Massive diphtheria outbreak in South Asia: an epidemiological evidence review and lesson learnt

Shamsal M. Islam, Salim M. Chowdhury, Mahfuz A., Bimal C. Das, Reza M., Mahbuba K., Alauddin M., A. K. M. M. Haque


Vaccination is to be considerd as one of the most well-known economically viable medical procedures to prevent massive diphtheria outbreaks happening in recent times. Under this circumstance, the available data on diphtheria and vaccination coverage of three South Asian countries is warranted. The published English-language literature between January 2007 and January 2019 was retrieved from search results in eight highly resourceful journal databases using the specific terms. A massive diphtheria outbreak was occurred in refugee camps in Cox Bazar, a harbour city in Bangladesh, between November 2017 and March 2019. A total of 8641 diphtheria case-patients were reported including 45 deaths in the refugee camps. Our synthesis data shows that there is a gap of immunity which creates a large scale of potentiality for a new pandemic for adult couples along with children. The DTP3 coverage in India and Myanmar is less than 90% and these two countries had no standard coverage of DTP3 dose. We concluded that the massive outbreak of diphtheria in South Asia normally occurred due to low coverage of vaccination or incomplete vaccination. Crowded living environment, low socio-economic conditions, cultural belief, and importation of microorganisms are considered for massive outbreak of diphtheria outbreaks. Community-based awareness program and vaccinating individuals and some cases revaccination of older age groups are needed to stop further transmission and control the diphtheria outbreaks in South Asia. Further research is required to fully assess the vaccination coverage in the stateless populations in this region.


Bangladesh, Diphtheria, Epidemic, India, Migration, Myanmar, Outbreak, Rohingya, Vaccination

Full Text:



DaS PP, Patgiri SJ, Saikia L, PauL D. Recent outbreaks of diphtheria in Dibrugarh district, Assam, India. J Clin Diagn Res. 2016;10(7):DR01.

Clarke KE. Review of the epidemiology of diphtheria 2000-2016. Geneva, Switzerland: World Health Organization. 2017.

Wagner KS, White JM, Lucenko I, Mercer D, Crowcroft NS, Neal S, et al. Diphtheria in the post epidemic period, Europe, 2000-2009. Emerg Infect Dis. 2012;18(2):217-25.

Magill AJ, Hill JR, Solomon T, Ryan ET. Hunter's Tropical Medicine and Emerging Infectious Disease. 9th Edn. Saunders: USA; 2012.

Zakikhany K, Efstratiou A. Diphtheria in Europe: current problems and new challenges. Fut Microbiol. 2012;7(5):595-607.

Markina SS, Maksimova NM, Vitek CR, Bogatyreva EY, Monisov AA. Diphtheria in the Russian Federation in the 1990s. J Infect Dis. 2000;181(1):S27-34.

Galazka A. The changing epidemiology of diphtheria in the vaccine era. J Infect Dis. 2000;181(1):52-9.

Golaz A, Hardy IR, Strebel P, Bisgard KM, Vitek C, Popovic T, et al. Epidemic diphtheria in the newly independent states of the former Soviet Union: Implications for diphtheria control in the United States. J Infect Dis. 2000;181(1):S237-43.

Golaz A, Vitek C, Popovic T, Wharton M. Epidemiology of diphtheria in the 1990s. Clin Microbiol Newsletter. 2001;23(5):33-7.

World Health Organization. Diphtheria- Cox’s Bazar in Bangladesh. 2020. Available at: Accessed on 10 September 2020.

ISCG Situation Report: Rohingya Refugee Crisis, Cox’s Bazar. 2019. Available at: Accessed on 10 September 2020.

Farizo KM, Strebel PM, Chen RT, Kimbler A, Cleary TJ, Cochi SL. Fatal respiratory disease due to Corynebacterium diphtheriae: case report and review of guidelines for management, investigation and control. Clin Infect Dis. 1993;16:59-68.

World Health Organization. Diphtheria- Cox’s Bazar in Bangladesh. 2020. Available at: Accessed on 10 September 2020.

Shrivastwa S, Gillespie BW, Kolenic GE, Lepkowski MJ, Boulton LM. Predictors of vaccination in India for children aged 12-36 months. Am J Prevent Med. 2015;49(6-4).

WHO vaccine-preventable diseases: monitoring system. 2020 global summary. Available at: Accessed on 10 September 2020.

WHO. Bangladesh/Myanmar: Rakhine Conflict 2017; Public Health Situation Analysis and Interventions. 2017. Available at: Accessed on 10 September 2020.

ISCG. Situation Update: Rohingya Refugee Crisis Cox’s Bazar. 2019. Available at: Accessed on 10 September 2020.

Flakoll D. Rohingya Crisis: Public Health Threats and What You Can Do to Help. Vigilint. 2017. Available at:

UNHCR (2019) Operational update. November 10, 2017. Available at: documents/download/60849. Accessed on 10 September 2020.

World Health Organization. Global vaccine action plan 2011-2020. World Health Organization; 2013. Available at: immunization-vaccines-and-biologicals/strategies/ global-vaccine-action-plan. Accessed on 10 September 2020.

Bangladesh: Epidemiological Highlights Week 42 (14-20 Oct), 2019. Available at:

Hsan K, Misti JM, Gozal D, Griffiths MD, Mamun MA. Diphtheria outbreak among the Rohingya refugees in Bangladesh: What strategies should be utilized for prevention and control? Travel Med Infect Dis. 2020:101591.

World Health Organization. Report: State of the world’s vaccines and immunization, Third edition. World Health Organization; 2009.

Khaleghian P. Immunization in developing countries: its political and organizational determinants. World Dev. 2002;30:2109-32.

Rainey JJ, Watkins M, Ryman TK, Sandhu P, Bo A, Banerjee K. Reasons related to non-vaccination and under-vaccination of children in low and middle income countries: findings from a systematic review of the published literature, 1999-2009. Vaccine. 2011;29:8215-21.

Oyo‐Ita A, Nwachukwu CE, Oringanje C, Meremikwu MM. Interventions for improving coverage of child immunization in low‐income and middle‐income countries. Cochrane Database Systemat Rev. 2009(4).

Kaji A, Parker DM, Chu CS, Thayatkawin W, Suelaor J, Charatrueangrongkun R, et al. Immunization coverage in migrant school children along the Thailand-Myanmar border. J Immigrant Minority Health. 2016;18(5):1038-45.

Ministry of Health. The Republic of the Union of Myanmar. Expanded programme on immunization Myanmar multiyear plan 2012-2016. Ministry of Health The Republic of the Union of Myanmar; 2012. Available from: Accessed on 10 September 2020.

Antai D. Migration and child immunization in Nigeria: individual- and community-level contexts. BMC Public Health. 2010;10:116.

Hu Y, Li Q, Chen E, Chen Y, Qi X. Determinants of childhood immunization uptake among socio-economically disadvantaged migrants in East China. Int J Environ Res Public Health. 2013;10:2845-56.

Ministry of Public Health in Thailand. Workshop on expanded programme on immunization: displaced person temporary Mae Sot, Tak province, 27 November 2013. Ministry of Public Health in Thailand; 2013.

Garib Z, Holliday MD, Tavarez Y, Leal I, Pedreira C. Diphtheria in the Dominican Republic: reduction of cases following a large outbreak. Pan Am J Public Health. 2015;38(4)292-9.

Wagner KS, White JM, Lucenko I, Mercer D, Crowcroft NS, Neal S, et al. Diphtheria Surveillance Network. Diphtheria in the postepidemic period, Europe, 2000­2009. Emerg Infect Dis. 2012;18(2):217-25.

Pan American Health Organization. Vaccines and immunization, disease prevention. Volume 1: Health in the Americas, 2002. Washington, DC: PAHO; 2002.