University of Creative Technology Chittagong

Assignment
on
Diphtheria

SUBMITTED TO

Mohammad Injamul Hoq

Department of Public Health
Program: Master of Public Health (Autumn 2020)
University of Creative Technology Chittagong

SUBMITTED BY

Rumana Arjuman Huree

ID-20072214
Program: Master of Public Health (Autumn 2020)
Department of Public Health
University of Creative Technology Chittagong
Date of Submission: 21/09/2020

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 Table of Contents

Particulars Pages
1. Introduction 03
2. Global Facts 05
3. Bangladesh Perspectives 06
4. Epidemiological Determinants 09
5. Symptom of the Diseases 09
6. Development of the Diseases 10
7. Stages 10
8. Risk Factors 11
9. Diagnosis 11
10. Control & Prevention Strategies 12
11. Management 14
12. Treatment 14
13. Conclusion 17
References 17

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1. Introduction

Diphtheria is a serious bacterial infection that affects the mucous membranes of the throat
and nose. Although it spreads easily from one person to another, diphtheria can be prevented
through the use of vaccines. Call doctor right away if believe have diphtheria. If it’s left
untreated, it can cause severe damage to kidneys, nervous system, and heart. It’s fatal in
about 3 percent of cases, according to the Mayo Clinic.

A type of bacteria called Corynebacterium diphtheriae causes diphtheria. The condition is

typically spread through person-to-person contact or through contact with objects that have
the bacteria on them, such as a cup or used tissue. You may also get diphtheria if you’re
around an infected person when they sneeze, cough, or blow their nose.
Even if an infected person doesn’t show any signs or symptoms of diphtheria, they’re still
able to transmit the bacterial infection for up to six weeks after the initial infection.
The bacteria most commonly infect your nose and throat. Once you’re infected, the bacteria
release dangerous substances called toxins. The toxins spread through your bloodstream and
often cause a thick, gray coating to form in these areas of the body:
 nose
 throat

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  tongue
 airway
In some cases, these toxins can also damage other organs, including the heart, brain, and
kidneys. This can lead to potentially life-threatening complications, such as:
 myocarditis, or inflammation of the heart muscle
 paralysis
 kidney failure
 Diphtheria is a bacterial infection due to Corynebacterium diphtheriae, characterized
by proliferation of the bacteria in the upper respiratory tract and systemic diffusion of
the diphtheria toxin through the body.
– The infection is spread by droplets (coughing, sneezing, speaking) from the upper
respiratory tract of a patient or carrier.
– The disease does not confer sufficient immunity. Immunisation protects against the
effects of the toxin but does not prevent individuals from becoming carriers.
 Clinical features
 – Signs related to the infection:
• Pseudomembranous tonsillitis (grey, tough and very sticky membranes) with
dysphagia and cervical adenitis, at times progressing to massive swelling of the neck;
• Airway obstruction and possible suffocation when the infection extends to the nasal
passages, the larynx, the trachea and the bronchi;
• Fever is generally low-grade.

 – Generalised signs due to the toxin, they determine the prognosis:

• Cardiac dysfunction (gallop on auscultation, arrhythmias), myocarditis with severe
heart failure at times leading to cardiogenic shock;
• Neuropathies 1 to 3 months after the onset of the disease leading to difficulty with:
swallowing (paralysis of the soft palate), vision (ocular motor paralysis), breathing
(paralysis of respiratory muscles) and ambulation (limb paralysis);
• Oliguria, anuria and renal failure.

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2. Global Facts

Diphtheria is an infectious disease caused by the bacterium Corynebacterium diphtheria,

which primarily infects the throat and upper airways, and produces a toxin affecting other
organs. The illness has an acute onset and the main characteristics are sore throat, low fever
and swollen glands in the neck, and the toxin may, in severe cases, cause myocarditis or
peripheral neuropathy. The diphtheria toxin causes a membrane of dead tissue to build up
over the throat and tonsils, making breathing and swallowing difficult. The disease is spread
through direct physical contact or from breathing in the aerosolized secretions from coughs
or sneezes of infected individuals.
Vaccination against diphtheria has reduced the mortality and morbidity of diphtheria
dramatically, however diphtheria is still a significant child health problem in countries with
poor EPI coverage. In countries endemic for diphtheria, the disease occurs mostly as
sporadic cases or in small outbreaks. Diphtheria is fatal in 5 - 10% of cases, with a higher
mortality rate in young children. Treatment involves administering diphtheria antitoxin to
neutralize the effects of the toxin, as well as antibiotics to kill the bacteria.
Diphtheria vaccine is a bacterial toxoid, ie. a toxin whose toxicity has been inactivated. The
vaccine is normally given in combination with other vaccines as DTwP/DTaP vaccine or
pentavalent vaccine. For adolescents and adults the diphtheria toxoid is frequently combined
with tetanus toxoid in lower concentration (Td vaccine).
WHO recommends a 3-dose primary vaccination series with diphtheria containing vaccine
followed by 3 booster doses. The primary series should begin as early as 6-week of age with

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subsequent doses given with a minimum interval of 4 weeks between doses. The 3 booster
doses should preferably be given during the second year of life (12-23 months), at 4-7 years
and at 9-15 years of age. Ideally, there should be at least 4 years between booster doses.
 To further promote immunity against diphtheria, combined diphtheria and tetanus
toxoid vaccine (Td or TD) should be used rather than tetanus toxoid alone. This can
be used in pregnancy as well as following injuries.
3. Bangladesh Perspectives
There has been one new suspected case of diphtheria reported in the past two weeks with an
onset date in week 22. A total of 8,641 diphtheria case-patients have been reported in
EWARS since the start of the outbreak. Out of these, 296 were classified as confirmed cases
after laboratory testing. Others were classified as probable (2,729) and suspected (5,616)
cases. In 2019, a total of 295 diphtheria case-patients were reported including 4 confirmed,
20 probable and 271 suspected cases. (WHO, 20 Jun 2019)
Nine suspected and 1 probable diphtheria case were reported from EWARS in week 38.
Number of diphtheria cases reported so far is 8779. Out of which 306 were confirmed, 2750
were probable and 5723 were reclassified as suspected. In 2019 a total 433 diphtheria cases
reported in EWARS. 14 were confirmed, 41 were probable and 368 were suspected. A total
45 deaths were reported due to diphtheria since the beginning of the outbreak. No death
reported in 2019. (WHO, 22 Sep 2019)
Two probable and 6 suspected cases reported from EWARS in week 42. Number of
diphtheria cases reported so far is 8,827. Out of which 308 were confirmed, 2,757 were
probable and 5,762 were reclassified as suspected. In 2019 a total 481 diphtheria cases
reported in EWARS. Sixteen were confirmed, 48 were probable and 411 were suspected.
Last confirmed case was reported in Week 38 (22 September 2019). (WHO, 20 Oct 2019)

From 3 November 2017 through 12 December 2017, a total of 804 suspected diphtheria
cases including 15 deaths were reported among the displaced Rohingya population in Cox’s
Bazar (Figure 1). The first suspected case was reported on 10 November 2017 by a clinic of
Médecins Sans Frontières (MSF) in Cox’s Bazar.

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Figure 1: Number of diphtheria cases among the displaced Rohingya population in Cox’s
Bazar, Bangladesh reported by date of illness onset from 3 November 2017 through 12
December 20171

1
Date of onset information is missing for 45 (5.6%) cases.

Source: Médecins Sans Frontières

Of the suspected cases, 73% are younger than 15 years of age and 60% females (the sex for
one percent cases was not reported). Fourteen of 15 deaths reported among suspected
diphtheria cases were children younger than 15 years of age. To date, no cases of diphtheria
have been reported from local communities.

Public health response

Since August 2017, more than 646 000 people from neighbouring Myanmar have gathered in
densely populated camps and temporary settlements with poor access to clean water,
sanitation and health services. A multi-agency diphtheria task force, led by the Ministry of
Health Family Welfare of Bangladesh, has been providing clinical and public health services
to the displaced population. WHO has mobilized US$ 3 million from its Contingency Fund
for Emergencies (CFE) to support essential health services in Bangladesh.

WHO is working with health authorities to provide tetanus diphtheria (Td) vaccines for
children aged seven to 15 years, as well as pentavalent vaccines (diphtheria, pertussis,
tetanus, Haemophilus influenzae type b, and hepatitis B) and pneumococcal conjugate
vaccines (PCV) for children aged six weeks to six years. A list of essential medicines and
required supplies to support the response is being finalized by WHO and partners.The Serum
Institute of India has donated 300 000 doses of pentavalent vaccines for use in the response.

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WHO risk assessment

The current outbreak in Cox’s Bazar is evolving rapidly. To date, all suspected cases have
occurred among the displaced Rohingya population, who are living in temporary settlements
with difficult and crowded conditions. The coverage of diphtheria toxoid containing vaccines
among the displaced Rohingya population is difficult to estimate, although diphtheria
outbreaks are an indication of low overall population vaccination coverage. Available
vaccination data for Bangladesh indicates that the coverage of diphtheria toxoid containing
vaccines is high. However, spillover into the local population cannot be ruled out. WHO
considers the risk at the national level to be moderate and low at the regional and global
levels.

WHO advice

WHO recommends timely clinical management of suspected diphtheria cases that is

consistent with WHO guidelines consisting of diphtheria antitoxin, appropriate antibiotics
and implementation of infection prevention and control measures. High-risk populations
such as young children, close contacts of diphtheria cases, and health workers should be
vaccinated on priority basis. A coordinated response and community engagement can reduce
the risk of further transmission and help to control the outbreak.

Miscellaneous diseases and Complications

Skin infections due to Corynebacterium diphtheriae, more common in the tropics.Infections
are characterized by chronic nonhealing ulcers, with dirty gray membrane and often
associated with Staphylococcusaureus and group AStreptococci.More recently the
significance of this infection in the United States has been by several outbreaks among
alcoholic homeless men and impoverished groups such as Native Americans.The
presentation is indolent and non-progressive and is only rarely associated with signs of
intoxication. Nonetheless, these infections can induce high antitoxin levels and thus appear
to act as natural immunization events . Renal failure from direct toxin action or hypotension
and pneumonia are common in severe cases.
Rarely encephalitis and cerebral infarction have been described. Several excellent clinical
descriptions of endemic and epidemic diphtheria in the United States indicate that both the
frequency of various symptoms and the severity of disease are inversely proportional to the
patient’s immunization history. Roughly half of these reported cases were categorized as
mild, often without membrane. Mortality rates from 3.5% to 12% and has not changed in the

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last 50 years. Rates are high in the very young and very old.
Endocarditismycoticaneurysms,osteomyelitis and septic arthritis have been described
recently in cluster of drug addicts, alcoholics, Australian aboriginals and young adults ,all
caused by nontoxigenic C.diphtheriae.Ribotyping has indicated that these outbreaks have
been caused by unique epidemic strains and both skin and throat colonization have been
implicated as portals of entry. These illnesses have been characterized by aggressive course,
a high proportion of bacteremia, endocarditis, arterial embolization, metastatic sites of
infection (joints ,spleen, central nervous system) and high mortality. Why these nontoxigenic
strains are so virulent remains a mystery .
4.Epidomiological Determinants
Diphtheria is an acute infectious disease caused by a toxin from the bacterium
Corynebacterium diphtheriae. The most common form of the disease affects the throat and
the tonsils. Other forms can cause skin infections. The disease spreads mainly by droplet
infection from person to person through the respiratory tract and can affect all age groups,
particularly unimmunized children. Overcrowded living conditions contribute to the spread
of the disease among family members and may lead to outbreaks. An infected patient, if not
treated, can die following complications affecting the heart, central nervous system and
respiratory system.
The treatment of diphtheria aims to neutralize the circulating toxin and eliminate the
diphtheria bacterium. In order to prevent complications and death, patients with suspected
diphtheria should be isolated and treated with antibiotics and diphtheria antitoxin.
Antibiotics should also be given to close contacts.
5. Symptom of the Disease
Diphtheria signs and symptoms usually begin two to five days after a person becomes
infected and may include:
 A thick, gray membrane covering your throat and tonsils
 A sore throat and hoarseness
 Swollen glands (enlarged lymph nodes) in your neck
 Difficulty breathing or rapid breathing
 Nasal discharge
 Fever and chills
 Malaise

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In some people, infection with diphtheria-causing bacteria causes only a mild illness — or no
obvious signs and symptoms at all. Infected people who remain unaware of their illness are
known as carriers of diphtheria, because they can spread the infection without being sick
themselves.
6. Development of the Disease
Diphtheria is caused by bacteria called Corynebacterium diphtheriae. The bacteria secrete a
powerful toxin that causes damage to body tissues.
Early symptoms of diphtheria are similar to those of a common cold. They include sore
throat, loss of appetite, and fever. As the disease progresses, the most notable feature of
diphtheria infection may emerge: a thick gray substance called a pseudomembrane may
spread over the nasal tissues, tonsils, larynx, and/or pharynx.
The pseudomembrane is formed from waste products and proteins related to the toxin
secreted by the bacteria. The pseudomembrane sticks to tissues and may obstruct breathing.
TRANSMISSION
Diphtheria is transmitted from person to person, usually via respiratory droplets. An infected
person, unless treated with antibiotics, is infectious for two to three weeks. 
COMPLICATIONS
The diphtheria toxin may travel to the heart, muscle, kidneys, and liver, where it may
temporarily or permanently damage these organs. Complications from diphtheria may
include myocarditis (damage to the heart muscle), neuritis (inflammation of nerves, which
may contribute to nerve damage, paralysis, respiratory failure, and pneumonia), airway
obstruction, and ear infection.
Diphtheria once was a major cause of illness and death among children. The United States
recorded a high of 206,000 cases of diphtheria in 1921, resulting in 15,520 deaths (a case-
fatality ratio of 7.5%). Diphtheria case fatality rates range from about 20% for those under
age five and over age 40, to 5-10% for those aged 5-40 years. Diphtheria was the third
leading cause of death in children in England and Wales in the 1930s. Diphtheria is
extremely rare in the United States today; between 2004 and 2011, no cases of diphtheria
were reported to public health officials. One case was provisionally reported in 2012.
7. Stage

 Diphtheria is transmitted to others through close contact with discharges from an

infected person’s nose, throat, eyes, and/or skin lesions.

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  Diphtheria can lead to breathing problems, heart failure, paralysis, and sometimes
death.
 Nearly one out of every 10 people who get diphtheria will die from it.
 Most cases of diphtheria occur among unvaccinated or inadequately vaccinated
people.
 Recovery from diphtheria is not always followed by lasting immunity, so even those
persons who have survived the disease need to be immunized.
 Although no longer a very common disease in the US, diphtheria remains a large
problem in other countries and can pose a serious threat to people in the US who may
not be fully immunized and who travel to other countries, or have contact with people
coming to the US from other parts of the world.
8. Risk Factors
Children are routinely vaccinated against diphtheria, so the condition is rare in these places.
However, diphtheria is still fairly common in developing countries where immunization rates
are low. In these countries, children under age 5 and people over age 60 are particularly at
risk of getting diphtheria.
People are also at an increased risk of contracting diphtheria if they:
 aren’t up to date on their vaccinations
 visit a country that doesn’t provide immunizations
 have an immune system disorder, such as AIDS
 live in unsanitary or crowded conditions

9. Diagnosis
Doctors usually decide if a person has diphtheria by looking for common signs and
symptoms. They can swab the back of the throat or nose and test it for the bacteria that cause
diphtheria. A doctor can also take a sample from an open sore or ulcer and try and grow the
bacteria. If the bacteria grow and make a toxin (poison), the doctor can be sure a patient has
diphtheria. However, it takes time to grow the bacteria, so it is important to start treatment
right away if a doctor suspects respiratory diphtheria.
CDC DIAGNOSIS CRITERIA
According to the CDC, the following clinical and laboratory criteria need to be met for a
diagnosis of diphtheria to be confirmed:
Clinical criteria
 Presence of upper respiratory tract infection along with sore throat

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  Presence of high fever
 Presence of the grey white membrane or pseudomembrane over the throat, back of
the mouth or tonsils

Laboratory criteria
 Presence of corynebacterium diphtheriae in the throat swab samples
 Histological or cellular level presence of the bacteria
10. Control & Prevention Strategies
Diphtheria is preventable with the use of antibiotics and vaccines.
The vaccine for diphtheria is called DTaP. It’s usually given in a single shot along with
vaccines for pertussis and tetanus. The DTaP vaccine is administered in a series of five shots.
It’s given to children at the following agesTrusted Source:
 2 months
 4 months
 6 months
 15 to 18 months
 4 to 6 years
In rare cases, a child might have an allergic reaction to the vaccine. This can result in
seizures or hives, which will later go away.
Vaccines only last for 10 years, so your child will need to be vaccinated again around age 12.
For adults, it’s recommended that you get a combined diphtheria-tetanus-pertussis booster
shot once. Every 10 years afterward, you’ll receive the tetanus-diphtheria (Td) vaccine.
Taking these steps can help prevent you or your child from getting diphtheria in the future.
Diphtheria Immunization. Diphtheria can be prevented by immunization. The diphtheria
vaccine was developed in 1923.It is on the World Health Organization’s List of Essential
Medicines, the most important needed in a basic health system. It use has resulted in a more
than 90% decrease in number of cases globally between 1980 and 2000[60].Three initial
doses are recommended after which it is about 95% effective. It is effective for about 10
years at which time a booster dose is needed. Immunization may start at six weeks of age
with further doses given every four weeks. The diphtheria vaccine is very safe, significant
side effects are rare. The vaccine is safe in both pregnancy and among those who have poor
immune function[1].The diphtheria vaccine is delivered in several combinations[6].One

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includes tetanus toxoid(known as dT or DT vaccine) and other comes with the tetanus and
pertussis vaccines,(DPT)[59].The World Health Organization has recommended its use since
1974,and about 84% of world population is vaccinated. Recommendations from the
Advisory Committee on Immunization Practices were up-dated in 2006 and 2008, published
by CDC include.
 For persons 11 years or more years old a single 0,5ml,Tdap is followed four to eight
weeks later by 0.5 ml
Td.with second dose of Td 6 to 12 months after the first.
 Booster immunization: persons 11 to 18 years old should receive one dose of Tdap and
then receive the standard Td booster at 10 years later intervals.
 Those 19 to 64 years old should have their next booster as Tadp,to reduce carriage,
clinical illness and transmission of pertussis.
Clinical Manifestations
Clinical manifestations of diphtheria usually begin two to seven days after infection. Clinical
symptoms of diphtheria include fever of 380C(100.4 0F) or above, chills fatigue, bluish skin
coloration(cyanosis),sore throat,horseness,cough,headache,difficultyswallowing, painful
swallowing, difficultybreathing, rapid breathing, foul-smelling bloodstained nasal discharge
and lymphadenopathy. Symptoms can also include cardiac arrhythmias, myocarditis, and
cranial and peripheral nerve palsies.Laryngeal diphtheria can lead to a characteristic swollen
neck and throat, or “Bull-neck”. The swollen throat is often accompanied by a serious
respiratory condition, characterized by a brassy or “barking: cough,stridor,hoarseness,and
difficulty breathing, and historically referred to variously as “Diphtheritic croup”,,and “true
croup” or sometimes simply as “croup”.Diphtheria croup is extremely rare in countries
where diphtheria vaccination is customary. As a result the term “croup” nowadays most
often refers to an unrelated viral illness that produces similar but milder respiratory
symptoms.
Myocarditis
Subtle evidence of myocarditis can be detected in as many as two third of patients, but 10%
to 25 % develop clinical cardiac dysfunction, with risk to an individual patient correlating
directly with the extent and severity of local disease.Cardiac toxicity can be acute,with
congestive failure and circulatory collapse, or more insidious, after 1 to 2 weeks of illness
with progressive dyspnea, weakness, diminished heart sounds, cardiac dilation, and
galloprhythm. Changes to electrocardiograph((ECG) pattern, particularly ST-T wave

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changes and first degree heart block, can progress to more severe forms of block,
atrioventricular(AV) dissociation, and other arrhythmias, which carry an ominous prognosis.
Patients with bundle branch blocks and complex dissociation have a much higher incidence
of death, and survivors may be left with permanent conduction defects.
Neurological Toxicity
Neurological toxicity is proportional to the severity of the primary infection: mild disease
only produces neurotoxicity, but up to three fourth of the patients with severe disease can
develop neuropathy. Within the first few days of disease, local paralysis of soft palate and
posterior pharyngeal wall occurs commonly, manifested by regurgitation of swallowed fluids
through the nose. Thereafter, cranial neuropathies causing oculomotor and ciliary paralysis
are also common, and dysfunction of facial, pharyngeal, or laryngeal nerves, although rare,
can contribute to the risk for aspiration. Peripheral neuritis develops later from 10days to 3
months after onset of disease in the throat.
11. Management
 Treatment involves administering diphtheria antitoxin to neutralize the effects of the
toxin and antibiotics to kill the bacteria.
 Administration of diphtheria antitoxin at the earliest is the most important element in
the treatment of diphtheria, specially, respiratory diphtheria.
 In addition to antitoxin, every case should be treated with appropriate antibiotics.
 Respiratory support and airway maintenance should also be provided as needed.
 The disease is usually not contagious 48 hours after antibiotics are instituted.
12. Treatment
Diphtheria is a serious illness. Doctors treat it immediately and aggressively. Treatments
include:
 Antibiotics. Antibiotics, such as penicillin or erythromycin, help kill bacteria in the
body, clearing up infections. Antibiotics cut the time that someone with diphtheria is
contagious.
 An antitoxin. If a doctor suspects diphtheria, he or she will request a medication that
counteracts the diphtheria toxin in the body from the Centers for Disease Control and
Prevention. Called an antitoxin, this drug is injected into a vein or muscle.
Before giving an antitoxin, doctors may perform skin allergy tests. These are done to
make sure that the infected person doesn't have an allergy to the antitoxin.

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 If someone has an allergy, he or she needs to be desensitized to the antitoxin. Doctors
do this by initially giving small doses of the antitoxin and then gradually increasing
the dose.
Children and adults who have diphtheria often need to be in the hospital for treatment. They
may be isolated in an intensive care unit because diphtheria can spread easily to anyone not
immunized against the disease.

 Diphtheria is an infectious disease caused by bacteria that usually produce exotoxins

that damage human tissue.
 The initial symptoms of diphtheria are flu-like but worsen to include fever,
swallowing problems, hoarseness, enlarged lymph nodes, coughing, and shortness of
breath; some patients may have skin involvement, producing skin ulcers.
 The history of diphtheria dates back to Hippocrates; once the organisms were
identified and found to produce exotoxins, the development of vaccines have
markedly reduced diphtheria worldwide.
 The cause of diphtheria is an infection by Corynebacterium species; the most severe
infections are due to those Corynebacterium diphtheriae strains that produce
exotoxins.
 The highest risk factor for developing diphtheria is not being immunized against the
disease; other factors include crowding, immunosuppression, and direct or indirect
contact with an infected individual.
 Doctors diagnose diphtheria by the patient's history and physical examination; culture
of Corynebacterium from the patient yields a definitive diagnosis although patient
should be treated if diphtheria is even suspected.
 The treatment of diphtheria involves early administration of antibiotics; antitoxin,
made in horses, neutralizes Corynebacterium exotoxin that has not bound to human
tissue.
 Complications of diphtheria include heart-rhythm problems, sepsis, organ damage,
and breathing problems that can be severe enough to cause death.
 If treated appropriately and early in the infection, the prognosis for diphtheria is
usually good; however, if complications develop, the prognosis decreases, especially
if sepsis and/or cardiac involvement occurs.

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  It is possible to prevent diphtheria; the main way is to vaccinate individuals with one
of the four major vaccine types available.
histopathologic diagnosis of diphtheria by Albert stain Clinical criteria include:
(a)Upper respiratory tract illness with sore throat
(b) Low grade fever(above 39oC(102oF) is rare)
(c) An adherent, dense, gray pseudo- membrane covering the posterior aspect of the pharynx.
In severe cases, it
may extend to cover the entire tracheobronchial tree.
Diphtheria case classification:
Probable: a clinically compatible case that is not laboratory-confirmed and is not
epidemiologically linked
to a laboratory-confirmed case
Confirmed: a clinically compatible case that is either laboratory-confirmed or
epidemiologically linked to a
laboratory-confirmed case.

Diphtheria is endemic in many areas of the world and still occurs sporadically in the US.
Early intervention by administering antitoxin is key to preventing systemic manifestations of
the disease, which can include respiratory and neurologic symptoms, cardiovascular
collapse, and death.
Prompt administration of antitoxin is necessary to enable it to bind to and deactivate the free
toxin in serum. Antitoxin cannot deactivate toxin once it has entered cells, which is signaled
by the presence of mucocutaneous symptoms.
Patients with respiratory diphtheria are placed in respiratory isolation (masks and standard
measures such as hand-washing), and those with cutaneous diphtheria are placed in contact
isolation (gloves and gowns), until cultures taken after cessation of therapy are negative.
Asymptomatic carriers play an important role in disease transmission.

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13. Conclusion
Symptoms of diphtheria begin with respiratory tract infection, with production of white-gray
pseudomembrane.In severe cases can cause respiratory embarrassment and a bull-neck
appearance. Complications include myocarditis, neurological toxicity, endocarditis and renal
failure. Early diagnosis and treatment have better outcome.
References
 https://www.healthline.com/health/diphtheria#prevention
 https://medicalguidelines.msf.org/viewport/CG/english/diphtheria-16689456.html
 https://www.who.int/immunization/diseases/diphtheria/en/
 https://reliefweb.int/disaster/ep-2017-000177-bgd
 https://www.who.int/csr/don/13-december-2017-diphtheria-bangladesh/en/
 https://www.nfid.org/infectious-diseases/diphtheria/
 https://www.healthline.com/health/diphtheria#prevention
 https://www.news-medical.net/health/Diphtheria-Diagnosis.aspx
 https://www.healthline.com/health/diphtheria#prevention
 Mohanmad Illzam Elahee, International Scientific Research Organization for
Science, Engineering and Technology, Diphtheria: Clinical Manifestations,
Diagnosis, and Role of ImmunizationIn Prevention
 https://www.mayoclinic.org/diseases-conditions/diphtheria/diagnosis-treatment/drc-
20351903

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