Should you worry about diphtheria?

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IN HER 26 years of working as a doctor, paediatrician Dr Yong Junina has not seen a single case of diphtheria. It was one of those considered eradicated infections that she never expected to see or hear of in her lifetime.

“I’ve never seen a single case of diphtheria. I studied in the UK in the 80s. I came back in 1990. Diphtheria was never a differential diagnosis. I’ve heard about it. I heard there was an outbreak in Sungai Pencala during the time of the Al-Arqam movement, and that was it. Then my daughter, who is a houseman, came back home recently and asked me about diphtheria. I told her not to worry as we don’t have cases here. She then told me that her friend just saw two cases. The next thing we knew, one of those children died,” she related last week.

To date, three children have died from diphtheria in the past month – one each in Kedah, Malacca and Sabah.

Not immunised

For the longest time, doctors have been speaking about herd immunity. Why has it failed us now? According to Dr Yong, the herd immunity only protects a country if enough people are immunised.

The new cases of diphtheria prove that not enough people in Malaysia have been immunised, and that includes foreign children who have slipped through the cracks and remain undocumented, untracked, unschooled and unvaccinated.

Malaysia has a National Immunisation Programme, with a list of jabs your child needs to get and the recommended age for each one. However, it is not mandatory to have your child immunised.

Malaysian parents do not face any legal action or sanctions for not immunising their children. They are not punished with a jail term nor are they fined and they are not deprived of education and healthcare for their child.

Dr Yong points out that even if unvaccinated children are denied entry to government schools, they can still go to other schooling systems in the country.

According to her, the anti-vaccination movement is a global concern now and many countries, inluding the US and Australia, are worried that more and more children are not protected against diseases like diphtheria, pertussis (whooping cough) and measles, which are making an unwelcome return globally.

Australia just passed a bill to say that parents who don’t immunise their children will lose childcare and welfare support.

“I know that in Germany, they keep track of all the infants in the country, and if they have not seen that child for a while, they ask the parents to submit the latest immunisation record,” said Dr Yong.

Last year, after the death of an 18-month-old boy, and the worst measles outbreak in Germany in the past decade, several groups called for mandatory measles vaccinations.

The World Health Organisation (WHO) admitted that progress towards reaching the vaccination goals has stalled in some countries. Among the challenges faced are a lack of access to health services, shortage of accurate information about immunisation, insufficient political and financial support, and inadequate supply of vaccines in some areas.

“We are not just worried about diphtheria. We have had an outbreak of measles, and we’ve had an outbreak of whooping cough, too. Children can die from all three of these,” added Dr Yong.

If a family has children who are not immunised and the whole family goes to Mecca, for example, they might be exposed to people from Pakistan and Afghanistan, two countries that still have polio. The children might contract polio.

According to Dr Yong, this scenario is very real. She agreed that children are not the only ones at risk. So is everyone else who then comes into contact with these children – including pregnant women, those who are too poor to get immunised, and the children who, for whatever medical reasons, cannot be immunised.

Are our children at risk?

Are children who have been immunised safe from diphtheria, pertussis and measles?

According to Dr Yong, the last dose for pertussis is given when a child is 18 months. This protects the child for 10 years, likewise the tetanus vaccine.

For diphtheria and polio, the protection is for life.

If your child is two years old and they have completed all the vaccines, then the child is protected. For parents, they can get the triple antigen booster for adults, which is available at selected clinics.

According to the WHO, the signs of diphtheria are:

  • Sore throat;
  • Loss of appetite;
  • Slight fever;
  • A bluish-white or grey membrane forms in the throat and on the tonsils; and
  • Patients with severe diphtheria do not develop a high fever but may develop a swollen neck and an obstructed airway.


Pertussis occurs mainly in infants and young children. It is transmitted through droplets.

According to WHO: “The first symptoms generally appear 7-10 days after infection, and include mild fever, runny nose, and cough, which in typical cases, gradually develops into a paroxysmal cough followed by whooping (hence the common name of whooping cough).

“In the youngest infants, the paroxysms may be followed by periods of apnoea. Pneumonia is a relatively common complication; seizures and encephalopathy occur more rarely. Untreated patients may be contagious for three weeks or more following onset of the cough.”

Symptoms of measles:

  • High fever;
  • Runny nose;
  • Cough;
  • Red and watery eyes;
  • Small white spots on the skin; and
  • Rash on face and upper neck.


Complications are more common in those below five. Serious complications include blindness, encephalitis, diarrhoea, ear infection, dehydration, and respiratory infections.

How to protect our kids

The signs and symptoms for all three are very non-specific. A runny nose, sore throat and cough could be just that, and they could also be signs of something more serious.

Dr Yong advises parents to take their children to the clinic for a checkup if they develop a high fever.

“If the child is fully vaccinated, then, chances are, it is not diphtheria. If your child is very ill, with high fever, then come in for a checkup as soon as possible.

“It is very, very worrying to see the return of infections and diseases that we haven’t seen for many years,” she said.

Because we have not seen things like diphtheria and whooping cough for a while, we think we are safe. “And people think that vaccines are bad for them. Many times, when I tell parents that you can die from chicken pox, they look at me in disbelief and say, ‘Oh really? I thought everyone must get chicken pox once in their life, so why stop it?’ It never crosses their minds that somebody can die from it. I have seen children die from chicken pox. I have seen secondary complications because of our traditional beliefs that children with chicken pox shouldn’t shower.”

She also raised the issue of how to immunise the large foreign community. Their children are undocumented because they were born here. They are not registered, and their parents are too scared to go for checkups at the Klinik Kesihatan (government clinic) for fear of action from the authorities.

“So, these kids remain unvaccinated. If they come from poorer socio-economic groups, chances are. they are exposed to unhygienic conditions, thereby increasing their risk of contracting diseases. But, these kids still go out. They still go to the grocery store. The family lives in abject poverty, so their main concern is feeding their family rather than getting immunised, if they even know about it.

“How do you immunise them when you don’t know where they are?” she asked.

Dr Yong also warned parents about getting advice from doctors who are against vaccinations, and believing claims found on the Internet and social media which are not based on scientific evidence.

“I hope that with this outbreak comes greater awareness, and parents who were sitting on the fence before, wake up and realise that the reintroduction of these diseases which were once the scourge of the 30s and 40s, is going to be the scourge of the 21st century if we don’t vaccinate our children,” she said.