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Diphtheria Outbreak in Makkah City.


Nine cases of suspected Diphtheria were reported from Makkah city in 2012, after a gap of 6 years. Due to this unusual clustering of this rare illness, team was sent from MOH to investigate the outbreak and suggest recommendations for control and future prevention.


During the investigation files of suspected cases in treating hospitals and Department of Preventive Medicine were reviewed; verbal autopsy were performed during house visits; throat swabs were collected from households around the residence of diphtheria cases for detection of C. diphtheria; Physicians who managed the patients were interviewed; vaccination record of PHCCs of case residence was reviewed; and facilities were reviewed in Laboratories who handled the specimens. As part of an exploratory study 303 throat swabs were collected from children below 12 years and above 18 years residing in areas which reported the cases and analyzed for presence of C. diphtheriae.


Out of 9 suspected cases, 6 were confirmed clinically (only one confirmed by laboratory) with a delay of 2-13 days between onset of disease and admission. Only 3 of them received diphtheria antitoxin although with a delay. All of confirmed cases died. None had history of diphtheria vaccination or contact with a known case. No clear SOP existed for handling suspected diphtheria specimens in Public Health Laboratory of Makkah. C. diphtheriae was not isolated from any of the throat swabs collected from Makkah residents. Review of vaccination record revealed a number of deficiencies for dealing with "non-eligible" children.


There was a clear evidence of clustering of diphtheria cases in Makkah in 2012. Delayed or non-availability of diphtheria antitoxin compounded with delayed arrival of patient to hospital and delayed suspicion of diphtheria were major contributors to very high mortality rate among clinically confirmed cases. Use of antibiotics before taking samples, delayed suspicion of diphtheria at treating facility, inadequate diagnostic facilities in laboratories and lack of clarity in destination of laboratory specimens contributed to low isolation and identification of C. diphtheria. Vaccination program for diphtheria and other EPI diseases should put additional focus on illegal residents and diagnostic facilities for diphtheria need to be enhanced in Makkah.