Clinical recognition of pediatric diphtheria in a resource-limited Somali hospital: a prospective observational study.

BACKGROUND

Diphtheria remains a life-threatening disease in low-resource settings where immunization coverage is poor and access to a laboratory is limited. Somalia is currently experiencing a resurgence of clinically suspected diphtheria among children, yet detailed case-level clinical data remain scarce. The purpose of this study was to illustrate clinical features, vaccination status, complications, and early outcomes of pediatric diphtheria in a resource-limited Somali hospital. Furthermore, it identified the factors associated with severity and mortality for enhanced early recognition and management.

METHODS

A prospective observational study was conducted, including 51 pediatric patients aged < 18 years admitted with clinically diagnosed diphtheria to a tertiary referral hospital in Somalia between January 2025 and December 2025. Diagnosis was based on WHO clinical criteria due to the absence of local laboratory capacity. Demographic, clinical, treatment, and outcome data were collected prospectively. The requirement for pediatric intensive care unit admission defined disease severity. Statistical comparisons between severe and non-severe cases used appropriate parametric or non-parametric tests, and univariable logistic regression explored predictors of severity and mortality. Statistical significance was set at p < 0.05. This study was guided by the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines to guarantee transparent, thorough, and consistent demonstration of the observational methods and results.

RESULTS

Fifty-one children met the clinical case definition (median age 6.0 years; 52.9% male). Classical airway manifestations were frequent: pseudomembrane (88.2%), bull neck (88.2%), stridor (58.8%), and airway obstruction (52.9%). Vaccination coverage was extremely low, with only 9.8% having received any diphtheria-containing vaccine. Systemic complications included neuritis in 47.1% and myocarditis in 19.6%. Eleven patients (21.6%) required PICU admission and were classified as severe. Toxin-mediated complications strongly predicted severity: myocarditis (72.7% in severe vs 5.0% non-severe) and neuritis (100% vs 32.5%). Eight children died (overall case-fatality rate: 15.7%), all in the PICU cohort. Mortality was highest among children with myocarditis (50.0%) and neuritis (33.3%), and all deaths occurred in unvaccinated children. Univariable logistic regression revealed that toxin-mediated problems such as myocarditis and neuritis were robust predictors of severe disease and mortality (p < 0.05), whereas the classical airway features and vaccination status were not substantial.

CONCLUSION

Clinically diagnosed pediatric diphtheria in Somalia is characterized by profound under-immunization, high rates of classical airway features, significant toxin-mediated complications, and substantial mortality. Early identification of severe illness is essential, particularly recognition of cardiac and neurological involvement. Strengthening immunization programs, ensuring timely diphtheria antitoxin availability, and expanding critical care capacity are urgent priorities to improve outcomes.