No 46 - 2017

Cases of toxin-producing diphtheria of the throat detected in Denmark

A 14-year-old boy was referred to the acute admission at the paediatric department after 8-9 days with fever, a sore throat and difficulty swallowing. During the disease course, a Strep A test had been performed, the result of which was negative. The boy was not catarrhous, but suffered from so much pain of the throat and when swallowing that he lay awake at night and refused to speak.

Upon arrival at the paediatric department, he was moderately dehydrated and had malaise. His tonsils presented with an off-white coating and he had large and sore glands of the throat. On admission, his blood work showed slightly increased infection counts (SR 16, CPR 44, normal leukocytes). The primary differential diagnosis was mononucleosis, and a monospot test was prescribed along with antibodies against CMV and EBV. These, however, did not indicate a current infection with either cytomegalovirus or Epstein-Barr virus.

Furthermore, a swab was taken from the tonsils, and as neither the patient nor his two siblings had received any of the vaccines given in the childhood vaccination programme, diphtheria was considered a possible diagnosis.

The patient’s clinical condition gradually improved in the course of a few days after he received analgesics and oral fluids.

After 6 days, Corynebacterium ulcerans was cultured from a tonsil swab. Statens Serum Institut confirmed this result, detecting a toxin-producing C. Ulcerans (PCR- and ELEK-positive). Doctors therefore decided to treat the patient and his entire household with oral ciprofloxacin (based on a resistance test). The patient was clearly recovering and therefore did not receive diphtheria antitoxin therapy.

Ciprofloxacin treatment was mainly given to eradicate any carrier state and thereby break the infection chain. The patient recovered fully after a total 4-5-week disease course.

Commentary

Diphtheria of the throat is rare in Denmark and is primarily caused by the classic Corynebacterium diphteriae. The most recent previous case of diphtheria of the throat due to toxin-producing corynebacteria was observed towards the end of 1998, EPI-NEWS 1/99. Since, a limited number of throat infections caused by Corynebacterium diphteriae have been observed. These infections have had the toxin gene (PCR positive), but without expressing it (ELEK negative). In 2015, a case of cutaneous diphtheria was detected in an asylum seeker who had a toxin-producing strain, EPI-NEWS 27-33/15.

Corynebacterium ulcerans is primarily zoonotic, but can lead to life-threatening diphtheria-like disease. For further details about the symptoms, diagnostics, treatment and prevention after exposure to infection, please see the description of the condition at the SSI website (in Danish).

The family had not travelled beyond Europe in recent years. The patient’s household counted a cat as well as a dog, but no other animals.

The family’s pets were not tested to determine if they were carriers of the condition. The patient’s two siblings had complained about soreness of the throat, but had recovered spontaneously, and neither they nor the remaining family members were swabbed as this is not recommended by the Danish Patient Safety Authority for findings of C. ulcerans because the bacterium does not transmit from person to person (in contrast to C. diphteriae, where close contacts shall be swabbed as well as treated with antimicrobials). Subsequently, the patient and the rest of the family were recommended diphtheria vaccination.

As appears from the above case story, it remains important to consider infection with toxin-producing corynebacteria in cases of acute infection of the throat, particularly in fully or partly unvaccinated individuals, even if they have no known exposure or relevant travel history.

(M. Bisgaard Pedersen, Paediatric Department, Aalborg Hospital, A. Hempel Jørgensen, The Danish Patient Safety Authority, Supervision and Guidance North, K. Fuursted, Department of Bacteria, Parasites and Fungi, P.H. Andersen, Department of Infectious Disease Epidemiology and Prevention)

European HIV-Hepatitis Testing Week 17-24 November 2017 – Test. Treat. Prevent.

Friday 17 November will see the launch of the fifth European HIV-Hepatitis Testing Week; once again, the week will focus on increasing the number of people who are tested for HIV and/or hepatitis.

The objective of the European HIV-Hepatitis Testing Week is to raise awareness of HIV and hepatitis and not least to draw attention to the advantages of being tested and initiating treatment early.

It has been demonstrated that the sooner HIV-positive people start treatment, the better are their chances of maintaining good health, and the risk of infecting others decreases. Even so, far too many remain unaware of their HIV status.

During the European HIV-Hepatitis Testing Week, nearly 600 NGOs, hospitals and clinics from more than 46 countries join forces to raise the number of people tested. A wide range of activities will be celebrated, from testing offered at clubs, in the street and outside of normal opening hours, to information campaigns designed to raise the awareness about HIV and hepatitis testing both locally, nationally and among the policy makers of Europe.

You can register for the European HIV-Hepatitis Testing Week at the week's website, where you will also find more information and materials that may be useful in the implementation of various activities.

In Europe, at least one in four of the 1.2 million people who are currently living with HIV in Europe are unaware that they are HIV positive. Also, 50% are diagnosed late, which delays their access to treatment. Furthermore, many of those who are living with chronic hepatitis are unaware of their status, but unfortunately data on this are lacking.

In Denmark, like in other European countries, a large share – about 1 in every 10 – of HIV positives are unaware of their HIV status, and like in the rest of Europe nearly half of Danish HIV positives are diagnosed late (i.e., only after their immune defense has suffered considerable damage). It is important to reverse this trend and have more people tested, and to ensure that more people initiate treatment.

In Denmark, HIV is not a frequently occurring infection, but the share of HIV-positive persons is not equally distributed across the country. The majority of HIV positives – particularly among men who have sex with men – reside in the largest cities. In Copenhagen, the occurrence of HIV among men is estimated to be from 5 to 10 per 1,000. This is much above the threshold that warrants HIV testing when a person comes into contact with the healthcare services, regardless of the cause of such contact.

Both hospital doctors and GPs are encouraged to test for HIV and hepatitis B and C more than they usually do during the HIV-Hepatitis Testing Week.

The European HIV-Hepatitis Testing Week is coordinated by HIV in Europe, which is located with CHIP under The Copenhagen University Hospital (Rigshospitalet), Clinic for Infectious Medicine. Feel free to contact CHIP at hie.rigshospitalet@regionh.dk.

(D. Raben, Centre of Excellence for Health, Immunity and Infections (CHIP), S. Cowan, Department of Infectious Epidemiology and Prevention)

The year’s antibiotic campaign is underway

“Use me with caution” - is the main message of the national antibiotic campaign that has just been launched. This year, there is a special focus on how everyone can help reduce the total consumption of antibiotics and reduce antibiotic resistance.

The campaign, among others, informs citizens about when you need antibiotics as a patient, and when they are superfluous.

The key messages of the campaign are:

"Viruses are a no go". Antibiotics never work on viral infections. Therefore, it is important to thoroughly test which type of infection you have caught.

"Your body is a canon – also against bacteria." The body can fight most mild bacterial infections without use of any antibiotics. Usually, the course of disease is only shortened slightly when antibiotics are given against a mild bacterial infection. Therefore, antibiotics should be used only against serious bacterial infections.

"I'm not a candy cane." Antibiotics can have side effects. In fact, the risk of suffering side effects is greater than the chance of experiencing a beneficial effect. Common side effects include abdominal pain, vaginal yeast infection, diarrhoea, vomiting or rash.

See the entire campaign at www.antibiotikaellerej.dk, where you may also download or order other materials from this year’s and previous years’ campaigns.

Eleven stakeholders present the campaign: The Danish Ministry of Health, The Danish Medicines Agency, The Danish Health Authority, Local Government Denmark, Statens Serum Institut, FOA, The Danish College of General Practitioners, European Antibiotic Awareness Day, The Danish Medical Association, Danish Regions and Apoteket.dk

(U. Wolff Sönksen, Microbiology and Infection Control, B. Jørgensen, Secretariat of the Management)

Various mono vaccine dosages against hepatitis B

Due to supply problems affecting the hepatitis B vaccine Engerix B^®, for some time Statens Serum Institut has been dispensing the replacement hepatitis B vaccine HBVaxpro^®. This vaccine will no longer be dispensed, but some vaccines may still be on stock in the doctors’ refrigerators.

It is important to be aware that the paediatric as well as the adult formulation of HBVaxpro^® contain only half the amount of hepatitis B antigen (10 microgram adult dose, 5 microgram paediatric dose) compared with Engerix B^® (20 microgram adult dose, 10 microgram paediatric dose). Nevertheless, the vaccines can be combined in the same vaccination programme, and it is then unnecessary to give a double dose of HBVaxpro^®. This will not affect the overall vaccination effect.

(The Consultancy Team, Department of Infectious Epidemiology and Prevention)

Limited subsidy for Prevenar13 for persons with diabetes mellitus above 65 years of age

As from 20 November 2017, the Danish Health Authority has decided to extend the limited subsidy for PCV13 by including diabetes patients above 65 years of age. From this date, the limited subsidy may therefore be given to:

Persons with:

• planned/performed splenectomy, organ transplant or cochlear transplant
• splenic dysfunction (e.g. following radiation) 
• leakage of cerebrospinal fluid 
• previous invasive pneumococcal disease 
• immunosuppression (e.g. due to HIV infection or lymphoma) 
• chronic obstructive pulmonary disease (COPD) above 65 years or in cases with an FEV1 below 40% of the expected value
• cardiac insufficiency (heart failure) above 65 years of age 
• diabetes mellitus above 65 years.

Persons below 18 years of age with:

• cyanotic heart disease 
• cardiac failure
• palliative surgery for cardiac condition
• haemodynamically significant residua following heart surgery
• chronic pulmonary condition (e.g. cystic fibrosis) 
• hypodynamic respiratory insufficiency 
• nephrotic syndrome 
• immunodeficiencies, excluding agammaglobulinaemia and SCID.

In order for the patient to qualify for a subsidy, the physician must mark the prescription “subsidy”, declaring that the person is covered by the limited subsidy.

(The Danish Health Authority)

Link to previous issues of EPI-NEWS

15 November 2017