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