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What is Diphtheria?Updated 8-29-24
  • Diphtheria is a highly contagious and serious infection caused by strains of bacteria that make toxins.
  • Diphtheria can infect the respiratory tract and skin. Symptoms will depend on the part of the body that is affected. People will display symptoms 2 to 5 days after being exposed to diphtheria.
  • Diphtheria can be treated with medications, but in advanced stages it can damage the heart, kidneys, and nervous system. Even with treatment, diphtheria can be deadly, especially in children.
  • Diphtheria is extremely rare in the United States due to widespread vaccination against the disease.
  • If you think you may have Diphtheria symptoms or have not yet received the diphtheria vaccine, talk with your healthcare provider.
Diphtheria: Symptoms and Complications

Respiratory diphtheria
Diphtheria commonly infects the respiratory system and can cause:

  • Weakness
  • Sore throat
  • Nasal discharge
  • Mild fever
  • Difficulty breathing or rapid breathing
  • Swollen glands (enlarged lymph nodes) in the neck

Diphtheria makes a toxin that kills healthy tissues in the respiratory system. Within two to three days, the dead tissue forms a thick, gray coating that can build up in the throat or nose.” It can cover tissues in the nose, tonsils, voice box, and throat, making it very hard to breathe and swallow.

If the toxin gets into the blood stream, it can cause heart, nerve, and kidney damage. Severe diphtheria can result in difficulty breathing, heart failure, paralysis, or death.

Skin diphtheria
Diptheria can also infect the skin and can cause:

  • Redness and swelling
  • Open sores or ulcers

Skin infections caused by diphtheria will rarely result in severe disease.

How does Diphtheria Spread?

Diphtheria most often spreads from person to person through respiratory droplets, like from coughing or sneezing. People can also get sick from touching open sores or ulcers from an infected person.

Anyone infected with diphtheria can spread the disease, even if they have no symptoms or only mild symptoms.

Those at increased risk of getting sick include people who do not have diphtheria immunity and are:

  • In the same household or who have frequent contact with an infected person
  • Exposed to open sores or ulcers from the suspected infection site (e.g., mouth, skin) of an infected person

CDC recommends that persons who are exposed to someone with diphtheria receive antibiotics to prevent them from getting sick. In addition to getting antibiotics, exposed persons should be:

  • Monitored for symptoms for 7 to 10 days from when they were last exposed to the infected person
  • Tested for diphtheria with a sample collected from the nose and throat
  • Given a diphtheria booster shot if they are not up to date with their vaccines
Information for the Public
Vaccine Information

The best way to protect against diphtheria is to get vaccinated. The diphtheria vaccines protect nearly everyone (97 in 100) against diphtheria for approximately 10 years.

There are three kinds of vaccines used in the United States today to help protect against diphtheria, all of which also provide protection against other diseases:

  • Diphtheria, tetanus, and pertussis (DTaP) vaccines
  • Tetanus, diphtheria, and pertussis (Tdap) vaccines
  • Tetanus and diphtheria (Td) vaccines
Vaccine Recommendations

CDC recommends vaccination for infants, children, teens, and adults to prevent diphtheria.

  • Babies and children younger than 7 years old receive DTaP. Tdap and Td vaccines are available for older children, adolescents, and adults.
  • Babies need 3 shots of DTaP to build high level of protection. Then children need 2 booster shots to maintain protection through early childhood.
  • It is recommended that children receive 5 doses of DTaP, usually at the following ages:
    • 2 months
    • 4 months
    • 6 months
    • 15–18 months
    • 4–6 years
  • DTaP may be given as a stand-alone vaccine, or as part of a combination vaccine (a type of vaccine that combines more than one vaccine together into one shot). DTaP may be given at the same time as other vaccines.
  • It is recommended that preteens receive a Tdap booster between 11—12 years of age and (Td or Tdap) every 10 years after into adulthood.
Where to get the Vaccine

There are many places to get the diphtheria vaccine. If you have insurance, talk to your doctor or check with your local pharmacy to see what vaccines are offered. Most health insurances cover the cost of all recommended vaccines for children and adults.

If you are uninsured or underinsured, there are programs available to help cover the cost of vaccines. Children who are 18 years of age or younger are eligible to receive vaccines at no cost through the Vaccines for Children (VFC) Program if they are:

  • Eligible for or are enrolled in Medi-Cal
  • American Indian or Alaskan Native
  • Uninsured (do not have health insurance)
  • Underinsured (private health insurance does not cover the full cost of vaccines)

Click to see if your child is eligible to receive VFC vaccines: English | Spanish

Uninsured or underinsured adults can access free or low cost vaccines at select clinics enrolled in the Vaccines for Adults (VFA) program. For more information on who is eligible, read VFA Eligibility Based on Insurance Status. You can use the following resources for more information on locating clinics:

You can also dial 2-1-1 for a list of free or low cost vaccine clinics. This includes Vaccines for Children (VFC) provider locations that serve Medi-Cal eligible children and uninsured or underinsured adults. Learn more about specific vaccine information for different age groups:

Keeping Record of Your Immunization Records

Are you not sure if you have been vaccinated against diphtheria or you can’t find your vaccine records?

If you need official copies of your vaccine records, or if you need to update your personal records:

Additional Resources
Information for Providers
Clinical Presentation

Infection with C. diphtheriae can present with respiratory or cutaneous disease, but can disseminate to affect the heart, the nervous system, and the kidneys.

Respiratory diphtheria

  • Respiratory diphtheria can present with a bluish – white membrane (pseudomembrane), a key diagnostic feature of diphtheria along with sore throat, low – grade fever, neck swelling due to cervical lymphadenopathy (bull neck), and difficulty swallowing.
  • The membrane can involve all parts of the respiratory tract from the nasal passages to trachea.
  • Most complications of respiratory diphtheria, including death, are attributable to effects of the diphtheria toxin. The most common complications of respiratory diphtheria include myocarditis and neuritis. Other complications include otitis media and respiratory insufficiency due to airway obstruction, especially in infants.
  • The risk of developing myocarditis and other toxicities is proportional to the severity of local infection and can range from 10-25% of all patients.
  • The overall case-fatality rate for diphtheria is 5%–10%, with higher death rates (up to 20%) among persons younger than 5 and older than 40 years of age.

Cutaneous diphtheria

  • Cutaneous diphtheria causes a scaling rash or non-healing skin ulcers that have clearly demarcated edges and an overlying membrane. Cutaneous diphtheria infections rarely cause system disease.
Specimen Collection and Storage

Presumptive diagnosis of respiratory diphtheria is usually made on the basis of clinical presentation and epidemiological risk factors (e.g. travel to endemic areas with low immunization coverage) since it is imperative to begin presumptive therapy quickly. However, definitive diagnosis for diphtheria infection is made by isolating C. diphtheriae and testing the isolate for toxin production by the Elek test.

  • Culture – Nasal, oropharynx, and throat specimens can be collected on separate swabs (cotton or synthetic swab) and place into separate Bacterial Culturettes or if available, a Diphtheria Culture Kit.
    • Collect a specimen from beneath the “adherent membrane”, on the pharyngeal tonsillar area of the oral cavity for patients who are symptomatic. Store specimen in sterile saline.
    • Specimens from an open sore or ulcer can also be obtained for culture to determine if the bacteria that causes diphtheria grows from the sample.
  • Virulence testing - If diphtheriae is found on cultures of nose or throat, isolate should be sent to Public Health Lab for additional testing.
  • Collect specimens before the patient starts antibiotic treatment.

Specimen Storage

  • Store swabs and pseudomembrane culture specimens in the refrigerator at (2-8°C) *.
  • Isolates should be stored at room temperature (15-25°C).
  • Transport refrigerated on cold packs to the laboratory overnight.

*If specimen cannot be transported to Public Health Laboratory within 8 hours, keep cool in refrigerator (2-8°C) (do not freeze) until lab pick-up the next day. Ship with a cold pack. Specimens should be transported and received in the PHL within 24 hours of collection.

Contact the Vaccine Preventable Disease Control (VPDC) Program for additional guidance on specimen collection and transport to PHL. See Reporting section for contact information.

Vaccine Recommendations
  • ACIP recommends routine diphtheria vaccination across the lifespan. Children younger than 7 years of age should receive DTaP (diphtheria, tetanus, acellular pertussis), while older children and adults receive Tdap (tetanus, diphtheria, acellular pertussis) or Td. See the table below for a list of diphtheria-containing vaccines and the recommended schedules.
  • Multiple combination vaccines containing diphtheria are available for use. Use of combination vaccines are also useful in reducing the number of injections in a single visit.
  • More than 97% of recipients develop protective antibody levels after 3 doses and booster (infants) or 3 doses (adults).
  • Diphtheria disease might not confer immunity. Unvaccinated or incompletely vaccinated persons recovering from diphtheria should begin or complete their immunization series with diphtheria toxoid during convalescence.

Adults

  • Administer a single dose of Tdap to adults who have never received Tdap regardless of when they last received Td. This should be followed by a Tdap booster every 10 years.

Catch – Up Guidance for Children 4 Months through 18 Years

Guidance for Td

  • TdVax has been discontinued and is no longer available in the U.S.
  • A limited supply of Tenivac (Td) is still available, but due to constraints in vaccine supplies, CDC has developed the following guidance for vaccine providers:
    • Us Tdap vaccine in lieu of Td vaccine whenever possible while Td vaccine supplies are constrained.
    • Tdap vaccine is an acceptable alternative to Td vaccine, including when a tetanus booster is indicated for wound management.
    • Tdap vaccine isn't an acceptable alternative only when a person has a specific contraindication to pertussis-containing vaccines, which is very rare.
Diphtheria – containing Vaccines and Brands Number of Doses Age Recommended Age Dose/Route
Daptacel (DTaP)
Sanofi Pasteur		 5 2, 4, 6 & 15-20 months;
Booster dose at 4-6 years		 6 weeks - 6 years 0.5mL
Intramuscular (IM)
Infanrix (DTaP)
Sanofi Pasteur		 5 2, 4, 6, & 15 -20 months;
Booster dose at 4 – 6 years 		6 weeks - 6 years 0.5mL
Intramuscular (IM)
Pediarix (DTaP-HepB-IPV)
GlaxoSmithKline 		3 2, 4, & 6 months 6 weeks - 6 years 0.5mL
Intramuscular (IM)
Pentacel (DTaP-IPV/Hib)
Sanofi Pasteur 		4 2, 4, 6, and 15 – 18 months 6 weeks - 4 years 0.5mL
Intramuscular (IM)
VAXELIS (DTaP-IPV-Hib-HepB)**
MSP Vaccine Company 		3 2, 4, and 6 months 6 weeks - 4 years 0.5mL
Intramuscular (IM)
Kinrix (DTaP-IPV)
GlaxoSmithKline 		1 4 - 6 years 4 - 6 years 0.5mL
Intramuscular (IM)
Quadracel (DTaP – IPV)
Sanofi Pasteur 		1 4 - 6 years 4 - 6 years 0.5mL
Intramuscular (IM)
Adacel (Tdap)
Sanofi Pastuer		 >1 ≥7 years 11 - 12 years*
Booster dose every 10 years		 0.5mL
Intramuscular (IM)
Boostrix (TdaP)
GlaxoSmithKline (GSK) 		>1 ≥7 years 11 – 12 years*
Booster dose every 10 years * 		0.5mL
Intramuscular (IM)
Tenivac (Td) >1 ≥7 years Booster every 10 years 0.5mL
Intramuscular (IM)

*Diphtheria – containing vaccines can be administered with other vaccines.
*Kinrix is approved only for dose 5 of DTaP and dose 4 of IPV.
*Quadracel is approved only for dose 5 of DTaP and dose 4 or 5 of IPV.
*ACIP prefers that, whenever feasible, the doses of vaccine in a series come from the same manufacturer.
*Either Tdap vaccine administered to a person age 65 years or older is immunogenic and would provide protection. A dose of either vaccine would be considered valid.
**Preferred for American Indian and Alaska Native infants based on the Haemophilus influenzae type b (Hib) component.

Storage and Handling

Proper vaccine storage and handling practices play an important role. For general recommendations and guidance access the Vaccine Storage and Handling Toolkit.

Reporting

Please contact the LAC DPH Vaccine-Preventable Disease Control Program to report a case, obtain any other technical assistance with specimen collection or completion of forms for diphtheria.  

Confirmed or suspected diphtheria cases are to be reported immediately from identification, by telephone to Los Angeles County Public Health Department. (Title 17, Section 2500, California Code of Regulations).

  • Weekdays Telephone: 8:30 am to 5:00 pm: Call 213-351-7800 
  • After Hours: Call 213-974-1234 
  • Email: vpdc@ph.lacounty.gov  
  • Fax number: 213-351-2782 

Click here for more information on reporting a Vaccine Adverse Event.

Treatment

Patients who have suspect or confirmed respiratory diphtheria, according to the Council of State and Territorial Epidemiologists case definition, are eligible to receive Diphtheria Antitoxin (DAT) early in the course of disease. DAT may also be used in cases of respiratory diphtheria-like illness caused by laboratory-confirmed toxigenic C. ulcerans. A patient’s eligibility for treatment will be determined through discussion between the CDC diphtheria duty officer and the treating clinician.

Physicians requesting DAT should contact the LA County Vaccine Preventable Disease Control Program (VPDCP) at 213-351-7800 during normal working hours to arrange for its release from the CDC Quarantine Station at Los Angeles International Airport. After working hours, contact the Administrative Officer of the Day through the County Operator at 213- 974-1234.

Treatment of cutaneous diphtheria with antibiotics is usually sufficient, and antitoxin is typically not needed.  Appropriate antibiotic therapy should be administered for at least 14 days to kill the organism and prevent further toxin production. Antibiotics recommended for the treatment of diphtheria include:

  • Erythromycin – 10 mg/kg/dose up to a maximum of 500 mg IV/po 4 times a day for 14 days.
  • Procaine Penicillin G – 300,000 units IM every 12 hours for patients <10kg, and 600,000 units IM every 12 hours.
    • Switch to oral penicillin V (250 mgs 4 times a day for 14 days) once the patient is able to tolerate oral intake.


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