Diphtheria

Department of Public Health

and Preventive Medicine
14-09-2019
 Aetiopathogenesis
• Bacterial disease caused by Gram Positive
Corynebacterium diphtheriae
• Exotoxin producing bacteria

• Humans are the only known reservoir of C.diphtheriae

• High case fatality (>10%) in endemic areas

Corynebacterium Diphtheriae
 Diphtheria
An illness characterized by laryngitis or pharyngitis or tonsillitis, and an
adherent membrane of the tonsils, pharynx and/or nose.

Standard Case Definition

Suspected Sore throat, mild fever, greyish white non adherent
membrane in throat
Probable Upper Respiratory Tract illness with an adherent
membrane of the nose, pharynx, tonsils, or larynx
Confirmed case a. Laboratory confirmed case from a clinical
specimen or greater rise of the antibody in the
serum
b. Linked epidemiologically to the lab confirmed
case.
 Transmission and Communicability
• Person to person spread
• droplet (airborne)
• direct contact with respiratory secretions
• rarely through discharges from skin lesions

• Incubation period
• Average 1-5 days (Range: 1-10 days)

• Period of infectivity
• 2 weeks from onset
• antibiotic therapy promptly terminates shedding
• chronic carriers may shed organisms for 6 months or more
 Occurrence and Reservoir
• Diphtheria has almost disappeared from developed
countries due to high immunisation coverage but exists
in countries with low immunisation coverage

• Transmission to susceptible individuals mostly leads to

transient pharyngeal carriage rather than disease

• Pre-school and school-age children are most commonly

affected in endemic countries
 Who are at Risk?
• Children under 5 years and adults over 60 years old
• People living in crowded or unclean conditions
• Under nourished children
• Children and adults who are not immunized including
booster doses
• Children who had history of travel to endemic areas or
history of exposure to children travelled in from
endemic areas
 Diphtheria cases in India
Diphtheria in Children 0-5 Years of Age
State
2017-18 2018-19
A & N Islands 0 0
Andhra Pradesh 0 125
Arunachal Pradesh 34 7
Assam 0 2
Bihar 133 185
Chandigarh 25 17
Chhattisgarh 101 127
Dadra & Nagar Haveli 0 0
Daman & Diu 0 2
 Diphtheria cases in India
Diphtheria in Children 0-5 Years of Age
State
2017-18 2018-19
Delhi 138 189
Goa 0 1
Gujarat 271 69
Haryana 4 2
Himachal Pradesh 11 0
Jammu & Kashmir 69 6
Jharkhand 62 75
Karnataka 47 135
Kerala 48 22
 Diphtheria cases in India
Diphtheria in Children 0-5 Years of Age
State
2017-18 2018-19
Lakshadweep 0 0
Madhya Pradesh 163 202
Maharashtra 11 22
Manipur 13 0
Meghalaya 0 3
Mizoram 0 5
Nagaland 0 0
Odisha 0 0
Puducherry 18 0
 Diphtheria cases in India
Diphtheria in Children 0-5 Years of Age
State
2017-18 2018-19
Punjab 18 34
Rajasthan 503 3,113
Sikkim 0 0
Tamil Nadu 1 0
Telangana 91 272
Tripura 3 0
Uttar Pradesh 3,676 2,631
Uttarakhand 3 0
West Bengal 119 9
 2017
2016

Diphtheria, Pertussis and Neonatal Tetanus Cases in Kerala

 VPD cases Kerala 2015-2017
Neo natal Neo natal
Measles Measles Diphtheria Diphtheria Pertussis Pertussis
Year Tetanus Tetanus
Cases Deaths Cases Deaths Cases Deaths
Cases Deaths

2015 2407 3 62 2 161 0 0 0

2016 1627 4 602 2 86 1 0 0

2017 919 1 518 8 80 0 0 0

TOTAL 4953 8 1182 12 327 1 0 0

Age distribution of Diphtheria Cases
2016 2017

< 2 Years
2 to 5 years
5 to 10 years
> 10 years
Immunisation Status of Diphtheria Cases
2016 2017
Immunisation Coverage x Diphtheria Cases
 Public Health Significance
• Occurrence of diphtheria cases reflects inadequate
coverage under the routine immunization programme
including DPT 1st Booster and 2nd Booster
• Helps to identify pockets of susceptible individuals

• Aggressive efforts should be made to improve

immunization coverage
 Public Health Significance
• Epidemiological surveillance ensuring early detection of
diphtheria outbreaks, with laboratory facilities for
diagnosis essential
• to guide control measures at local level
• to assess the progress and impact of vaccination programme
• to generate data to formulate vaccination strategies
Clinical features
• Mostly asymptomatic or mild clinical course

• Natural Infection does not confer any immunity

as in the case of Tetanus

• Respiratory diphtheria
• moderate fever
• exudative pharyngitis
• sore throat and difficulty in swallowing
 Greyish White Pseudomembrane
• tonsils, pharynx, larynx, nasal or any combination
• bleeds on attempt to dislodge
• The pseudo-membrane may progressively extend into
the larynx and trachea and cause airway obstruction
• laryngeal diphtheria is medical emergency: may
require tracheostomy
Other associated Signs and Symptoms
• Dysphagia: difficulty in swallowing
• Difficulty in breathing
• Headache
• Change of voice: hoarseness
• Nasal regurgitation, pooling oral secretions
• Sero-sanguineous nasal discharge
• Cyanosis and shock
Complications
 Complications
• Bull Neck Diphtheria
• massive cervical adenopathy
with oedematous swelling of
submandibular region and
surrounding areas
 Complications due to absorption of toxins
from the site of infection
• Cardiac complications (Upto 3rd week)
• Myocarditis
• Arrhythmias
• Cardiomyopathy
• Neurological complications (3rd week onwards)
• Bulbar dysfunctions: palatal, pharyngeal, laryngeal,
facial and oculomotor or ciliary paralysis
• Peripheral neuropathy
• Polyneuritis
 Complications due to absorption of toxins
from the site of infection

• Pneumonia occurs in >50% of fatal diphtheria

• Renal failure, encephalitis, cerebral infarction
and pulmonary embolism
• In infants
• Otitis media
• Respiratory insufficiency
 Laboratory diagnosis
• Culture of organism on special media containing
tellurite is gold standard test

• Toxigenicity test: Elek test

• Molecular test
• detection of regulatory gene for toxin production
• Screening of primary isolates for presence of
Diphtheria toxin gene
Sample Collection, Storage and Transportation

• Diphtheria and Pertussis are fastidious organisms

• Die quickly if samples are not stored or transported in
appropriate conditions
• Poor sample quality may result in
• false negative results
• wastage of resources
• improper case management and interventions
• blinding from the reality
 Laboratory Specimen for Diphtheria
Nasopharyngeal or pieces of
Type of specimen
membrane

Number of samples 2
One at admission and another a day
Frequency
before the discharge
Swab Nylon swab is preferred

Transport media Silica gel / Amies transport media

Storage and transportation 2-8 OC

Preferably bacterial Culture Should be done immediately

Control Measures in the event of the
occurrence of
Suspected / Clinical / Lab confirmed
Case of Diphtheria
Case Management
Components of Case Management

• Administration of Diphtheria Anti Toxin

• Antibiotic therapy
• Supportive Care
 General Principles
• Morbidity and mortality still high in developing countries
• Early treatment reduces complications and mortality
• Prompt initiation of therapy on clinical suspicion
• Don’t wait for laboratory results for initiating specific
therapy

• Collect specimen preferably prior to initiation of

treatment
• Patient should be kept in strict isolation
 Case Management
• Make sure the child or adult patient gets high quality
treatment in a Tertiary Care Centre
• Diphtheria Anti Toxin (DAT) should be made available
to the patient
• Crystalline Penicillin/ Erythromycin are the antibiotics
of choice for treating Diphtheria
• Appropriate samples to be taken for lab confirmation
 Antibiotic therapy for cases
• Antibiotics halt further production of toxins

• Drug of choice
• Crystalline Penicillin
• Erythromycin

• Advantages
• Limit further bacterial growth
• Limits carrier state
Limitation of Antibiotic therapy for cases
• No impact on already established toxin induced
lesions
• It is important to maintain high level of clinical
suspicion
• General Practitioners and ENT surgeons should
be sensitized to the possibility of Diphtheria
 Antibiotic therapy for cases
Antibiotic of Children Adult
Choice

Inj.Crystalline 1.5 lakh units Per Kg per 20 lakh IU x 6th Hourly

Penicillin (After day in four divided doses for 14 days
test dose)* 6th hourly for 14 days

Tab.Erythromycin 40 mg /kg/day in four Erythromycin 500 mg

divided doses 6th hourly 6th hourly for 14 days
for 14 days
 Administration of Diphtheria Antitoxin
• Mainstay of case management
• Reduces case fatality rates
• Hyper-immune antiserum produced in horse
• Administered Intramuscularly or intravenously after test dose
• Early administration recommended as it neutralizes free toxin
• Recommended dose
• Tonsillar diphtheria : 10,000 units
• Pharyngeal diphtheria : 40,000 to 60,000 units
• Extensive disease : 1,00,000 to 1,50,000 units
Administration of Diphtheria Anti Toxin
• Dose is same for children and adults
• Entire recommended therapeutic dose should
be administered as IV infusion diluted in 200 ml
to 500 ml of Normal saline after test dose over
4 hours at one time
 Method of giving Test Dose for
Diphtheria Anti Toxin
• Site selection: Right arm
• Choose a site 5 cm away from any other test site.
• Administer 0.02 ml of 1 in 100 dilution of the
Diphtheria anti toxin serum intradermally using
insulin syringe.
• The confirmation of Intradermal site is the raising of a
small wheal in the site.
• Draw a circle encircling the margin .
• Read at 15 minutes
 Method of giving Test Dose for DAT

Negative Control Test

• Raise a intradermal wheal using Normal saline 0.02
ml in the left arm 5 cm away from any other test.

• Read the test at 15 minutes

• There should be no reaction

Method of giving Test Dose for DAT

Positive Test Result

• A wheal with surrounding erythema at least 3mm
larger than the negative control test should be
considered as positive requiring desensitization.
 Instructions for Desensitization
If the test result is positive carry out desensitization
Be prepared to manage anaphylaxis
Keep a tray containing Adrenaline, Hydrocortisone, or
Methyl Prednisolone, IV fluids, ready by the side of
the Patient
IV line should be inserted for the patient and check
that it is patent.
The desensitization is carried IV.
 Preparation of dilutions of Diphtheria
Anti Toxin for desensitization
• 1ml DAT + 9 ml of NS* = 1:10 dilution
• 1 ml of 1in 10 dilution + 9 ml of NS = 1:100 dilution
• 1 ml of 1in 100 dilution + 9ml NS = 1:1000 dilution

NS* - 0.9% Normal Saline

Each dose should be administered at 15 minutes interval
At the end of desensitization full dose can be given IV over the next 2-4
hours.
Methodology of desensitization
Dose No Dilution of DAT in Normal Saline Amount of injection
1 1:1000 0.1cc
2 1:1000 0.3 cc
3 1:1000 0.6 cc
4 1:100 0.1 cc
5 1:100 0.3 cc
6 1:100 0.6 cc
7 1:10 0.1 cc
8 1:10 0.3 cc
9 1:10 0.6 cc
10 Undiluted 0.1 cc
11 Undiluted 0.2 cc
12 Undiluted 0.6 cc
13 Undiluted 1.0 cc
Administration of Diphtheria Anti Toxin
after Desensitisation

• At the end of Desensitization full dose may

be given IV over 2- 4 hours.

• Monitor the child for reaction.

 Close Monitoring
• Regular ECG to monitor cardiac manifestations –
conduction defects, arrhythmias
• Vitals

• Pulseoximetry

• Attention to airway
 Early interventions

• Pace maker for conduction disturbances

• Drugs for arrhythmias

• Tracheostomy or intubation to ensure continued patency

of airway
• Mechanical removal of tracheobronchial membrane
Indication for airway management

• Inspiratory stridor/ Fast Breathing

• Chest Indrawing
• Restlessness/Lethargy

• Cyanosis
 Shock Management
• Shock could be due to sepsis or cardiac cause.

• If no sign of cardiac failure or fluid overload (absence of

crackles at lung bases, hepatomegaly or oedema of

dependant parts) then give bolus of fluids - 10ml/kg of
NS monitoring the liver enlargement, basal crackles
 Shock Management

• If signs of cardiac failure are evident then

Ionotropes Dopamine/ adrenaline may be given
• Other Measures:
• If fever >38oC then Paracetamol 10-15mg/kg/dose
6th hourly
• If the child is stable encourage oral feeds
• If the child has difficulty in swallowing then NG tube
feeding may be given
Discharge Policy
 Discharge Policy – Lab Confirmed cases
1. Clinical Diphtheria and Culture Positive cases
• Clinically stable and free from Signs and Symptoms
• 14 days of Intravenous Inj.Crystalline Penicillin should have
been completed.
• On Day 13, Throat swab for culture should be taken. Culture
should be negative before discharge.
• Age appropriate Immunisation should be given as per Schedule
• DPT for children less than 7 years
• Td for children more than 7 years and Adults
 Discharge Policy - Probable case
2. Clinical Diphtheria and Culture Negative cases
• Clinically stable and free from Signs and Symptoms
• 14 days of Intravenous Inj.Crystalline Penicillin should have
been completed.
• On Day 13, Throat swab for culture should be taken. Culture
should be negative before discharge.
• Age appropriate Immunisation should be given as per Schedule
• DPT for children less than 7 years
• Td for children more than 7 years and Adults
 Discharge Policy - Suspected Case

3. Suspected case and Culture Negative

• Clinically stable and free from Signs and Symptoms
• Minimum 7 days of antibiotics should have been given
• Age appropriate Immunisation should be given as per
Schedule
• DPT for children less than 7 years
• Td for children more than 7 years and Adults
 Follow up after discharge from
Tertiary Care Hospital
General Instructions
• All the Diphtheria cases should be followed up for
three weeks after discharge
• Follow up should be on daily basis
• Follow up should be done by MO-PHC/ MMU MO/School
Health Team MO and area VHN/HI/SHN/CHN
• Admit those who show cardiac or neurological
complications
 Follow up after discharge from
Tertiary Care Hospital
Week Location Frequency

First week In UG PHC Four times in a day

Second Week At Home Twice in a day

Third Week At Home Once in a day

 1st week after discharge from
Tertiary Care Hospital

• Admit in an Upgraded PHC closer to the

residence of the child

• Doctors and nurses should follow up atleast

four times in a day following the protocols

 1st week after discharge follow up in UG PHC
Ask Palpitation
Regurgitation of Feeds
Decrease in Voice volume
Feel Pulse
• Irregular
• Increased Heart Rate
Look Asymmetrical palatal movement or
decreased Palatal movement
Act Refer for admission at Medical College
Hospital
 2nd week after discharge
Twice Daily Home Followup
Ask Palpitation
Regurgitation of Feeds
Decrease in Voice volume
Feel Pulse
• Irregular
• Increased Heart Rate
Look Asymmetrical palatal movement or decreased
Palatal movement
Act Refer for admission at Medical College
Hospital
 3rd week after discharge
Once Daily Home Followup
Ask Palpitation
Regurgitation of Feeds
Decrease in Voice volume
Difficulty in moving limbs
Double vision
Respiratory distress
Feel Pulse
- Irregular
- Increased Heart Rate
Flaccid limbs
 3rd week after discharge
Once Daily Home Followup
Look • Asymmetrical palatal movement or
decreased Palatal movement
• Fast breathing/ Chest indrawing
• Squint/ Lack of eye movements
Act Urgent and Immediate admission at
Medical College Hospital
Outbreak Investigation,
Response and Control
 Outbreak Definition
• An outbreak is defined as the occurrence of an illness in
the community, clearly in excess of the expected
numbers.
• When an out break covers a larger geographical area and
more than one focal point, it is referred to as an
epidemic
• Outbreaks are defined differently for different Vaccine
Preventable Diseases
Even a single case is considered as an
outbreak for
• Diphtheria

• Polio

• Japanese Encephalitis

• Pertussis
 Even a single case of
Neonatal Tetanus
indicates the inadequacies in
immunisation programme
Active Case Search (ACS)
 Active Case Search is done in
response to identification of
clinically suspected or
clinically/ lab confirmed case of
Diphtheria
 Benefits of Active Case Search (ACS)
in the community
• High probability of finding additional cases among
contacts due to high secondary attack rates
• Prevents possible outbreak by identification of
clustering of cases and timely intervention
• Generate awareness in the community

• Increases visibility and acceptability of the program

 Case definition (WHO)
A suspected case of diphtheria is
defined as:
• An illness of upper respiratory tract
characterized by the following:
• Laryngitis or pharyngitis or tonsillitis
and
• Adherent membranes of tonsils, pharynx
and/or nose.
• Date of onset: Day of onset of fever with sore
throat
 Adherent membrane
• Pseudomembrane: confluent, sharply demarcated
membrane, tightly adherent and dark grey in color
• Initially isolated spots of grey or white exudate in tonsillar and
pharyngeal area
• Spots coalesce within a day to form pseudo-membrane that becomes
progressively thicker
• Extends beyond margins of tonsils into tonsillar pillars,
palate and uvula
• Streptococcal infection: white membrane limited to tonsillar area
• Dislodging of membrane likely to cause severe bleeding
 Active Case Search (ACS)
• ACS should be conducted within 24 hours of
reporting of suspected / clinical / laboratory
confirmed case

• Proper micro planning is essential

 Active Case Search in the Community
• Since Diphtheria can occur in any age it is always better to
look for more cases in all age groups
• Search for additional cases in the community starting with
the immediate household contacts
• Report/refer immediately if any of the contact develop
symptoms suggestive of Diphtheria (Fever with sore
throat)
 Active Case Search in the Community
• Teams should start from close contacts of the case
and then move towards the periphery of the
village/locality
• Continue the search in the entire village with index case
and all surrounding villages within five kms radius of the
affected village
• If the situation warrants, extend the search to wider
areas
• All the Migrant settlement areas in the whole
HUD to be searched
 ACS in Schools/ ICDS centres/
Work Places
• Workplace/ICDS/school contacts should also be assessed
• Reliable immunization history is important to understand
the susceptible cohort of the community
• Share contact numbers for immediate reporting of any
suspected case to the medical officer
• Immunisation coverage of the area and DPT 2 nd Booster
school immunization coverage should be evaluated
 Active Case Search in Hospitals

• Active Search for fever with sore throat in all the major
hospitals both Government and private in the area.

• Contact all the Paediatricians, Physicians and ENT

Surgeons for any suspected case occurrence

• Major labs may also be contacted

 Micro planning
• Identification/mapping of area that should be
covered for ACS
• Households and neighbourhood
• Workplaces/schools/ICDS centres
• Team composition:
• Should have a health worker trained in identifying
suspected cases of Diphtheria
• Preferable: VHN / SHN / CHN / HI / BHS
• A medical officer should supervise 3-5 teams
 Response to additional suspected cases
• MO should investigate any additional suspected
cases on the spot
• Case investigation should be done
• Appropriate sample should be collected
immediately
• Initiation of case management and public health
interventions as required
 Public Health Interventions
• Two main components
• Immunisation in community
• Antimicrobial prophylaxis for contacts
 Close contacts

• Household members, care providers and others who

come into potential contact with the oral / nasal
secretions of the diphtheria case.
• Close contact could be
• Household members
• Neighbours
• School/work place contacts
 Antibiotic Prophylaxis for Contacts
Antibiotic of Children Adult
Choice

Inj.Benzathine 6 Lakhs units IM 12 lakhs Units IM

Penicillin (after Single dose Single dose
test dose)
Tab.Erythromycin 40 mg /kg/day in four Erythromycin 250 mg
divided doses for 7-10 6th hourly for 7-10 days
days
Note:
Erythromycin not recommended for children less than one month
age
 Other measures for close contacts

• Contacts should be followed for first sign of illness

atleast for 10 days

• If symptoms like Fever or Sore Throat, such child or

adult should be immediately hospitalized and to be
administered with parenteral penicillin.

• Face mask and frequent hand washing

Public Health Classification of Cases

• Laboratory confirmed

• Epidemiologically confirmed

• Clinically confirmed
 Suspected Case
Clinical Examination

Meets Case Definition

Yes No

Sample No

Yes

Lab Epidemiological
Result Negative
linkages

Rejected
Yes No
Positive
Laboratory Epidemiologically Clinically
confirmed confirmed Confirmed
 Diphtheria
Guidelines for Containment measures
Containment Immunisation
 Vaccines for Containment Immunisation
• DPT to children less than 7 years of age

• Persons aged more than 7 years are

to be given Td
Note: Td-Low dose Diphtheria toxoid with full dose of
Tetanus Toxoid
 Caution
• DPT and DTwP vaccines are not recommended

for children aged 7 years and above due to

increased risk of side effects
 General Criteria
• Containment immunisation for diphtheria should be given
to children up to 12th standard.
• If the affected village is bordering another block or
municipality the nearby block and municipality should also
be covered.
• If the child is studying in another block, such block should
also be covered
Time line for Containment immunization from the
date of occurrence of suspected case

Containment Vaccination Area Time Line

Health Sub Centres area 3 days

Primary Health Centre area 7 days

Block 15 days
When to organize containment immunisation?

• Whenever a Laboratory confirmed or Epidemiologically

confirmed or Clinically suspected or confirmed case of
diphtheria is reported containment immunisation should
be organized.
 Who should be immunized?

• Children between 16 months and 7 years can

be given DPT

• Children up to 12th Standard are to be given

Td vaccine.
Case Reported PHC area and the school in
which the child is studying / hostelmates
• 16 months to six years (First Standard)
• one dose of DPT irrespective of previous
immunization status
• 2nd to 12th standard
• one dose of Td irrespective of previous
immunization status
For the remaining areas of the block and
adjoining Municipal/Corporation Area in
which case is reported
 DPT 1st Booster
• Children in the age group of 16 to 24 months
• Due dose of DPT 1st booster should be given as part of
Routine Immunization programme

• Children in the age group of 3 years to 5 years

• Children who have not received the 1st booster or no records
available, one dose of DPT should be given
 DPT 2nd Booster

• Children in 1st Standard (5 – 6 years)

• DPT 2nd booster should be given for all
children studying in 1st Standard as a part
of School Immunisation.
Children in 1st Standard to 12th Standard
Td vaccine
• One dose Td vaccine for all children from 1st
standard to 12th standard irrespective of
previous vaccination status.
• For first standard DPT should be given as part
of School Immunisation (DPT second booster)
 Antenatal Mothers (Td Vaccine)

• All Antenatal mothers are to be vaccinated with Td if not

vaccinated earlier.
• If Antenatal mother received 1st dose as TT in private
sector such mothers should be given one dose of Td
Vaccine.
• Ensure Td vaccine availability in Pharmacies and Private
sectors for immunizing Pregnant mothers
 Containment Immunisation with
Td Vaccine for above 17 years
• If adult Diphtheria is reported at a higher age, up to that
age in which case is reported plus five years should be
covered.
• Example:
Case age 25 years- all people up to 30 years in
the village should be covered.
 Td Vaccine for Health Care Staff

• All Health Care Personnel in areas where cases

are reported should be given one dose of Td

vaccine
 Containment Immunization with Td Vaccine for above
7 years for children who have not received any dose of
Diphtheria vaccine / partially immunized

• Three doses

• Interval between first and second dose is 4 weeks

• Interval between second and third is 6 months

 Vaccination for close contacts
• All family members above 7 years should be

given one dose of Td

• Children between 16 months to 7 years

should be given DPT one dose immediately

 Logistics
• At least 100 vials of Diphtheria Anti Toxin
(DAT) should be available in each HUD.
• Adequate antibiotics should be available
• Tab.Erythromycin
• Inj.Crystalline Penicillin
• Inj.Benzathine Penicillin
Diphtheria Anti Toxin (DAT) manufacturers as
per GoI List

• CRI, Kasauli
• Haffkine Bio Pharmaceutical Corporation
(India), Mumbai
• BS & V Ltd, Thane
• Vins Bioproducts Limited (India), Hyderabad
Frequently Asked Questions
 Unimmunized children under one year

• Start the schedule fresh and complete all

vaccines as per schedule
Partially immunized children under one year

• Remaining doses of penta and other vaccines to

be completed
If a child is brought late for a subsequent dose,
should one restart with the first dose of a vaccine?
• No. Do not restart the schedule again. Start where the
schedule was left off.

• For example, if a child who has received BCG, Penta-1,

Rota1, OPV-1, and IPV-1 at 5 months of age, returns at 11
months of age
• then vaccinate the child with Penta-2, OPV-2 , Rota-2,and
Measles-Rubella-1, and JE-1 (where applicable).
If a child who has never been vaccinated is brought in at 9
completed months but before 12 completed months of
age, then, can all the due vaccines be given to a child on
the same day?
• Yes. All the due vaccines can be given during the same session
but at recommended injection sites, using separate AD syringes.
It is safe and effective to give BCG, Penta, OPV, IPV, Measles-
Rubella, Rota, JE (where applicable) vaccines to a 9-month-old
child who has never been vaccinated.
• If more than one injection has to be given in one limb, then
ensure that the distance between the two injection sites is at
least 1 inch apart.
If a child who has never been vaccinated is brought in
immediately after completing 12 months of age, (beyond
one year) what vaccines would you give?

• As per the national immunization schedule this child need not be

given – BCG, Hepatitis B, Rota, Penta and IPV.
• This child should be administered DPT 1, OPV 1, Measles-Rubella-1,
and JE-1 (if applicable).
• The subsequent doses of DPT and OPV should be given at an interval
of 4 weeks. Administer Measles-Rubella-2, JE-2 (If applicable), and
a booster dose of DPT at recommended age as per National
Immunization schedule.
What vaccines can be given to a child between 1 and 5
years of age who has never been vaccinated?
• Start with DPT, OPV, MR and JE

• Follow with second and third doses of DPT and OPV with one
month interval

• After 6 months give DPT booster

Note: In an unvaccinated child more than 16 months the interval

between MR 1 and MR 2 is one month and for JE 1 and JE 2 the
interval is three months
 Which vaccines can be given to a child between 5 and 7
years of age who has never been vaccinated?
• DPT 1,2,3 and OPV at one month intervals
• OPV can be given up to 5 years of age: If the child had never
received OPV it can be given at any age
• Booster dose of DPT at a minimum of 6 months interval after
DPT 3 up to the age of 7 years
• JE 1 and JE 2 with 3 months interval up to the age of 15
• MR vaccine should be given up to 5 years with one month
interval
Whether a child recovered from Diphtheria
needs vaccination?

• Due to poor immunogenicity of primary infection

recovered child should also be administered Diphtheria
Vaccine
 Summary
• Caused by exotoxin producing bacteria
• Pseudomembrane over tonsil, pharynx, larynx is
pathognomonic
• Myocarditis /neuritis are common complications
• Bacterial culture is gold standard laboratory test
• Case management involves antibiotics, antitoxin serum
and supportive care
• Public health interventions involve antibiotic prophylaxis
for contacts and appropriate containment immunisation.