Episode 120
120: Gray and Present Danger
Drs. Sumanth Cherukumilli, Milagritos Tapia, and Adama Mamby Keita join Febrile to describe an approach to a gray membranous pharyngitis!
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Transcript
Hi everyone.
Speaker:Welcome to Febrile, a cultured podcast about all things infectious disease.
Speaker:We use consult questions to dive into ID clinical reasoning, diagnostics
Speaker:and antimicrobial management.
Speaker:I'm Sara Dong, your host and a Med-Peds ID doc.
Speaker:In today's episode, we're continuing to talk a little bit more about
Speaker:vaccine preventable illnesses.
Speaker:If you haven't already, check out our last episode with Dr. Adam Ratner.
Speaker:You can also check out episode number 102 called Rubeola Response.
Speaker:I will go ahead and introduce our guests today.
Speaker:First up, we have Dr. Sumanth Cherukumilli, who was previously on
Speaker:Febrile in episode number 95, which was live from Memphis and the St.
Speaker:Jude PIDS Pediatric ID conference.
Speaker:He is a 3rd year pediatric ID fellow at the University of Maryland.
Speaker:He works with Drs.
Speaker:Milli Tapia, Karen Kotloff, Samba Sow, and Adama Mamby Keita on childhood
Speaker:antimicrobial resistance in West Africa.
Speaker:He was the winner of the 2024 Pediatric ID Society, PIDS, Sanofi
Speaker:Pasteur Fellowship Award, which he used to launch a new neonatal sepsis
Speaker:study designed to study the impact of antibiotic choice on patient survival.
Speaker:Hi, I am Sumanth.
Speaker:I'm a third year Peds ID fellow at the University of Maryland.
Speaker:Thanks for having me on, Sara, it's good to see you again.
Speaker:He is joined by two of his mentors I just mentioned.
Speaker:Dr. Adama Mamby Keita is the head of the Department of Epidemiology
Speaker:at the Center for Vaccine Development Mali in Bamako Mali.
Speaker:He has spent over two decades conducting field research in Mali and has played
Speaker:critical roles in multiple surveillance studies, sero survey studies, and clinical
Speaker:trials from phase two to phase four.
Speaker:He has played a key role in data to action implementation in Mali and has
Speaker:been instrumental in saving the lives of many Malian children through his efforts.
Speaker:Hi everyone.
Speaker:My name is Adama Keita.
Speaker:I am, uh, a medical doctor from CVD-Mali working in clinical
Speaker:research, uh, to save lives.
Speaker:Thank you.
Speaker:Nice to meet you.
Speaker:And last we have Dr. Milagritos Tapia or Millie Tapia.
Speaker:She's a professor of pediatrics and a pediatric ID attending
Speaker:at the University of Maryland.
Speaker:She has served as PI or co-PI on multiple large vaccine based surveillance studies
Speaker:and clinical trials, and she has also played an extremely important role
Speaker:in introducing multiple vaccinations, including Hib, pneumococcal, and
Speaker:meningococcal vaccines in Mali, leading to a major decrease in the burden
Speaker:of vaccine preventable illnesses.
Speaker:Hi, I am Mili Tapia.
Speaker:I'm at the University of Maryland School of Medicine at the Center for
Speaker:Vaccine Development and Global Health.
Speaker:And, happy to be here.
Speaker:Uh, nice to meet you and look forward to a great conversation.
Speaker:So Febrile is everyone's favorite cultured podcast.
Speaker:So we ask our guests to share a little piece of culture, just
Speaker:something that makes you happy or that you've enjoyed recently.
Speaker:I really like reading, and I like writing.
Speaker:Um, so my favorite author is Jhumpa Lahiri.
Speaker:And my favorite book is The Lowland and I try to plug that book to everyone I meet.
Speaker:Um, if anyone has a chance , I would highly recommend reading it.
Speaker:I recently, uh, reset up my home office and have a standing desk, and I, um, now
Speaker:have this other wall behind me, which of course your audience won't be able to see.
Speaker:But, um, so I, I have to decide whether or not I want those things
Speaker:to show up on, on video conferences.
Speaker:But, um, the standing desk is good, although I think
Speaker:I'm leaning on it right now.
Speaker:I'm joined the, the 2020s.
Speaker:Excellent.
Speaker:And rounding us out, Adama, how about you?
Speaker:Yeah.
Speaker:Um, I, I really like outdoor activities, outdoor fishing and, uh, hunting.
Speaker:Uh, people usually call me the man with two guns, one to kill pathogen, save
Speaker:life in in the city, and the second one to control some animal in the bush.
Speaker:So I really like that.
Speaker:Thank you.
Speaker:Alright, um, well I'm gonna tell you guys a little bit about
Speaker:a case and get your thoughts.
Speaker:So today we have an 18 month old male who presents with worsening
Speaker:respiratory distress after approximately three days of illness.
Speaker:The symptoms were initially mild with minor rhinorrhea, but have progressively
Speaker:worsened, and the patient is having rapidly worsening difficulty in
Speaker:breathing over the past 48 hours.
Speaker:The mother initially presented to a community hospital and was
Speaker:hospitalized, and later that patient was transported to a tertiary care center.
Speaker:The patient is otherwise healthy, has never had similar episodes to this, has
Speaker:no history of prior hospitalization, atopy, or a family history of
Speaker:asthma or other medical conditions.
Speaker:The patient lives in the city, has no contact with animals, but is unvaccinated
Speaker:and drinks unpasteurized milk.
Speaker:There are no known sick contacts.
Speaker:There's no family history of recurrent infections or autoimmune
Speaker:disease, and no additional family members, uh, attend daycare.
Speaker:On physical exam, the child has an O2 saturation of 88% on supplemental oxygen.
Speaker:He is tachycardic to 168 beats per minute and tachycardic to 75 breaths per minute.
Speaker:He is afebrile.
Speaker:Pertinent physical exam findings include a markedly exhausted appearance.
Speaker:He does respond to the physical exam by crying and is moving all extremities
Speaker:appropriately, but otherwise is, you know, diminished and uninterested, and not
Speaker:really interacting with folks around him.
Speaker:He has significant respiratory distress with tachypnea, head bobbing, nasal
Speaker:flaring, tracheal tugging, as well as intercostal and subcostal retractions.
Speaker:He has audible stridor at rest.
Speaker:His lungs are clear on auscultation and coating his nares is a thick gray
Speaker:nasal discharge, which appears to be adherent to the mucus membrane.
Speaker:He has bilateral tonsillar hypertrophy with a thick gray layer extending
Speaker:over the bilateral tonsils and adherent to surrounding structures.
Speaker:And so all of this is also associated with some bilateral cervical lymph adenopathy.
Speaker:All right, so you guys get a lot of information.
Speaker:What do you think is going on at the moment?
Speaker:The first and most important thing always to do is to make an anatomic
Speaker:diagnosis, and it looks like this patient has a membranous pharyngitis.
Speaker:So, I think that with a case like this, it's important to kind of break your
Speaker:differential diagnosis down by setting.
Speaker:I think you would be thinking about different things based
Speaker:on where you are in the world.
Speaker:So if you are in the United States, the most likely cause of
Speaker:membranous pharyngitis in a high income country, especially in people
Speaker:who are vaccinated, is going to be EBV, um, sometimes Arcanobacterium
Speaker:hemolyticum can also cause, uh, a membranous pharyngitis like picture.
Speaker:But given that this child is unvaccinated, even if you were in a high income setting,
Speaker:you would definitely think about something like diptheria, which is kind of the
Speaker:classic cause of a membranous pharyngitis.
Speaker:Um, and, you know, taking a step back, this patient is very, very sick.
Speaker:Really critically ill.
Speaker:So before you do this throat exam and find these kind of like very particular
Speaker:findings, you also need to consider other causes of really significant respiratory
Speaker:distress or severe respiratory distress, especially in the context of the stridor.
Speaker:Um, and in that case you might be thinking about croup.
Speaker:Obviously this is a very severe presentation for something like croup,
Speaker:which would make you think about like a community acquired bacterial
Speaker:tracheitis, which as most people are aware, is caused by Staph aureus.
Speaker:You would al also think about something like epiglottitis, um,
Speaker:which in the United States is more likely to be caused by a nontypeable
Speaker:H flu, um, or another organism.
Speaker:But, you know, outside the US where vaccination coverage is still
Speaker:low, Hib would still be what you would be thinking about there.
Speaker:And then obviously you'd be thinking about pneumonia, severe viral infections that
Speaker:could be causing respiratory distress.
Speaker:Obviously, they don't perfectly fit with the picture and given the degree of
Speaker:illness here, the fact that the patient is minimally responsive, you might be
Speaker:thinking about a systemic bacterial infection of some kind, may be associated
Speaker:with the localized picture, um, uh, a sepsis or a meningitis type picture.
Speaker:I think that those are the things to really consider in a patient like
Speaker:this, but primarily with your physical exam, you're thinking about causes of
Speaker:membranous pharyngitis, and I'll turn it over to Adama to, to kind of talk
Speaker:about how we might approach a patient like this in a resource limited setting.
Speaker:Thank you so much.
Speaker:Thank you.
Speaker:I think I will not repeat all you said, taking into, into account the clinical,
Speaker:uh, aspects that has been presented.
Speaker:So in uh, the resource constrained setting, uh, people might think first
Speaker:about a severe respiratory infection, or, uh, something like a foreign body
Speaker:in the upper respiratory, uh, level or tonsillitis, throat infection, angina.
Speaker:So that's the first thing we might think of.
Speaker:But with the presence of, uh, a pseudomembrane, which is thick, and
Speaker:adherent, that is something not very common in the past year, but we might
Speaker:think about diphtheria with this outbreak in our area in West Africa.
Speaker:So that's something to think about.
Speaker:So it's very difficult in the resource, uh, constrained setting to have a clear
Speaker:diagnosis at first glance because of the limited test available, diagnostic
Speaker:test to have a, a clear diagnosis as compared to the developed world.
Speaker:Yeah.
Speaker:Those are all very good points.
Speaker:Adama, I think another really difficult aspect of managing cases like this
Speaker:in resource limited settings is going to be the fact that oftentimes even
Speaker:in referral hospitals and national reference centers, it's very hard
Speaker:to find mechanical ventilators.
Speaker:So patients who have severe respiratory distress, no matter what the
Speaker:cause, it can be very difficult to appropriately treat these patients.
Speaker:And at this point, I think it's important to reveal that this patient
Speaker:was actually seen in a resource limited setting, in West Africa, and part of
Speaker:the reason why he was clearly hypoxic and had severe stridor, um, but wasn't
Speaker:intubated is because there wasn't mechanical ventilation available.
Speaker:In the United States or in a resource rich setting, people always think about
Speaker:kind of croup versus bronchiolitis.
Speaker:It's really bad when you have stridor, which is indicative of an upper airway
Speaker:obstruction of some kind, in this case, probably related to the pseudo
Speaker:membrane of the patient, and you have hypoxia because that means that your
Speaker:airway is literally constricting.
Speaker:Mm-hmm.
Speaker:Um, and that is usually an indication for intubation and mechanical ventilation,
Speaker:um, in a resource rich setting, but in a setting, in West Africa, since those
Speaker:resources are not available, oftentimes the best you can do is just oxygen.
Speaker:Yeah.
Speaker:I think one more thing to add is the training.
Speaker:Even if the ventilator is available, people are not trained how to use
Speaker:this properly and to make a good surveillance of the patient that
Speaker:will be put on on ventilation.
Speaker:So, beside that, the training on how to, uh, make a good intubation.
Speaker:Yeah.
Speaker:So to clear the airway, uh, is not also something that is
Speaker:right on hand in our context.
Speaker:I would also add that, Adama, to add to what you just, um, said, an additional
Speaker:aspect to take into account is a monitoring that ventilation requires.
Speaker:And, to take it a step further, even if you have the machine and even if you have
Speaker:absolutely trained to do the intubation, and which in this case is very, of
Speaker:course, medically complex in any setting.
Speaker:Mm-hmm.
Speaker:Um.
Speaker:Uh, to be able to monitor a patient who is on ventilation, you need for
Speaker:capacity, for example, to do arterial blood gas measurements, which are not
Speaker:possible routinely, whether it's from lack of equipment or lack of reagents
Speaker:for the use of any available equipment.
Speaker:So those are additional limitations.
Speaker:So with that, we can talk a little bit about what our thought process was
Speaker:and has been during cases like this.
Speaker:So we talked about EBV being a potential cause.
Speaker:Membranous pharyngitis is a relatively rare manifestation of EBV.
Speaker:So if you see multiple cases of membranous pharyngitis in an
Speaker:unvaccinated population, especially in a resource limited setting, it's
Speaker:not likely to all be related to EBV.
Speaker:It's much more likely to be related to diphtheria, especially if you
Speaker:have confirmatory diagnostic testing for at least a few of those cases.
Speaker:And that's kind of what you know happened here.
Speaker:This patient was not formally diagnosed with diphtheria, uh, with lab testing,
Speaker:but given that there were multiple cases that happened around the same
Speaker:time in the context of a West African outbreak, the clinical diagnosis that
Speaker:was given to this patient was diphtheria.
Speaker:And with that, I think it's important to discuss some of the features of
Speaker:diphtheria, some of the things to look out for with diphtheria, some of the
Speaker:clinical manifestations . Um, and for that I will turn over to Dr. Tapia.
Speaker:All right.
Speaker:So diphtheria is caused by one of three Corynebacterium.
Speaker:That's Corynebacterium diptheriae, ulcerans, or, pseudotuberculosis.
Speaker:On gram stain you have a gram-positive pleomorphic rods that stain irregularly.
Speaker:They grow best on media containing sheep's blood and fosfomycin, or
Speaker:on, uh, Tindale medium, which is tellurite medium with cysteine.
Speaker:Only the strains containing the beta pro phage or related phages are toxigenic,
Speaker:and it's the expression of the toxin, um, is based on the nutritional environment.
Speaker:The toxin is composed of two subunits, an A and B sub unit, and it's the
Speaker:B sub unit that allows for entry in the A subunit, which exerts its
Speaker:toxic effect through inhibition of protein synthesis in the host cell.
Speaker:The toxin is highly expressed in the absence of iron and, the phage
Speaker:mediates production of toxin and can be transferred in vitro and in vivo.
Speaker:There are a number of clinical manifestations.
Speaker:One is nasal diphtheria, which occurs primarily in infants.
Speaker:And it begins as a cold and a thick membrane that develops.
Speaker:This is the less lethal form of the disease.
Speaker:There is tonsillar diptheria where it obviously affects the tonsils and pharynx,
Speaker:which can coexist with nasal diphtheria.
Speaker:It begins with one to two days of URI symptoms, followed by a pseudo membrane.
Speaker:The membrane can expand and extend into the larynx and
Speaker:trachea causing suffocation.
Speaker:Cervical lymphadenopathy is present and causes a bulls neck or obliterative edema.
Speaker:And this is the presentation that we're discussing here
Speaker:in the patient that we saw.
Speaker:There is also laryngeal diphtheria and cutaneous diphtheria and other
Speaker:manifestations include conjunctivitis, otitis media, and septic arthritis.
Speaker:It's important to note that there can be toxic complications of diphtheria.
Speaker:So in addition to these presentations, which can be
Speaker:very acute and life-threatening.
Speaker:There can be additionally life-threatening complications, including myocarditis.
Speaker:That can begin, uh, week between two and six.
Speaker:Typically week two.
Speaker:Um, this can occur in 10% of children and up to a two-thirds of them
Speaker:can present with severe illness.
Speaker:The occurrence of this complication can be predicted based on the extent of the
Speaker:pseudo membrane, and a delay in antitoxin administration usually increases the risk
Speaker:of this complication, and unfortunately there is a 50% mortality rate.
Speaker:There can also be neuropathies.
Speaker:Um, two out of three children with severe illness develop these and
Speaker:they occur typically three to six weeks after illness and can be motor,
Speaker:symmetric and indistinguishable from Guillain Barre syndrome.
Speaker:It's a pretty complex presentation sometimes and again can be very,
Speaker:very serious and life threatening.
Speaker:Yeah.
Speaker:So, it's important to, to discuss what we know about diphtheria now.
Speaker:Diphtheria was kind of an illness which was declining internationally.
Speaker:There used to be millions of cases in the 1980s, but we've seen a
Speaker:resurgence of diptheria primarily in regions that are war torn.
Speaker:Initially, like in Bangladesh, there was a huge outbreak in the
Speaker:late 2010s among the Rohingya, which were refugees from Myanmar.
Speaker:Then there was an outbreak in Yemen, and now currently there's
Speaker:an outbreak in West Africa.
Speaker:The latter outbreak is most likely related to declining vaccination
Speaker:coverage in the context of COVID-19.
Speaker:Um, but because a lot of previous outbreaks were in eras when
Speaker:we had less data, there was a paper, uh, that came out in 2020.
Speaker:Written by Sean Truelove.
Speaker:They attempted to look at outbreaks over the last 100 years to put together some
Speaker:of the major features of the illness.
Speaker:So they looked at like 7,000 articles.
Speaker:Ended up including about 800 articles, which spanned outbreaks over the
Speaker:last 100 years and determined the transmissibility of diphtheria, the
Speaker:case fatality rate overall, and multiple other features of the illness, which are
Speaker:important to note in an era when we see increasing transmission of the disease.
Speaker:What they determined is that the case fatality rate of
Speaker:diptheria is about 29% overall.
Speaker:Kids who are older are less likely to die.
Speaker:Kids who are vaccinated obviously are less likely to die.
Speaker:And those treated with antitoxin are significantly less likely to die.
Speaker:So the odds of someone dying after being given antitoxin is 0.24 in contrast
Speaker:to people who are not given antitoxin.
Speaker:The best way to protect yourself from diphtheria, obviously, is to
Speaker:have universal vaccine coverage.
Speaker:Having three doses of vaccination is 87% protective against illness.
Speaker:It's not 100% protective against illness.
Speaker:Unfortunately, developing natural infection does not confer
Speaker:immunity against diptheria.
Speaker:The typical schedule for diptheria vaccine is obviously the DTaP vaccine.
Speaker:So it's at two months, four months, six months, 15 to 18 months, and
Speaker:one dose at four to six years.
Speaker:Children can get the vaccine afterwards, especially in the context of an outbreak,
Speaker:the problem if you're greater than seven years old is if you get either
Speaker:Tdap or the Td containing vaccine.
Speaker:The amount of diphtheria antigen present in that vaccine is actually
Speaker:significantly lower than what's present in the DTaP vaccine.
Speaker:So the protective efficacy of that version of vaccine is not well described
Speaker:as opposed to the DTaP vaccine.
Speaker:As far as management of diptheria, there are two things that are critical.
Speaker:One is antitoxin, which reduces mortality by about 76%.
Speaker:And the second thing is antibiotics.
Speaker:Antibiotics reduce transmissibility.
Speaker:Antitoxin reduces mortality.
Speaker:The two are mutually exclusive.
Speaker:Antibiotics do not impact mortality.
Speaker:Antitoxin does not impact transmissibility, so the problem
Speaker:is in most cases where diptheria is still present antitoxin is not
Speaker:widely available, which leads to very, very high mortality rates.
Speaker:The other issue is that we, we have seen increasing resistance to penicillin,
Speaker:which was one of the first line treatments for diptheria to reduce
Speaker:transmissibility, making macrolides kind of the first line treatment.
Speaker:But macrolides, in some places where diptheria is present may not be as widely
Speaker:available as penicillin and may not be guaranteed by the government making
Speaker:it difficult to control transmission.
Speaker:The other thing is that infection control practices are, are, are
Speaker:difficult to enforce, especially in resource limited settings.
Speaker:So if kids are in an open unit.
Speaker:You can't really enforce droplet transmission precautions, and that kind
Speaker:of makes it easy for the disease to spread even in the hospital setting.
Speaker:Now, the main points of diagnosis.
Speaker:So there are two things that you need to be able to do, especially in the
Speaker:context of a small number of cases.
Speaker:In an outbreak, it's a little different.
Speaker:But when you have a small number of cases, if for instance, someone
Speaker:presents to the hospital and you think that they have diptheria in the
Speaker:context of the United States, you need to be able to isolate the organism.
Speaker:So you take a swab and you want to get either on the tonsils or around the
Speaker:pseudo membrane, and then send that swab for culture and actually grow it.
Speaker:And then demonstrate phenotypic toxin production through
Speaker:something called the Elek Test.
Speaker:Now, the problem is that the Elek test requires antitoxin as one of its reagents.
Speaker:If you don't have antitoxin, which is the case in many resource limited
Speaker:settings, it can be very difficult, um, to actually perform the Elek test.
Speaker:So you have no evidence of phenotypic toxin production in that setting.
Speaker:Also, if you don't have great microbiologic capacity in
Speaker:your country, it can also be difficult to culture the organism.
Speaker:And keep in mind that many of these patients get pretreated.
Speaker:So if they're very sick at the time of presentation to another
Speaker:hospital, then they may get antibiotics as soon as they show up.
Speaker:So their culture will be sterile by the time that they present to a hospital
Speaker:where the test is actually performed.
Speaker:So another way that you can make the diagnosis theoretically,
Speaker:is through the use of PCR.
Speaker:The problem with PCR is that you can get what looks like a toxigenic
Speaker:Corynebacterium diphtheriae, but the presence of the toxigenic gene
Speaker:doesn't actually mean that the toxin is expressed phenotypically.
Speaker:So Elek testing actually tells you whether or not the isolate is phenotypically
Speaker:producing toxin, but PCR can give you an idea of whether or not toxin is
Speaker:present in the isolate, doesn't tell you whether or not it's actually expressed.
Speaker:So it's kind of challenging.
Speaker:You need to demonstrate phenotypic toxin production, but if you don't have
Speaker:the ability to culture, you can't do that, so sometimes PCR is all you have.
Speaker:And only toxigenic diptheria can produce the manifestations
Speaker:that we're talking about.
Speaker:Non toxigenic Cornyebacterium diphtheriae can produce other things
Speaker:like myocarditis, conjunctivitis, the things that we were discussing,
Speaker:especially in immunocompromised patients, but only toxigenic diphtheria
Speaker:can produce this aggressive tonsillar disease that we're talking about.
Speaker:So in the context of just a few cases, culture is vital.
Speaker:But in the context of an outbreak, you either have to use PCR knowing that it's
Speaker:an imperfect surrogate for culture, or you have to make the clinical diagnosis.
Speaker:In Mali, oftentimes the clinical diagnosis is all we have.
Speaker:Most of our patients were pretreated with antibiotics, and about 52 patients
Speaker:were ultimately tested, but only one or two had positive cultures.
Speaker:Whereas when we use PCR, we find we found higher positivity rates.
Speaker:So that is kind of like a primer on the diagnosis of diptheria.
Speaker:It would be good to talk a little bit about antitoxin, and its
Speaker:restricted availability in the region.
Speaker:And I, I think Adama maybe if, if you could talk about that.
Speaker:Yeah, it's very sad.
Speaker:It's very heartbreaking hearing that 76% would have been saved
Speaker:if antitoxin, uh, were available.
Speaker:So that's something that, uh, uh.
Speaker:Is, uh, making me very, very sad.
Speaker:You know, over 50 suspected cases that have been identified in Malian
Speaker:Bamako here, at Gabriel Toure.
Speaker:All of them unfortunately died.
Speaker:So that's very, very sad because the anti-toxin is
Speaker:not available in the country.
Speaker:The only thing that we were able to implement is, uh, the vaccination
Speaker:around, uh, each suspected case, but the case themself, we were not
Speaker:able to save them with something that is available elsewhere.
Speaker:So that's really, uh, a big challenge.
Speaker:So, we also mentioned some of the challenge, that's the vaccine coverage.
Speaker:Recently, Anna Roose and a team in Mali here.
Speaker:They publish on vaccine coverage after rotavirus vaccine introduction
Speaker:in our national immunization.
Speaker:So the vaccination coverage is really low, below what is
Speaker:expected to be the acceptable one.
Speaker:So it was around 86% vaccine coverage.
Speaker:So with the Covid pandemic and vaccine hesitancy, public unrest
Speaker:within the country, within the region, all these contribute to
Speaker:this decreased vaccine coverage.
Speaker:So making more vulnerable people, uh, and children, subject to
Speaker:this preventable disease.
Speaker:I wonder if, do you guys think it would be helpful to talk about
Speaker:management of household contacts?
Speaker:Like Adama when with these patients, caretakers, relatives, other members,
Speaker:did you provide antibiotics to those?
Speaker:Is that something that was considered.
Speaker:Yeah, absolutely.
Speaker:It's really important to prevent the spread of the disease by
Speaker:preventive antibiotics and vaccination of the close contact.
Speaker:So this patient, the route from their home to the health facility, the final
Speaker:endpoint, is really sometime long.
Speaker:They pass by several parts.
Speaker:Some are seen by traditional healers.
Speaker:Some go to, uh, CSComs (Centres de Santé Communauté) level.
Speaker:CSComs is the first level of the overall health system, so there are a lot of
Speaker:contact to be monitored, to be treat.
Speaker:So looking at the resource that is need for that and the,
Speaker:movement of the, the people in the country, it's really difficult.
Speaker:It's really very challenging to get hand on all the potential contact and
Speaker:prevent the spread of the illness.
Speaker:This approach is used for some of the suspected case administration
Speaker:of antibiotic and vaccination, but it's not done for all, unfortunately.
Speaker:Yeah,
Speaker:And just to piggyback off of that, um, the Red Book actually has
Speaker:recommendations on how to manage, uh, diptheria and diptheria exposure.
Speaker:First of all, the, the, the primary thing that you need to do.
Speaker:This is why cultures are so important.
Speaker:You need to document elimination of toxigenic strains.
Speaker:Um, so you need two consecutive negative cultures, taken 24
Speaker:hours apart after therapy.
Speaker:You also need to assess everyone in the household and close contacts, to see if
Speaker:they're carriers of toxigenic strains.
Speaker:All close contacts should also receive antimicrobial prophylaxis with either
Speaker:oral erythromycin or penicillin.
Speaker:Um, and if they're carriers, then they need to be treated.
Speaker:Those patients who are carriers need to be treated for 10 to 14 days with oral
Speaker:erythromycin or, or azithromycin for five days, or one dose of IM penicillin.
Speaker:Now that's what the Red Book says.
Speaker:Given that globally there are increasing resistance rates to penicillin.
Speaker:The WHO recommends macrolide antibiotics for diptheria period over penicillin.
Speaker:Um, if you are a carrier, just like someone who has been treated, you need
Speaker:two consecutive negative cultures.
Speaker:If you're still positive, you need an additional 10 days of oral erythromycin.
Speaker:All patients need to be on droplet precautions until they've completed
Speaker:therapy and they're culture negative.
Speaker:And then all close contacts, in addition to being tested for active
Speaker:surveillance and getting antibiotic prophylaxis to, you need to have
Speaker:seven days of active surveillance.
Speaker:Everyone who's a close contact needs to receive a dose of DTaP, T dap or
Speaker:Td. So just, um, some things to keep in mind, uh, with regards to people
Speaker:who are, um, exposed to the disease, especially in a high resource setting.
Speaker:Now, I think we've also discussed the West Africa outbreak a lot.
Speaker:And I think it's important to put some numbers around it.
Speaker:We've had around 40,000 cases of diptheria throughout the West African region.
Speaker:The outbreak, I think, began in Mauritania.
Speaker:And then spread to regional countries.
Speaker:Um, there's probably significant undercounting the number of cases
Speaker:because most of this number is based on cases that are actually confirmed.
Speaker:Um, so as we discussed, it can be very hard to confirm a case of diptheria
Speaker:in a resource limited setting.
Speaker:Um, and we don't have great ideas of what the mortality rate is, but.
Speaker:You know, at least in a place like Mali, while we don't have the same numbers as
Speaker:in places like Nigeria, the mortality rate for confirmed cases has been very, very
Speaker:high because of the lack of antitoxin.
Speaker:I'll take another opportunity to ask Adama about unvaccinated children, period.
Speaker:So the reasons for unvaccinated children in the United States
Speaker:are different from unvaccinated children in a country like Mali.
Speaker:And I think that, you know, it is very uncommon to actually have unvaccinated
Speaker:children in Bamako, whereas it is much more common in rural areas.
Speaker:And I think what, um, Adama brought up is that the route that a baby takes
Speaker:to get to us in Bamako can be long.
Speaker:And he brought that up, but I don't know that he actually highlighted the fact
Speaker:that many of the cases that we saw in Bamako were actually from rural areas.
Speaker:Yeah.
Speaker:Um, and so maybe, um, Adama, if you could just talk a little bit more about zero
Speaker:vaccination, zero vaccinated babies.
Speaker:And that's actually, I forget what the term is now, Sara, but there is
Speaker:a term now in public health looking at zero that the zero vaccine
Speaker:babies or something like that.
Speaker:Mm-hmm.
Speaker:There's a term in public health.
Speaker:It's a zero dose targeting.
Speaker:Zero, yeah.
Speaker:Zero dose, thank you.
Speaker:Zero dose.
Speaker:Mm-hmm.
Speaker:Yeah.
Speaker:I think, uh, we have a lot of zero dose in in Bamako in a area
Speaker:where we found some suspected case of diphtheria in common six.
Speaker:So, but as you mentioned, most of the case were coming from the rural area outside
Speaker:Bamako, and all of them did not have the diphtheria vaccine previously or have a
Speaker:s reported by the parents few, uh, doses.
Speaker:So yeah, it's really important to have the zero dose number, the
Speaker:vulnera vulnerability of the children.
Speaker:So yeah, there are some project now working on that.
Speaker:I hope that will con to reduce the zero dose within our uh, region.
Speaker:Usually people, uh, said in our culturally that you will not die
Speaker:before the day you set with God.
Speaker:But, uh, we are seeing that people are dying before that day in our country and
Speaker:for something that is really preventable.
Speaker:So I think we need to resolve basic medical need all around the
Speaker:world to have equity in access of, uh, basic medical needs.
Speaker:Thank you.
Speaker:Thanks to Sumanth, Adama and Millie for joining us today.
Speaker:This is part of a series of vaccine preventable illness topics.
Speaker:Don't forget to check out episode 1 0 2 called Rubeola Response, as
Speaker:well as our last episode of Febrile entitled Old Scourges, New Surges.
Speaker:You can find more info on the website febrile podcast.com, where
Speaker:we have the Consult Notes, which are written supplements to the
Speaker:episodes with links to references, our library of ID infographics,
Speaker:and a link to our merch store.
Speaker:Febrile is produced with support from the IDSA, Infectious
Speaker:Diseases Society of America.
Speaker:Please reach out if you have any suggestions for future shows or want
Speaker:to be more involved with febrile.
Speaker:Thanks for listening.
Speaker:Stay safe and I'll see you next time.
