Diphtheria in Indonesia: a survey of vaccine coverage and

carriage in response to the current outbreak

A. Mikhail
12
, G. Hughes
13
, E. Irawan
4
, D. Husada
5
, G. Kafatos
1
, A. de Zoysa
1
, R. Pebody
1
, S. Bracebridge
1
& A. Efstratiou
1
.

1 Public Health England, UK; 2 European Public Health Microbiology Training Program (EUPHEM), European Centre for Disease Prevention & Control, Sweden;
3 Field Epidemiology Training Program (FETP), UK; 4 Balai Besar Laboratorium Kesehatan Surabaya, Indonesia; 5 Airlangga University, Indonesia.
BACKGROUND: INDONESIA BECOMES 2
ND
HIGHEST CONTRIBUTOR TO THE GLOBAL INCIDENCE OF DIPHTHERIA IN THE POST-VACCINATION ERA
METHODS: VACCINE FAILURE OR FAILURE TO VACCINATE? A VACCINE COVERAGE AND CARRIAGE SURVEY TO INVESTIGATE
Vaccinations against diphtheria toxin (DTP) given in 3 consecutive doses to infants aged 2, 3 and 4 months as part of Indonesias routine EPI schedule since 1981.
Incidence of diphtheria decreased steadily until 2000; but by 2012 the number of new cases had increased 30-fold and an outbreak was declared.
Increase in cases concomitant with an apparent drop in vaccination coverage for DTP3 since 2007 (fig. 1).
Majority of cases from East Java (fig. 2); 941 cases (3 per 100,000 population) and 37 deaths due to diphtheria in this province in 2012 alone.
CONCLUSIONS RECOMMENDATIONS
A DTP (primary course) vaccination catch-up
campaign targeting children of all ages in villages
with low vaccination coverage is strongly
recommended.
The survey methodology piloted in this study may be
adopted as a useful tool to assess vaccination
coverage in this region.
ACKNOWLEDGEMENTS
This study was supported by a PHE Global Health Fund
grant. AM and GH gratefully acknowledge the support of the
ECDC funded EUPHEM and PHE funded FETP fellowship
programs, respectively.

We acknowledge with thanks the invaluable contribution of all
the East Java health staff who conducted the field work and
provided the contextual background to this study. We are
also very grateful for the support of the Indonesian Ministry of
Health, WHO and UNICEF offices in Jakarta.

Finally, we thank the children and parents of Bangkalan and
Kediri districts who participated in the study.
RESULTS: RELATIVELY POOR VACCINATION COVERAGE AND EVIDENCE OF C. DIPHTHERIAE CARRIAGE IN HIGH INCIDENCE DISTRICT

Fig. 2 Expansion of diphtheria cases across East Java province, Indonesia, 2007 2012. Fig. 1 Diphtheria incidence and estimated vaccination coverage, Indonesia, 2000 2012.
Objectives: Pilot survey of children aged 1-15 years resident in one high (>7/100k) and one low (<1/100k) incidence district of East Java province to determine:
(a) DTP vaccine coverage
(b) prevalence of Corynebacterium diphtheriae carriage
Study design: Cross-sectional survey random selection of 10 villages per district, weighted cluster sampling of 10 children per single-year age group per district.
Vaccination status: Determined by guardian interview validated by reviewing vaccination cards or midwife birth cohort records.
Risk factors: Determined by guardian interview socio-economic variables, history of infection, immunological conditions and contact with diphtheria cases.
Carriage status: Determined by throat swab culture culture on selective media, positive isolates identified via APICoryne system, ELEK test for toxigenicity.
Vaccine coverage (n = 294): overall = 81.5%; validated with written records = 46%.
Majority of unvaccinated children from the high incidence district (63/67).
Having a validated record of vaccine status is negatively associated with age.
C. diphtheriae carriage: 1.7% (n = 5) associated with residency in a village with
low vaccine coverage and local knowledge of the presence of diphtheria cases.
The most likely cause of the recent increase in
diphtheria cases across East Java province is low
DTP3 vaccination coverage affecting all age groups.
Vaccination records are not an appropriate tool to
assess vaccination coverage in East Java as older
children are under-represented in this data source.
ESCAIDE 2013, Stockholm Contact: Amy.Mikhail@phe.gov.uk
Fig. 3 Vaccine coverage and Corynebacterium diphtheriae carriage in surveyed villages, East Java, 2013.
No carriage Non-toxigenic Corynebacteriumdiphtheriae detected Toxigenic Corynebacteriumdiphtheriae detected Key:
T 1 DTP3 vaccine coverage with respect to diphtheria incidence and data source, East Java, 2013.
T 2 DTP3 vaccine coverage with respect to age group and data source, East Java, 2013.