Primary prevention
Universal immunisation with a diphtheria toxoid-containing vaccine is the only effective measure. The efficacy of this approach is strongly demonstrated by historical data; in the 1920s, 100,000-200,000 cases were reported each year in the US, but following the introduction of diphtheria toxoid-containing vaccines in the 1940s, the number of cases declined, and now an average of <1 case per year is reported in the US.[27] In the UK, in 1940, more that 61,000 cases were reported, but in 1957, once immunisation had been well established, only 38 cases were notified.[32] Decades of worldwide experience have confirmed diphtheria toxoid vaccines as safe and well tolerated.
Diphtheria vaccines are made from cell-free purified toxin, treated with formaldehyde, and adsorbed onto an adjuvant. They are produced in two strengths, according to the diphtheria toxoid content; the higher strength is abbreviated to ‘D’ and the lower strength is abbreviated to ‘d’. In general, vaccines containing the higher dose of toxoid (D) are used to achieve a satisfactory primary immune response in younger children. Vaccines containing the lower dose of toxoid (d) are used for older age groups and boosters, where they provide a satisfactory immune response with a lower risk of adverse reactions (e.g., pain, redness, and tenderness at the injection site).[33][34] Monovalent diphtheria vaccines are not available, so immunisation can only be given as part of combined products.
In the UK, diphtheria vaccination is usually given to babies as part of the diphtheria, tetanus, acellular pertussis/inactivated polio/Haemophilus influenzae b/hepatitis B [DTaP/IPV/Hib/HepB] vaccine) at age 2, 3, and 4 months, followed by a DTaP/IPV pre-school booster dose given at age 3 years 4 months and a Td/IPV booster at 14 years. Older children and adults who have never been immunised should be vaccinated with three doses of a d-containing product (e.g., Td/IPV) administered 1 month apart. If the primary course is interrupted, it should be resumed but not repeated, allowing the same interval of 1 month between the remaining doses. Booster doses should still be given, ideally 1 year and 10 years after primary vaccination. Travellers and those going to live in epidemic or endemic areas should have a further Td/IPV booster dose if their last vaccine was administered more than 10 years ago.[32] A single dose of dTaP/IPV is also recommended for women during each pregnancy from 16 weeks' gestation onwards to boost pertussis immunity. NHS Choices: vaccinations and when to have them Opens in new window
In the US, the Advisory Committee on Immunization Practices (ACIP) recommends that a series of 5 doses of DTaP vaccine are given at 2, 4, and 6 months, at 15-18 months, and at 4-6 years of age.[35] The DTaP-IPV-Hib-HepB vaccine is also approved by the US Food and Drug Administration for use in children aged 6 weeks to 4 years and is indicated for the primary vaccination series in infants at ages 2, 4, and 6 months.[36] ACIP also provides catch-up vaccination schedules for those in older age groups who have not completed primary courses.[35]
ACIP recommends that adults should receive a booster dose of Td or Tdap vaccine every 10 years.[33][37] One dose of Tdap should be administered to pregnant women during each pregnancy (preferably between 27 and 36 weeks' gestation) regardless of time since prior Td or Tdap vaccination.[37][38] Tdap vaccination during pregnancy is not associated with an increased risk of infant hospitalisation or death in the first 6 months of life.[39]
As in the UK, travellers from the US to countries with epidemic or endemic diphtheria should ensure completion of a primary immunisation schedule and receive appropriate booster doses if indicated.[12]
Secondary prevention
People travelling to areas where diphtheria is endemic should have their vaccination status checked and updated.[12]
Close contacts and household members of patients should be followed throughout the incubation period for evidence of infection. Nasopharyngeal, oropharyngeal, and cutaneous lesion cultures should be taken.[43] Prophylactic antibiotics should be given, irrespective of the immunisation status, although efficacy has not been proved.[43] Individuals who are not fully immunised (i.e., have received fewer than three doses of vaccine) or whose immunisation status is unknown should be fully vaccinated.[43] Children who have not received their fourth dose of vaccine should be immunised. Previously immunised patients should receive a booster vaccine if they have not received one in the previous 5 years.
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