There are two main types of diphtheria:

Respiratory (nose and throat) diphtheria
Symptoms may include:

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

The bacteria produce a toxin that destroys healthy tissues in the respiratory system. Within two to three days, a thick gray coating may form in the nose or throat. This coating can cover tissues in the nose, tonsils, voice box, or throat and make it very hard to breathe and swallow.

If the toxin spreads through the blood, it can damage the heart, nerves, and kidneys. Severe illness can lead to breathing problems, heart failure, paralysis, or death.

Skin diphtheria
Diphtheria can also infect the skin. Symptoms may include:

• Redness and swelling
• Open sores or ulcers

Skin infections caused by diphtheria rarely cause severe disease.

• Diphtheria usually spreads from person to person through droplets in the air (coughing, sneezing and spitting). People can also get sick from touching open sores or ulcers from an infected person.
• A person can spread diphtheria even if they have mild symptoms or no symptoms at all.
• People who are not vaccinated have a higher risk of getting sick.

People may also have a higher risk if they:

• Have a weakened immune system
• Live with or have close contact with an infected person
• Touch an open sore on an infected person
• Are experiencing unstable housing
• Recently used illicit substances
• Travel to areas where diphtheria is more common, including Africa, Haiti, the Dominican Republic; Asia, the South Pacific, Eastern Europe, and the Middle East

If You Are Exposed to Diphtheria
The American Academy of Family Physicians (AAFP) recommends that people who are exposed to diphtheria receive antibiotics to prevent illness.

In addition to antibiotics, people who are exposed should:

• Monitor for symptoms for 7 to 10 days after their last exposure
• Be tested for diphtheria using samples from the blood, urine, sputum, spinal fluid, nose, throat, or an open sore/ulcer
• Get a diphtheria booster vaccine if they are not up to date with their vaccines

Getting vaccinated is the best way to protect yourself from diphtheria. The diphtheria vaccines protect about 97 out of 100 people and protection usually lasts about 10 years.

There are three vaccines available in the United States to help protect against diphtheria. All of these vaccines also provide protection against other diseases:

• DTaP vaccine: protects against diphtheria, tetanus, and pertussis
• Tdap vaccine: protects against tetanus, diphtheria, and pertussis
• Td vaccine: protects against tetanus and diphtheria

If you have insurance:

• Talk to your doctor or check with your local pharmacy to see what vaccines they offer.
• Most health insurance plans cover the cost of recommended vaccines for children and adults.

If you are uninsured or underinsured:

• Programs are available to help cover the cost of vaccines.
• Children 18 years or younger may 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)
• Adults who are uninsured or underinsured may be able to get free or low-cost vaccines at clinics enrolled in the Vaccines for Adults (VFA) program. For more information on who is eligible, read VFA Eligibility Based on Insurance Status.

Locating Vaccine Clinics:

• A list of free and low-cost clinics in Los Angeles County.
• Interactive county map to locate free and low-cost vaccine clinics.
• Call 1-833-540-0473 (Public Health InfoLine) 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.

• Immunization Schedules: Birth to 6 Years Old | 7 to 18 Years Old | 19 Years and Older (AAP & AAFP)
• What You Need to Know: DTaP (Diphtheria, Tetanus, Pertussis) | Tdap (Tetanus, Diphtheria, Pertussis) | Td (Tetanus, Diphtheria) | Multi-Vaccine (DTaP, Hib, Hepatitis B, Polio, PCV) (Immunize.org)
• Diphtheria: Questions and Answers (Immunize.org)
• Diphtheria (History of Vaccines)
• Diphtheria (Vaccinate Your Family)
• DTaP (Diphtheria, Tetanus, Pertussis) Vaccine (Voices for Vaccines)
• DTaP Vaccine: Preparing for Your Child’s Well-Baby Visit (Voices for Vaccines)
• Travelers' Health: Travel Vaccines (LAC DPH)
• Paying for Vaccines (LAC DPH)

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 grayish-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 or older than 40 years.

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.

Do not wait for laboratory confirmation - report immediately by telephone for both confirmed and suspected cases upon clinical suspicion of diphtheria per Title 17, California Code of Regulations, Section 2500.

Public Health will guide you through the collection of specimens for testing and management of the patient under investigation. Consultation is required before sending specimens to the Public Health Laboratory.

• Weekdays 8:30 am - 5:00 pm: Call 213-351-7800 - Epidemiologist on Duty
• Non-Business Hours, Holidays & Weekends: Call 213-974-1234, option 8 - Administrative Officer on Duty

After the initial report, please send the patient’s medical records and any available immunization records and/or laboratory results via secure email to vpdc@ph.lacounty.gov or fax to 213-351-2782.

A 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 therapy for presumptive diphtheria quickly. However, a definitive diagnosis for diphtheria infection is made by isolating C. diphtheriae and testing the isolate for toxin production by the Elek test.

Collect specimens in consultation with Vaccine Preventable Disease Control (VPDC) before starting the patient on antibiotic treatment.

• Culture – Nasal, oropharynx, and throat specimens can be collected on separate swabs (polyester, rayon, or nylon swab) and placed 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 (not formalin).
  • 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 (again, use polyester, rayon, or nylon swabs).
  • Store swabs and pseudomembrane specimens in the refrigerator at 2-8°C.
  • Transport refrigerated on cold packs to the laboratory within 8 hours.
    • If specimen cannot be transported to Public Health Laboratory within 8 hours, store specimens refrigerated at 2-8°C (do not freeze) until lab transport the next day. Ship on cold packs. Specimens should be transported to/received by PHL within 24 hours of collection.
• Virulence Testing - If C. diphtheriae is found on cultures of nose or throat, isolate should be sent to Public Health Lab for additional testing.
  • Store pure isolates from cultures on agar or transport medium that supports the growth of Corynebacterium species at room temperature between 15-25°C.
  • Transport refrigerated on cold packs to the laboratory.

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 physician.

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 Port Health Station at the Los Angeles International Airport. After working hours, contact the Administrative Officer of the Day through the County Operator at 213-974-1234, option 8.

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 for patients ≥10kg.
  • Switch to oral penicillin V (250 mg 4 times a day for 14 days) once the patient is able to tolerate oral intake.

Administration Data: California healthcare providers are required to report data on all valid immunizations that they administer to their patients into the California Immunization Registry (CAIR) within 2 weeks of administration per AB 1797.

Administration Errors: Healthcare providers are strongly recommended to report all vaccine administration errors to the Institute for Safe Medication Practices.

Adverse Events: Healthcare providers are required to report any adverse event on the reportable events list to the Vaccine Adverse Event Reporting System (VAERS) per HR 5546.

Storage and Handling: For general recommendations and guidance access the Vaccine Storage and Handling Job Aids.

• Check List: Managing Patients Suspected of Having Diphtheria (LAC DPH)
• Diphtheria B-73 (LAC DPH)
• Diphtheria Quicksheet (CDPH)
• Immunization Schedules: Birth to 18 Years (AAP) | 19 Years and Older (AAFP) | CA Healthcare Personnel (CDPH)
• Vaccine Information Statements (Immunize.org): DTaP | Tdap | Td | Multi-Vaccine
• Diphtheria (WHO)
• Ask the Experts: Diphtheria Vaccine Products (Immunize.org)
• Los Angeles Health Alert Network (LAHAN) (LAC DPH)