No 27-33 - 2015

A case of cutaneous diphtheria
Reminder to reconstitute Act-HIB® with DTaP-IPV
Pilgrimages to Mecca
List of the most frequently used EPI-NEWS issues at
Vaccine Day at the SSI on 14 September 2015

A case of cutaneous diphtheria

This summer, a case of diphtheria was detected in a sore in an adult asylum seeker from Eritrea. When the patient arrived to Denmark on 20 June 2015, he had a large open sore on one of his shins, which he had sustained following a trauma approx. 2 months earlier.

On 25 June the patient was transferred from the reception centre to an asylum centre; and on 29 June, following contact to healthcare staff, wound care was initiated. To exclude the presence of MRSA or other multiresistant bacteria, the wound was swabbed and a biopsy was taken. The wound was then covered.

On 3 July, culture confirmed haemolytic streptococci of group A and Staphylococcus aureus and Corynebacterium diphtheriae was detected by Maldi-Tof mass spectrometry and confirmed by PCR.

The patient was afebrile and generally unaffected, and the wound was looking better already after it had been cleaned. Due to mixed growth from the wound, treatment with amoxicillin/clavulanic acid was recommended, and a throat swab was requested to assess if the patient carried diphtheria bacteria in his throat. The patient had probably received primary diphtheria vaccination in childhood.

On 6 July, the toxin gene was detected by PCR performed on diphtheria bacteria cultured from the wound, and on 8 July the ELEK test confirmed that the bacterium expressed the toxin gene and was therefore toxin-producing. Following instructions from the Medical Officer of Health, asylum centre staff identified a total of seven asylum seekers and healthcare staff who had come into close contact with the patient within the previous 10 days. These were throat-swabbed and received prophylactic azithromycin and a diphtheria-tetanus booster vaccination if their previous dose had been given more than 5 years ago. All throat swabs from both the index patient and close contacts tested negative, and there were no cases of throat symptoms among the asylum centre's remaining residents.


Detection of toxin-producing Corynebacterium diphtheriae is rare in Denmark, and the latest case of diphtheria (of the throat) was recorded in 1998, EPI-NEWS 1/99. In the present case, only persons with close contact to the patient and the patient's wound were at increased risk, and the wound had remained covered throughout the risk period. Due to an error, the patient had not initiated antibiotic treatment prior to his throat swab, and therefore the negative culture result may be considered fully valid. It was important to establish if an asymptomatic carrier was present in the patient’s immediate environment, someone who - in theory - could also be the source of the infection. No such carrier was found, and therefore there was no indication for further prophylactic measures.

The case was reported through the EU's notification system for infectious diseases, and subsequently Sweden and Germany also reported a total of six cases (four toxigenic and two non-toxigenic) of cutaneous diphtheria in 2015, detected among asylum seekers from Eritrea, Ethiopia and Syria, respectively. In response to an ECDC survey, a total of 13 other EU countries reported that they had not detected any cases of cutaneous diphtheria among refugees in 2015. Subsequently, the ECDC published a risk assessment on 30 July 2015.

Diphtheria is still found in many countries and it is important that everyone has received primary vaccination against diphtheria (normally as part of the childhood vaccination programme) and receives booster vaccination every 10 years. Exposure to infection may occur during travels to an endemic area, but persons who carry the bacterium in the throat are also seen in Denmark as the vaccination protects against disease caused by diphtheria toxin, but not against the carrier state. Everyone should therefore be protected against the disease by vaccination. Healthcare workers and asylum centre staff should pay particular attention to sores in travellers and asylum seekers from endemic areas.

Suspected cases of diphtheria shall be notified by phone to the Danish Health and Medicines Authority's Medical Officers of Health (MAMOH) in the region where the patient resides and in writing on Form 1515 to the MAMOH and to the Department of Infectious Disease Epidemiology at Statens Serum Institut.
(K. Fuursted, Microbiology and Infection Control, G. St-Martin, MAMOH East and Supervision, P.H. Andersen, Department of Infectious Disease Epidemiology)

Reminder to reconstitute Act-HIB® with DTaP-IPV

From time to time the SSI receives reports that healthcare staff forget to reconstitute Act-HIB® with DTaP-IPV. This constitutes an adverse event, which is registered with the National Agency for Patients' Rights and Complaints in the Danish Patient Safety Database, EPI-NEWS 46/14.

Please note that the DTaP-IPV/Act-HIB® consists of two units; a prefilled syringe and a vial containing powder.

The vial contains lyophilised vaccine (powder) against Haemophilus influenzae type b (Act-HIB®).
The prefilled syringe contains vaccine against diphtheria, tetanus, pertussis and polio (DTaP-IPV).

The contents of the prefilled syringe must be used for reconstitution of the lyophilised vaccine in the vial. After reconstitution and shaking of the lyophilised vaccine, the entire vaccine is drawn into the syringe and a new injection needle is placed on the syringe, after which the combined vaccine is ready for intramuscular injection.

In cases where the reconstitution procedure has been omitted and only the DTaP-IPV was given, the patient should receive Act-HIB® vaccination separately, which should be given as soon as possible. Act-HIB® may be reconstituted in 0.5 ml of isotonic saline and is injected intramuscularly.

Be sure to report such incidents to the Danish Patient Safety Database.
(M. Andersen Stevner, Regulatory and Medical Affairs, P.H. Andersen, Department of Infectious Disease Epidemiology)

Pilgrimages to Mecca

In 2015, the dates for the Hajj are 20-25 September.

Meningococcal disease:
To obtain a visa for Saudi Arabia, anyone doing a pilgrimage shall have received the tetravalent vaccine against meningococcal disease of serogroups A+C+W135+Y no later than 10 days prior to entering the country, and the vaccine shall have been administered within a 3-year-period.

Two tetra-valent conjugate vaccines have been registered for protection against meningococcal disease caused by group A, C, Y or W135; Nimenrix® and Menveo®.

Nimenrix® can be used for children aged ≥ 1 year of age and for adults. The vaccine is administered as a single dose.

Menveo® can be used for children aged ≥ 2 year of age and for adults. The vaccine is administered as a single dose.

If indicated, children aged 2 months to 1 year may receive primary vaccination in the form of two Menveo® doses given at a minimum 1-month interval. The Danish Medicines Agency (now the Danish Health and Medicines Authority) has previously assessed that the vaccine may be used off-label in this age group, EPI-NEWS 37/10. In case of continued risk of exposure, a booster dose is given 12 months after the primary vaccination programme.

Influenza vaccination is not a requirement, but it is recommended by the Saudi Arabian authorities, particularly in persons with chronic conditions.

International outbreaks, including Middle East respiratory syndrome coronavirus (MERS-CoV):
The Saudi Arabian authorities recommend that persons aged 65 years or above, persons with chronic diseases (i.e. coronary, pulmonary or renal conditions), diabetes, immune deficiency, cancer and pregnant women and also children postpone their pilgrimage (Hajj and Umrah) for a later occasion.

Furthermore, it is recommended that travellers observe standard hygiene advice, including:

  • avoiding contact to persons suffering from acute infections of the respiratory tract 
  • maintaining good hand hygiene 
  • using a mask in case of acute airway symptoms
  • avoiding close contact to animals, including camels (particularly contact to animal excretions such as saliva and faeces)
  • avoiding the ingestion of raw camel milk and fresh camel meat.

Persons who experience severe infection of the respiratory tract (fever with pneumonia and/or difficulty breathing) or other severe infectious disease within the first 14 days after returning from the Arabian Peninsula should see a doctor.
(A.H. Christiansen, P.H. Andersen, Department of Infectious Disease Epidemiology)

List of the most frequently used EPI-NEWS issues at

The Consultancy Team at the Department of Infectious Disease Epidemiology receives many inquiries with questions that may be answered by reading certain issues of EPI-NEWS. We have therefore prepared a list of the EPI-NEWS issues that are used most frequently for providing advice for healthcare staff. The list will be updated continually.

Additionally, we would like to take this opportunity to draw attention to the search facility on the EPI-NEWS page, which supports free-text searching in all issues from 2000 onwards and which allows you to sort results by best match or latest mention. Please find further search tips on the EPI-NEWS page.
(The Consultancy Team, Department of Infectious Disease Epidemiology)

Vaccine Day at the SSI on 14 September 2015

The SSI invites GPs and practice staff with a healthcare background related to vaccines and vaccination to attend an instructive and educational day focusing on the childhood vaccination programme. The day will comprise sessions offered by the Department of Infectious Disease Epidemiology and the Danish Health and Medicines Authority, among others, and there will be ample opportunity to ask questions and share experiences from clinical practice.

See the programme and learn how to sign up.
(Department of Infectious Disease Epidemiology) 

Link to previous issues of EPI-NEWS

12 august 2015