Rapid risk assessment: A fatal case of diphtheria in Belgium, 30 March 2016

risk assessment
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European Centre for Disease Prevention and Control. A fatal case of diphtheria in Belgium, 24 March 2016. Stockholm: ECDC; 2016.

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​On 17 March 2016, Belgian authorities reported a fatal case of toxigenic respiratory diphtheria through the Early Warning and Response System.

This rapid risk assessment describes the epidemiological situation of diphtheria surrounding this case of toxigenic respiratory diphtheria and lists public health options aimed at resolving the acute shortage of diphtheria antitoxin, improving the knowledge required to promptly recognise and treat diphtheria, and tackling the issue of non-vaccination against diphtheria in the EU/EEA.

Executive summary

​Universal immunisation with diphtheria toxoid-containing vaccine is the only effective preventive control measure for diphtheria, concludes ECDC Rapid Risk Assessment following a fatal case of diphtheria reported in a three-year-old unvaccinated child in Belgium. A range of actions are therefore important to reduce the risks associated with non-vaccination against diphtheria, as well as with limited access to the diphtheria antitoxin in the EU. 

The disease 
Diphtheria is a transmissible bacterial disease primarily infecting the pharynx, larynx, tonsils and nose. It is transmitted via droplets during close contact.
Vaccination against diphtheria is included in all immunisation schedules in the EU/EEA Member States. It is offered as part of primary vaccination during the first year of life and subsequent boosters later during childhood and adolescence. The reported vaccination coverage among children in the EU/EEA is >95%.
Between 2009 and 2014, 140 cases of diphtheria have been reported to the ECDC in the EU/EEA, with an increase since 2011.The overall case–fatality rate for diphtheria is 5 to 10%, with higher death rates of up to 20% among persons younger than 5 and older than 40 years of age.  Successful treatment of diphtheria depends on rapid administration of equine diphtheria antitoxin in combination with antibiotics.

ECDC threat assessment
Cases of diphtheria are not unexpected among unvaccinated individuals since exposure to the causative agent of diphtheria may occur among travellers to, or those with social connections to, endemic countries.
While the diphtheria case in Belgium does not currently represent a serious cross-border threat to health in the EU, it is a matter of concern in light of the limited availability of diphtheria antitoxin across the EU/EEA Member States.

Options for EU and EEA Member States
In support to the EU/EEA Member States, ECDC risk assessment identifies a number of options for reducing the risks associated with non-vaccination against diphtheria, as well as with the limited access to the diphtheria antitoxin in the EU, such as:
 

  • Ensure that clinicians have the knowledge required to promptly recognise and treat diphtheria 
  • Ensure that laboratories have provisions to confirm toxigenic diphtheria infections
  • Assess the level of access to diphtheria antitoxin and consider transnational options for securing rapid access to it
  • Advise travellers to diphtheria-endemic countries to check if diphtheria vaccination or a booster dose is required prior to the travel
  • Promote and monitor access to immunisation

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