1. Diphtheria and Diphtheria Toxoid Epidemiology and Prevention of Vaccine- Preventable Diseases National Immunization Program Centers for Disease Control and Prevention Revised March 2002

2. Diphtheria Greek diphtheria (leather hide) Recognized by Hippocrates in 5th century B.C. Epidemics described in 6 th century C. diphtheriae described by Klebs in 1883 Toxoid developed in 1920s

3. Corynebacterium diphtheriae Aerobic gram-positive bacillus Toxin production occurs only when C. diphtheriae infected by virus (phage) carrying tox gene If isolated, must be distinguished from normal diphtheroid

4. Diphtheria Clinical Features Incubation period 2-5 days (range, 1-10 days) May involve any mucous membrane Classified based on site of infection –Anterior nasal –Tonsillar and pharyngeal –Laryngeal –Cutaneous –Ocular –Genital

5. Pharyngeal and Tonsillar Diphtheria Insidious onset of exudative pharyngitis Exudate spreads over 2-3 days and may form adherent membrane Membrane may cause respiratory obstruction Fever usually not high but patient appears toxic

6. Diphtheria Complications Most attributable to toxin Severity of generally related to extent of local disease Most common complications are myocarditis and neuritis Death occurs in 5%-10% for respiratory disease

7. Diphtheria Antitoxin First used in 1891 Produced in horses Used only for treatment of diphtheria Neutralizes only unbound toxin

8. Diphtheria Epidemiology ReservoirHuman carriers Usually asymptomatic TransmissionRespiratory Skin and fomites rarely Temporal patternWinter and spring CommunicabilityUp to several weeks without antibiotics

9. Diphtheria - United States, 1940-2001* *2001 provisional data

10. Diphtheria - United States, 1980-2001* *2001 provisional data

11. Diphtheria – United States, 1980-2000 Age Distribution of Reported Cases N=49

12. Diphtheria in the Newly Independent States Outbreak began in 1990 in the Russian Federation All 15 NIS affected by 1994 >157,000 cases and 5000 deaths Adults accounted for many cases

13. DTaP, DT, and Td DTaP, DT Td (adult) Diphtheria 7-8 Lf units 2 Lf units Tetanus 5-12.5 Lf units 5 Lf units Pertussis vaccine and pediatric DT used through age 6 years. Adult Td used for persons 7 years and older.

14. Diphtheria Toxoid Formalin-inactivated diphtheria toxin ScheduleThree or four doses + booster Booster every 10 years EfficacyApproximately 95% DurationApproximately 10 years Should be administered with tetanus toxoid as DTaP, DT, or Td

15. Routine DTaP Primary Vaccination Schedule Dose Primary 1 Primary 2 Primary 3 Primary 4 Age 2 months 4 months 6 months 15-18 months Interval --- 4 wks 6 mos

16. Children Who Receive DT The number of doses of DT needed to complete the series depends on the child’s age at the first dose: –if first dose given at <12 months of age, 4 doses are recommended –if first dose given at >12 months, 3 doses complete the primary series

17. Routine DTaP Schedule Children <7 years of age 4-6 years, before entering school 11-12 years of age if 5 years since last dose (Td) Every 10 years thereafter (Td) Booster Doses

18. Routine Td Schedule Persons >7 years of age Dose Primary 1 Primary 2 Primary 3 Interval --- 4 wks 6-12 mos Booster dose every 10 years

19. Diphtheria and Tetanus Toxoids Adverse Reactions Local reactions (erythema, induration) Exaggerated local reactions reactions (Arthus-type) Fever and systemic symptoms uncommon Severe systemic reactions rare

20. Diphtheria and Tetanus Toxoids Contraindications and Precautions Severe allergic reaction to vaccine component or following prior dose Moderate to severe acute illness

21. National Immunization Program Hotline800.232.2522 Emailnipinfo@cdc.gov Websitewww.cdc.gov/nip