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In May 2015, following a 30-year diphtheria-free interval in Catalonia, an unvaccinated 6-year-old child was diagnosed with diphtheria caused by toxigenic . After a difficult search for equine-derived diphtheria antitoxin (DAT), the child received the DAT 4 days later but died at the end of June. Two hundred and seventeen contacts were identified in relation to the index case, and their vaccination statuses were analysed, updated and completed. Of these, 140 contacts underwent physical examination and throat swabs were taken from them for analysis. Results were positive for toxigenic in 10 contacts; nine were asymptomatic vaccinated children who had been in contact with the index case and one was a parent of one of the nine children. Active surveillance of the 217 contacts was initiated by healthcare workers from hospitals and primary healthcare centres, together with public health epidemiological support. Lack of availability of DAT was an issue in our case. Such lack could be circumvented by the implementation of an international fast-track procedure to obtain it in a timely manner. Maintaining primary vaccination coverage for children and increasing booster-dose immunisation against diphtheria in the adult population is of key importance.


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  1. European Centre for Disease Prevention and Control (ECDC). A case of diphtheria in Spain, 15 June 2015. Stockholm: ECDC; 2015. Available from: http://ecdc.europa.eu/en/publications/Publications/diphtheria-spain-rapid-risk-assessment-june-2015.pdf
  2. Public Health England (PHE). Public health control and management of diphtheria (in England and Wales). 2015 Guidelines. London: PHE; March 2015. Available from: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/416108/Diphtheria_Guidelines_Final.pdf
  3. World Health Organization (WHO). Diphtheria reported cases. Geneva: WHO. [Accessed 27 Mar 2018]. Available from: http://apps.who.int/immunization_monitoring/globalsummary/timeseries/tsincidencediphtheria.html
  4. Kantsone I, Lucenko I, Perevoscikovs J. More than 20 years after re-emerging in the 1990s, diphtheria remains a public health problem in Latvia. Euro Surveill. 2016;21(48):30414.  https://doi.org/10.2807/1560-7917.ES.2016.21.48.30414  PMID: 27934582 
  5. Wagner KS, White JM, Crowcroft NS, De Martin S, Mann G, Efstratiou A. Diphtheria in the United Kingdom, 1986-2008: the increasing role of Corynebacterium ulcerans. Epidemiol Infect. 2010;138(11):1519-30.  https://doi.org/10.1017/S0950268810001895  PMID: 20696088 
  6. Perkins S, Cordery R, Nixon G, Abrahams A, Andrews J, White J, et al. Investigations and control measures following a non-travel-associated case of toxigenic Cornyebacterium diphtheriae, London, United Kingdom, December 2009-January 2010. Euro Surveill. 2010;15(16):19544. PMID: 20430002 
  7. Ganeshalingham A, Murdoch I, Davies B, Menson E. Fatal laryngeal diphtheria in a UK child. Arch Dis Child. 2012;97(8):748-9.  https://doi.org/10.1136/archdischild-2011-300272  PMID: 22535233 
  8. Deshpande A, Inkster T, Hamilton K, Litt D, Fry N, Kennedy IT, et al. Colonisation with toxigenic Corynebacterium diphtheriae in a Scottish burns patient, June 2015. Euro Surveill. 2015;20(49):30088.  https://doi.org/10.2807/1560-7917.ES.2015.20.49.30088  PMID: 26691231 
  9. Rousseau C, Belchior E, Broche B, Badell E, Guiso N, Laharie I, et al. Diphtheria in the south of France, March 2011. Euro Surveill. 2011;16(19):19867. PMID: 21596008 
  10. European Centre for Disease Prevention and Control (ECDC). A fatal case of diphtheria in Belgium, 24 March 2016. Stockholm: ECDC; 2016. Available from: http://ecdc.europa.eu/en/publications/Publications/RRA-Diphtheria-Belgium.pdf
  11. Fredlund H, Norén T, Lepp T, Morfeldt E, Henriques Normark B. A case of diphtheria in Sweden, October 2011. Euro Surveill. 2011;16(50):20038. PMID: 22221495 
  12. Sane J, Sorvari T, Widerström M, Kauma H, Kaukoniemi U, Tarkka E, et al. Respiratory diphtheria in an asylum seeker from Afghanistan arriving to Finland via Sweden, December 2015. Euro Surveill. 2016;21(2):30105.  https://doi.org/10.2807/1560-7917.ES.2016.21.2.30105  PMID: 26840007 
  13. Jakovljev A, Steinbakk M, Mengshoel AT, Sagvik E, Brügger-Synnes P, Sakshaug T, et al. Imported toxigenic cutaneous diphtheria in a young male returning from Mozambique to Norway, March 2014. Euro Surveill. 2014;19(24):20835.  https://doi.org/10.2807/1560-7917.ES2014.19.24.20835  PMID: 24970370 
  14. Berger A, Meinel DM, Schaffer A, Ziegler R, Pitteroff J, Konrad R, et al. A case of pharyngeal diphtheria in Germany, June 2015. Infection. 2016;44(5):673-5.  https://doi.org/10.1007/s15010-016-0882-2  PMID: 26883545 
  15. Jablonka A, Behrens GM, Stange M, Dopfer C, Grote U, Hansen G, et al. Tetanus and diphtheria immunity in refugees in Europe in 2015. Infection. 2017;45(2):157-64.  https://doi.org/10.1007/s15010-016-0934-7  PMID: 27541038 
  16. European Centre for Disease Prevention and Control (ECDC). Annual Epidemiological Report 2016 – Diphtheria. Stockholm: ECDC; 2016. Available from: https://ecdc.europa.eu/sites/portal/files/documents/Diphtheria%20AER_0.pdf
  17. Ministerio de Sanidad y Consumo. Gobierno de España. Vacunación en adultos. Recomendaciones. Vacuna de difteria y tétanos. [Vaccination in adults. Recommendations. Diphtheria and tetanus vaccine]. Madrid: Ministerio de Sanidad y Consumo; 2009. Spanish. Available from: https://www.msssi.gob.es/ciudadanos/proteccionSalud/vacunaciones/docs/TetanosDifteria_2009.pdf
  18. Castillo-Salgado C. Trends and directions of global public health surveillance. Epidemiol Rev. 2010;32(1):93-109.  https://doi.org/10.1093/epirev/mxq008  PMID: 20534776 
  19. Subaiya S, Dumolard L, Lydon P, Gacic-Dobo M, Eggers R, Conklin L. Global routine vaccination coverage, 2014. MMWR Morb Mortal Wkly Rep. 2015;64(44):1252-5.  https://doi.org/10.15585/mmwr.mm6444a5  PMID: 26562454 
  20. Borba RCN, Vidal VM, Moreira LO. The re-emergency and persistence of vaccine preventable diseases. An Acad Bras Cienc. 2015;87(2);1311-22.  https://doi.org/10.1590/0001-3765201520140663  PMID: 26312431 
  21. Departament de Salut. Decret 95/2014, d'1 de juliol, pel qual s'estableix el calendari de vacunacions sistemàtiques. [Decree 95/2014, 1 July, which implements the systematic immunisation schedule]. Barcelona: Diari Oficial Generalitat de Catalunya; 2014. Catalan. Available from: http://dogc.gencat.cat/ca/pdogc_canals_interns/pdogc_resultats_fitxa/?documentId=665990&action=fitxa
  22. Ministerio de Sanidad Servicios Sociales e Igualdad (MSSSI). Consejo Interterritorial del Sistema Nacional de Salud. Calendario común de vacunación infantil. Calendario recomendado año 2015. [National Health System Interterritorial Board. Common childhood vaccination schedule. Schedule recommended 2015]. Madrid: MSSSI; 2015. Spanish. Available from: https://www.msssi.gob.es/ciudadanos/proteccionSalud/vacunaciones/docs/CalendarioVacunacion2015.pdf
  23. Ministerio de Sanidad Servicios Sociales e Igualdad (MSSSI). Tabla 4: Coberturas de primovacunación en niños de 0 a 1 año. Comunidades autónomas 2016. [Table 4: Immunisation coverage, children 0–1 year. Spanish Autonomous Communities 2016]. Madrid: MSSSI; 2016. Spanish. Available from: http://www.msssi.gob.es/profesionales/saludPublica/prevPromocion/vacunaciones/docs/CoberturasVacunacion/Tabla4.pdf
  24. McKee C, Bohannon K. Exploring the Reasons Behind Parental Refusal of Vaccines. J Pediatr Pharmacol Ther. 2016;21(2):104-9.  https://doi.org/10.5863/1551-6776-21.2.104  PMID: 27199617 
  25. Harmsen IA, Mollema L, Ruiter RA, Paulussen TG, de Melker HE, Kok G. Why parents refuse childhood vaccination: a qualitative study using online focus groups. BMC Public Health. 2013;13(1):1183. https://doi.org/10.1186/1471-2458-13-1183  PMID: 24341406 
  26. Bolt F, Cassiday P, Tondella ML, Dezoysa A, Efstratiou A, Sing A, et al. Multilocus sequence typing identifies evidence for recombination and two distinct lineages of Corynebacterium diphtheriae. J Clin Microbiol. 2010;48(11):4177-85.  https://doi.org/10.1128/JCM.00274-10  PMID: 20844217 
  27. Both L, White J, Mandal S, Efstratiou A. Access to diphtheria antitoxin for therapy and diagnostics. Euro Surveill. 2014;19(24):20830.  https://doi.org/10.2807/1560-7917.ES2014.19.24.20830  PMID: 24970373 
  28. Agència de Salut Pública de Catalunya. Generalitat de Catalunya. Procediment d’actuació davant un cas de diftèria. [Protocol for the management of a case of diphtheria]. Barcelona: Agència de Salut Pública de Catalunya; 2017. Catalan. Available from: http://canalsalut.gencat.cat/web/.content/home_canal_salut/ciutadania/la_salut_de_la_a_a_la_z/d/difteria/Procediment-Difteria10062015.pdf
  29. Centro Nacional de Epidemiología Centro Nacional de Epidemiologia. Instituto de Salud Carlos III (ISCIII). Red Nacional de Vigilancia Epidemiológica. Protocolos de enfermedades de declaración obligatoria. [Protocols concerning mandatory communicable diseases notification]. Madrid: ISCIII; 2013. Spanish. Available from: http://www.isciii.es/ISCIII/es/contenidos/fd-servicios-cientifico-tecnicos/fd-vigilancias-alertas/PROTOCOLOS_RENAVE.pdf
  30. Centers for Disease Control and Prevention (CDC). Diphteria. In: Hamborsky J, Kroger A, Wolfe S, editors. Epidemiology and Prevention of Vaccine-Preventable Diseases. 13th ed. Washington DC: Public Health Foundation; 2015. Available from: https://www.cdc.gov/vaccines/pubs/pinkbook/downloads/table-of-contents.pdf
  31. Wagner KS, Stickings P, White JM, Neal S, Crowcroft NS, Sesardic D, et al. A review of the international issues surrounding the availability and demand for diphtheria antitoxin for therapeutic use. Vaccine. 2009;28(1):14-20.  https://doi.org/10.1016/j.vaccine.2009.09.094  PMID: 19818425 
  32. Bermejo-Martin JF, Avila-Alonso A, González-Rivera M, Tamayo E, Eiros JM, Almansa R. Postbooster Antibodies from Humans as Source of Diphtheria Antitoxin. Emerg Infect Dis. 2016;22(7):1265-7.  https://doi.org/10.3201/eid2207.151670  PMID: 27314309 

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