March 9, 1995
CDC IMMUNIZATION INFORMATION
DIPHTHERIA OVERVIEW

The Disease

Years ago, diphtheria was a widespread and greatly feared disease. Through the 1920's it struck about 150,000 people a year, and killed about 15,000 of them. Since then, these figures have dropped considerably, thanks to parents who have gotten their children immunized against this terrible disease. There were only 918 cases in 1960, 435 in 1970, and 128 in 1976. Today, only a few cases occur each year. Diphtheria is caused by a germ that lives in the mouth, throat, and nose of an infected person. It is easily passed to others through coughing or sneezing.

Early symptoms of diphtheria are a sore throat, a slight fever, and chills. Usually, the disease develops in the throat. It can make it hard to swallow and even cause the patient to suffocate. Some people may be infected but not appear ill. They can also spread the infection. If diphtheria is not properly treated, or not treated in time, the bacteria may produce a powerful poison. This poison can spread throughout the body causing serious complications such as heart failure or paralysis. About 1 person in 10 who gets diphtheria dies from it.

Immunization

Diphtheria vaccine is usually given together with tetanus and pertussisvaccines in a shot called DTP. You can read about DTP vaccine on page __.

State Immunization Requirements

All 50 States have laws that require children attending school and day care to be immunized against diphtheria.

DTP Immunization

You can protect your children from Diphtheria, Tetanus and Pertussis by getting them immunized with DTP vaccine. DTP is actually three vaccines--Diphtheria, Tetanus, and Pertussis--combined into one shot. A child needs five DTP shots for complete protection. The first shot should be given at 2 months of age, and the second and third shots given within the child's first year. The fourth shot is given at about 15 or 18 months, and a fifth shot, or booster, is given when the child is about to enter school. When DTP vaccine is given in the recommended number of shots it protects over 95% of children against tetanus, over 85% against diphtheria, and 70%- 90% against pertussis. It also make the diseases milder for those who do catch them.

Possible Side Effects and Adverse Reactions to DTP Immunization
Most children will get a slight fever and be cranky for a day or two after getting a DTP shot. Half of them will have a sore spot and some swelling where the shot was given. Occasionally, a child will have a more serious side effect. For every 330 DTP shots given, one child will get a fever of 105°F or more. About one child in 100 may cry for a long time (3 hours or more) after getting the shot. About once in 1,750 shots a child will have convulsions. Also, about one child in 1,750 shots may become limp or pale afterwards. These side effects are not long-lasting and have not been known to cause any permanent harm. Convulsions that occur after a DTP shot are usually caused by fever, and not the vaccine itself. Some experts say that giving a child drugs to lower the fever (Tylenol®* or other acetaminophen products) should also make these convulsions less likely. These drugs can be given at the time of vaccination and every 4-6 hours over the next 24 hours. Most experts believe that convulsions with fever do not cause any permanent damage to the child.

Serious reactions to DTP are very rare. Permanent brain damage has been reported on rare occasions after a child has been vaccinated with DTP. However, most experts believe that a connection between DTP and brain damage has not been proven. If DTP ever does cause brain damage, this would be very rare. As with any drug or vaccine, there is a very slight possibility that suggested that DTP shots might cause Sudden Infant Death Syndrome (SIDS), but studies have not shown this to be true.

A child who has had convulsions or other nervous system problems in the past has a slightly higher risk than other children of having a serious reaction after DTP, although this risk is still very small. Children whose brothers or sisters or parents have had convulsions are also slightly more likely to have a convulsion after a DTP shot. If you can answer "yes" to any of the following questions, check with a doctor before having your child vaccinated with DTP vaccine.

Is the child sick with anything more serious than a common cold?
Has the child ever had a convulsion?
Has the child had any kind of nervous system problem, or does it seem not to be developing normally?
Has the child ever had a serious reaction to DTP, DTaP, DT, or Td shots before, such as:

A serious allergic reaction (swelling in the mouth, throat, or face, or difficulty breathing) within 1 day after getting the shot?

A temperature of 105°F or higher within 2 days after getting the shot?
Limpness and paleness within 2 days after getting the shot?
Crying that lasts for more than 3 hours and cannot be stopped, within the 2 days after getting the shot?
A convulsion within 3 days after getting the shot?
Encephalopathy within 7 days after getting the shot?

Alternate Vaccines

DTaP is a vaccine that contains diphtheria and tetanus vaccines, and a type of pertussis vaccine that is different from that used in standard DTP. DTaP may be used instead of DTP vaccine for the 4th and 5th shots of the series. Fewer children will be cranky or drowsy after DTaP vaccine that after DTP. They are also less likely to be sore or swollen where the shot was given, and less likely to have a fever. Since convulsions that occur after DTP vaccine are usually caused by fever, there will probably also be fewer convulsions with DTaP. DTaP is being tested to see if it can be used for the first, second and third doses of the DTP series.

Td is a vaccine for children 7 years old and over. Td does not contain the pertussis part of the vaccine, because pertussis is not very serious in older children. It also has less of the diphtheria part, because reactions to diphtheria vaccine occur more often among older children. Booster shots of Td vaccine should be gotten every 10 years.

DT is a vaccine which contains the diphtheria and tetanus parts, but no pertussis. DT is given to children under 7 who should not get pertussis vaccine. Usually these are children who have had certain reactions, such as very high fever or convulsions, after a previous DTP shot. Report any reactions to your health care provider. He or she can then decide whether your child should get DTP or DT.

Side effects from DT or Td vaccine are not common and usually consist only of soreness and slight fever. If your child has any serious or unusual problem after getting any of these vaccines, call a doctor or get the child to a doctor promptly.

DISEASE INFO

Diphtheria is a bacterial disease that can cause a leathery membrane to form in the throat causing suffocation. It can also cause problems with the other body organs such as the heart and lungs. There are two major strains of diphtheria bacteria, one that produces a poison, and one that does not produce a poison. It is the poison that is responsible for the more severe symptoms of the disease, such as the heart problems. The poison produced at the site of the infection is absorbed into the bloodstream and then distributed to other parts of the body. Immunization permits the body to neutralize the poison. Disease associated with non-poison producing strains is generally milder, but rarely severe cases have been reported. Diphtheria generally occurs more frequently in the colder months, and is associated with crowded indoor living conditions. The bacteria is known to exist in a person and not cause symptoms. However, immunization may reduce an individual's likelihood of being such a carrier. Diphtheria can infect the nose, tonsils, throat, and larynx or voice-box. The course of the disease ranges from fairly mild in the case of an infection of the nose, to severe illness and death. Skin diphtheria produces a scaling rash or ulcers. When untreated, the most frequent complications of diphtheria are abnormalities in the heart rhythms and transient paralysis of various muscles of the limbs and diaphragm. Diphtheria can also cause pneumonia, respiratory failure, and heart failure. In most cases it is the poison that is responsible for causing these problems. Diphtheria is passed from person-to-person by coughing and sneezing, or in the case of skin diphtheria, from touching the open sores. More rarely, articles soiled with discharges from lesions of infected persons can transmit the disease. The period from exposure to the disease to the time when symptoms occur is usually 2 to 4 days, but can range from 1 to 6 days.

Patients with diphtheria are treated with both antibiotics and antitoxin. The antibiotics are used to kill the bacteria, while the antitoxin neutralizes the poison. Untreated patients can spread the disease until the bacteria is destroyed in their body, usually 2 weeks or less and seldom more than 4 weeks. Effective antibiotic therapy will generally shorten this period. However, a person can also carry the diphtheria bacteria, and have no signs of disease. Such chronic carriers may transmit disease organisms for 6 months or more.

The major problems of diphtheria can be prevented in individual patients by adequate immunization with diphtheria toxoid. However, immunity declines slowly over time. Booster doses of diphtheria toxoid should be administered at 10-year intervals, to maintain a protective immunity. As many as 50 percent of individuals over age 60 may be susceptible to the disease because of failure to obtain such boosters. Recovery from diphtheria disease does not always produce lasting immunity, therefore, immunization is needed for all recovering patients.

VACCINE INFO

Simultaneous immunization against diphtheria, tetanus, and pertussis during infancy and childhood has been routine practice in the United States since the late 1940's. This practice has played a major role in markedly reducing the number of cases and deaths from each of these diseases.

Diphtheria toxoid is a preparation of inactivated diphtheria toxin, and is highly effective in producing immunity that will prevent the disease. There are two different toxoid strengths; one given to children under seven years of age, and the other given to adults and children over seven years old. The adult preparation has a lower concentration of the diphtheria toxoid, which should produce fewer side effects. Diphtheria toxoid for children under seven years old should generally be administered in a combination with pertussis vaccine and tetanus toxoid as DTP vaccine. For adults and children over 7 years of age, diphtheria toxoid is generally given in a combination with tetanus toxoid.

Whether diphtheria toxoid is given by itself or in combination with tetanus toxoid or pertussis vaccine, the same level of immunity is produced in the body.

WHO SHOULD RECEIVE THE VACCINE & DOSING SCHEDULE -CHILDREN

Immunization against diphtheria is recommended for all residents of the United States. Normally, for children under 7 years old the combined diphtheria toxoid, tetanus toxoid, and pertussis vaccine, called DTP, is recommended. For children past their 7th birthday and for adults, the combination of diphtheria toxoid and tetanus toxoid, called Td (big T, small d), is recommended.

For most infants and children up to age seven, the primary immunizing series consists of four doses of DTP, with the first three doses given at 4 to 8 week intervals, starting at age 6 weeks to 2 months. Customarily, DTP doses are given at 2, 4, and 6 months of age. The fourth dose is given 6 to 12 months later. Those children who receive all four doses before their fourth birthday should receive a fifth dose of DTP before entering kindergarten or elementary school. This fifth dose is not necessary if the fourth dose in the primary series was given on or after the fourth birthday. During an outbreak situation, shorter time intervals may be used to provide protection as early as possible.

If the recommended immunizing schedule is interrupted or delayed, then simply complete the required number of doses at the customary intervals. There is no need to restart the series. Once the primary series is completed, Td boosters are recommended every 10 years to maintain immunity to both diphtheria and tetanus.

ADULTS

Immunization against diphtheria is recommended for all residents of the United States. Normally, for children under 7 years old the combined diphtheria toxoid, tetanus toxoid, and pertussis vaccine, called DTP, is recommended. However, for children past their 7th birthday and for adults, the combination of diphtheria toxoid and tetanus toxoid is recommended.

For un-immunized children past their seventh birthday and for un-immunized adults, the primary immunization consists of 3 doses of adult type tetanus diphtheria toxoid combination called Td, spelled with a capital T and small d. The second dose is given 4 to 8 weeks after the first, and the third dose given 6 to 12 months after the second.

BOOSTER DOSES

To ensure continued protection a booster dose of adult formulated tetanus and diphtheria toxoid, called Td and spelled with a capital T and small d, should be received every 10 years. More frequent boosters are not recommended and getting them can result in increased severity of adverse reactions. In certain circumstances, a booster dose may be given between the 5th and 10th year, but should not be given if only 5 years have elapsed since the last dose.

DIPHTHERIA - NORMAL SIDE EFFECTS AND ADVERSE REACTIONS

Acetaminophen is frequently given by physicians to lessen fever and irritability associated with DTP immunization. It may also be useful in preventing seizures in children who have a tendency to have seizures associated with a fever. However, fever which starts 24 hours or more after a DTP immunization, or persists more than 24 hours, should not be assumed to be due to the immunization.

Local reactions such as redness, pain and swelling are common. Occasionally, a lump can be felt at the injection site for several weeks. Reactions such as fever, drowsiness, fretfulness, and loss of hunger occur frequently. Most of these problems resolve by themselves.

Less frequently, high fever, persistent inconsolable crying lasting more than 3 hours, fainting, and convulsions can occur. Most of these events have no long term consequences. Very rarely severe nervous system problems have been reported.

Local reactions and fever tend to increase with the number of DTP immunizations given, while other reactions such as fretfulness and vomiting become less frequent. More severe reactions following pertussis vaccination have been reported and include encephalitis, which is inflammation of the brain, with or without permanent neurologic damage. However, based on thorough review of scientific studies, the Immunization Practices Advisory Committee, know as ACIP, concludes:

A relationship of cause and effect between DTP vaccine and brain damage has not been demonstrated. If the vaccine ever causes brain damage, then the occurrence of such an event must be exceedingly rare.

A similar conclusion has been reached by the American Academy of Pediatrics, the Child Neurology Society, The Canadian National Advisory Committee on Immunization, the British Joint Committee on Vaccination and Immunization, and the British Pediatric Association.

There has also been a suggested link between DTP vaccination and sudden infant death syndrome (SIDS). However, several recent large studies have found no association between receiving DTP vaccine and SIDS.

Finally, claims that DTP may be responsible for transverse myelitis, hyperactivity, learning disorders, infantile autism, and progressive degenerative central nervous system conditions have no scientific basis.

DIPHTHERIA - WHO SHOULD NOT RECEIVE THE VACCINE

Children with moderate or severe fever can be vaccinated as soon as they have recovered. Children with minor illness, such as a mild upper-respiratory infection with or without low-grade fever, can be vaccinated.

Persons on immunosuppressive therapies given for cancer or other treatments may not develop the same immune response as a normal person. Therefore, if immunosuppressive therapy is to be discontinued shortly, it is reasonable to defer immunization until the patient has been off the therapy for one month. If the therapy is not going to be discontinued, then proceed with immunization. Those who are infected with HIV may receive a diphtheria-toxoid containing immunization like DTP, DT, or Td.

Persons who have experienced an immediate life-threatening, allergic reaction, requiring medical attention after a dose of diphtheria-toxoid containing vaccine, should not receive additional doses of the vaccine. Persons who develop encephalitis, which is a swelling of the brain that can be due to a variety of causes, within 7 days of DTP immunization should not receive additional immunizations containing the pertussis vaccine. The immunization series should be completed using DT (big D, big T) vaccine. It may be desirable, however, to postpone further doses of diphtheria-tetanus toxoid until the child's neurologic status becomes clear.

Immunizing children with known or suspected neurologic disorders must be decided on an individual basis. A family history of convulsions or other central nervous system disorders does not justify withholding diphtheria immunization. In most cases the decision to not immunize should be made with guidance from a local doctor, who is familiar with the patient's history and circumstances.

PREGNANCY

A pregnant woman should not be concerned if she inadvertently received a dose of diphtheria toxoid. Diphtheria toxoid is usually available only in combination with tetanus toxoid in a vaccine called Td, spelled with a capital T and small d. If possible, waiting until the second trimester of pregnancy to administer Td is a reasonable precaution for minimizing any theoretical possibility of any reactions.

Children living in the same household as a pregnant women can receive diphtheria toxoid, and this will pose no risk to the pregnant woman. Diphtheria illness during pregnancy may be associated with an increased risk of miscarriages, premature delivery, or harmful effects to the unborn child.

STATISTICS

At one time respiratory diphtheria was common, occurring primarily in children, and was one of the leading causes of death in infants and children. For example, in the l920's, when data were first gathered, in the United States there were approximately 150,000 cases and 13,000 deaths reported annually. After diphtheria immunization was introduced, the number of cases gradually fell to about 19,000 in 1945. When diphtheria immunization became widespread in the late 1940's, a more rapid decrease in the number of cases and deaths occurred.

From 1970 to 1979, an average of 196 cases per year were reported. From 1980-1989, only 24 cases of respiratory diphtheria were reported in the United States; two cases were fatal and 18 occurred in persons 20 years of age or older. Most cases have occurred in un-immunized or inadequately immunized persons. Seventeen outbreaks of 15 or more cases occurred in the United States between 1959 and 1980, but there have been none since 1980.

About one person in 10 who gets diphtheria dies of it. Diphtheria is more severe for those under 5 and over 40 years of age. The current rarity of diphtheria in the United States is due primarily to the high level of appropriate immunization in children, and to an apparent reduction in the poison-carrying strains of the bacteria. However, the increasing percentage of diphtheria cases in adults suggests that many adults may not be protected against diphtheria, because they do not receive boosters every 10 years as recommended.

* Use of trade names is for identification only and does not imply endorsement by the Public Health Service or the U.S. Department of Health and Human Services. Aspirin products are not generally recommended for children.

Rubella (German Measles) from the Centers for Disease Control and Prevention