Diphtheria
It is an acute bacterial infectious disease caused by Corynebacterium diphtheriae.
1. Anterior nasal part
2. Laryngeal Part
• Skin, Conjunctiva, vulva and other parts of the body may be a ected.
• The bacilli multiply locally, usually in the throat, and elaborate a powerful exotoxin which is
responsible for :
- The formation of a greyish or yellowish membrane commonly over the tonsils, Pharynx or
larynx.
- marked congestion, oedema ,destruction of local tissue
- enlargement of the regional lymph nodes.
- And in children under 5 years of age 1 out of 5 children who get diphtheria dies.
AGENT FACTOR
a) AGENT:
• The causative agent, C. Diphtheriae is a gram-positive, non motile organism.
• Four types of diphtheria bacilli are di erentiated - gravis, mitis, belfanti and intermedius, all
pathogenic to man.
• In general, gravis infections tend to be more severe than mitis infections.
• The toxin can a ect the heart leading to myocarditis or the nerves leading to paralysis.
• Diphtheria bacilli are sensitive to penicillin and are readily killed by heat and chemical agents.
They may survive for - short periods in dust and fomites.
b) SOURCE OF INFECTION:
• It may be case or carrier:
(1) CASE: Cases range from subclinical to frank clinical cases.
• Mild or silent infections may exhibit no more than a mere running nose or sore throat.
• These cases play a more important role than frank cases in spreading the infection
(2) CARRIER: Carriers are common sources of infection, their ratio is estimated to be 95 carriers
for 5 clinical cases.
• Carriers may be temporary or chronic nasal or throat carriers.
• The nasal carriers are particularly dangerous as source of infection because frequent shedding
of the organism into the environment.
• The temporary carrier state may last for about a month ,but chronic carrier state may persist
for a year or so unless the patient is treated
C) INFECTIVE MATERIAL:
• Nasopharyngeal secretions
• Discharges from skin lesions
• Contaminated fomites
• Infected dust.
PERIOD OF INFECTIVITY:
Unless treated, the period of infectivity may vary from 14 to 28 days from the
HOST FACTORS
1. AGE:
• Diphtheria particarly a ects children aged 1-5.
• In countries where widespread immunization is practiced, A shift in age incidence has been
observed from preschool to school age.
Both sexes are a ected
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2. IMMUNITY:
• Infants born of immune mother's are relatively immune during the rst few weeks or months of
life.
ENVIRONMENTAL FACTORS
• Cases of diphtheria occur in all seasons, although winter months favour it's spread.
MODE OF TRANSMISSION
• The disease is spread mainly by droplet infection.
• It can also be transmitted directly to susceptible persons from infected cutaneous lesions.
• Transmission by objects contaminated by the Nasopharyngeal secretions of the patient is
possible but for only short period.
PORTAL OF ENTRY
1. Respiratory Route - common is Respiratory tract.
2. Non-respiratory Routes - skin where cuts, wounds and ulcers not properly healed may get
infected with diphtheria bacilli.
• The site of implantation may be eye, genitalia or middle ear.
• The non respiratory routes of infection are less common in developed countries where spread
by droplet infection is more common.
INCUBATION PERIOD
• 2 to 6 days occasionally later.
•CLINICAL FEATURES -
1. Respiratory tract forms of diphtheria consist of :
1. Pharyngotonsillar
2. laryngotracheal
3. Nasal
• Patients with pharyngotonsillar diphtheria usually have a sore throat, di culty in swallowing,
and low grade fever at presentation.
• Laryngotracheal diphtheria - fever, horseness, croupy cough.
• If the infection extends into bronchial tree, it is the most severe disease.
• Nasal diphtheria- mildest form of Respiratory diphtheria. .
• Usually is localized to nasal septum.
2. Non Respiratory form of diphtheria- conjunctiva and genitals may also be site of infection.
• Cutaneous diphtheria. common in tropical areas.
• Infection appears as a secondary infection of previous skin infection. senting lesion, often an
ulcer, may be sorrounded by erythema and covered with a membrane.
• generally seek treatment because of chronicity of the skin lesion
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• CONTROL OF DIPHTHERIA
1. CASES AND CARRIERS
(a) Early detection :
• An active search for cases and carriers should start immediately amongst family and school
contacts .
• Carriers can be detected only by culture method.
• Swabs should be taken from both the nose and throat and examined by culture methods for
diphtheria bacilli.
(b) Isolation:
• All cases, suspected cases and carriers should be promptly isolated, preferably in a hospital,
for at least 14 days or until proved free of infection.
• At least 2 consecutive nose and throat swabs, taken 24 hours apart, should be negative before
terminating isolation.
(C) Treatment:
(i) CASES: When diphtheria is suspected, diphtheria antitoxin should be given without delay, IM
or IV, in doses ranging from 20,000 to 100,000 units or more, depending upon the severity of the
case.
• In addition to antitoxin, every case should be treated with penicillin or erythromycin for 5 to
6 days to clear the throat.
(ii) CARRIERS: The carriers should be treated with 10 days course of oral erythromycin.
2. CONTACTS
• where primary immunization or booster dose was received within the previous 2 years, no
further action would be needed
• where primary course . booster dose of diphtheria toxoid was received more than 2 years
before, only a booster dose of diphtheria toxoid need be given
non-immunized close contact should receive prophylactic penicillin or erythromycin.
• They should be given 1000-2000 units of diphtheria antitoxin and actively immunized against
diphtheria.
• Contacts should be placed under medical surveillance and examined® daily for evidence of
diphtheria for at least a week after exposure.
(f)The bacteriological surveillance of close contacts should be continued for several weeks by
repeated swabbing at approximately weekly intervals
• 3. COMMUNITY
• The only e ective control is by active immunization with diphtheria toxoid of all infants as early
in life as possible, as scheduled, with subsequent booster doses every 10 years thereafter .
• The aim should be to immunize before the infant loses his maternally derived immunity so that
there will be continuous protection from birth without any gap in immunity to natural disease.
DIPHTHERIA IMMUTIZATION
A) COMBINED VACCINES
• DPT (diphtheria-pertussis-tetanus vaccine)
• DTPw (diphtheria, tetanus, whole-cell pertussis)
• DTPa (diphtheria, tetanus, acellular pertussis)
• DT (diphtheria-tetanus toxoid)
• dT (diphtheria-tetanus, adult type)
• Pentavalent (diphtheria, tetanus, pertussis, hepatitis B and Hib).
1. DPT Vaccine
• For immunizing infants, the preparation of choice is DPT Firstly because, the infant can be
immunized simultaneously against three diseases, viz., diphtheria, pertussis and tetanus which
is a great gain administratively.
• Secondly the pertussis component in DPT vaccine enhances the potency of the diphtheria
toxoid.
• There are two types of DPT vaccines : plain and adsorbed.
• Studies have shown that adsorption increases the immunological e ectiveness of the vaccine.
STORAGE: DPT/DT vaccines should not be frozen. They should be stored in a refrigerator
between 2 to 8 celsius
• Optimum age: It has been found that young infants respond well to immunization with potent
vaccines and toxoids even in the presence of low to moderate levels of maternal antibodies.
Accordingly the Global Advisory Group recommended that DPT vaccine can be safely and
e ectively of the Expanded Programme on Immunization (EPI), has administered as early as 6
weeks after birth .
• Number of doses: Three doses of DPT each of which is usually 0.5 ml.
• Interval between doses: 4 weeks between the 3 doses, with a booster injection at one and a
half vear t wo years, followed by another booster at the age of 5 to 6 years
• Mode of administration: DPT should be administered intramuscularly in antero lateral aspect
of the thigh.
• Reactions: Fever and mild local reactions following DPT immunization are common. It is
estimated that 2 to 6 per cent of vaccinees develop fever of 39 deg. C or higher, and that 5 to
10 per cent experience swelling and induration or pain lasting more than 48 hours.
• Contraindications: Minor illnesses such as cough, cold, mild fever are not considered
contraindications to vaccination, only such children who are seriously ill or need hospitalization
are not vaccinated.
• DPT should not be repeated if a severe reaction occurred after a previous dose. Such reactions
include collapse or shock-like state. Persistent screaming episodes, temperature above 40
deg.C, convulsions.
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2. Pentavalent vaccine-
Pentavalent vaccine provides protection to a child from 5 life threatening diseases diphtheria,
pertussis, tetanus, hepatitis B and haemophilus in uenzae type b (Hib).
• Giving pentavalent vaccine reduces the number of pricks to a child.
• Pentavalent vaccine is very safe.
• As with all medicines, a few side e ects are possible. Pain, redness and swelling at the site of
injection, fever, vomiting, loss of appetite, abnormal crying, irritability are the common side
e ects.
• The rare side e ects are high fever (more than 39.5°C) and ts or seizures, and very rarely
severe allergic reaction can occur.
SINGLE VACCINES
FT (formal-toxoid)
APT (alum-precipitated toxoid)
• PTAP (puri ed toxoid atum nium phosphate)
• PTAH (puri ed toxoid aluminium hydroxide)
• TAF (toxoid-antitoxin occulus)
• Single vaccines (e.g.. FT, PTAP, APT. PTAH) are less frequently used.
• They are all good immunizing agents. APT is hardly used because it is prone to give rise to
serious reactions.
• 3) ANTISERA
• Diphtheria antitoxin prepared in horse serum is still the mainstay of passive prophylaxis and
also for treatment of diphtheria.
• It has been shown, protection against diphtheria toxin is a quantitative phenomenon, so that a
serum antitoxin titre that protects against a small dose of toxin may not protect against a large
dose.
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