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    Increase in diphtheria cases caused by C. diphtheriae in France in 2022. Update as of December 31, 2022.

    Update on December 31, 2022 following cases of diphtheria caused by C. diphtheriae reported in several regions of metropolitan France as well as in Mayotte and Réunion.

    Posted on February 10, 2023


    Since the beginning of 2022, several cases of diphtheria have been reported in 9 regions of metropolitan France as well as in Mayotte and Réunion. Compared to other years, the number of cases of C. diphtheriae is significantly higher than average. In metropolitan France, the majority of cases were reported in migrants and travelers. Thanks to the very high vaccination coverage for many years, the occurrence of serious cases or clustered cases within the general population appears extremely low in metropolitan France and Reunion. In Mayotte, where vaccination coverage is insufficient, the bacterium has been circulating for several years.

    Public Health France is monitoring the evolution of the situation and the increase in cases of diphtheria among migrants, the vast majority of whom are not up to date with their vaccinations. A reminder of the recommendations for vaccination and care has been sent to associations and health professionals.

    Reminder about illness

    Diphtheria due to Corynebacterium diphtheriae is a highly contagious bacterial infection which is transmitted from man to man from sick subjects but also from healthy carriers (carrying possible for several weeks or months). Transmission is either direct by droplets, or indirect from soiled objects (rare) or untreated skin lesions. Its incubation period is short, less than 7 days (from 2 to 5 days). The disease manifests itself in ENT or cutaneous form.
    1. Diphtheria is a reportable disease .
    2. Learn more about the disease

    Update in France

    As of December 31, 2022, 60 cases of diphtheria (biologically confirmed as tox -positive, i.e. carriers of the tox -coding gene for diphtheria toxin) have been reported in France since the beginning of the year (figure 1):
    • 8 cases of diphtheria due to Corynebacterium ulcerans ( C. ulcerans ) in metropolitan France;
    • 35 cases of diphtheria due to Corynebacterium diphtheriae (C. diphtheriae ) in metropolitan France;
    • 13 cases of diphtheria caused by C. diphtheriae in Mayotte and 4 in Reunion.
    In 2022 and compared to the last 5 years, the number of diphtheria cases due to C. ulcerans was similar (on average 7.2 cases per year), but the number of cases of diphtheria due to C. diphtheriae was significantly higher than the average then observed (metropolitan France: 3.4 cases per year; Mayotte: 2.6 cases per year; Reunion: 0.6 cases per year). There is therefore a clear increase in C. diphtheriae cases in 2022, particularly in mainland France.

    Figure 1 - Number of reported diphtheria cases, per year, France, 2002-2022 – Data as of December 31, 2022


    In France

    The majority of cases were reported in migrants (n=28) but also in travelers (n=6) (Figure 2). For these 34 cases, the notion of a stay in one or more of the following countries was found: Afghanistan (n=24), Turkey (n=6), Italy (n=5), Serbia (n=6), Austria (n=4), Tunisia (n=3), Bulgaria (n=2), Iran (n=2), Hungary (n=2), Mali (n=2), Switzerland (n=2), Bosnia (n=1), Slovenia (n=1), Syria (n=1), Senegal (n=1), Thailand (n=1), Madagascar (n=1). When the date of their arrival in France was known (n=12), it was most often less than 15 days before the date of notification of the disease (n=9). A case, which could not be questioned, for which we have no information on the concept of travel.
    In addition, a case was probably infected on French territory during contact with a person returning from a trip to Togo.
    Cases of diphtheria due to C. diphtheriae in mainland France were mainly men (n=32), aged 11 to 59 years (23 years on average). Only three of them were up to date with their diphtheria vaccination. For 25 of them, the vaccination status was unknown.
    Among the cases that occurred among migrants, 11 were staying in shelters.
    Cases have been diagnosed in 9 regions. The Normandy region was the most affected with 7 reported cases but the cases were scattered over the metropolitan territory (figure 3). Twenty-seven cases were cutaneous forms, 3 were asymptomatic carriers (at the level of the oropharyngeal sphere), one was a slightly symptomatic respiratory form (autochthonous case) and four others presented the symptoms of classic diphtheria angina (migrant person). One of these ENT cases died.
    Genotyping by genomic sequencing of the 34 isolates by the National Reference Center (CNR) for corynebacteria of the diphtheriae complex (https://www.pasteur.fr/fr/sante-publ...es-du-complexe -diphteriae ) showed 12 different genetic clusters (defined by their ' sublineage ' (SL) and more finely by their ' genomic cluster ' (GC)), including 5 among the migrant cases linked to Afghanistan: SL377-GC817 ( 8 cases), SL466-GC823 (1 case), SL384-GC805 (7 cases), SL698-GC795 (7 cases), SL698-GC804 (2 cases). These groups have also been identified in other European countries.
    Two grouped cases were reported: one concerned 4 cases who had traveled together on a bus and the other two cases who had traveled together. Genotyping by genomic sequencing showed that among the cases that had traveled on the bus, there were two pairs of cases with two distinct genotypes and therefore probably two chains of transmission.


    Figure 2 - Number of diphtheria cases caused by C. diphtheriae according to the notion of a return from a foreign country, by reporting week, metropolitan France, 2002 – Data as of December 31, 2022


    Figure 3 - Number of cases by region, France, 2022 - Data as of December 31, 2022


    An increase in the number of cases among migrants is also observed in other European countries, particularly in England, Germany and Switzerland. As of 25 November 2022, England reported 50 cases since the start of the year ( UK Health Security Agency, Public health control and management of diphtheria in England Supplementary guidance for cases and outbreaks in asylum seeker accommodation settings, December 2022 ). Germany was reporting three times more cases in 2022 (week 30 to 39) compared to the number of cases reported in the last three years ( Badenschier et al Euro Surveill. 2022 ). Switzerland announced, in October 2022, two ongoing diphtheria epidemics among migrants ( Kofler J et al Euro Surveill 2022). The European Center for Disease prevention and Control (ECDC) and WHO also reported cases of diphtheria in Austria, the Czech Republic, Belgium, Italy and Norway .

    Mayotte and Reunion

    In Mayotte, the autochthonous circulation of the bacterium has been known for several years. In 2022, of the 13 cases reported, 7 were cutaneous forms, 1 ENT form and 5 were asymptomatic (ENT) carriers of the bacterium. These last 5 infections were discovered among close contacts of 2 symptomatic cases. One death occurred in an unvaccinated 7-month-old baby.In Reunion, over the period 2021-2022, all the cases reported were imported cases. In 2022, 4 cases were declared and no notion of travel was found. These 4 cases were not related to each other and were cutaneous forms.
    The analysis of the genomic groupings, by the CNR, showed that 10 strains (6 in Mayotte and 4 in Reunion) had the same characteristics, which strongly suggests that these cases are linked. We have no hypothesis at this stage on the nature of this link.


    What measures are in place?

    France (excluding Mayotte) has a very high vaccination coverage (VC) against diphtheria: 99% for the primary vaccination and 96% for the booster at 11 months in infants in 2019. These vaccination coverages have been very high since many years, the vaccine having been made compulsory until the age of 13 until 2018. In addition, vaccination is compulsory for infants born from 2018. The risk of occurrence of cases, in particular serious cases and/or clusters within the general French population, therefore remains extremely low.

    On the other hand, the increase in cases of diphtheria among migrants, the vast majority of whom are not up to date with their vaccinations, raises fears of the appearance of grouped cases of infection with C. diphtheriae in places of accommodation for migrants, refugees or asylum seekers (this scenario has been described in Switzerland, ( Kofler J et al Euro Surveill 2022 )). In order to prevent this risk, a message 1 informing of this increase in cases among migrants and recalling the recommendations for vaccination and care 2 has been sent to associations caring for migrant populations and to health professionals.

    Investigations and discussions on cases occurring among migrants are carried out at European level (ECDC and WHO) in particular to identify a possible place of contamination (countries crossed on the migratory route or country of origin such as Afghanistan).

    During the first 3 weeks of January 2023, cases of diphtheria in migrants, particularly from Afghanistan, continued to be reported. Professionals caring for these populations should be reminded to be particularly vigilant in identifying the signs of diphtheria and caring for these people for whom access to care may be difficult (Diphtheria sheet: identifying and caring for a suspected patient in France 06/07/2022, COREB ).

    In Mayotte, studies carried out over the past few years show an insufficient CV to ensure collective immunity. In 2019, 93.2% of children aged 24 to 59 months; 45.3% of 7-11 year olds and 27.1% of 14-16 year olds were up to date with their diphtheria vaccination. Interventions aimed at increasing vaccination coverage in these populations must be reinforced in this territory.
    ...

    https://www.santepubliquefrance.fr/l...-decembre-2022





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  • France - Increase in diphtheria cases caused by C. diphtheriae in 2022

    Translation Google
    Increase in diphtheria cases caused by C. diphtheriae in France in 2022

    Update on November 30, 2022 following cases of diphtheria caused by C. diphtheriae reported in several regions of metropolitan France as well as in Mayotte and Réunion.

    Posted on December 29, 2022

    Since the beginning of 2022, several cases of diphtheria have been reported in 9 regions of metropolitan France as well as in Mayotte and Réunion. Compared to other years, the number of cases of C. diphtheriae is significantly higher than average. In metropolitan France, the majority of cases were reported in migrants and travelers. Thanks to the very high vaccination coverage for many years, the occurrence of serious cases or clustered cases within the general population appears extremely low in metropolitan France and Reunion. In Mayotte, where vaccination coverage is insufficient, the bacterium has been circulating for several years.
    Public Health France is monitoring the evolution of the situation and the increase in cases of diphtheria among migrants, the vast majority of whom are not up to date with their vaccinations. A reminder of vaccination and management recommendations has been sent to associations and healthcare professionals.

    Reminder about illness

    Diphtheria is a disease caused by bacteria ( Corynebacterium diphtheriae ). Very contagious, it is transmitted from person to person from sick subjects but also from healthy carriers (carrying possible for several weeks or months). Transmission is either direct by coughing and sneezing (via droplets), or indirect from soiled objects (rare) or untreated skin lesions. Its incubation period is short, 2 to 5 days. The signs of diphtheria are those of sore throat, with fever, swelling of the neck and headache or skin infection.
    1. Learn more about the disease


    Update in France

    As of November 30, 2022, 55 cases of diphtheria have been reported in France since the start of the year (figure 1):
    • 8 cases of diphtheria due to Corynebacterium.ulcerans ( C. ulcerans ) in metropolitan France;
    • 30 cases of diphtheria caused by Corynebacterium diphtheriae ( C. diphtheriae ) in metropolitan France;
    • 13 cases of diphtheria caused by C. diphtheriae in Mayotte and 4 in Reunion.
    In 2022 and compared to the last 5 years, the number of diphtheria cases due to C. ulcerans was similar (on average 7.2 cases per year), but the number of cases of diphtheria due to C. diphtheriae was significantly higher than the average then observed (metropolitan France: 3.4 cases per year over the last 5 years; Mayotte: 2.6 cases per year over the last 5 years; Réunion: 0.6 cases per year over the last 5 years).

    Figure 1 - Number of reported diphtheria cases, per year, France, 2002-2022 – Data as of November 30, 2022



    In France

    The majority of cases were reported in migrants (n=24) but also in travelers (n=5) (Figure 2). For these 29 cases, a link was found with one or more of the following countries: Afghanistan (n=21), Turkey (n=6), Italy (n=5), Serbia (n=5), Austria (n= 4), Tunisia (n=3), Bulgaria (n=2), Iran (n=2), Hungary (n=2), Mali (n=2), Switzerland (n=2), Slovenia (n=1 ), Syria (n=1), Senegal (n=1), Thailand (n=1). When the date of their arrival in France was known (n=9), it was less than 15 days before the date of notification of the disease.

    In addition, a case was probably infected on French territory during contact with a person returning from a trip to Togo.

    Cases of diphtheria due to C. diphtheriae were mainly men (n=28), aged 11 to 47 years (21 years on average). Only two of them were up to date with their diphtheria vaccination. For 24 of them, the vaccination status was unknown.

    Among the cases that occurred among migrants, 6 lived in a shelter.

    Cases have been diagnosed in 9 regions. The Normandy region was the most affected with 7 cases reported (figure 3). Twenty-five cases were cutaneous forms, 3 were asymptomatic carriers (oropharyngeal), one was a slightly symptomatic respiratory form (autochthonous case) and another presented the symptoms of classic respiratory diphtheria (migrant person).

    Two grouped cases were reported: one concerned 4 cases who had traveled together on a bus and the other two cases who had traveled together.

    Genotyping of 19 isolates by the National Reference Center (CNR) for corynebacteria of the diphtheriae complex by genomic sequencing showed 5 different genetic groups: ST377a (2 cases), ST377b (1 case), ST384 (2 cases), ST574 ( 3 cases), ST698 (2 cases). These groups have also been identified in other European countries. The other isolates are being sequenced.


    Figure 2 - Number of diphtheria cases caused by C. diphtheriae, by reporting week, France, 2022 – Data as of November 30, 2022



    Figure 3 - Number of cases by region, France, 2022 - Data as of November 30, 2022



    This increase in the number of cases among migrants is also observed in other European countries. As of September 26, 2022, the European Center for Disease prevention and Control (ECDC) reported 92 cases of C. diphtheriae diphtheria in 2022 in 7 European countries (Germany, Austria, Belgium, France, Great Britain, Norway, Switzerland)

    Mayotte and Reunion

    In Mayotte, the autochthonous circulation of the bacterium has been known for several years. In 2022, of the 13 cases reported, 7 were cutaneous forms, 1 ENT form and 5 were asymptomatic (ENT) carriers of the bacterium. These last 5 infections were discovered among close contacts of 2 symptomatic cases. One death occurred in an unvaccinated 7-month-old baby. In Reunion, over the period 2021-2022, all the cases reported were imported cases. In 2022, 4 cases were declared and no notion of travel was found. These 4 cases were apparently unrelated and were cutaneous forms.

    The analysis of the genomic groupings, by the CNR, showed that 12 strains (8 in Mayotte and 4 in Reunion) had the same characteristics, which strongly suggests that these cases are linked. We have no hypothesis at this stage on the nature of this link.

    What measures are in place?

    In mainland France and Reunion

    France has a very high vaccination coverage (VC) against diphtheria: 99% for the primary vaccination and 96% for the booster at 11 months in infants in 2019. These vaccination coverages have been very high for many years, the vaccine having been made compulsory up to the age of 13 until 2018. In addition, vaccination is compulsory for infants born from 2018. The risk of occurrence of cases, in particular serious and /or cases grouped within the general French population, therefore remains extremely low.

    In Réunion, the CV is also high (97.4% for the 11-month recall in 2018). On the other hand, the increase in cases of diphtheria among migrants, the vast majority of whom are not up to date with their vaccinations, raises fears of the appearance of grouped cases of infection with C. diphtheriae in places of accommodation for migrants, refugees or asylum seekers (this scenario has been described in Switzerland, Kofler et al Eurosurveillance 2022). In order to prevent this risk, a message 1 informing of this increase in cases among migrants and recalling the recommendations for vaccination and care 2 has been sent to associations caring for migrant populations and to health professionals.

    Investigations and discussions on cases occurring among migrants are carried out at European level (ECDC and WHO) in particular to identify a possible place of contamination (countries crossed on the migratory route or country of origin such as Afghanistan).


    In Mayotte

    In Mayotte, studies carried out over the past few years show an insufficient CV to ensure collective immunity. In 2019, 93.2% of children aged 24 to 59 months; 45.3% of 7-11 year olds and 27.1% of 14-16 year olds were up to date with their diphtheria vaccination. Interventions aimed at increasing vaccination coverage in these populations must be reinforced in this territory.


    1- MINSANTE No. 2022_66 dated 09/27/2022
    2- Opinion of the High Council for Public Health on the conduct to be followed around a case of diphtheria of March 4, 2011 and supplement of September 10, 2022: https:/ /www.hcsp.fr/explore.cgi/avisrapportsdomaine?clefr=215





    https://www.santepubliquefrance.fr/l...france-en-2022
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