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Epidemiology and Society Health Review| ESHR 
 

Vol 1 No1 2019 
 

9 

 
EPIDEMIOLOGY OF DIPHTHERIA IN PURWAKARTA 
REGENCY, INDONESIA 
 
Siwi Pramatama Mars Wijayanti* and Alfianti Nur Fadillah  
 
Department of Public Health, Faculty of Health Sciences, Jenderal Soedirman 
University, Purwokerto, Indonesia 

*Correspondence: siwimars@gmail.com. Telp,: +628112522937 
Received 07 August 2019; Accepted 09 September 2019; Published 09 September 2019 

 

ABSTRACT  

Background: Diphtheria is considered as a neglected disease since it was 
successfully eliminated in many countries. However, there were several sporadic re-
emergence cases of Diphtheria and the peak was outbreak in Indonesia in 2017.  
This research was a descriptive study aimed to explore epidemiology of diphtheria 
by person, time and place in one of diphtheria endemic area.  
Methods: This was a descriptive study with cross sectional design in Purwakarta 
Regency, West Java, Indonesia in 2018. Several data were collected in this study 
such as diphtheria cases by age, time of occurrence, gender, place and 
immunization status. The data was collected from Purwakarta Health Office. It was 
the data from the year of 2015-2017. The data was analysed by using descriptive 
analysis with percentages displayed in graphs and tables. 
Results: This study reveals that Purwakarta regency is an endemic area of 
diphtheria with fluctuated cases since 2015-2017. More cases of diphtheria occurred 
from September to December in rainy season. More cases suffered by children in 5-
9 years old, however, this disease also infected adult population. The area with high 
diphtheria cases in this study also areas with high population densities which is 
conducive for C diphteriae transmission. Low coverage of immunization is 
highlighted in the result of this study, which could explain why diphtheria cases 
occurred continuously in this area.  
Conclusions: High number of diphtherias in this area should be an awareness for 
local health officer to do an effective preventive effort such as increasing the 
coverage of vaccination. Furthermore, optimizing the role of religious and community 
leader should be made to support diphtheria vaccination programs. 

Keywords: Diphtheria, epidemiology, bacteria  

 

 

 

 



Epidemiology and Society Health Review| ESHR 
 

Vol 1 No1 2019 
 

10 

 INTRODUCTIONS 

Diphtheria is considered as a neglected disease since it was successfully 
eliminated in many countries. This acute communicable disease is caused by 
Corynebacterium diphtheriae that is transmitted from person to person by airborne 
droplets. There are three Corynebacterium species which caused diphtheria, 
namely, C. diphtheriae, C. ulcerans, and C. Pseudotuberculosis (1). The 
characteristic of this bacterial infection is the local growth of the bacterium in 
pharynx. Symptoms and clinical signs of this disease are a fever up to 38 degrees 
Celsius, a greyish white pseudo-membrane that is not easily released andan easy 
bleeding in faring, larynx or tonsils. The incubation period of the disease is 2-5 days 
and can spread to other people 2-4 weeks from the incubation period. The 
transmission period reaches 6 months (2). Exotoxin of C. diptheriae could inhibit the 
production of proteins by cells, destroy the tissue at the site of the infection, lead to 
membrane formation and cause inflammation of the heart and cause nerve 
damage. Besides, It also could affect low platelet counts, or thrombocytopenia, and 
produce protein in the urine in a condition called proteinuria (3).  
 
Elimination of Diphtheria in Indonesia had been successful in 1998 after the 
implementation of massive vaccination. However, there were several sporadic 
cases which occurred in Indonesia. In 2011, Indonesia was the second highest 
country in the world after India with 806 cases of diphtheria and 4.71% Case 
Fatality Rate (CFR). In the following years, Diphtheria infection also occurred in 
several parts of Indonesia. And in mid-November 2017, the Ministry of Health of the 
Republic of Indonesia (MoHRI) declared that there was an outbreak of diphtheria in 
Indonesia. Since January 1 and week 44 in 2017, it was reported that there were 
586 clinically-diagnosed diphtheria cases in 95 regencies among 21 provinces in 
Indonesia. The case fatality rate (CFR) reached 5.03 nationally, and between 0%-
20% provincially (4).  
 
The emergence of this outbreak raises the question whether there has been an 
epidemiological change in this disease. Based on Indonesia Basic Health Survey, 
Diphtheria immunization rate in Indonesia was only 67.7% in 2007, 61.9% in 2010 
and 75.6% in 2013. Based on the previous studies, the outbreak of Diphtheria was 
correlated with incompleteness or low coverage of immunization program (4, 5). 
Based on The Health Ministry data, Diphtheria in 2017 outbreak was experienced 
by different age groups. Previously, diphtheria is considered as childhood diseases, 
and when it affected adults it could create more fatal clinical manifestations (6). 
Indeed, it is important to do routine surveillance to monitor the incidence of 
Diphtheria.  
 
One of the districts in West Java Province with high diphtheria cases is Purwakarta 
Regency. This area is located at the intersection of three main strategic traffic 
corridors, namely Purwakarta-Jakarta, Purwakarta-Bandung and Purwakarta-
Cirebon. The re-emergence of Diphtheria cases has occurred in this area for 
several years. In this study, the author would explore by descriptive study about 
epidemiology of diphtheria by person, time and place in the area of study. This 
information would be beneficial for basic data of the diphtheria prevention 
programme.  



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Vol 1 No1 2019 
 

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METHODS 

Study design and area  
This was a descriptive study with cross sectional design in Purwakarta Regency, 
West Java, Indonesia in 2018. This location of study is approximately 80 km 
southeast of Jakarta. The total area of Purwakarta Regency is 971.72 km² or 
approximately 2.81% of the total area of West Java Province with population of 
845,509 people with an average population growth rate of 2.28% per year. The male 
population is 420,380 people, while the female population is 425,129. Climatic 
conditions in Purwakarta Regency are included in the tropical climate zone, with an 
average rainfall of 3,093 mm/year and are divided into 2 rain zone areas, namely: 
zones with temperatures ranging between 22 0 – 28 0 C and zones with temperatures 
ranging from 17 0- 260C. 

Data source and data collection 
Several data were collected in this study such as diphtheria cases by age, gender, 
place and immunization status. The Data were collected from Purwakarta Health 
Office. They were data from the year of 2015-2017.  

Analysis 
The Data were analysed by using descriptive analysis with percentages displayed in 
graphs and tables. 

 

RESULT 

Based on data from Purwakarta Health Office, Diphtheria cases in this area from 
2015-2017 were 2, 52 and 33 respectively. The fluctuation of cases could be seen in 
Figure 1. The highest cases were observed in 2016.  

 
 
Figure 1. Distribution of Diphteria Cases in Purwakarta Regency 2015-2017  

 
We also recorded the cases based on the month of occurrence (2015-2017) and 
observed that more cases of diphtheria occurred from September to December 
(Figure 2). 

2

52

33

0
10
20
30
40
50
60

2015 2016 2017

Diphteria Cases in Purwakarta Regency 2015-2017

diphteria cases



Epidemiology and Society Health Review| ESHR 
 

Vol 1 No1 2019 
 

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Figure 2. Diphtheria cases by month of occurrence in Purwakarta Regency (2015-
2017) 

While based on the age groups, more cases occurred in 5-9 years old children, 
however, this disease also infected adult population as it can be seen  in Figure 3.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Figure 3. Diphteria cases by age groups in Purwakarta Regency (2015-2017) 
 
 
 
 
 
 
 
 

0 0 0 0 0 0 0 0

2

0 0 00 0 0 0 0 0 0 0

11

14

18

9

1 1

3
2

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3

1
2

3

1

8
9

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6

8

10

12

14

16

18

20

Jan Feb Mar Apr May Jun July Aug Sept Oct Nov Dec

N
um

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es

2015

2016

2017

0
2
4
6
8

10
12
14
16
18
20

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yearsold

1-4
yearsold

5-9
yearsold

10-14
yearsold

15-19
yearsold

20-44
yearsold

45-54
yearsold

1 11

8

19

5
3

13

3

8

15

4 5

1

2015 2016 2017



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Vol 1 No1 2019 
 

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We also collected data of Diphtheria cases by gender and also immunization status 
(Table 1) 
 
Table 1. Frequency Distribution of Cases of Diphtheria by Gender and immunization 

status in 2015-2017 
 

Variables 
Frequency 

(N) 
Precentage 

(%) 
N= 87 

Gender   
a. Male 53 61 
b. Female 34 39 
Immunization Status   
a. Yes 14 16 
b. No/Not known 73 84 

Total 87 100.0 

Table 1 shows that more cases were experienced by male (61%) and out of 87 
people, 73 people (84%) were not immunized. 

Meanwhile, epidemiology of diphtheria cases in Purwakarta regency by each sub 
district could be seen in Figure 4. 

 

 

 

 

 

 

 

 

 

 

Figure 4. Diphtheria cases based on sub district in Purwakarta regency, West Java. 

Figure 4 shows that the highest cases of diphtheria in 2016 were in Jatiluhur 
Subdistrict which were as many as 21 cases, while in 2017 there were in Purwakarta 
Subdistrict, which were 11 cases. 

 

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2015 2016 2017



Epidemiology and Society Health Review| ESHR 
 

Vol 1 No1 2019 
 

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DISCUSSIONS 

Information about epidemiology of diphtheria, particularly in outbreak occurrence is 
undoubtedly important as basic data for its prevention and control program. In 
Purwakarta Regency, diphtheria cases from 2015-2017 were 2, 52 and 33 
respectively. This fact indicates that diphtheria is endemic in this area, in fact there 
was also high cases (52 cases) in 2016 before the national outbreak in 2017. In this 
study, it was found that more cases of diphtheria occurred from September to 
December in rainy season.  According to Indonesian Meteorology and Geophysics 
Agency, the rainy season in Indonesia begins in the late October-November while 
the peak of the rainy season occurs in December-February. This result is in 
accordance with the previous studies which stated that more diphtheria cases 
occurred in rainy season because immunity of people tend to decrease in rainy 
season which affects more susceptibility for infectious diseases (7). Several 
seasonal changing and environmental factors, such as temperature, sunlight, rain, 
wind and humidity are correlated with the increasing number of infectious diseases 
(8).  
 
Based on the age groups, more cases occurred in children between 5-9 years old, 
however this disease also infected adult population. Among 5-9 age groups, 19 
cases occurred in 2016 and 15 cases in 2017.  This result is also in accordance to 
the previous belief that diphtheria is childhood disease and responsible for childhood 
morbidity and mortality in the pre-vaccination era (6, 9). In this study, it was also 
found that Diphtheria cases occurred more in male (61%) than female (39%). 
Meanwhile, based on immunization status, it was found that 84% of cases were 
caused by not being immunized. Low coverage of DPT (Diphtheria, tetanus and 
pertussis) immunization in this area could be an explanation of the diphtheria 
occurrence. The World Health Organization had recommended  this vaccination 
since 1974 and resulted more than 90% decrease in number of cases globally 
between 1980 and 2000 (10). The Low coverage of vaccination in Purwakarta 
regency could be due to some communities who refused to bring their children to be 
vaccinated because of religious reason. The communities’ belief in several areas in 
Purwakarta that the vaccine is haram made parents refuse to vaccinate their 
children.  Several studies showed that the number of religious exemptions has been 
increasing and it is leading to the outbreak of vaccine preventable diseases (11, 12). 
Research in India also found that, Muslim children had greater chance of being 
under-vaccinated or unvaccinated compared to Hindus (13). 
 
Based on the location, the highest cases of diphtheria in 2016 were in Jatiluhur 
Subdistrict which were as many as 21 cases, while in 2017 were in Purwakarta 
Subdistrict, which were 11 cases. In the research setting, Purwakarta Regency 
experienced a sporadic occurrence of Diphtheria infection. The first re-emergence of 
diphtheria case happened in 2007 when the first case was discovered in Maniis Sub-
District area. The high cases which were observed in Jatiluhur sub district could be 
because this area is a tourism area where there is a reservoir of Ir. H Juanda so that 
there are many tourists from outside of the area bring the source of transmission. 
The first case in 2016 was also the first case appeared in the Jatiluhur Health Center 
until it spread to the village of Cisalada, Jatiluhur sub-district. The previous research 
in Indonesia showed that child/parent mobility was the major risk factor of diphtheria 



Epidemiology and Society Health Review| ESHR 
 

Vol 1 No1 2019 
 

15 

outbreak (14). Other risk factors of diphtheria occurrence were nutritional status of 
children and the source of transmission (15). The area with high diphtheria cases in 
this study is also areas with high population densities which is condusive for C 
diphteriae transmission. In line with it, several previous studies confirmed that high 
population density is correlated with higher risk of diphtheria infection in certain area 
(16, 17). 
 

CONCLUSIONS 

This study revealed that Purwakarta regency, West Java is an endemic area of 
diphtheria with fluctuated cases since 2015-2017. A low coverage of immunization is 
a highlighted finding of this study, which could explain why diphtheria cases occurred 
continuously in this area. High number of diphtheria in this area should be an 
awareness for the local health officer to do effective preventive effort such as 
increasing the coverage of vaccination. Besides, Optimizing the role of religious and 
community leaders should be made to support diphtheria vaccination programs.  

AUTHORS’ CONTRIBUTION 

SPMW the conceptor of research, writing paper manuscript   

ANF data collection  

FUNDING 

This research received no external funding 

Conflict of interest 

There are no conflicts of interest 

 

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