Diphtheria: changing patterns in the developing world and the industrialized world

In the past, diphtheria was considered one of the most serious childhood diseases because it took a heavy toll in health and life among preschool-aged children. Prior to the widespread availability of diphtheria toxoid, nearly 70% of cases were in children younger than 15 years of age. In the industrialized countries, immunization against diphtheria became widespread in the 1940s and 1950s. This led to a marked decrease in the incidence of diphtheria. There was also a decrease in circulating toxigenic Corynebacterium diphtheriae organisms, resulting in less natural boosting of antibody levels. This had led to gaps in the immunity of the adult population. Since 1990, diphtheria has made a spectacular comeback in several European countries, with a high proportion of cases in adults. In developing countries, immunization of infants with diphtheria toxoid was introduced with the Expanded Programme on Immunization in the late 1970s. Coverage rose slowly to 46% in 1985 and 79% in 1992. Because the pool of immunized persons is not yet large, the process of maintaining immunity still operates through natural mechanisms, including frequent skin infections caused by C. diphtheriae. But recently, several developing countries where coverage has been high for 5-10 years have reported diphtheria outbreaks. These outbreaks have been characterized by high case fatality rates, a large proportion of patients with complications, and their occurrence in both young and older age groups. In all countries, priority should be given to efforts to reach at least 90% coverage with three doses of diphtheria toxoid in children below one year of age. In countries where diphtheria has been successfully controlled, immunity levels should be maintained by booster doses.