Diphtheria, Tetanus, Pertussis
- What is Diphtheria
- Diphtheria Symptoms
- Diphtheria Treatment
- What is Tetanus
- Tetanus Symtoms
- Conventional Medical Management of Tetanus
- Wound Management When Suspecting Tetanus
- What is Pertussis
- Pathogenesis of Pertussis
- Pertussis Symptoms
- Pertussis Complications
- Conventional Medical Management of Pertussis
- The DTaP/DTP Vaccine
- When is the DTaP Vaccine Given
- Ingredients in the DTaP Vaccine
- FDA Vaccine Package Inserts
- DTaP Vaccine Reactions
- The Bottom Line and the DTaP Vaccine
- Who Should Not Get the DTaP Vaccine
What is Diphtheria
- Diphtheria is a very severe throat infection that is caused by a bacterium (Corynebacterium diphtheriae). The germ secretes a toxin that irritates the lining of the throat and upper lungs. The toxin can enter the cells surrounding the infected area, say the throat, and kill them. The buildup of dead cells along with the inflammation causes severe coughing and breathing difficulty. The toxin may also enter the bloodstream and travel to other parts of the body, damaging various organs and the nervous system. Damage to the heart is common and is usually irreversible. If the breathing muscles are affected, pneumonia and respiratory failure can develop. [1,2]
- Diphtheria is a highly contagious bacterial disease that is spread by the coughing and sneezing of infected persons. Rarely, transmission may occur from skin lesions or articles soiled with discharges from lesions of infected persons (fomites). The incubation period for the disease is two to five days. [3,9]
- The diagnosis is made by sending a cotton swab of the throat to a lab for testing. Diphtheria is transmitted like the common cold. The illness may run its course without any treatment, or it may worsen. 
Symptoms of diphtheria include hoarseness, cough, noisy breathing, sore throat, slight fever (100-104F), irritability, chills, and an increasing inability to breathe. 
- sore throat and a visible white coating on the tonsils or in the nose with no other symptoms.
- labored breathing as the throat and airway become more swollen.
- visible swollen neck glands.
- hospitalization in an ICU for treatment with intravenous antitoxin (a substance that neutralizes the germ’s toxin) and antibiotics.
- recovery without longterm problems.
- when too much damage to the airway has occurred from delay of treatment, can be fatal.
IMPORTANT TO NOTE: Many infections can create the same type of symptoms (strep throat, croup, etc), so the primary clue to diphtheria is recent travel to a developing nation and the white membrane visible in the throat or nose.
- Antibiotics Treatment with erythromycin orally or by injection (40 mg/kg/day; maximum, 2 gm/day) for 14 days, or procaine penicillin G daily, intramuscularly (300,000 U/day for those weighing 10 kg or less, and 600,000 U/day for those weighing more than 10 kg) for 14 days.
- The disease is usually not contagious 48 hours after antibiotics are instituted.
- Elimination of the organism should be documented by two consecutive negative cultures after therapy is completed. 
What is Tetanus
- Tetanus is a painful, often deadly disease that is caused by an anaerobic gram-postive spore forming bacteria (Clostridium tetani) that live in soil, manure , and in the digestive systems of animals (horses, sheep, cattle, dogs, cats, guinea pigs, rats, and chickens) and pass into the soil in their stool. Soil treated with manure may also contain the germs. People also carry it in their digestive systems. 
- Tetanus is also known as lockjaw due to one of the main symptoms- the muscles, including the jaw, become rigid and locked. Many people associate stepping on a rusty nail with getting a tetanus shot, because the tetanus bacteria typically enter the body through a wound, including lacerations, punctures, scratches, animal bites, and cuts, especially those made by dirty or rusty objects. Because tetanus bacteria cannot live in the presence of oxygen, they thrive in deep wounds. It can also be introduced through surgery, burns, crush wounds, dental infections, animal bites, minor wounds and scrapes, self-piercing, and tattoos.
- Once in the body, the bacteria produce a toxin that blocks the nerve signals that allow the muscles to relax. The result is extremely strong and painful muscle spasms that have the ability to break bones. Those who die of tetanus usually suffocate when the chest muscles become rigid. It can lead to “locking” of the jaw so the victim cannot open his mouth or swallow.
- Tetanus leads to death in about 1 in 10 cases. 
- Today, tetanus is uncommon in the United States, with an average of 29 reported cases per year from 1996 through 2009. 
- If an unvaccinated person gets a deep puncture wound that can’t easily be flushed out, or a large, deep wound with dirt in it, a vaccine at that time may help prevent tetanus. It isn’t as effective as already having the series of shots in the system, though. A tetanus immune globulin injection (called TIG) can also be given to an unvaccinated person to inactivate any tetanus toxin that may develop in the coming days. TIG is made from antibodies that are filtered out of donated human blood units and then treated and sterilized with various chemicals and filtering steps. 
Three Types of Tetanus:
- Local – when the toxin affects only nerves near the wound site. Continuous muscle contractions can persist for several weeks, then gradually dissipate. A TIG shot will neutralize any toxin that is still floating around in the body tissues, but it won’t affect toxin that is already bound to the nerve cells. Antibiotics will be given to kill the tetanus bacteria. This milder form is fatal in only about 1 percent of cases. Rarely, it can progress into generalized tetanus. [2,9]
- Cephalic – is a rare form of the disease, occasionally occurring with otitis media (ear infections) in which C. tetani is present in the flora of the middle ear, or following injuries to the head. The in involvement of the cranial nerves, especially in the facial area.
- General (80%) – most common form of tetanus, when the toxin spreads into the spinal cord and brain, affecting the entire nervous system. The severity of the disease is determined mainly by the timing of TIG treatment. Spasms last 3-4 weeks, and complete recovery may take months.
The incubation period of tetanus is 8 days, ranging between 3-21 days. The first symptoms of tetanus are usually headache, fever, chills, muscular stiffness of the jaw and neck, irritability, and fever. These occur one to three weeks after infection. They are followed by spasms and rigidity of the muscles: the legs and feet become extended, the arms stiffen, the hands clench, and the jaw is unable to open. As the stomach and chest muscles are affected, convulsions may occur and breathing becomes difficult. 
- Is tetanus common? No. From the CDC:
From 2009 through 2015, a total of 197 cases and 16 deaths from tetanus were reported in the United States. Forty-nine (25%) cases were in persons 65 years of age or older, 124 (63%) were in persons 20 through 64 years of age, and 24 (12%) were in persons younger than 20 years, including 2 cases of neonatal tetanus (Figure 2). All tetanus-related deaths occurred among patients >55 years of age.
- From 2009-2015, 100% of deaths from tetanus occurred in >55 years of age population.
Conventional Medical Management of Tetanus
Centers for Disease Control (CDC):
- All wounds should be cleaned.
- Necrotic tissue and foreign material should be removed.
- If tetanic spasms are occurring, supportive therapy and maintenance of an adequate airway are critical.
- Tetanus immune globulin (TIG) is recommended for persons with tetanus.
- TIG can only help remove unbound tetanus toxin. It cannot affect toxin bound to nerve endings.
- A single intramuscular dose of 3,000 to 5,000 units is generally recommended for children and adults, with part of the dose infiltrated around the wound if it can be identified.
- Intravenous immune globulin (IVIG) contains tetanus antitoxin and may be used if TIG is not available.
- Because of the extreme potency of the toxin, tetanus disease does not result in tetanus immunity.
- Active immunization with tetanus toxoid should begin or continue as soon as the person’s condition has stabilized. 
Wound Management When Suspecting Tetanus
Persons with wounds that are neither clean nor minor, and who have had 0–2 prior doses of tetanus toxoid or have an uncertain history of prior doses should receive TIG as well as Td or Tdap. This is because early doses of toxoid may not induce immunity, but only prime the immune system. The TIG provides temporary immunity by directly providing antitoxin. This ensures that protective levels of antitoxin are achieved even if an immune response has not yet occurred. 
What is Pertussis
- Whooping cough, also known as the hundred-day cough, is a highly contagious disease that is caused by bacteria (Bordetella pertussis) found in the nose, throat, and mouth of infected individuals. Like diphtheria, it is spread through coughing, speaking, and sneezing. Most people who get whooping cough and recover acquire permanent immunity , although some people do get a milder case in the future. 
- Outbreaks of Pertussis were first described in the 16th century. Bordetella pertussis was isolated in 1906.
Pathogenesis of Pertussis
Pertussis is primarily a toxin-mediated disease. The bacteria attach to the cilia of the respiratory epithelial cells, produce toxins that paralyze the cilia, and cause inflammation of the respiratory tract, which interferes with the clearing of pulmonary secretions. Pertussis antigens appear to allow the organism to evade host defenses, in that lymphocytosis is promoted but chemotaxis is impaired. Until recently it was thought that B. pertussis did not invade the tissues. However, recent studies have shown the bacteria to be present in alveolar macrophages. 
- The incubation period is commonly 7-10 days, with a range of 4-21 days, and rarely up to 42 days.  The disease usually starts with cold-like symptoms and maybe a mild cough or fever. After 1 to 2 weeks, severe coughing can begin. Unlike the common cold, pertussis can become a series of coughing fits that continues for weeks.
- In infants, the cough can be minimal or not even there. Infants may have a symptom known as “apnea.” Apnea is a pause in the child’s breathing pattern. Pertussis is most dangerous for babies. About half of infants younger than 1 year of age who get the disease are hospitalized.
- Pertussis can cause violent and rapid coughing, over and over, until the air is gone from the lungs and you are forced to inhale with a loud “whooping” sound. This extreme coughing can cause you to throw up and be very tired. The “whoop” is often not there and the infection is generally milder (less severe) in teens and adults, especially those who have been vaccinated.
Catarrhal Stage (1-2 weeks)– Early symptoms can last for 1 to 2 weeks and usually include:
- Runny nose
- Low-grade fever (generally minimal throughout the course of the disease)
- Mild, occasional cough
- Apnea — a pause in breathing (in infants)
Because pertussis in its early stages appears to be nothing more than the common cold, it is often not suspected or diagnosed until the more severe symptoms appear. Infected people are most contagious up to about 2 weeks after the cough begins. This means that patients are most contagious during this stage because the highest number of bacteria are being produced. Antibiotics may shorten the amount of time someone is contagious, however most people do not know they have pertussis in this stage.
Paroxysmal Cough Stage (1-6 weeks, 4-7 days may seem terrible for the patient)– As the disease progresses, the traditional symptoms of pertussis appear and include:
- Minimal Fever
- Elevated mucus production
- Paroxysms (fits) of many, rapid coughs, due to difficulty expelling thick mucus from the tracheobronchial tree. This is followed by followed by a high-pitched “whoop,” due to the long inspiratory effort
- Patient may become cyanotic during the paroxysms (small children especially)
- Vomiting (throwing up)
- Exhaustion (very tired) after coughing fits
The coughing fits can go on for up to 10 weeks or more, usually lasting no more than 2-3 weeks. In China, pertussis is known as the “100 day cough.” Although you are often exhausted after a coughing fit, you usually appear fairly well in-between. Coughing fits generally become more common and severe as the illness continues, and can occur more often at night. The illness can be milder (less severe) and the typical “whoop” absent in children, teens, and adults who have been vaccinated with a pertussis vaccine.
Convalescence Stage (weeks to months)– Recovery from pertussis can happen slowly. The cough becomes less severe and less common. However, coughing fits can return with other respiratory infections for many months after pertussis started. [3,5,6,7,9]
NOTE FROM THE CDC:
“In those who have been vaccinated:
- In most cases, the cough won’t last as many days
- Coughing fits, whooping, and vomiting after coughing fits occur less often
- The percentage of children with apnea (long pause in breathing), cyanosis (blue/purplish skin coloration due to lack of oxygen) and vomiting is less”
Translation: Children who are vaccinated from pertussis still may catch pertussis. It is assumed in these children that symptoms will be less severe.
- The most common complication, and the cause of most pertussis related deaths, is secondary bacterial pneumonia. From 1997-2000, CDC data indicate that pneumonia occurred in 5.2% of all reported pertussis cases, and among 11.8% of infants younger than 6 months of age. From 2004-2008, 111 deaths from pertussis were reported to the CDC. Children 3 months of age or younger accounted for 92 (83%) of these deaths. 
- On average, 18 deaths occur each year due to Bordetella pertussis.
- 16 of the 18 deaths are children under 3 months of age. 
Conventional Medical Management of Pertussis
- Erythromycin is the drug of choice. This therapy eradicates the organism from secretions, thereby decreasing communicability and, if initiated early, may modify the course of the illness. 
- All close contacts of persons with pertussis: An antibiotic affective against pertussis (such as azithromycin, erythromycin, or trimethoprim-sulfamethoxazole) should be administered, regardless of age and vaccination status. 
The DTaP/DTP Vaccine
First on the market was a vaccine for pertussis in 1906, followed by a diphtheria vaccine in the 1920s and a tetanus vaccine in 1933. A combined vaccine— DTP— became available in 1946. 
When is the DTaP Vaccine Given
DTaP is given at two months, four months, and six months. Boosters are given at eighteen months, between four and six years, and at twelve years to extend protection throughout childhood so that older kids won’t pass the disease to babies.
- For more information, please see Vaccine Schedules
Diphtheria Toxoid Vaccine: 
- Efficacy- Approximately 95% effective against the disease
- Duration of Protection- Approximately 10 years
Tetanus Toxoid Vaccine: 
- Efficacy- Tetanus Toxoid Vaccine efficacy has “never been studied in a vaccine trial” ((9)- straight from the CDC Pink Book)
- Duration of Protection- Approximately 10 years
Whole-Cell Pertussis Vaccine: 
- Efficacy- After 3 doses, 70-90% affective against the disease
- Duration of Protection- 5-10 years
Ingredients in the DTaP Vaccine
Daptacel brand (Sanofi Pasteur)
- The germ and toxoid components
- Saline solution
- 2-phenoxyethanol (0.6 percent of the vaccine solution)
- Aluminum— 330 micrograms
- Glutaraldehyde —less than 50 nanograms (even smaller than a microgram)
- Formaldehyde— less than 0.5 micrograms (a recent change— it used to contain 100 micrograms)
Tripedia brand (Sanofi Pasteur, but no longer being produced)
- The germ and toxoid components (made from cow tissue)
- Saline solution
- Aluminum— 170 micrograms
- Formaldehyde— 100 micrograms
- Polysorbate 80— a preservative used in various vaccines
- Mercury— less than 0.3 micrograms
Infanrix brand (GlaxoSmithKline)
- The germ and toxoid components (made from cow tissue)
- Saline solution
- Aluminum— 625 micrograms
- Polysorbate 80— 100 micrograms
- Formaldehyde— 100 micrograms
- Glutaraldehyde (although used in production, isn’t listed as a final ingredient. Some is probably there)
If you would like specific information about each ingredient, including studies: Vaccine Ingredients
FDA Vaccine Package Inserts
- Daptacel (Sanofi Pasteur) Daptacel FDA Package Insert
- Tripedia (Sanofi Pasteur) Tripedia FDA Package Insert (not available anymore- good thing as “Autism” is a known adverse event on page 11)
- Infanrix (GlaxoSmithKline) Infanrix FDA Package Insert (confidential Infanrix info from GSK, re: adverse events)
- Boostrix (GlaxoSmithKline) Boostrix FDA Package Insert
- Adacel (Sanofi Pasteur) Adacel FDA Package Insert
- D and T Toxoids Absorbed (Sanofi Pasteur) D and T Toxoids Absorbed FDA Package Insert
- Tetanus Toxoid (Sanofi Pasteur) – BOOSTER ONLY Tetanus Toxoid FDA Package Insert
- Tenivac (Sanofi Pasteur) – ADULT Tenivac FDA Package Insert
- (*)Pentacel (Sanofi Pasteur). This is a DTaP, HIB, and polio combo. Pentacel FDA Package Insert
- (*)Pediarix (GlaxoSmithKline). This combines DTaP, hep B, and polio. Pediarix FDA Package Insert
- (*)Kinrix (GlaxoSmithKline). This is a DTaP/ polio combo. Kinrix FDA Package Insert
- TriHIBit (Sanofi Pasteur). This is a mix of DTaP and HIB. TriHIBit FDA Package Insert (discontinued)
* Studies have shown a diminished antibody response to B. pertussis antigens when poliovirus vaccine was administered with DTP. The data are also similar to the findings of a number of earlier studies that consistently demonstrated a trend toward lower values of agglutinins to B. pertussis when IPV was combined with DTP. 
The whole cell DTP vaccine is not given anymore, so with the new acellular pertussis, the above may not be the case.
DTaP Vaccine Reaction
Signs to look for include:
- According to the CDC, moderate or severe reactions to DTP/DTaP vaccines should be reported to and checked by a doctor immediately.
- All adverse reactions should also be reported to the Vaccine Adverse Events Reporting System (VAERS).
- Common systemic reactions occur in 25 percent of children (see postmarketing surveillance below).
- Injection site reactions occur in 25 percent, but they become increasingly more common and severe with the fourth and fifth doses, 3 percent of which will cause swelling of the entire arm that lasts up to a week. 
Known Severe Reactions:
- ~ 1 in 1000 infants will suffer nonstop crying for three or more hours (which indicates encephalitis; see here ).
- ~ 1 in 14,000 kids will have a seizure reaction.
- ~ 1 in 16,000 children will have a fever greater than 105 degrees.
- Brain injury, coma, and severe seizure disorders have been very rarely reported.
- The vaccine package inserts state that the Institute of Medicine has determined that any tetanus-containing vaccine can very rarely cause brachial neuritis (dysfunction of the nerves in the arm) or Guillain-Barré syndrome (a temporary muscle weakness or paralysis). 
Postmarketing Surveillance: (common reactions noted after the release of the vaccine)
- Cyanosis (blue color from low oxygen levels)
- nodule and mass at the injection site
- extensive swelling of the injected limb and nearby joints
- skin infection (cellulitis) and abscess at the injection site
- severe allergic reactions (anaphylactic shock, swelling , hives)
- nonallergic rashes
- seizures, including febrile seizures, grand mal seizures, and mild seizures
- hypotonic/ hyporesponsive episodes (shock)
- hypotonia (low muscle tone or decreased muscle function)
- lymph node swelling
- bleeding from low platelet counts
- sudden infant death syndrome
- autism. 
The Bottom Line and the DTaP Vaccine
IMPORTANT, PLEASE READ:
- FDA Press Release and Study Regarding the Rise in Pertussis (Nov 27, 2013)
- Waning Protection after Fifth Dose of Acellular Pertussis Vaccine in Children (September 13, 2012) (web version here)
- The pertussis vaccine does not work as well as most others; it is only about 85 to 90 percent protective. 
- Researchers have recently discovered in various countries some new strains of pertussis that may not be covered by the vaccine. 
- There are indications that the B. pertussis organism may be becoming vaccine resistant. 
- Pertussis vaccine titres drop as the child ages and by adulthood, most people are not protected.
- Most people who get whooping cough and recover acquire permanent immunity. 
- Tetanus is not an infant disease, and virtually all cases occur in adults. Also, diphtheria is virtually nonexistent in the United States.
- A baby could skip the tetanus and diphtheria shots for a few years and be just fine.
- Your child could then get the DT series prior to age seven, or the dT series as a teenager, before traveling the world.
- Whooping cough is a cyclical disease with natural increases in countries around the world every three to four years (meaning some years we hear a lot about the disease and other years not at all. [1,2]
- Cave, Stephanie; Mitchell, Deborah (2007-11-01). What Your Doctor May Not Tell You About(TM) Children’s Vaccinations (What Your Doctor May Not Tell You About…). Grand Central Publishing. Kindle Edition.
- Sears, Robert W. (2011-10-26). The Vaccine Book: Making the Right Decision for Your Child (Sears Parenting Library). Little, Brown and Company. Kindle Edition.
- Stehr K, Cherry JD, Heininger U, et al. A comparative effectiveness trial in Germany in infants who received either the Lederle/Takeda acellular pertussis component DTP (DTaP) vaccine, the Ledele whole-cell component DTP vaccine, or DT vaccine. Pediatrics. 1998;101(1 Pt 1):1-11.
- Ward JI, Cherry JD, Swei-Ju C, et al. Bordetella pertussis infections in vaccinated and unvaccinated adolescents and adults, as assessed in a national prospective randomized acellular pertussis vaccine trial (APERT). Clin Infect Dis. 2006;43:151-7.
- Tozzi AE, Ravá L, Ciofi ML, et al. Clinical presentation of pertussis in unvaccinated and vaccinated children in the first six years of life. Pediatrics. 2003;112(5):1069-75.
- Effect of Inactivated Poliovirus Vaccine on the Antibody Response to Bordetella pertussis Antigens When Combined with Diphtheria-Pertussis-Tetanus Vaccine
- Epidemiology and Prevention of Vaccine-Preventable Diseases, 12th Edition (The Pink Book)
- Make an Informed Vaccine Decision for the Health of Your Child: A Parent’s Guide to Childhood Shots
- Vaccinations: A Thoughtful Parent’s Guide: How to Make Safe, Sensible Decisions about the Risks, Benefits, and Alternatives
- Vaccine Epidemic: How Corporate Greed, Biased Science, and Coercive Government Threaten Our Human Rights, Our Health, and Our Children
- Immunization Action Coalition – DTaP Vaccine Information Statement
- World Health Organization (WHO) DTP Disease and Vaccine information
- CDC DTaP VIS
- Vaccine Book List (with approximately 100 resource books)
- World Health Organization (WHO)
- Center for Disease Control (CDC)
- Vaccination Information Network
CDC Pink Book Web Edition:
- Prevalence and Molecular Characterization of Pertactin-Deficient Bordetella pertussis in the United States
- Antibody Responses to Bordetella pertussis Fim2 or Fim3 following Immunization with a Whole-Cell, Two-Component, or Five-Component Acellular Pertussis Vaccine and following Pertussis Disease in Children in Sweden in 1997 and 2007
- A Nonadjuvanted Transcutaneous Tetanus Patch Is Effective in Boosting Anti-Tetanus Toxoid Immune Responses
- Dynamic profiles of neutralizing antibody responses elicited in rhesus monkeys immunized with a combined tetravalent DTaP-Sabin IPV candidate vaccine
- Evaluation of several approaches to immunize parents of neonates against B. pertussis
- Vaccine-Preventable Disease Among Homeschooled Children: Two Cases of Tetanus in Oklahoma
- Respiratory Diphtheria
- Importance of Timing of Maternal Combined Tetanus, Diphtheria, and Acellular Pertussis (Tdap) Immunization and Protection of Young Infants
- Parent “cocoon” immunization to prevent pertussis-related hospitalization in infants: The case of Piemonte in Italy
- Adapting Group Sequential Methods to Observational Postlicensure Vaccine Safety Surveillance: Results of a Pentavalent Combination DTaP-IPV-Hib Vaccine Safety Study
- Re-emergence of diphtheria and pertussis: Implications for Nigeria
- Thrombocytopenic Purpura Following Vaccination in Early Childhood: Experience of a Medical Center in the Past 2 Decades
- U.S. Postlicensure safety surveillance for adolescent and adult tetanus, diphtheria and acellular pertussis vaccines: 2005–2007
Content Created: 05/14