The COVID-19 pandemic has caused widescale disruption to many essential health services globally. In Indonesia, WHO is supporting the programme surveillance of immunization services and vaccine preventable diseases (VPD), including diphtheria.

Diphtheria is an infectious bacterial disease that primarily infects the throat and upper airways and produces a toxin that affects other organs. It is spread through direct physical contact or from breathing in contaminated droplets from coughs or sneezes of infected individuals. The disease is fatal in 5-10% of cases with a higher mortality rate among children. In some areas where adequate diagnosis and treatment is not available, diphtheria can reach a fatality rate of almost 50%. Early childhood vaccination against the disease can be effective in dramatically reducing the mortality and morbidity of diphtheria.

Vaccination against diphtheria has reduced the mortality and morbidity of diphtheria dramatically, however, diphtheria is still a significant child health problem in countries with low immunization coverage. In 2019, Indonesia reported 948 cases of diphtheria nationwide. Eighty-one per cent of those who fell ill with the disease either had not completed the full dosage of immunization (7 doses or more) or had no vaccinations against diphtheria.

Caption: Diphtheria outbreak response immunization (ORI) in Sorong, West Papua, 2019. Credit: Aning Isfandyari/WHO

WHO and the Indonesian government are working together to achieve the national target of diphtheria control by 2024. Overcoming disruptions caused by the large-scale social restrictions, limited movement and closure of transportation services during the COVID-19 pandemic, WHO is continuing to support Indonesia by providing technical assistance at both the national and subnational levels, facilitating capacity building and training opportunities for surveillance officers and sourcing lifesaving diphtheria antitoxin treatments.

Diphtheria antitoxin is a crucial treatment that can reduce the case-fatality rate for diphtheria by approximately 15%. The earlier the antitoxin treatment is administered to a patient with suspected or confirmed diphtheria, the more effective it is in steering the course of the disease and preventing further spread.

In late July, 700 vials (10 000 international units per vial) of diphtheria antitoxin were procured and delivered to the Indonesian Ministry of Health. These vials have been distributed to provinces with high transmission of diphtheria such as Aceh, DKI Jakarta, East Java and West Java.

Caption: A delivery of 700  lifesaving diphtheria antitoxin vials will be distributed to provinces across Indonesia with high diphtheria transmission. Credit: Ministry of Health

Between January and June 2020, case reporting of VPD significantly declined in comparison to surveillance in the same period last year: diphtheria reporting dropped by 68%. It is vital that case detection, reporting and treatment remain ongoing throughout the COVID-19 pandemic to ensure community wellbeing and lasting progress against VPD transmission.

WHO is committed to supporting the Indonesian government to analyze the national immunization programme and services to ensure their safe continuity during the COVID-19 pandemic in line with WHO recommendations. Over the past six months, stakeholders across the country have coordinated multiple webinars to address challenges and find solutions to maintain immunization programmes and VPD surveillance, and various information, education and communication (IEC) materials have been developed and disseminated to generate demand for these services to continue.

Procurement of further quantities of the antitoxin are planned, in anticipation of a possible surge in diphtheria cases as a result of low routine immunization coverage during the COVID-19 outbreak. 

However, the best way to reduce VPD cases in Indonesia, including diphtheria, is for communities to undergo complete vaccination. Widescale and comprehensive immunization will prevent multiple disease outbreaks from occurring during the COVID-19 pandemic and provide lasting health protection for everyone.

Thumbnail caption: Child receives essential routine immunization during COVID-19 pandemic. Credit: Sri Kusyanti /Arso Kota Health Center.