Between 1 January 2024 and 27 April 2025, 48 confirmed cases of respiratory diphtheria, 1 probable respiratory diphtheria case and 40 asymptomatic carriers of toxigenic C. diphtheriae, detected during contact tracing, have been identified in South Africa. The majority of confirmed cases and carriers (75%, 66/88) were from the Western Cape, comprising 31 respiratory diphtheria cases and 35 asymptomatic carriers. The median age for cases of confirmed respiratory diphtheria was 28 years (range: 2–55 years), with 73% (35/48) being 18 years and older. The overall case-fatality ratio (CFR) among probable and confirmed respiratory diphtheria cases was 22% (11/49). Among children and adolescents under 18 years, the CFR was 23% (3/13), compared to 25% (8/36) among adults.
Highlights:
- Since the last situational report (week 16), the following updates are included in this report:
o Two new laboratory-confirmed cases of toxigenic respiratory diphtheria, one from Limpopo and one from KwaZulu Natal.
o No new asymptomatic carriers of toxigenic C. diphtheriae.
o One additional death has been reported, bringing the total to 11 deaths. - Appropriate public health responses have been initiated for each case.
Information for clinicians
Clinical presentation of respiratory diphtheria
Respiratory diphtheria is a vaccine-preventable illness caused by toxigenic C. diphtheriae (and more rarely C. ulcerans or C. pseudotuberculosis), and can occur in persons of all ages.
The clinical presentation includes the following signs and symptoms:
- sore throat
- low-grade fever
- AND an adherent membrane of the nose, pharynx, tonsils, or larynx (Figure 2) – the membrane is greyish-white and firmly adherent to the tissue
- AND/OR enlarged glands in the neck (bull neck)
- toxin-mediated systemic signs including myocarditis, polyneuropathy and renal damage
Patient management
Treatment includes antibiotics (azithromycin or penicillin) to clear the organism from the throat and prevent onward transmission, and diphtheria anti-toxin (DAT) to neutralise unbound toxin. The dosage of DAT is determined by the duration and severity of illness. Treatment, contact tracing and chemoprophylaxis should be started prior to laboratory confirmation. Early administration of DAT may be life-saving and should not be delayed in cases with a high index of suspicion. Supportive care is primarily aimed at airway management and includes providing oxygen, monitoring with electrocardiogram and intubation or performance of a tracheostomy if necessary.
To access previous diphtheria situational reports, click here.
