Diphtheria: A Major Cause of Preventable Deaths in Nigeria

Practicing medicine in Nigeria can be quite heartbreaking.

A young boy of about eight years was brought into the hospital looking very weak. His mother carried his small frame on her back, like a toddler, and barged in the hospital in tears. Her son was dying. Working with advice she received from relatives and neighbours, she had sold the mattress in her room to pay for transportation fare to travel to the hospital in the big city.

Her son had been ill with fever for the past six days and all attempts to treat the febrile illness at the PHC in the neighbouring village proved futile. The child also had a history of cough, sore throat and difficulty in swallowing and breathing. His temperature was through the roof, and he had lost much weight. The boy’s eyeballs, located deep in their sockets, looked deathly pale, and his breathing was laboured and noisy. He also had a swollen neck which made all the health workers immediately uncomfortable. Is it what we think it is? While the child was being resuscitated, a quick oral examination showed a well-formed greyish, tough substance covering his tonsils. Our fears were confirmed- the boy had diphtheria in its late stages. Treatment involves administering diphtheria antitoxin to neutralise the effects of the toxin, as well as antibiotics to kill the bacteria. Sadly, his condition worsened despite treatment and the child passed away three days after admission. Very few people survive the late stages of diphtheria.

However, the mother did not sell her mattress for nothing. The death of her son from diphtheria served as a wake-up call for her and made her vigilant. Six days later, when her youngest son started shaking from fever, she wasted no time in traveling to the city. This time, she told us she sold her bed. Afterall, of what use was a bed without a mattress? 

In the hospital, the four-year-old was isolated and treated aggressively. Because of the early presentation, complications of diphtheria that cause difficulty in breathing and subsequent death were aborted. The child responded to treatment and was discharged eight days after admission. 

These cases were reported to the disease surveillance unit which immediately triggered actions at district, village and state levels. The village where the woman came from was a small settlement accessed only by motorcycles. The community was said to have witnessed a spike in deaths of children from febrile illness. When asked if the children in the village had received any immunisation when they were babies, the old man who acted as village head, chuckled softly. The children in the community are what we refer to as ‘Zero dose children’. These are kids who have not received any form of basic immunisation. For operational purpose, Zero-dose children are defined as children who have not received a single dose of diphtheria,tetanus and pertussis-containing vaccine. They are usually untraceable and not trackable by governments. About 50% of children that die from vaccine preventable diseases are zero dose children.

So much for eradicating diphtheria.

Diphtheria is a highly contagious vaccine-preventable disease which spreads between people mainly by direct contact or through the air via respiratory droplets. The disease can affect all age groups, however unimmunised children are particular at risk. It is potentially fatal. The disease can be treated by administering diphtheria antitoxin as well as antibiotics. Vaccination against diphtheria has reduced the mortality and morbidity of diphtheria dramatically.

Since the beginning of 2023, 557 confirmed cases of diphtheria have been detected in Nigeria, affecting 21 of the 36 states and the Federal Capital Territory. In December 2022, the Nigeria Centre for Disease Control and Prevention (NCDC) was notified of suspected diphtheria outbreaks in Kano and Lagos States. From May 14, 2022 to April 9, 2023, 1439 suspected cases have been reported, of which 557 (39%) have been confirmed, including 73 deaths among the confirmed cases (case fatality ratio of 13%).

When news of an outbreak started trickling in last year, we were all alarmed. Personally, I have not treated or managed the disease in over ten years. Truth be told, I thought it had been eradicated. Along, with whooping cough (pertussis), the incidence of these diseases has been quite low. The last time I managed whooping cough was over fourteen years ago in a child from a rural village buried deep in the forests of Borno state.

And yet, here we are. Many years later, still loosing children to a preventable disease. The situation is disheartening as it is embarrassing.

Have you ever seen a child die from diphtheria? 

The day you do, will be the day you become a staunch advocate of immunisation.

Nicknamed ‘the strangler of children’, the toxin produced by the bacteria causes a thick film to develop in the throat making it increasingly difficult to breathe and ultimately strangling the patient to death in many cases. Quite literally, the patient chokes to death while conscious. It is one of the scariest things to witness. Despite advances in medicine (like intubation), when a child presents in the late stages with that substance already formed in the throat and the characteristic ‘bull neck’, that child is not likely to make it. Additionally, the spread of the toxin in the body can also affect the heart and other organs causing myocarditis (which in itself can result in an abnormal heart rate), inflammation of nerves (which can result in paralysis), kidney problems, and bleeding problems. 

Medical reports of a deadly “strangulation” disease first appeared in the 1600s with the growth of cities and easier person to person spread. The name ‘diphtheria’ is derived from the Latin word ‘diptherite’ which means ‘leather’ or ‘hide’ describing the tough substance that covers that back of the throat.

The persistence of diphtheria in Nigeria has been linked to various factors, including low vaccine coverage, insufficient vaccine storage and transportation. The best prevention against diphtheria remains immunisation. However, Nigeria’s immunisation coverage rate remains suboptimal, fluctuating over the last decade. There has been some improvement recorded in the past 5 years, but current immunisation coverage rate is 57%, far below the national target of 90%. 

The World Health Organisation has recommended vaccination against diphtheria since 1974. Therefore, for the past 50 years, a vaccine has been available for diphtheria. The diphtheria vaccine is usually delivered in several combinations including that of Tetanus and whooping coup (pertussis). Currently, the Pentavalent vaccine administered in Nigeria provides protection to a child from 5 life-threatening diseases – Diphtheria, Pertussis, Tetanus, Hepatitis B and Hib. For adults, immunity against diphtheria reduces with time and further booster shots may be needed. A course of diphtheria-containing vaccine is recommended for anyone who has never been vaccinated.

Vaccines saves lives. There is no reason for anyone in this era to be sell their furniture in search of a cure for a disease that could have been prevented in the first place. The death of a child is not just heartbreaking but alters family dynamics in deeper ways than can be immediately noticed. The mother of the boy that died eventually developed generalised anxiety and depression for which she continues to be managed. Like a sad story, we watched as the quality of her life took a nose hill dive after the incident while her husband, other children and relatives suffered.

The death of a child is painful. More so, a preventable one. Let us support the government to ensure more babies are immunised so that we can prevent future outbreaks.

A word is enough for the wise.