Outcomes of home-based versus facility-based care for mild diphtheria during a large epidemic in Kano State, Nigeria: A retrospective matched cohort study
4 affiliations
- 1Epicentre, Paris, France
- 2Geneva Centre of Humanitarian Studies, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- 3Médecins Sans Frontières, Operational Centre West and Central Africa (MSF WaCA), Abidjan, Côte d’Ivoire
- 4Kano State Ministry of Health, Kano, Nigeria
Abstract
Background: During Nigeria’s largest recorded diphtheria epidemic (first notified on 1 December 2022; more than 40,000 confirmed cases by January 2026), hospital capacity in Kano State was overwhelmed. Médecins Sans Frontières (MSF) introduced home-based care (HBC) for patients with mild disease; we asked whether mortality, long-term sequelae, and household transmission differed between HBC and care in a diphtheria treatment centre (DTC). Methods and findings: We conducted a retrospective matched cohort study using MSF registry data and household interviews to compare mortality, long-term sequelae, and household transmission between patients with mild diphtheria treated under HBC or in a DTC. The primary outcomes were mortality, long-term sequelae, and household transmission. Mild diphtheria cases notified between January 2023 and January 2024 were exactly matched by treatment modality (HBC or DTC) on sex, age group, vaccination status, and ward of residence, and interviewed between September and October 2024, a median of 421 days after notification. Conditional logistic regression, adjusted for age, vaccination status, and treatment delay, was used to estimate the association between treatment modality and mortality, with robustness checked with propensity score weighting and sensitivity analyses. Of the 986 originally sampled patients, 491 (49.8%) were interviewed; with 178 replacements (substitute patients of similar age, sex, vaccination status, and area, interviewed when an originally selected patient could not be), 669 patients (362 HBC, 307 DTC) were analysed. After adjustment, mortality was lower with HBC than DTC care, but the interval included 1 (odds ratio [OR] 0.36, 95% confidence interval [CI] [0.12,1.07]; p = 0.066); treatment delay was associated with increased mortality (OR 1.29 per day, 95% CI [1.00,1.67]; p = 0.048). Adding calendar time gave a similar estimate (OR 0.35, 95% CI [0.08,1.57]; p = 0.170). Vaccination was associated with lower odds of death (OR 0.32, 95% CI [0.10,0.98]; p = 0.047). HBC was not associated with increased household transmission or long-term sequelae. Residual confounding by disease severity, the small number of deaths (24), and replacement patients limit these findings. Conclusions: Vaccination and early treatment were associated with survival; care setting was not clearly associated. When supported by clinical triage and structured follow-up, decentralised care may be an option to manage mild cases during diphtheria epidemics in settings with constrained hospital capacity. Why was this study done?: What did the researchers do and find?: What do these findings mean?: In a cohort study, Jonathan Polonsky and colleagues compare outcomes of home-based and facility-based care during a major diphtheria outbreak in Nigeria, finding that home-based care was not associated with increased mortality or transmission, and could be an option for mild disease when facility capacity is overwhelmed.
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BibTeX
@article{polonsky2026outcomes,
title = {{Outcomes of home-based versus facility-based care for mild diphtheria during a large epidemic in Kano State, Nigeria: A retrospective matched cohort study}},
author = {Jonathan Polonsky and Suleiman Hudu and Khadidja Uthman and Yves Katuala and Philip Eghosa Evbuomwan and Hashim Juma Omer Osman and Abdulwahab Kabir Sulaiman and Ichola Ismael Adjaho and Cheick Oumar Doumbia and Etienne Gignoux and Franck Ale},
journal = {PLOS Medicine},
year = {2026},
month = oct,
doi = {10.1371/journal.pmed.1005097},
url = {https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005097},
note = {CC BY 4.0},
}
RIS
TY - JOUR
TI - Outcomes of home-based versus facility-based care for mild diphtheria during a large epidemic in Kano State, Nigeria: A retrospective matched cohort study
AU - Jonathan Polonsky
AU - Suleiman Hudu
AU - Khadidja Uthman
AU - Yves Katuala
AU - Philip Eghosa Evbuomwan
AU - Hashim Juma Omer Osman
AU - Abdulwahab Kabir Sulaiman
AU - Ichola Ismael Adjaho
AU - Cheick Oumar Doumbia
AU - Etienne Gignoux
AU - Franck Ale
PY - 2026
DA - 2026/10/26
JO - PLOS Medicine
DO - 10.1371/journal.pmed.1005097
UR - https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005097
AB - Background: During Nigeria’s largest recorded diphtheria epidemic (first notified on 1 December 2022; more than 40,000 confirmed cases by January 2026), hospital capacity in Kano State was overwhelmed. Médecins Sans Frontières (MSF) introduced home-based care (HBC) for patients with mild disease; we asked whether mortality, long-term sequelae, and household transmission differed between HBC and care in a diphtheria treatment centre (DTC). Methods and findings: We conducted a retrospective matched cohort study using MSF registry data and household interviews to compare mortality, long-term sequelae, and household transmission between patients with mild diphtheria treated under HBC or in a DTC. The primary outcomes were mortality, long-term sequelae, and household transmission. Mild diphtheria cases notified between January 2023 and January 2024 were exactly matched by treatment modality (HBC or DTC) on sex, age group, vaccination status, and ward of residence, and interviewed between September and October 2024, a median of 421 days after notification. Conditional logistic regression, adjusted for age, vaccination status, and treatment delay, was used to estimate the association between treatment modality and mortality, with robustness checked with propensity score weighting and sensitivity analyses. Of the 986 originally sampled patients, 491 (49.8%) were interviewed; with 178 replacements (substitute patients of similar age, sex, vaccination status, and area, interviewed when an originally selected patient could not be), 669 patients (362 HBC, 307 DTC) were analysed. After adjustment, mortality was lower with HBC than DTC care, but the interval included 1 (odds ratio [OR] 0.36, 95% confidence interval [CI] [0.12,1.07]; p = 0.066); treatment delay was associated with increased mortality (OR 1.29 per day, 95% CI [1.00,1.67]; p = 0.048). Adding calendar time gave a similar estimate (OR 0.35, 95% CI [0.08,1.57]; p = 0.170). Vaccination was associated with lower odds of death (OR 0.32, 95% CI [0.10,0.98]; p = 0.047). HBC was not associated with increased household transmission or long-term sequelae. Residual confounding by disease severity, the small number of deaths (24), and replacement patients limit these findings. Conclusions: Vaccination and early treatment were associated with survival; care setting was not clearly associated. When supported by clinical triage and structured follow-up, decentralised care may be an option to manage mild cases during diphtheria epidemics in settings with constrained hospital capacity. Why was this study done?: What did the researchers do and find?: What do these findings mean?: In a cohort study, Jonathan Polonsky and colleagues compare outcomes of home-based and facility-based care during a major diphtheria outbreak in Nigeria, finding that home-based care was not associated with increased mortality or transmission, and could be an option for mild disease when facility capacity is overwhelmed.
SN - 1549-1676
SN - 1549-1277
ER -