AN EXPERIENCE OF DIPHTHEHA IN WESTMINSTER

A five-year-old girl from Bangladesh living in Westminster developed diphtheria. She was the second case reported in 1982:

2 weeks previously, a three-year-old English girl, died of the disease in Winchester on 19 August, 1982. Contacts of the dead girl were traced in the Westminster area and three carriers of a toxigenic strain of 'Corynebacterium diphtheriae' were isolated. Circumstantial evidence alone suggested a probable link between the two cases. The organisms identified, in both the cases and the carriers of toxigenic organisms were identical and of a strain not recently encountered in the U.K. It is likely that the source of infection was a chance importation by a healthy carrier probably from the Indian sub-continent.

Introduction

Diphtheria is now regarded as a disease of the past, and undoubtedly immunization has played a significant role in its control in this country. In 1914, there were 59.324 notifications and 5863 deaths in England and Wales. The number of deaths declined, but notifications changed little, until after 1940 when routirfe immunization of the child population was introduced. Over the next 10 years notifications fell 50-fold and by the 1970s had reached single figures. Prior to 1982, the last reported death from diphtheria was in 1975.

The case history

On 5 September a five-year-old Bangladeshi girl presented in the casualty department of Westminster Children's Hospital with stridor and follicular tonsillitis. She had been well until 2 September, when she developed a cough and complained of a sore throat.

She was admitted to hospital and treated as a case of croup. The folowing day her condition deteriorated and on re-examination of her throat, a grey exudate was seen extending backwards covering the uvula and tonsils. A clinical diagnosis of diphtheria was made and she was transferred to Coppett's Wood Isolation Hospital. On 7 September, a sucrosefermenting strain of 'Coryne­bacterium diphtheria' var mitis was isolated from her throat swab. She was treated with benzyl penicillin and diphtheria antitoxin. She required a tracheostomy and was maintained on intravenous fluids and strict bed rest. After 5 days she improved and was extubated, and subsequently made a full recovery.

Toxigenic 'Corynebacterium diphtheria' with the same biochemical characteristics as the patient, were isolated from the nose and throat of her sister aged 7 years and throat of her brother aged 3 years.

Background to the case in Westminster

On 19 August, 1982, a three-year-old English girl died of diphtheria in hospital in Winchester. She was an Army child and lived in barracks in Westminster. However, she had left there with

her mother, brother and sister, a few hours before the men of the barracks returned from the Falklands War.

Investigation of close contacts living in the barracks revealed three child carriers of toxigenic strains of diphtheria in two families.

A probable connection' between the child who died in Winchester, the Bangladeshi case in Westminster and one of the carriers living in the barracks was established on the following circumstantial evidence: one of the barrack carriers had attended a day nursery which was also attended by a close friend of the Westminster case. The children lived in the same block of flats, and this child was assumed to ,be the link between the two cases. However, repeated nose and threat swabs of this presumed link child, failed to grow 'Corynebacterium diphtheriae'.

No other direct link between the two cases could be established. The organisms isolated from the dead girl, her carrier siblings and carriers contacts at the barracks were indistinguishable from that of the case and her family carriers in Westminster, on the basis of sugar-fermentation reactions and phage type.