Scribd Logo
Upload

Welcome to Scribd!

  • 62 views

    Diphtheria 388970 7

    Uploaded by

    Triponia
    This document provides guidelines for investigating cases of diphtheria in Michigan. It defines diphtheria clinically as an upper respiratory illness with an adherent membrane and confirms it based on isolation of Corynebacterium diphtheriae from the nose or throat. Health care providers should report suspected cases immediately to the local health department, who will investigate using forms, contact tracing, and laboratory testing. Control measures include isolation, antitoxin treatment, antibiotic prophylaxis of contacts, and vaccination of susceptible individuals.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Diphtheria 388970 7

    Uploaded by

    Triponia
    62 views5 pages
    This document provides guidelines for investigating cases of diphtheria in Michigan. It defines diphtheria clinically as an upper respiratory illness with an adherent membrane and confirms it based on isolation of Corynebacterium diphtheriae from the nose or throat. Health care providers should report suspected cases immediately to the local health department, who will investigate using forms, contact tracing, and laboratory testing. Control measures include isolation, antitoxin treatment, antibiotic prophylaxis of contacts, and vaccination of susceptible individuals.

    Original Description:

    YYYY

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    This document provides guidelines for investigating cases of diphtheria in Michigan. It defines diphtheria clinically as an upper respiratory illness with an adherent membrane and confirms it based on isolation of Corynebacterium diphtheriae from the nose or throat. Health care providers should report suspected cases immediately to the local health department, who will investigate using forms, contact tracing, and laboratory testing. Control measures include isolation, antitoxin treatment, antibiotic prophylaxis of contacts, and vaccination of susceptible individuals.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    62 views5 pages

    Diphtheria 388970 7

    Uploaded by

    Triponia
    This document provides guidelines for investigating cases of diphtheria in Michigan. It defines diphtheria clinically as an upper respiratory illness with an adherent membrane and confirms it based on isolation of Corynebacterium diphtheriae from the nose or throat. Health care providers should report suspected cases immediately to the local health department, who will investigate using forms, contact tracing, and laboratory testing. Control measures include isolation, antitoxin treatment, antibiotic prophylaxis of contacts, and vaccination of susceptible individuals.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 5

    MDCH Vaccine-Preventable Disease

    Investigation Guidelines Diphtheria


    Revised 2014

    Diphtheria
    CLINICAL CASE DEFINITION
    An upper-respiratory tract illness characterized by sore throat, low-grade fever, and an adherent
    membrane of the tonsil(s), pharynx, larynx, or nose.

    CASE CLASSIFICATION

    Probable: A clinically compatible case that is not laboratory confirmed and is not
    epidemiologically-linked to a laboratory-confirmed case.

    Confirmed: An upper respiratory tract illness with an adherent membrane of the nose,
    pharynx, tonsils, or larynx; and any of the following:
    isolation of Corynebacterium diphtheriae from the nose or throat; or
    histopathologic diagnosis of diphtheria; or
    epidemiologic linkage to a laboratory-confirmed case of diphtheria.

    Comment: Respiratory disease caused by nontoxigenic Corynebacterium diphtheriae should be


    reported as diphtheria. Cutaneous diphtheria should not be reported. All diphtheria isolates,
    regardless of association with disease, should be sent to the Diphtheria Laboratory, National
    Center for Infectious Diseases, CDC. Arrangements should be made through the MDCH
    laboratory.
    Note: On rare occasions, respiratory diphtheria may result from infection with other
    Corynebacterium species (C. ulcerans or C. pseudotuberculosis). These isolates should also be
    forwarded to the CDC.

    TRANSMISSION
    Transmission is most often person-to-person via respiratory secretions.
    On rare occasions, transmission may occur from skin lesions or articles (fomites) soiled with
    discharges from lesions of infected persons.

    INCUBATION PERIOD
    2 5 days, range 1 -10 days. See Diphtheria Timeline, below.

    REPORTING/INVESTIGATION
    Health care providers should report immediately any cases/suspect cases of diphtheria to the
    local health department serving the residence of the case.
    Local health department responsibilities:

    Contact case/guardian and health care provider;

    Determine if case meets clinical case definition;

    If definition met (probable or confirmed cases), investigate using report form/surveillance


    worksheet and control guidelines given below.

    Notify MDCH Immunization Division Vaccine-Preventable Disease (VPD) Surveillance

    Page 1 of 5

    MDCH Vaccine-Preventable Disease


    Investigation Guidelines Diphtheria
    Revised 2014

    Coordinator at 517-335-8159.

    Report/ensure reporting of case to the Michigan Disease Surveillance


    System (MDSS). CDC Diphtheria Surveillance Worksheet may be
    helpful in field investigation to collect and capture data; CDC guidelines
    for managing a diphtheria case and close contacts may also be helpful.
    Obtain immunization history information from provider record or MI Care
    Improvement Registry (MCIR - state immunization registry).

    Update the MDSS record in a timely manner with new or additional info
    as it becomes available. Finalize MDSS record when case investigation
    is complete.

    In the event of death, obtain and send copies of hospital discharge summary, death
    certificate, and autopsy report to MDCH Immunization Division.

    LABORATORY CONFIRMATION
    Laboratory criteria for diagnosis

    Isolation of Corynebacterium diphtheriae from a clinical specimen; or

    Histopathologic diagnosis of diphtheria.

    See LABORATORY SPECIMENS: PROCEDURES AND CONSIDERATIONS, below for more


    details

    IMMUNITY/SUSCEPTIBILITY

    Lifelong immunity is usually but not always acquired after infection.

    Immunization with toxoid produces prolonged, but not lifelong, immunity.

    Serosurveys in the U.S. indicate that 40 percent of adults lack protective levels of
    circulating antitoxin.

    Antitoxin immunity protects against systemic disease but not colonization in the
    nasopharynx.

    CONTROL MEASURES
    Patient-related measures:

    Reports of suspect diphtheria should be investigated immediately.

    Suspect cases should be reported promptly by telephone to MDCH VPD Surveillance


    Coordinator so that arrangements can be made to obtain diphtheria antitoxin for the
    patient from CDC and the MDCH Laboratory can be notified to set up for cultures.
    Contact information:
    MDCH VPD Surveillance Coordinator: 517-335-8159
    MDCH Communicable Disease Epidemiology Office: 517-335-8165
    MDCH After hours emergency: 517-335-9030
    MDCH Laboratory: 517-335-8067
    CDC consultation - Meningitis and Vaccine-Preventable Diseases Branch,
    Natl Center for Immunization and Respiratory Diseases 404-639-3158
    CDC after-hours: 770-488-7100 or 404-639-7100 or 404-639-2888

    Page 2 of 5

    MDCH Vaccine-Preventable Disease


    Investigation Guidelines Diphtheria
    Revised 2014

    CDC laboratory: 404-639-1231


    The patient should be placed in strict isolation, which should be maintained until
    elimination of the organism is demonstrated by negative cultures of two samples obtained
    at least 24 hours apart after completion of antimicrobial therapy.

    Obtain both nasal and pharyngeal swabs for culture, if this has not yet been done, to
    confirm the diagnosis. Ideally these should be collected prior to initiation of antibiotic
    treatment.

    Obtain serum for serology studies of antibodies to diphtheria toxin.

    Obtain, if possible, a consultation from an Infectious Disease physician on the patient;


    consider treatment with diphtheria antitoxin in consultation with MDCH and CDC
    authorities.

    Begin/assure antimicrobial therapy (antimicrobial therapy is not a substitute for antitoxin


    treatment). Per the AAP Red Book the following constitute acceptable therapy;
    consultation with CDC and an infectious disease phyisician is advised:
    o
    o
    o

    Erythromycin given orally or parenterally for 14 days, OR


    Penicillin G given intramuscularly or intravenously for 14 days, OR
    Penicillin G procaine given intramuscularly for 14 days

    Administer/assure active immunization with diphtheria toxoid during convalescence,


    because clinical diphtheria does not necessarily confer immunity.

    Obtain repeat nasal and pharyngeal specimens for culture a minimum of two weeks after
    completion of antimicrobial treatment to assure eradication of the organism.

    Persons who continue to harbor the organism after treatment with either penicillin or
    erythromycin should receive an additional 10-day course of oral erythromycin and should
    submit samples for follow-up cultures.

    Contact management:

    Identify close contacts:


    o household members;
    o persons with a history of direct contact with a case-patient (e.g., caretakers,
    relatives, or friends who regularly visit the home);
    o medical staff exposed to case-patients oral or respiratory secretions.

    Assess and monitor contacts for signs and symptoms for diphtheria for at least 7 days.

    Obtain nasal and pharyngeal swab specimens from contacts for C. diphtheriae cultures.

    Administer/assure antimicrobial prophylaxis for contacts. Recommended prophylaxis (for


    all close contacts, regardless of immunization status):
    o

    A single dose of intramuscular benzathine penicillin G (600,00 units for children


    weighing less than 30 kg, 1.2 million units for persons weighing 30 kg or more);
    - this course is preferable to erythromycin for any contacts who cannot be kept
    under surveillance.

    OR
    o A 7- to 10-day course of oral erythromycin (40 mg/[kg/d]) for children and 1 g/d
    for adults).

    Page 3 of 5

    MDCH Vaccine-Preventable Disease


    Investigation Guidelines Diphtheria
    Revised 2014

    Any persons found to be carriers or who continue to harbor the organism after treatment
    with either penicillin or erythromycin should receive an additional 10-day course of oral
    erythromycin and should submit samples for follow-up cultures.

    Assess diphtheria toxoid vaccination history status of contacts:


    o
    o
    o

    If < 3 doses: Administer immediate dose of diphtheria toxoid and complete


    primary series according to schedule.
    If 3 doses with last dose >5 years ago: Administer immediate booster dose of
    diphtheria toxoid.
    If 3 doses with last dose <5 years ago: Children in need of their fourth primary
    dose should be vaccinated; otherwise vaccination not required.

    Provide information about diphtheria to persons at risk and/or the general public. A
    Question-&-Answer diphtheria information sheet in .PDF format is available from the
    Immunization Action Coalition (www.immunize.org/catg.d/p4203.pdf)

    Persons who continue to harbor the organism after treatment with either penicillin or
    erythromycin should receive an additional 10-day course of oral erythromycin and should
    submit samples for follow-up cultures.

    LABORATORY SPECIMENS: PROCEDURES AND CONSIDERATIONS


    Guidelines for Collection of Specimens for Isolation of C. diphtheriae (source: World Health
    Organization):
    Throat Swabs

    Pharynx should be clearly visible and well illuminated.

    Depress tongue with an applicator and swab the throat without touching the tongue or
    inside of the cheek.

    Rub vigorously over any membrane, white spots, or inflamed areas; slight pressure with a
    rotating movement must be applied to the swab.

    If any membrane is present, lift the edge and swab beneath it; diphtheria organisms are
    often deeply embedded.

    Nasopharygeal specimens

    Insert the swab into the nose through one nostril beyond the anterior nares.

    Gently introduce the swab along the floor of the nasal cavity, under the middle turbinate
    until the pharyngeal wall is reached. Force must not be used to overcome any
    obstruction.

    Skin Diphtheria and Other Lesions

    Lesions should be cleansed with sterile normal saline and crusted material removed.

    Press the swab firmly into the lesion.

    Diphtheria testing may not be available in most clinical laboratories. Contact MDCH Microbiology
    Laboratory (517-335-8067) and MDCH VPD Surveillance Coordinator (517-335-8159) for further
    direction.

    Page 4 of 5

    MDCH Vaccine-Preventable Disease


    Investigation Guidelines Diphtheria
    Revised 2014

    Key: Numbers in parentheses, e.g., (12-25d), are outer ranges.

    Diphtheria timeline diagram

    Signs or
    symptoms

    Onset

    Incubation

    Infectiousness

    Lab
    specimens

    Prophylaxis

    Disease
    control

    Exposure

    Incubation 2-5d (1-10d)

    Recovered.
    5-10% of respiratory diphtheria patients die. Cutaneous
    diphtheria is less severe.

    Diseased

    Infectious while organisms are


    present*, or until ~48h of a course of
    antibiotics.
    Acute serum for IgG
    ASAP after onset
    10-30d

    Convalescent serum
    for IgG

    Nasopharyngeal or throat swabs for culture, in contacts as well as cases. Skin


    swabs may be needed for cutaneous cases.
    Immunize, although it may not prevent
    illness if given after exposure.
    Antibiotic prophy for close contacts
    with 1 dose benzathine penicillin G or
    7-10d course of erythromycin.
    Keep close contacts under surveillance
    for 7d. Exclude them from school or
    food handling until neg. lab test.

    Antibiotic treatment with 14d course of erythromycin


    or procaine penicillin G. Also rule out antitoxin
    hypersensitivity, and then treat with antitoxin.
    Exclude susceptibles until 10d after onset in
    the final case.

    Immunize during convalescence.


    Diphtheria disease does not
    always result in immunity.

    Isolate ill until 2 neg. cultures at least 24h


    apart are obtained after a course of
    antibiotics has been completed.

    * Rarely, chronic carriers may shed bacteria for ~6 months.


    This applies to both immunized and nonimmunized close contacts.
    Sources: APHA Control of Communicable Diseases Manual, AAP Red Book, CDC Pink Book, CDC VPD surveillance manual

    Page 5 of 5

    You might also like