We deal with vaccinations. Part 12. Diphtheria

2024 Author: Seth Attwood | [email protected]. Last modified: 2023-12-16 15:55

1. Like tetanus, diphtheria is also a rather dangerous disease. However, what is the likelihood of getting sick with it in our time, and how effective is the vaccine?

2. Diphtheria is caused by the bacterium Corynebacterium diphtheriae, which itself is quite harmless. But if this bacterium is infected with a specific virus, then it starts producing and releasing a strong toxin. This toxin is responsible for the severe symptoms of diphtheria. Diphtheria toxin destroys the tissues in the pharynx, and forms a pseudomembrane in it, and without the toxin, the bacteria can only cause pharyngitis. If this toxin enters the bloodstream, complications can lead to myocarditis and temporary paralysis. The mortality rate is 5-10%.

The disease is transmitted mainly by airborne droplets, but transmission through household items is also possible.

Most people who become infected with a diphtheria bacterium do not get sick, but are simply a reservoir of bacteria and a carrier. During epidemics, most children are carriers but do not get sick. Most cases of the disease occur in winter and spring (you can already guess why).

3. The vaccine against diphtheria is not produced separately, it is always combined with tetanus (DT, Td), and usually with pertussis (DTaP / DTP). As with tetanus, the vaccine is a toxoid, i.e. formalin inactivated toxin.

Antibiotics and diphtheria immunoglobulin are used as treatment. But since diphtheria is an extremely rare disease, no human immunoglobulin is produced for it, and even in developed countries equine immunoglobulin is used.

4. Such a thing as an allergy was unknown until 1906. It was invented by an Austrian pediatrician to describe the strange symptoms he observed in those who received diphtheria immunoglobulin.

The concept of anaphylactic shock also did not exist until 1902.

5. In 1926, Glenny and his group experimented with the diphtheria vaccine and tried to improve its effectiveness. By chance, they discovered that adding aluminum to a vaccine produced a stronger immune response. Since then, aluminum has been added to all non-living vaccines.

Glenny had no interest in the safety of aluminum in a vaccine 90 years ago. Nobody is interested in her even today.

6. Diphtheria in North America. (Dixon, 1984, J Hyg (Lond).)

- Diphtheria has always been considered a childhood disease, but in the middle of the 20th century, adults began to fall ill with it. In 1960, 21% of diseases were in adults (over 15 years old). In 1964, there were already 36% of adults, and in the 1970s, 48%. The mortality ratio has also changed. In the 1960s, 70% of those who died from diphtheria in Canada were children, and in the 1970s, 73% of those who died were already adults.

- In the 1960s, Indians suffered from diphtheria 20 times more than whites, and 3 times more than blacks. The reason for this is believed to be the reduced hygiene of the Indians due to their poverty.

- In the late 1960s, there was an outbreak of diphtheria in Austin (88 cases) and San Antonio (196 cases). Diphtheria was observed mainly in urban areas with a low socioeconomic status.

- One of the forms of diphtheria is cutaneous diphtheria. It is usually found among the homeless, and is much less dangerous.

Cutaneous diphtheria is associated predominantly with the poor, crowded, and poor hygiene standards. By 1975, 67% of diphtheria cases were cutaneous diphtheria, and it was mostly found in poor Indians.

In the vast majority of cases, cutaneous diphtheria infection is also accompanied by staphylococcus and streptococcus. It appears that streptococcal and staphylococcal skin infections predispose to secondary infection with diphtheria and poor hygiene is a major contributing factor.

- In the 1970s, there was an epidemic of diphtheria in Seattle. Of the 558 cases, 334 were from Skid Road (i.e. homeless).3 people have died. 74% suffered from cutaneous diphtheria. 70% were severe alcoholics.

- In 1971 there was an outbreak of diphtheria in Vancouver (44 cases). Most of the cases were alcoholic beggars.

- In 1973, an outbreak among Indian children. The source was 4 children with cutaneous diphtheria.

- Cutaneous diphtheria was recognized as a reservoir of infection in 1969 in Louisiana and Alabama. The bacterium was isolated from 30% of healthy people. The vaccinated and unvaccinated were equally infected.

- Since the 1980s, diphtheria has practically not been observed in North America.

7. Immunity and immunization of children against diphtheria in Sweden. (Mark, 1989, Eur J Clin Microbiol Infect Dis)

- The protective level of antibodies for diphtheria is considered to be from 0.01 to 0.1 IU / ml. The exact value cannot be determined.

- In Sweden, from the late 1950s to 1984, there were no cases of diphtheria. In 1984, there were 3 outbreaks (17 cases, 3 deaths). Almost all of the patients were chronic alcoholics. Mainly those with the level of antibodies were sick below 0.01.

- Researchers measured the level of antibodies in children. 48% of children who received 3 doses of vaccine in infancy had antibody levels below 0.01 IU / ml. Among six-year-olds, this was 15%. Among 16-year-olds who, in addition to infant vaccinations, also received a booster, 24% had an antibody level below 0.01.

It is possible that the low antibody level in Sweden is due to the removal of the pertussis component from the vaccine in the 1970s. Since pertussis toxin itself is an adjuvant, eliminating it makes the diphtheria vaccine less effective.

- The immune response to the booster shot among 16-year-olds was much worse than that of 6-year-olds, even though 16-year-olds received a 2.5 fold dose. The authors have no explanation for this phenomenon.

- An antibody level of more than 1 IU / ml is believed to provide protection for 10 years. Only 50% of 16-year-olds and 22% of 10-year-olds had this level of antibodies after vaccination.

- The level of antibodies drops by 20-30% per year. In children, it falls even faster. While 94% of children aged 15 months had an antibody level of more than 1 IU / ml, after 4 years their average level was only 0.062.

8. Serological immunity to diphtheria in Sweden in 1978 and 1984. (Christenson, 1986, Scand J Infect Dis)

The authors measured antibody levels in 2,400 people in Sweden. Nineteen percent of those in their twenties and younger did not have immunity from diphtheria. Among people over 40, only 15% had sufficient antibody levels. Among those over 60, 81% of women and 56% of men lacked immunity. On average, among adults, 70% of women and 50% of men had antibody levels below 0.01 IU / ml.

9. Tetanus and diphtheria immunity in urban Minnesota adults. (Crossley, 1979, JAMA)

84% of men and 89% of women in Minnesota had diphtheria antibody levels below 0.01.

10. Serologic Immunity to Diphtheria and Tetanus in the United States. (McQuillan, 2002, Ann Intern Med)

40% of Americans do not have sufficient immunity to diphtheria (below 0.1).

11. Diphtheria Outpeaks in Immunized Populations. (Karzon, 1988, N Engl J Med)

The decline in diphtheria cases in the 1970s occurred despite a lack of immunity among adults.

Recent epidemics of diphtheria occur only among alcoholics and the homeless.

12. An Outpeak Of Diphtheria In A Highly Immunized Community. (Fanning, 1947, BMJ)

Outbreak of diphtheria in 1946 in an English school (18 cases). All but two (or three) were vaccinated (thanks to this, according to the authors, probably no one died).

Among the 23 unvaccinated, 13% fell ill. Among the 299 vaccinated, 5% fell ill. One of the unvaccinated was actually vaccinated, but more than ten years ago. If we exclude it, then among the unvaccinated 9% fell ill.

If we divide patients into two groups - those who were vaccinated less than 5 years ago, and more than 5 years ago - then the incidence rate between them is the same. Nevertheless, among the recently vaccinated, the disease was easier than among the long-term vaccinated and unvaccinated.

The authors conclude that vaccination without follow-up boosters is not particularly effective and calls for the vaccine every three years, in addition to vaccinations in infancy.

13. The Diphtheria Epidemic in Halifax. (Morton, 1941, Can Med Assoc J)

Diphtheria outbreak in Halifax, Canada in 1940. 66 cases, of which 30% were fully vaccinated.

14. Some Observations on Diphtheria in the Immunized. (Gibbard, 1945, Can J Public Health)

In the early 1940s, there was an epidemic of diphtheria in Canada (1028 cases, 4.3% died). 24% of cases were vaccinated (or protected). Among them, five died, one was vaccinated six months before the illness.

In general, the vaccinated had less severe symptoms. The authors conclude that the vaccine is effective, but not 100% effective.

15. An Outpeak of Diphtheria in Baltimore in 1944. (Eller, 1945, Am J Epidemiol)

Diphtheria outbreak in Baltimore. In 1943, 103 cases were reported. Of these, 29% were vaccinated, and another 14% stated that they were vaccinated, but this was not documented.

As a result, more vaccinations have begun in Baltimore. For the first half of 1944, 142 cases were already registered. Of these, 63% have already been vaccinated.

16. In Western countries, no one remembers what diphtheria is, and even in medical faculties they teach practically nothing about this disease, it is so rare (asked my wife). But due to the epidemic in Russia and the CIS in the early 90s, many people in these countries are still afraid of diphtheria. But who got sick during this epidemic?

17. Diphtheria in the Former Soviet Union: Reemergence of a Pandemic Disease. (Vitek, 1998, Emerg Infect Dis)

- The role of antibacterial immunity in protection against diphtheria has not been studied since the 30s.

- Before World War II, diphtheria was rarely observed in Western Europe. During the war, an epidemic began in the German-occupied territories - in the Netherlands, Denmark and Norway. This was the last diphtheria epidemic in developed European countries. The isolated cases remaining since then were observed mainly among the low socioeconomic class.

- In Russia in the early 90s, cases of diphtheria among the military were 6 times more common than among the civilian population. In the late 1980s, this proportion was even higher.

- In the epidemic of the 90s in the CIS countries, 83% of all cases were registered in Russia. Most of the cases were adults.

Most of the sick were homeless people, patients in psychiatric hospitals living in crowded conditions and in poor sanitary conditions. There were very few cases of the disease among people working under normal conditions.

Children were rarely sick, but they were carriers of the disease. The economic crisis after the fall of the USSR worsened living conditions and intensified the epidemic.

Since almost the entire population of the USSR was vaccinated, it is difficult to blame the lack of vaccination for the epidemic, but the authors succeeded. After all, this article was written by the CDC.

18. Diphtheria outpeak in St. Petersburg: clinical characteristics of 1860 adult patients. (Rakhmanova, 1996, Scand J Infect Dis)

1,860 cases of diphtheria at Botkin hospital in St. Petersburg. The mortality rate was 2.3%. 69% of those who died were chronic alcoholics.

Among those who had a toxic form of the disease, the mortality rate was 26%. The toxic form was in 6% of the vaccinated, and in 14% of the unvaccinated. However, only those who were vaccinated in the last 5 years were considered vaccinated.

Overall, mortality from diphtheria (2.3%) was comparatively low compared to the last known epidemics. And if we exclude alcoholics, then the mortality rate was about 1%. Most of the deceased were admitted to hospital in the advanced stages of the disease, and were either alcoholics or very busy people.

The authors conclude that the diphtheria epidemic in developed countries is unlikely to lead to high mortality in the future. Also, since there were no vaccination data for alcoholics, the authors believe that they were probably unvaccinated.

Vaccination gives immunity for a relatively short period. Exactly how diphtheria is transmitted from person to person is not well known.

19. Risk factors for diphtheria: a prospective case-control study in the Republic of Georgia, 1995-1996. (Quick, 2000, J Infect Dis)

- To catch diphtheria from another person, the distance from him must be less than 1 m. If it is more, the risk of infection is significantly reduced.

- 40-78% of unvaccinated children in Afghanistan, Burma and Nigeria have developed natural immunity by the age of five.

- Socioeconomic factors such as cramped conditions, poverty, alcoholism and poor hygiene contribute to the spread of diphtheria.

Study of 218 cases of diphtheria in Georgia in 1995-1996. The mortality rate was 10%.

- Among children, the mother's initial education level increased the risk of diphtheria by 4 times compared to those whose mother had an academic background.

- Among adults, people with primary education suffered from diphtheria 5 times more often than those who graduated from the university.

- Chronic diseases increased the risk of diphtheria by 3 times. Unemployed people were sick 2 times more often. Taking a shower less than once a week doubled the risk of illness.

- The unvaccinated were sick 19 times more than the vaccinated. However, the vaccinated included only those who received all doses of the vaccine and boosters and were vaccinated in the past 10 years. The rest were identified as unvaccinated. The authors write that perhaps the patients did not remember well whether they were vaccinated or not.

- Among 181 cases, 9% were unvaccinated, 48% had a chronic illness, 21% took a shower less than once a week. The authors conclude that vaccination is the most important tool in diphtheria control, but they do not emphasize that it is worth washing more often than once a week.

The authors also write that diphtheria is not a very contagious disease, and in order to get it, long-term contact with the patient is needed. Visiting crowded places was not a risk factor.

Compared to past epidemics in Europe and the United States, which occurred primarily among alcoholics, the authors did not find an increased risk of alcoholism in this study. They conclude that low socioeconomic status is likely, and not alcoholism, is a risk factor.

20. Diphtheria after visit to Russia. (Lumio, 1993, Lancet)

In the 90s, thanks to the opening of borders, a stream of tourists rushed from Finland to Russia and from Russia to Finland. 400,000 Finns visit Russia every year, and 200,000 Russians visit Finland. There have been 10 million trips. Despite the epidemic in Russia, only 10 Finns contracted diphtheria in Russia, almost all were middle-aged men, of whom only three had a severe form (described below), five had a mild form, and two were only carriers.

1) A 43-year-old resident of Finland visited St. Petersburg in 1993. There he kissed his St. Petersburg girlfriend, and when he returned to Finland, he was diagnosed with diphtheria. He was vaccinated against diphtheria 20 years ago and was considered unvaccinated (antibody level: 0.01). His Petersburg girlfriend did not fall ill. Another carrier of the bacterium was also found, who was traveling with the first in the same group. He also had an intimate relationship with the same "friend" in St. Petersburg. This was the first case in Finland in 30 years.

2) A 57-year-old man visited Vyborg for one day in 1996 and returned with diphtheria. He denied close contact with local residents, but his friends said that he went to prostitutes. It is not known if he was vaccinated (antibody level: 0.06).

3) A 45-year-old man visited Vyborg for 22 hours and returned with diphtheria. His friends said that he went to a prostitute. He was vaccinated and even received a booster one year before the trip (antibody level: 0.08). He was the only one fully vaccinated, and the only one who died.

All three drank large amounts of alcohol during the trip, and two of them were chronic alcoholics.

21. Sexually transmitted diphtheria. (Berger, 2013, Sex Transm Infect.)

First case of diphtheria infection through oral sex. A man, an immigrant from the USSR, living in Germany, went to a male sex worker (how can this be translated?), And received from him, along with a blowjob, also urethritis in addition to diphtheria.

In Germany (and France), diphtheria has become more common in the last few years than in other developed countries (several cases per year). The reason for this is the liberal policy of these countries regarding the admission of migrants from third world countries.

22. In 2016, 25 after diphtheria was completely eradicated, there was an outbreak of diphtheria in Venezuela. Since vaccination coverage has only increased from year to year, and given the humanitarian catastrophe that is now happening there, it is difficult to blame the lack of vaccinations for this outbreak. But WHO would not be WHO if it let the facts confuse it.

Besides humans, guinea pigs are the only mammals that do not synthesize vitamin C.

23. The effect of diphtheria toxin on the vitamin C content of guinea pig tissues. (Lyman, 1936, J. Pharm. Exp. Ther)

Guinea pigs were injected with diphtheria toxin. Those on the low vitamin C diet lost more weight than those on the regular diet. Diphtheria toxin depleted vitamin C stores in the adrenal glands, pancreas, and kidneys.

24. The influence of vitamin C deficiency upon the resistance of guinea pigs to diphtheria toxin glucose tolerance. (Sigal, 1937, J Pharmacol Exp Ther)

- Lack of vitamin C results in decreased resistance to infections, and increased damage from bacterial toxins. Reduced resistance occurs before scurvy symptoms are visible.

- Guinea pigs on a low vitamin C diet that were injected with a sublethal dose of diphtheria toxin showed wider tissue damage, greater weight loss, wider areas of necrosis, poorer dental development, and a lower lifespan than unrestricted guinea pigs in a vitamin.

Most likely, a low level of vitamin C leads to systemic disorders of the whole body and especially the endocrine system.

The authors conclude that vitamin C levels for diphtheria detoxification should be substantially higher than the required vitamin C levels to prevent scurvy.

25. Effects of Vitamin C Intake upon the Degree of Tooth Injury Produced by Diphtheria Toxin. (King, 1940, Am. J. Public Health)

- When guinea pigs are injected with a sublethal dose of diphtheria toxin, there is a 30-50% decrease in tissue vitamin C levels within 24-48 hours.

- Children who received low vitamin C levels developed scurvy during infection. It resolved spontaneously after recovery, with no increase in vitamin C in the diet.

- What correlates with the absence of caries in children 10-14 years old is good nutrition and the absence of disease in infancy and childhood.

- Guinea pigs were injected with 0.4 or 0.8 of the minimum lethal dose of diphtheria toxin. Dental destruction was observed among those who received 0.8 mg of vitamin C per day. Those who received 5 mg of vitamin C did not have tooth decay.

26. The influence of vitamin C level upon resistance to diphtheria toxin. (Menten, 1935, J. Nutr)

Guinea pigs with limited vitamin C in their diet were injected with sublethal doses of diphtheria toxin. They developed arteriosclerosis in the lungs, liver, spleen and kidneys.

27. The effect of diphtheria toxin upon vitamin C in vitro. (Torrance, 1937, J Biol Chem)

Guinea pigs with low vitamin C stores, which were injected with a lethal dose of diphtheria toxin, died faster than pigs on a normal diet.

Guinea pigs given high doses of vitamin C survived even when injected with several lethal doses of the toxin.

28. Since the 1940s, no one has studied the effect of vitamin C on diphtheria. In 1971, Klenner reported that a girl had been cured of diphtheria by an intravenous injection of a vitamin. Two other children who did not receive vitamin C died. All three also received antitoxin.

29. As with other diseases, the decline in mortality from diphtheria began long before the introduction of the vaccine.

30. Since the diphtheria vaccine is a toxoid, it cannot prevent infection, but it can prevent complications from the disease. Thus, it was logical to expect that with the introduction of the vaccine, mortality from diphtheria will decrease. However, this did not happen. Although the incidence of diphtheria has steadily declined, mortality remained at about 10% from the 1920s to the 1970s, despite increasing vaccination coverage (data from here).

31. And here is the data from India, more or less the only country in the world where diphtheria still remains. Despite the increased vaccination coverage, the number of diphtheria cases has not decreased significantly since the 1980s.

32. Today, diphtheria is an extremely rare disease; it practically does not occur even in most third world countries.

Since 2000, only 6 cases of diphtheria have been reported in the United States. One of them died. He was 63 years old and contracted the infection in Haiti. It is such a rare disease that the CDC writes a separate report for almost every case [1], [2], [3].

But since 2000, 96 people have been sick with bubonic plague in the United States, and 12 have died. Their deaths were not widely publicized, since children are not vaccinated against the plague.

33. Deaths from diphtheria in developed countries are so rare that each case is widely reported in the press. In 2015, a boy died of diphtheria in Spain, and in 2016 a girl in Belgium, and in 2008 a girl in England. These are the only cases of death of children from diphtheria in developed countries in the last 30 years.

In Israel over the past 40 years there have been only 7 cases of diphtheria, and over the past 15 years there have been none at all.

Several cases of the disease are registered in Russia per year. In 2012, there were 5 cases of the disease. Among them, four are vaccinated. Also, 11 carriers were identified, of which 9 were vaccinated. In 2013, there were two cases of the disease, both were vaccinated. 4 carriers were identified, all were vaccinated. In 2014, there was one case, and in 2015 two more (it is unclear whether they were vaccinated or not). For all these years, no one has died of diphtheria.

In Russia, there are many more cases of anthrax (anthrax), a much more dangerous disease (36 cases in 2016, 3 cases in 2015). But since she is not vaccinated, and no one scares her, parents are not very afraid that the child will suddenly pick her up.

34. Since diphtheria vaccine is always combined with tetanus / pertussis vaccine, the safety data are similar to those given in the relevant parts.

Vaccination (without pertussis) leads to Guillain-Barré syndrome, anaphylactic shock and brachial neuritis, lowers lymphocyte count, increases the risk of allergies, and antiphospholipid syndrome In VAERS from 2000 to 2017 after diphtheria vaccine without pertussis component (DT / Td) registered 33 deaths, and 188 cases of disability. During this time 6 fell ill from diphtheria and one died. Considering that only 1-10% of all cases are registered in VAERS, the probability of dying from vaccination is hundreds of times higher than the probability of contracting diphtheria.

The chances of getting diphtheria in developed countries is at most 1 in 10 million, and usually even less. The probability of only anaphylactic shock is 1 in a million, and brachial neuritis is 1 in 100 thousand.

TL; DR:

- Since the diphtheria vaccine appeared back in the 1920s, it has not undergone any clinical trials, much less efficacy tests. Nevertheless, judging by the available data, it still gives some immunity from diphtheria, although far from complete [1], [2]. In any case, it is clearly more effective than tetanus vaccination, which is quite logical, since diphtheria toxin spreads through the circulatory system, where there are antibodies, and tetanus through the nervous system, where they are not. However, this immunity is very short-lived, and it is necessary to vaccinate every 3-5 years for the amount of antibodies to be sufficient. Because no one is vaccinated so often, most people are not immune to diphtheria.

- The vaccine contains aluminum.

- Diphtheria affects mainly alcoholics and homeless people, and even they rarely get sick. Getting sick with diphtheria today is almost impossible.

- Diphtheria seems to be cured with vitamin C.

- The likelihood of dying from vaccination is many times greater than the likelihood of contracting diphtheria.