Guinea: An almost-forgotten disease makes a resurgence in West Africa

In recent months, countries across West Africa have been battling the worst wave of diphtheria on record. The first cases were diagnosed in August 2022 in Niger, before the disease spread to Algeria, Mauritania, Nigeria and Guinea. The first patient in Guinea was diagnosed in July 2023 in Siguiri, a prefecture in the northeast of the country. Since then, cases of the life-threatening disease have continued to rise.

“My daughter was not feeling well – she had sores in her throat, she was struggling to eat and drink, and all she did was cry,” says Saran Keita, cradling her five-year-old daughter in her arms and handing her an orange to comfort her. “It was then that someone took us to the Centre for the Treatment of Epidemics in Siguiri.” On their arrival at the treatment centre, which is supported by Médecins Sans Frontières/Doctors Without Borders (MSF), her daughter was examined before being given a diphtheria antitoxin.

With diphtheria cases on the rise, a major response is underway in Siguiri.

MSF mounted a major response in Siguiri in mid-August 2023. As of January 4, 2024, the treatment centre’s team – made up of 64 MSF staff and 184 Ministry of Health staff – have treated 2,122 people for diphtheria, most of them young children, but also teenagers and adults. Eighteen per cent of patients were children under five; 43 per cent were aged five to 15; 29 per cent were aged 15 to 29; and 10 per cent were over 30.

In the waiting room, patients and caregivers listen to MSF health promoters explain in Malinké, the local language, how to recognise the symptoms of diphtheria and how the disease spreads.

“Diphtheria is a bacterial infection that attacks the respiratory tract,” says MSF medical coordinator Dr Adélard Shyaka. “It is transmitted by airborne droplets and can be fatal, especially for small children. It can also release a toxin that can affect the body's organs, including the heart and kidneys. Among other things, the toxin kills the cells in the heart, nerves and airways. A pseudomembrane can also form due to the toxin.”

The pseudomembrane is a thick, gray coating, so-called because it is not naturally produced by the body. If an antitoxin is not administered quickly, the fast-growing pseudomembrane can soon block an infected person’s airways, leaving them struggling to breathe.

The incubation period for diphtheria is two to 10 days. “It often starts on the second day after exposure with a moderate fever, followed by inflammation of the pharynx or larynx, and difficulty eating and breathing,” says Dr Shyaka. “The pseudomembrane usually appears on the third or fourth day.”

Before the current outbreak, diphtheria had largely disappeared worldwide. Guinea had had no diphtheria cases in more than 30 years. As a result, most local health workers had never come across the disease until recently, while the antitoxin to treat it is not widely available.

“We lack health professionals who know how to recognise and treat this disease,” says MSF deputy medical coordinator Dr Charles Tolno. “The treatment is complex and requires a lot of resources, especially in terms of the antitoxin’s availability. Given its scarcity, we have no choice but to be selective in giving it to patients with the most severe symptoms.”

With only 50 beds at the treatment centre, patients with mild symptoms are sent home with antibiotics to treat the disease and reduce the risk of spreading it to others. They also receive strict instructions on how to reduce the risk of transmission. After three and seven days, patients return to the centre for a check-up.

Patients with more severe symptoms are admitted to the centre for treatment, where they stay for up to five days. If they need to receive the antitoxin, they must also undergo a battery of tests including blood oxygen, glucose, and temperature, beforehand. For instance, the antitoxin cannot be administered if the patient had a fever that would need to be lowered.

This strategy has been successful in bringing down the number of deaths from diphtheria. “Thanks to MSF's intervention, the mortality rate has dropped drastically,” says Dr Tolno. “When we arrived, the mortality rate was around 38 per cent. Now it’s under 5 per cent.”

“I only had 10,000 Guinean Francs (about €1) with me"

Most patients and caregivers heard about the treatment centre in Siguiri on the radio, at school or by word of mouth. Because of the general lack of awareness about the disease and its symptoms, many had no idea what was wrong with them until they were diagnosed.

“I did not know I was sick with diphtheria until I came here,” says 40-year-old Fanta Fofana. “When I arrived three days ago on my motorcycle, I had already lost my voice. Since taking my treatment, I feel better. I’ve been eating well and sleeping well; I take my medication twice a day and I’ve been able to regain my health. I hope to be discharged soon.”

Djigui Berete’s 11-year-old son is also being treated for diphtheria. “As soon as I noticed that my child had a fever, a sore throat and a headache, I went to the clinic,” he says. “They told me it was diphtheria. I asked the clinic for an ambulance. I only had 10,000 Guinean Francs (about €1) with me. What can you do with that? I couldn't get my child treated. Since I arrived at the treatment centre, we've been able to eat, drink and receive treatments without having to pay anything. Everything offered by MSF is free. Today my son is taking his medication and is feeling so much better.”

Patients and those living under the same roof can also get vaccinated at the centre to protect them against a range of diseases: diphtheria and tetanus for adults; and diphtheria, tetanus, polio, hepatitis B and hib (Haemophilus influenzae type B) for children.

Diphtheria vaccination protects against severe forms of the disease and prevents people transmitting it to others. At least two doses of the vaccine are needed to achieve a significant level of protection. Unfortunately, long production times and back-orders mean that there is currently a shortage of diphtheria vaccines worldwide. Given the situation in West Africa, MSF is calling for vaccine production to be accelerated to bring the disease under control.

“Ideally we should have vaccinated the entire Siguiri area – all ages, but especially children – as soon as the first cases appeared,” says Dr Tolno. “However, because of the shortage of vaccines available, we have had to focus on vaccinating patients and their close contacts. What we need now is the means to obtain and carry out a full-scale vaccination campaign in Siguiri to curb the disease.”