Comparison of Diphtheria Cases in Children Before and During the Pandemic Era in Surabaya, Indonesia: A Study of Six-Year Data.

Introduction Indonesia has a high incidence of diphtheria, especially in children. Surabaya has become a government regional reference center, as it is the capital of East Java province, which has the highest rate of diphtheria across the 38 regions. The aim of this study is to report our six-year pediatric diphtheria data, focusing on comparisons between before and during the pandemic era. Method This surveillance report was collected from community health centers and hospitals throughout Surabaya from January 1, 2017 to December 31, 2022. Collected data included demographic characteristics, clinical and laboratory aspects, the health centers, immunization history, and management. As per Indonesian guidelines, the diagnosis of diphtheria in this country requires a positive microbiological culture or approval from the National Experts on Diphtheria Committee. Results In total, there were 112 cases, of which 89 were found before the pandemic era. Although the number of cases declined during 2020-2022, the predominant age group, the immunization status, and the most common type of diphtheria remained consistent with pre-pandemic trends. Most cases had incomplete immunization or unimmunized children (67.8%), with the age group of 5-12 years old (44.6%), and with tonsillar diphtheria (83%). The case fatality ratio was 1.8%. Regarding the biovar of Corynebacterium diphtheriae, gravis is the most frequent finding. Conclusion The incidence of diphtheria cases in children in Surabaya was significantly lower during the pandemic. Although immunization coverage was not better, preventive measures during the pandemic may have played a role. Most patients did not have complete immunization histories during the study period, and the predominant type was tonsillar diphtheria. Since the trend in 2021-2022 increased, routine surveillance is essential.

Impact of a three-dose diphtheria outbreak response immunization in East Java, Indonesia, 6 months after completion.

Several outbreaks of diphtheria have occured in the East Java Province of Indonesia since 2011. The last effort to stop the outbreak in the province was a three round outbreak response immunization (ORI) in 2018.The aim of the this study was to evaluate the impact of the 2018 ORI in East Java province - 6 months following the completion of the program. Surveillance data was collected for 6 month period, from January to June 2019. The source of data was the district health offices, hospitals, community health centers, and private physician and paramedic practices. The data included demographic characteristics, involved health facilities, patient immunization history, clinical signs and symptoms, some laboratory test results and other additional examinations. All cases were evaluated by the East Java Provincial Diphtheria Expert Committee and not based on the individual physician decision. During the 6 month period, there were 97 diphtheria cases which approved by the Diphtheria Expert Committee. The reports came from 36 of 38 districts. One patient died, denoting a case fatality rate of 1%. The majority were 19 years of age or less, with uncomplete immunization. Patients above 19 years were 24%. Compared with 2017 (438 cases) and 2018 (310), 2019 saw a significant reduction in the number of reported cases. Only 4 positive culture results were collected (positivity rate 4,13%). Two patients had Mitis subtype and the other two had Gravis subtype. Diphtheria ORI in East Java had a significant impact during the first 6 months of 2019.

An evaluation of the clinical features of measles virus infection for diagnosis in children within a limited resources setting.

BACKGROUND: Measles is a recurrent health problem in both advanced and developed countries. The World Health Organization (WHO) recommends anti-measles immunoglobulin M (Ig M) as the standard method of detecting the virus; however, many areas still present the inability to perform a serology test of anti-measles IgM. Therefore, a typical clinical feature is necessary to establish the diagnosis of measles. The objective of this study was to evaluate hyperpigmented rash and other clinical features as the diagnostic tools with respect to measles, especially in an outbreak setting. METHODS: In this observational diagnostic study, the inclusion criteria were as follows: between 6 and 144 months of age, fever, maculopapular rash for 3 days or more, accompanied by a cough, or coryza, or conjunctivitis. Those with a prior history of measles vaccination (1-6 weeks) were excluded, in addition to those with histories of corticosteroid for 2 weeks or more and immunocompromised conditions. The samples were taken from Dr. Soetomo General Academic Hospital in Surabaya, Indonesia. We evaluated the sensitivity, specificity, the positive predictive value, and the negative predictive value of such clinical features. Hyperpigmented rash was validated using Kappa and Mc Nemar tests. Anti-measles Ig M was considered as the gold standard. RESULTS: This study gathered 82 participants. The clinical manifestations of all subjects included fever, cough, coryza, conjunctivitis, Koplik spots, and maculopapular rash (which turns into hyperpigmented rash along the course of the illness). Most maculopapular rashes turn out to be hyperpigmented (89%). Sensitivity, specificity, positive predictive value, and negative predictive values ​​of the combination of fever, maculopapular rash, and hyperpigmented rash were found to be at 90.7, 28.6, 93.2, and 22.2%, respectively. The Mc Nemar and Kappa tests showed p values of 0.774 and 0.119, respectively. CONCLUSION: The combination of fever, maculopapular rash, and hyperpigmented rash can be used as a screening tool regarding measles infection in an outbreak setting, which can then be confirmed by anti-measles Ig M. Cough, coryza, and Koplik's spot can be added to this combination, albeit with a slight reduction of sensitivity value.

First-line antibiotic susceptibility pattern of toxigenic Corynebacterium diphtheriae in Indonesia.

BACKGROUND: Diphtheria has been reported as an outbreak in some regions in Indonesia, most especially in East Java Province. Resistance to penicillin, erythromycin, and other antibiotics, single or multiple, has been reported in several studies. This study aims to evaluate the first-line antibiotic susceptibility pattern of toxigenic Corynebacterium diphtheriae isolates. METHODS: This descriptive observational study was performed from August to November 2018. C. diphtheriae isolates were collected from diphtheria patients and carriers in East Java from 2012 to 2017 and kept at the Balai Besar Laboratorium Kesehatan Daerah Surabaya or the Public Health Laboratory of Surabaya. Sample selection was done by random cluster sampling. The sensitivity test by E-test®of the five antibiotics (penicillin, oxacillin, erythromycin, azithromycin, and clarithromycin) was done to determine the minimum inhibitory concentration (MIC). The Clinical and Laboratory Standards Institute M45A (2015) Corynebacterium spp. for penicillin and erythromycin was used as standard. RESULTS: From 114 targeted isolates, 108 were viable and toxigenic. The E-test was performed on the viable isolates. The majority of the hosts were male (58.3%), with median (range) age of 6.5 (1-14) years. Half of the samples were from the 1 to 5-year-old age group. The isolates were acquired much more from patients (78.7%) than carriers (21.3%) and from pharyngeal swab (74.1%). Most of these isolates were from Madura Island (47.2%) and the northern and eastern parts of the province (horseshoe area). Mitis isolates were the major variant (76.9%). The susceptibility pattern of C. diphtheriae to erythromycin was better than that to penicillin. The E-test result for penicillin was 68.52% susceptible, 31.48% intermediate, and 0% resistant (MIC range, < 0.016 to 2 µg/L) and for erythromycin (MIC range, < 0.016 to > 256 µg/L) was 85.2% susceptible, 12% intermediate, and 2.8% resistant The MIC range for oxacillin was 1 to 96 µg/L, while for both azithromycin and clarithromycin were <  0.016 to > 256 µg/L. CONCLUSION: The susceptibility rate of C. diphtheriae to erythromycin is higher than that to penicillin. The regular update of antibiotic selection to the national guidelines is recommended. The MIC reference standard to azithromycin and clarithromycin is also needed.

Uncommon Pathogen Bacillus Cereus Causing Subdural Empyema in a Child.

BACKGROUND: Subdural empyema (SDE) in children is a severe intracranial infection. Many pathogens can cause SDE. CASE DETAILS: In this articlewe present a 15-month old Indonesian boy diagnosed as SDE based on the clinical symptoms and neuroimaging. A complete blood count showed white blood cell count of 13.800/mm3 and the CRP level was 8.3 mg/L. Craniotomy following burr hole drainage procedure was performed to decrease intracranial pressure. The liquor culture indicated Bacillus cereus. A meropenem injection and metronidazole infusion were administered appropriately with antibiotic sensitivity for several weeks. Immediate initiation of appropriate antibiotic therapy related to an accelerated surgical drainage can improve the outcome. CONCLUSION: The combination of medication and surgery treatment for Bacillus cereus in SDE resulted in a good response, leaving neurological sequelae.