On the first week of March, in one of the wards in San Lazaro Hospital in Manila, two mothers kept close watch as their sons were recovering from diphtheria.
One of the mothers recalled her nine year-old son’s condition when he was rushed to the hospital: “He could barely breathe; he was already gasping for air.” Examination showed that a whitish-gray layer almost completely blocked his throat.
On the next bed was a four year-old boy admitted three days earlier. He had milder respiratory infection, but it was his chest pains that concerned his mother.
San Lazaro Hospital, the Philippines’ largest facility for infectious diseases, reported one-third of the diphtheria cases in the country in 2015. The Department of Health (DOH) Epidemiology Bureau recorded 105 cases for the year.
Diphtheria continues to threaten the lives of Filipino children. In severe cases, the toxin-producing bacteria Corynebacterium diphtheriae form layers called pseudomembranes. These layers block the airways, causing difficulty in breathing. The toxins, if absorbed from infected areas, can also weaken the heart muscles, cause chest pains and in extreme cases result to heart failure.
“The persistence of diphtheria in the Philippines calls for improving the reach of the national childhood immunization program and preparedness for immediate treatment of cases. We need to work further in saving the lives of children from vaccine-preventable diseases like diphtheria. The World Health Organization (WHO) continues to partner with the Department of Health towards this goal,” says Dr Gundo Aurel Weiler, WHO Representative in the Philippines.
Improving routine immunization coverage
Vaccination remains as a successful and cost-effective health intervention against diphtheria. In the Philippines, the pentavalent vaccine protects against diphtheria, whooping cough, tetanus, Hepatitis B and Haemophilus influenza B . The routine immunization schedule includes three doses of pentavalent vaccine, given at ages 1½, 2½ and 3½ months.
The DOH Expanded Program on Immunization (EPI) reports a 79% coverage for the third dose of the pentavalent vaccine last 2014. This falls below the national target of 95%, required to ensure population immunity against the diseases covered.
Moreover, a child’s immunity against diphtheria - developed through the first three doses – declines within ten years. Children thus need to receive a booster dose when they reach school age.
Of the two cases seen last March at San Lazaro Hospital, one failed to complete the primary doses while the other missed the additional dose given at school, when the child is six to seven years old.
“Low coverage and high vaccination drop-out rate in depressed areas are the main reasons that diphtheria remains to be a problem in the Philippines,” notes Dr Kohei Toda, EPI Team Leader at WHO Philippines.
The Global Vaccine Action Plan – endorsed by the member states of the World Health Assembly in 2012 - calls for countries to reach 90% coverage nationally against diphtheria, tetanus and whooping cough by 2015. The Philippines remains as one of the countries which need to reach the target.
In closing this immunization gap, WHO Philippines EPI Team works closely with the DOH through provision of technical support for immunization activities and strengthening of strategies for communication and advocacy.
“We consult WHO for technical inputs especially in addressing issues in vaccine-preventable diseases, as well as in improving access to vaccination. It has been a constant partnership, and also a learning process for us on how we can [localize] WHO’s technical advice,” shares Dr Joyce Ducusin, Director III, Officer-in-Charge of the DOH Family Health Office.
Ensuring availability of life-saving antitoxins
Severe diphtheria cases – those with established pseudomembranes – require emergency treatment with the diphtheria antitoxin (DAT). Half of the cases die if left untreated. With the antitoxin, the risk of death decreases to one in ten cases.
WHO advocates that adequate doses of DAT should be readily available nationally. In the last quarter of 2015, WHO supported the prepositioning of limited vials of the DAT. The two cases in San Lazaro Hospital in early March were first to receive the complete doses.
In 2016, WHO supported the procurement of additional vials of DAT, given the continuing public health threat of diphtheria in the country. DOH also works with WHO in securing sustainable funding for the live-saving treatment.
The recent diphtheria cases serve as reminder to bolster the country’s efforts in improving access to and demand for vaccination and in ensuring availability of antitoxins.
"We look forward to the day when mothers do not have to worry anymore about their children getting infected and having to suffer through life-threatening diseases like diphtheria. We hope that soon, sufficient immunization coverage will empty hospitals from such cases,” adds Dr Weiler.