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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

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


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
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

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

Diphtheria Antitoxin
First used in 1891

Produced in horses

Used only for treatment of
diphtheria

Neutralizes only unbound toxin

Diphtheria Epidemiology
Reservoir Human carriers
Usually asymptomatic

Transmission Respiratory
Skin and fomites rarely

Temporal pattern Winter and spring

Communicability Up to several weeks
without antibiotics

0
2000
4000
6000
8000
10000
12000
14000
16000
18000
20000
1940 1950 1960 1970 1980 1990 2000
C
a
s
e
s
Diphtheria - United States, 1940-2001*
*2001 provisional data
0
2
4
6
8
10
12
14
16
18
20
<5 5-14 15-24 25-39 40-64 65+
Age group (yrs)
C
a
s
e
s
Diphtheria United States, 1980-2000
Age Distribution of Reported Cases
N=49
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

CONTROL OF DIPHTHERIA

Preventive Measures:
1- Active immunizatn. with diph. toxoid,
including an adequate program to maintain
immunity.
Triple Antigen DPT:
Schedules:
a. < 6-7 yrs: 4 doses of DPT Ist 3 doses to be
given at 4-8 wks. Intervals beginning when
infant is 6-8 wks. Old (2 and 4 and 6 months
in S.A.) The 4th dose given 1 yr after the 3rd
dose. A 5th dose, usually given at school
entry.1


b. For persons > 7 yrs., : for previously
unimm. Individual, a primary series of 3 doses
of tetanus and dipth. Toxoids (adult type, Td)
is given. The Ist 2 doses at 4-8 wks. Intervals,
the 3rd dose 6/m 1 yr. After 2nd dose.
c. Active protectn. Should be maintained by
administering a dose of Td every 10 yrs.
thereafter, (esp. for persons who are at higher
risk to pt. exposure e.g. health workers).
2 . Educational measures:
to inform the public and esp. parents of
young children of the hazards of diptheria
and the imp. of immunization.
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.
Diphtheria Toxoid
Formalin-inactivated diphtheria toxin

Schedule Three or four doses + booster
Booster every 10 years

Efficacy Approximately 95%

Duration Approximately 10 years

Should be administered with tetanus
toxoid as DTaP, DT, or Td

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
4 wks
6 mos
Children Who Receive DT
The number of doses of DT needed
to complete the series depends on
the childs 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
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
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
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

Diphtheria and Tetanus Toxoids
Contraindications and Precautions
Severe allergic reaction to
vaccine component or following
prior dose

Moderate to severe acute illness

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