were among children 5-9 years of age, and 11 were among persons 40-49 years of age. From 1993-1995, vaccine supplies donated by Finland were used in vaccination programs. In 1995, the International Federation of Red Cross and Red Crescent Societies and the Estonian Red Cross launched a mass vaccination campaign targeting the adult population. By the end of 1997, it was estimated that 46% of adults had received at least one dose of vaccine. Although the vaccination campaigns did not target the pediatric population, vaccination coverage in school-aged children remained high due to continuing routine vaccination programs. The reappearance and epidemic of clinical diphtheria cases and the mass vaccination campaign efforts demonstrated that preventive measures are important and must be maintained in order to keep diphtheria under control.

Adolescent↗

PubMed2000

Epidemic investigation of diphtheria in the Republic of Armenia, 1990-1996.

While incidence rates of diphtheria steadily declined in Armenia after World War II, reemergence of the disease in 1990 brought about changes in public health practices and identified resource needs. The Armenian Ministry of Health (MOH) routinely collected diphtheria case reports, as a reportable health outcome. Diphtheria incidence rates increased from 0.02/100,000 in 1993 to 1/100,000 (36 cases) in 1994. The distribution of cases showed that the greatest number of illnesses and deaths occurred among persons 5-14 years old, yet incidence rates among persons 1-4 and 5-14 years old were similar (4. 4 cases/ and 4.3 cases/100,000, respectively). During 1990-1996, 9 (75%) of 12 cases who died and 18 (21%) of 84 cases who survived had not been vaccinated. The diphtheria epidemic in Armenia was an important, serious, and signal public health event. The Armenian MOH responded by revising immunization practices (1994), improving epidemic control measures (1995), and soliciting international resources (1992-1996).

Adolescent↗

PubMed2000

Epidemic diphtheria in the 1990s: Azerbaijan.

The diphtheria epidemic in the former Soviet Union reached Azerbaijan in 1991, when 66 cases of diphtheria were reported, a number that compared with 4 cases in 1990. From 1990-1996, 2182 cases of diphtheria and 286 diphtheria fatalities (case fatality rate: 13.1%) were reported in Azerbaijan, primarily among persons 5-39 years of age. Almost 45% of cases and 61% of deaths occurred among children 5-14 years of age. The high burden of severe disease among children and young adults suggested a different pattern of preexisting immunity against diphtheria in the Azerbaijani population than was observed in the concurrent diphtheria epidemic in Russia. Because resources were limited in Azerbaijan, mass immunization of the population was carried out in stages, focusing initially on school-aged children. Mass immunization campaigns targeting children were moderately successful in stabilizing the epidemic; mass immunization campaigns targeting both adults and children were eventually needed to fully stop the epidemic.

Adolescent↗

PubMed2000

Diphtheria epidemic in the Republic of Georgia, 1993-1997.

Epidemic diphtheria reemerged in the republic of Georgia in 1993. From 1993 to 1997, 1405 cases were reported (28 in 1993, 312 in 1994, 429 in 1995, 348 in 1996, and 288 in 1997), with a cumulative incidence of 25.8/100,000 and a case fatality ratio of 9.5%. During 1993-1997, 53% of the diphtheria cases occurred among persons >/=15 years of age. Unvaccinated patients were more likely to have toxic forms (relative risk=2.24; 95% confidence interval=1.69-2.96) or to die of diphtheria (relative risk=2.24; 95% confidence interval=1. 36-3.68) than those who had received at least one dose of diphtheria toxoid. Improvement in routine childhood vaccination coverage and implementation of mass adult vaccination campaigns have been critical to bringing the epidemic under control. By mid-1998, the overall diphtheria situation in Georgia appeared to have been controlled. Only 53 cases were reported from January to June 1998, representing a 64% decrease from the 148 cases during the corresponding period in 1997.

Adolescent↗

PubMed2000

Universal immunization: the diphtheria control strategy of choice in the Republic of Tajikistan, 1993-1997.

During the 1993-1997 diphtheria epidemic in Tajikistan, the incidence rate was the highest observed throughout the Newly Independent States of the former Soviet Union (76.2 cases/100,000 population in 1995). Factors that contributed to this situation included an increase in the number of persons who were not fully immunized, a breakdown of health care services and disease surveillance, civil war, an increase in migration, shortages of qualified medical personnel, and shortages of products, resources, and services. The Ministry of Health and numerous international organizations have worked to address the needs of the republic, and in the fourth quarter of 1995, the number of reported cases began to decrease. It is believed that this decrease was largely the result of routine immunization, implementation of national immunization days, and use of a World Health Organization-recommended system for working with patients and contacts, and it underscores the importance of universal diphtheria immunization with special booster doses in such an epidemic setting.

Adolescent↗

PubMed2000

Epidemic investigation of diphtheria, Republic of Kazakhstan, 1990-1996.

The diphtheria epidemic that began in Russia in 1990 reached Kazakhstan in 1992 when 45 case-patients (a 50% increase over 1991) were reported. In 1993, 82 case-patients were reported, and 489 were reported in 1994. The epidemic peaked in 1995 when 1105 case-patients were reported (incidence rate=6.7/100,000 population). In 1996, after public health practice modifications and several mass vaccinations, 455 case-patients were reported. From 1990 to 1996, children </=14 years old represented 35% (2234) of the reported case-patients (and 33% of the population) but had a disproportionate share (49%) of the fatalities. Females represented 63% of the adult case-patients. In 1996, 297 (65%) of 455 case-patients and 26 (84%) of 31 fatalities were unvaccinated. Kazakhstan controlled the diphtheria epidemic by using a multifaceted public health strategy of prevention and control, which included changing the routine immunization schedule, modifying the official list of contraindications to vaccination, conducting mass campaigns to vaccinate persons, and treating close contacts of case-patients with antibiotics.

Adolescent↗

PubMed2000

Epidemic diphtheria in the Kyrgyz Republic, 1994-1998.

The Kyrgyz Republic experienced a widespread diphtheria epidemic during 1994-1998. National diphtheria surveillance and vaccination coverage information were used to describe the course of the epidemic. The epidemic began in August 1994, reached a peak in 1995 with 704 cases (incidence rate: 15.4/100,000 population) and 30 deaths, and declined to an incidence rate of 4.0/100,000 during the first 8 months of 1998. Age-specific incidence was highest in 1995 among persons 15-19 and 20-29 years old. Three rounds of mass vaccination with tetanus and diphtheria toxoids for adult use (Td) were conducted; reported coverage was 69% in 1995 and >95% in 1996 and 1997. Reported routine vaccination coverage with three doses of diphtheria toxoid by age 12 months increased from 62% in 1989 to 98% in 1997. Mass vaccination of the adult population with Td and improvements in childhood vaccination coverage played a major role in controlling the epidemic.

Adolescent↗

PubMed2000

Diphtheria epidemic in the Republic of Uzbekistan, 1993-1996.

The Republic of Uzbekistan, like the other Newly Independent States in the 1990s, experienced epidemic diphtheria during the 1990s. The outbreak in Uzbekistan began in 1993 in southern regions that bordered areas of Tajikistan that were experiencing a very intense diphtheria epidemic. However, the Uzbek epidemic rapidly spread and threatened to involve the entire country. From 1993-1996, 1169 cases of diphtheria were reported, compared with 58 in 1990-1992. Unvaccinated or only partially vaccinated cases were more likely to have clinically severe forms of diphtheria than those who were fully vaccinated. Strong epidemiologic links with the Tajik diphtheria epidemic and the predominance of mitis biotype strains of Corynebacterium diphtheriae in Uzbekistan make it likely that the Uzbek outbreak arose independently of the predominantly biotype gravis epidemic that began in Russia. The epidemic appeared to be due to low population immunity and the large-scale reintroduction of toxigenic strains of C. diphtheriae. Several mass vaccination campaigns and general enhancement of routine immunization procedures led to control of the epidemic in 1996.

Adolescent↗

PubMed2000

Ukraine, 1992: first assessment of diphtheria vaccine effectiveness during the recent resurgence of diphtheria in the Former Soviet Union.

A case-control study in Ukraine provided the first data on the field effectiveness of Russian-produced vaccine during the 1990 diphtheria resurgence in the former Soviet Union. For each of 262 diphtheria cases <15 years of age who were reported from January through October 1992, 2 controls, matched by age and clinic, were selected. The effectiveness of three doses of diphtheria vaccine was 98.2% (95% confidence interval: 90.3-99.9). Among controls, 84% had received three or more vaccinations by 2 years of age. These results suggest that the following five hypothesized causes of the outbreak appeared unlikely: appearance of a new "mutant" diphtheria strain, low potency of the Russian-produced diphtheria vaccine, inadequate cold chain, poor host immunogenicity due to radiation exposure from Chernobyl, and low routine childhood vaccination coverage. It is concluded that initial priority for scarce resources for controlling this outbreak should be placed on vaccination of persons susceptible to diphtheria (e.g., adults) rather than revaccination of children.

Adolescent↗

PubMed2003

Measles outbreak in Sri Lanka, 1999-2000.

A large measles outbreak occurred in Sri Lanka from October 1999 through June 2000 following a period of low incidence. During this period, >15,000 suspected cases were reported to the central Epidemiological Unit of the Department of Health Services. The outbreak was investigated through review of surveillance data for 1999-2000, which were compared with previous surveillance data. Among the clinically confirmed cases, the highest morbidity rate (114/100,000 population) was observed among children <9 months of age. Nearly 54% of the cases were among persons >/=15 years old, and this percentage had increased over the previous decade. Forty percent of cases had a history of measles vaccination. There were 5 deaths, giving a case-fatality rate of 0.1%. Action taken during the outbreak and plans for future outbreak prevention strategies were also evaluated.

Adolescent↗

PubMed2003

Progress toward interruption of endemic measles transmission in Tunisia.

Measles was the second leading cause of infant mortality in Tunisia prior to introduction of measles vaccination in 1979. The number of reported measles cases has decreased from 3007 in 1981 to 47 cases in 2000 due in part to the high coverage rates achieved after 1992. During 1998, a measles catch-up campaign vaccinated 1,846,657 children (95%) aged 6-16 years, and a follow-up campaign for children aged 9 months to 5 years in 2001 reached 547,766 (94%). During 1999-2001, 1717 cases of rash and fever illness were tested for measles; only 3 (0.2%) were positive for measles. From February to July 2002, an outbreak of measles involving 87 cases occurred in Tunisia in a health care setting and 56 (64%) patients were aged 15-30 years. The low number of laboratory-confirmed measles cases during 1999-2001 suggests endemic measles transmission may have been interrupted.

Adolescent↗

PubMed2004

Measles surveillance in the United States: an overview.

The elimination of endemic measles from the United States has been a national goal since the introduction of measles vaccine, and measles surveillance has been crucial to guide the elimination efforts. The United States surveillance system is geared towards detection of measles virus transmission, rapid discovery of measles outbreaks to facilitate outbreak control, and identification of risk factors for measles. The surveillance system is a passive reporting system that, when activated by a reported case of suspected measles, triggers a search for additional cases around the reported case. Cases are typically reported by health care providers or from schools and day care centers. The sensitivity of the system is increased through reporting and investigation of all suspected measles cases by means of an inclusive case definition (generalized maculopapular rash and fever), and the specificity is increased through laboratory testing for measles of all suspected cases.

Disease Notification↗

PubMed2004

Assessment of the status of measles elimination from reported outbreaks: United States, 1997-1999.

The status of measles elimination is best summarized by evaluation of the effective reproduction number R; maintaining R<1 is necessary and sufficient to achieve elimination. Previously described methods for estimating R from the sizes and durations of chains of measles transmission and the proportion of cases imported were applied to the measles data reported for the United States in 1997-1999. These comprised 338 cases, forming 165 chains of transmission, of which 43 had >1 case. One hundred seven cases were classified as importations. All 3 methods suggested that R was in the range 0.6-0.7. Results were not sensitive to the minimum size and duration of outbreak considered (so long as single-case chains were excluded) or to exclusion of chains without a known imported source. These results demonstrate that susceptibility to measles was beneath the epidemic threshold and that endemic transmission was eliminated.

Disease Notification↗