Diphtheria in the postepidemic period, Europe, 2000-2009

Abstract

Diphtheria incidence has decreased in Europe since its resurgence in the 1990s, but circulation continues in some countries in eastern Europe, and sporadic cases have been reported elsewhere. Surveillance data from Diphtheria Surveillance Network countries and the World Health Organization European Region for 2000-2009 were analyzed. Latvia reported the highest annual incidence in Europe each year, but the Russian Federation and Ukraine accounted for 83% of all cases. Over the past 10 years, diphtheria incidence has decreased by >95% across the region. Although most deaths occurred in disease-endemic countries, case-fatality rates were highest in countries to which diphtheria is not endemic, where unfamiliarity can lead to delays in diagnosis and treatment. In western Europe, toxigenic Corynebacterium ulcerans has increasingly been identified as the etiologic agent. Reduction in diphtheria incidence over the past 10 years is encouraging, but maintaining high vaccination coverage is essential to prevent indigenous C. ulcerans and reemergence of C. diphtheriae.

Figure 1

Diphtheria Surveillance Network (DIPNET) and World Health Organization (WHO) European Region countries. 1, Albania; 2, Andorra; 3, Armenia; 4, Austria; 5, Azerbaijan; 6, Belarus; 7, Belgium; 8, Bosnia and Herzegovina; 9, Bulgaria; 10, Croatia; 11, Cyprus; 12, Czech Republic; 13, Denmark; 14, Estonia; 15, Finland; 16, France; 17, Georgia; 18, Germany; 19, Greece; 20, Hungary; 21, Iceland; 22, Ireland; 23, Israel (neighboring countries not shown); 24, Italy, 25; Kazakhstan; 26, Kyrgyzstan; 27, Latvia; 28, Lithuania; 29, Luxembourg; 30, Malta; 31, Monaco; 32, Montenegro; 33, the Netherlands; 34, Norway; 35, Poland; 36, Portugal; 37, Republic of Moldova; 38, Romania; 39, Russian Federation; 40, San Marino; 41, Serbia; 42, Slovakia; 43, Slovenia; 44, Spain; 45, Sweden; 46, Switzerland; 47, Tajikistan; 48, Former Yugoslav Republic of Macedonia; 49, Turkey; 50, Turkmenistan; 51, Ukraine; 52, United Kingdom (Great Britain and Northern Ireland); 53, Uzbekistan.

Figure 2

Diphtheria cases per 1 million population in the World Health Organization (WHO) European Region and number of countries with a rate >1 cases/1 million population, 2000–2009.

Figure 3

Diphtheria incidence per 1 million person-years for Latvia (Corynebacterium diphtheriae, 2002–2009) and the remaining 24 Diphtheria Surveillance Network (DIPNET) countries (C. diphtheriae and C. ulcerans, 2000–2009). Error bars indicate 95% CIs. The period 2002–2009 excludes the military outbreak in 2000 and cases from 2001 for which limited information was available.