Diphtheria vaccine: Difference between revisions
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{{Short description|Vaccine against diphtheria}} |
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| verifiedrevid = 446095512 |
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| image = DT-vaccine.jpg |
| image = DT-vaccine.jpg |
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| caption = DT vaccine in Japan |
| caption = DT vaccine in Japan |
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<!-- Vacine data --> |
<!-- Vacine data --> |
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| type = vaccine |
| type = vaccine |
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| target = [[Corynebacterium diphtheriae]] |
| target = ''[[Corynebacterium diphtheriae]]'' |
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| vaccine_type = toxoid |
| vaccine_type = toxoid |
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<!-- Clinical data --> |
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| tradename = |
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| MedlinePlus = a607027 |
| MedlinePlus = a607027 |
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| legal_CA = <!-- Schedule I, II, III, IV, V, VI, VII, VIII --> |
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| legal_US = <!-- OTC / Rx-only / Schedule I, II, III, IV, V --> |
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| legal_EU_comment = <ref>{{cite web|url=https://www.ema.europa.eu/documents/psusa/diphtheria/tetanus-vaccines-adsorbed-diphtheria-vaccines-adsorbed-list-nationally-authorised-medicinal-products/00001128/202005_en.pdf|title=List of nationally authorised medicinal products - Active substance: diphtheria / tetanus vaccines (adsorbed), diphtheria vaccines (adsorbed)|work=[[European Medicines Agency]]|date=14 January 2021|access-date=28 October 2021}}</ref> |
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<!-- Chemical data --> |
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<!-- Definition ad effectiveness --> |
<!-- Definition ad effectiveness --> |
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'''Diphtheria |
'''Diphtheria vaccine''' is a [[toxoid]] vaccine against [[diphtheria]], an illness caused by ''[[Corynebacterium diphtheriae]]''.<ref name=Jong2022.2>{{cite book | vauthors = Donahue ML, Eberly MD | veditors = Jong EC, Stevens DL |title=Netter's Infectious Diseases |date=2022 |publisher=Elsevier |location=Philadelphia |isbn=978-0-323-71159-3 |pages=5–10|edition=2nd |chapter-url=https://books.google.com/books?id=l8skEAAAQBAJ&pg=PA5|language=en |chapter= Chapter 2: Diphtheria and tetanus}}</ref> Its use has resulted in a more than 90% decrease in number of cases globally between 1980 and 2000.<ref name=WHO2006/> The first dose is recommended at six weeks of age with two additional doses four weeks apart, after which it is about 95% effective during childhood.<ref name=WHO2006/> Three further doses are recommended during childhood.<ref name=WHO2006/> It is unclear if further doses later in life are needed.<ref name=WHO2006/> |
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<!-- Safety --> |
<!-- Safety --> |
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The diphtheria vaccine is very safe.<ref name=WHO2006/> Significant side effects are rare.<ref name=WHO2006/> Pain may occur at the injection site.<ref name=WHO2006/> A bump may form at the site of injection that lasts a few weeks.<ref name=CDC2012Pink/> The vaccine is safe in both pregnancy and among those who have a [[immunosuppression|poor immune function]].<ref name=CDC2012Pink>{{cite book| |
The diphtheria vaccine is very safe.<ref name=WHO2006/> Significant side effects are rare.<ref name=WHO2006/> Pain may occur at the injection site.<ref name=WHO2006/> A bump may form at the site of injection that lasts a few weeks.<ref name=CDC2012Pink/> The vaccine is safe in both pregnancy and among those who have a [[immunosuppression|poor immune function]].<ref name=CDC2012Pink>{{cite book| vauthors = Atkinson W |title=Diphtheria Epidemiology and Prevention of Vaccine-Preventable Diseases |date=May 2012|publisher=Public Health Foundation |isbn=9780983263135 |pages=215–230 |edition=12th |url= https://www.cdc.gov/vaccines/pubs/pinkbook/dip.html|url-status=live|archive-url= https://web.archive.org/web/20160915204257/http://www.cdc.gov/vaccines/pubs/pinkbook/dip.html|archive-date=15 September 2016}}</ref> |
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<!-- Usage --> |
<!-- Usage --> |
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The diphtheria vaccine is delivered in several combinations.<ref>{{cite web|title=Diphtheria Vaccination|url=https://www.cdc.gov/vaccines/vpd-vac/diphtheria/default.htm#vacc|publisher=[[Centers for Disease Control and Prevention]] (CDC)| |
The diphtheria vaccine is delivered in several combinations.<ref>{{cite web|title=Diphtheria Vaccination|url=https://www.cdc.gov/vaccines/vpd-vac/diphtheria/default.htm#vacc|publisher=[[Centers for Disease Control and Prevention]] (CDC)|access-date=8 November 2011|url-status=dead|archive-url=https://web.archive.org/web/20111102042325/http://www.cdc.gov/vaccines/vpd-vac/diphtheria/default.htm#vacc|archive-date=2 November 2011}}</ref> Some combinations (Td and DT vaccines) include [[tetanus vaccine]], others (known as [[DPT vaccine]] or [[DTaP]] vaccine depending on the [[pertussis]] antigen used) comes with the tetanus and pertussis vaccines, and still others include additional vaccines such as [[Hib vaccine]], [[hepatitis B vaccine]], or [[inactivated polio vaccine]].<ref name=WHO2006 /> The [[World Health Organization]] (WHO) has recommended its use since 1974.<ref name=WHO2006>{{cite journal | vauthors = | title = Diphtheria vaccine: WHO position paper – August 2017 | journal = Relevé Épidémiologique Hebdomadaire | volume = 92 | issue = 31 | pages = 417–435 | date = August 2017 | pmid = 28776357 | url = http://apps.who.int/iris/bitstream/10665/258681/1/WER9231.pdf?ua=1 | hdl = 10665/258681 }}</ref> About 84% of the world population is vaccinated.<ref name="auto">{{cite web|title=Diphtheria|url=https://www.who.int/immunization/monitoring_surveillance/burden/diphtheria/en/|website=[[World Health Organization]] (WHO)|access-date=27 March 2015|date=3 September 2014|url-status=dead|archive-url=https://web.archive.org/web/20150402121723/http://www.who.int/immunization/monitoring_surveillance/burden/diphtheria/en/|archive-date=2 April 2015}}</ref> It is given as an [[intramuscular injection]].<ref name=WHO2006/> The vaccine needs to be kept cold but not frozen.<ref name=CDC2012Pink/> |
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The diphtheria vaccine was developed in 1923.<ref>{{cite book| |
The diphtheria vaccine was developed in 1923.<ref>{{cite book| vauthors = Macera C |title=Introduction to Epidemiology: Distribution and Determinants of Disease|date=2012|publisher=Nelson Education|isbn=9781285687148|page=251|url=https://books.google.com/books?id=U8FuCgAAQBAJ&pg=PA251|url-status=live|archive-url=https://web.archive.org/web/20160305040732/https://books.google.com/books?id=U8FuCgAAQBAJ&pg=PA251|archive-date=5 March 2016}}</ref> It is on the [[WHO Model List of Essential Medicines|World Health Organization's List of Essential Medicines]].<ref name="WHO23rd">{{cite book | vauthors = ((World Health Organization)) | title = The selection and use of essential medicines 2023: web annex A: World Health Organization model list of essential medicines: 23rd list (2023) | year = 2023 | hdl = 10665/371090 | author-link = World Health Organization | publisher = World Health Organization | location = Geneva | id = WHO/MHP/HPS/EML/2023.02 | hdl-access=free }}</ref> |
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==History== |
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In 1890, [[Kitasato Shibasaburō]] and [[Emil von Behring]] at the [[University of Berlin]] reported the development of 'antitoxins' against diphtheria and tetanus. Their method involved injecting the respective toxins into animals and then purifying antibodies from their blood. Behring called this method '[[Serotherapy|serum therapy]]'. While effective against the pathogen, initial tests on humans were unsuccessful.<ref>{{cite web | title=A Diphtheria Cure, 1894 | website=[[New York Times]] | date=10 May 2010 | url=https://www.nytimes.com/2010/05/11/health/11first.html }}</ref> By 1894, the production of antibodies had been optimised with help from [[Paul Ehrlich]], and the treatment started to show success in humans.<ref name = "mBio2017">{{cite journal | vauthors = Kaufmann SH | title = Remembering Emil von Behring: from Tetanus Treatment to Antibody Cooperation with Phagocytes | journal = mBio | volume = 8 | issue = 1 | pages = e00117–17 | date = February 2017 | pmid = 28246359 | pmc = 5347343 | doi = 10.1128/mbio.00117-17 }}</ref> The serum therapy reduced mortality to 1–5%, although there were also reports of severe adverse reactions, including at least one death. Behring won the very first [[Nobel Prize in Physiology or Medicine]] for this discovery. Kitasato, however, was not awarded.<ref name = "mBio2017"/> |
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By 1913, Behring had created Antitoxin-Toxin (antibody-antigen) complexes to produce the diphtheria AT vaccine. In the 1920s, [[Gaston Ramon]] developed a cheaper version by using formaldehyde-inactivated toxins.<ref name = "mBio2017"/> As use of these vaccines spread across the world, the number of diphtheria cases was greatly reduced. In the United States alone, the number of cases fell from 100,000 to 200,000 per year in the 1920s to 19,000 in 1945 and 14 in the period 1996–2018.<ref>{{cite web | title=Diphtheria | website=[[Centers for Disease Control and Prevention]] | date= 19 October 2022| url=https://www.cdc.gov/vaccines/pubs/pinkbook/dip.html }}</ref> |
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==Effectiveness== |
==Effectiveness== |
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==Side effects== |
==Side effects== |
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Severe side effects from diphtheria [[toxoid]] are rare.<ref name=WHO2006/> Pain may occur at the injection site.<ref name=WHO2006/> A bump may form at the site of injection that lasts a few weeks.<ref name=CDC2012Pink/> The vaccine is safe during pregnancy and among those who have a [[immunosuppression|poor immune function]].<ref name=CDC2012Pink/> DTP vaccines may cause additional adverse effects such as fever, irritability, drowsiness, loss of appetite, and, in 6–13% of vaccine recipients, vomiting.<ref name=WHO2006/> Severe adverse effects of DTP vaccines include fever over 40.5 °C/104.9 °F (1 in 333 doses), [[febrile seizures]] (1 in 12,500 doses), and [[hypotonic-hyporesponsive episode]]s (1 in 1,750 doses).<ref name=WHO2006/><ref>{{cite journal | |
Severe side effects from diphtheria [[toxoid]] are rare.<ref name=WHO2006/> Pain may occur at the injection site.<ref name=WHO2006/> A bump may form at the site of injection that lasts a few weeks.<ref name=CDC2012Pink/> The vaccine is safe during pregnancy and among those who have a [[immunosuppression|poor immune function]].<ref name=CDC2012Pink/> DTP vaccines may cause additional adverse effects such as fever, irritability, drowsiness, loss of appetite, and, in 6–13% of vaccine recipients, vomiting.<ref name=WHO2006/> Severe adverse effects of DTP vaccines include fever over 40.5 °C/104.9 °F (1 in 333 doses), [[febrile seizures]] (1 in 12,500 doses), and [[hypotonic-hyporesponsive episode]]s (1 in 1,750 doses).<ref name=WHO2006/><ref>{{cite journal | vauthors = DuVernoy TS, Braun MM | title = Hypotonic-hyporesponsive episodes reported to the Vaccine Adverse Event Reporting System (VAERS), 1996-1998 | journal = Pediatrics | volume = 106 | issue = 4 | pages = E52 | date = October 2000 | pmid = 11015547 | doi = 10.1542/peds.106.4.e52 | collaboration = The VAERS Working Group | s2cid = 12743062 }}</ref> Side effects of DTaP vaccines are similar but less frequent.<ref name=WHO2006/> Tetanus toxoid containing vaccines (Td, DT, DTP and DTaP) may cause [[brachial neuritis]] at a rate of 0.5 to 1 case per 100,000 toxoid recipients.<ref>{{cite web|url=https://www.cdc.gov/vaccines/pubs/pinkbook/tetanus.html|title=Tetanus|date=15 April 2019|website=[[Centers for Disease Control and Prevention]] (CDC)}}</ref><ref>{{cite web|url=https://beta.health.gov.au/health-topics/immunisation|title=Immunisatio |date=10 October 2017|website=Australian Government Department of Health}}</ref> |
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==Recommendations== |
==Recommendations== |
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The World Health Organization has recommended vaccination against diphtheria since 1974.<ref name=WHO2006 /> The first dose is recommended at six weeks of age with two additional doses four weeks apart, after receiving these three doses about 95% of people are immune.<ref name=WHO2006/> Three further doses are recommended during childhood.<ref name=WHO2006/> Booster doses every ten years are no longer recommended if this vaccination scheme of 3 doses + 3 booster doses is followed.<ref name=WHO2006 /> Injection of 3 doses + 1 booster dose, provides immunity for 25 years after the last dose.<ref name=WHO2006 /> If only three initial doses are given, booster doses are |
The World Health Organization has recommended vaccination against diphtheria since 1974.<ref name=WHO2006 /> The first dose is recommended at six weeks of age with two additional doses four weeks apart, after receiving these three doses about 95% of people are immune.<ref name=WHO2006/> Three further doses are recommended during childhood.<ref name=WHO2006/> Booster doses every ten years are no longer recommended if this vaccination scheme of 3 doses + 3 booster doses is followed.<ref name=WHO2006 /> Injection of 3 doses + 1 booster dose, provides immunity for 25 years after the last dose.<ref name=WHO2006 /> If only three initial doses are given, booster doses are needed to ensure continuing protection.<ref name=WHO2006 /> |
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==See also== |
== See also == |
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*[[Bundaberg tragedy]] |
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*[[DTP-HepB vaccine]] |
*[[DTP-HepB vaccine]] |
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==References== |
== References == |
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{{Reflist}} |
{{Reflist}} |
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== Further reading == |
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{{refbegin}} |
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* {{cite book | title=Immunisation against infectious disease | chapter=Chapter 15: Diphtheria | chapter-url=https://www.gov.uk/government/publications/diphtheria-the-green-book-chapter-15 | publisher=Public Health England | veditors = Ramsay M | url=https://www.gov.uk/government/collections/immunisation-against-infectious-disease-the-green-book | year=2013 }} |
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* {{cite book | publisher = U.S. [[Centers for Disease Control and Prevention]] (CDC) | title = Epidemiology and Prevention of Vaccine-Preventable Diseases | veditors = Hall E, Wodi AP, Hamborsky J, Morelli V, Schillie S | edition = 14th | location = Washington D.C. | year = 2021 | vauthors = Acosta AM, Moro PL, Hariri S, Tiwari TS | chapter = Chapter 7: Diphtheria | chapter-url = https://www.cdc.gov/vaccines/pubs/pinkbook/dip.html | url=https://www.cdc.gov/vaccines/pubs/pinkbook/index.html }} |
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{{refend}} |
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* {{cite web | title=Infanrix | website=U.S. [[Food and Drug Administration]] (FDA) | date=6 November 2019 | url=http://www.fda.gov/vaccines-blood-biologics/vaccines/infanrix }} |
* {{cite web | title=Infanrix | website=U.S. [[Food and Drug Administration]] (FDA) | date=6 November 2019 | url=http://www.fda.gov/vaccines-blood-biologics/vaccines/infanrix }} |
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* {{cite web | title=Daptacel | website=U.S. [[Food and Drug Administration]] (FDA) | date=22 July 2017 | url=http://www.fda.gov/vaccines-blood-biologics/vaccines/daptacel }} |
* {{cite web | title=Daptacel | website=U.S. [[Food and Drug Administration]] (FDA) | date=22 July 2017 | url=http://www.fda.gov/vaccines-blood-biologics/vaccines/daptacel }} |
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* {{MeshName|Diphtheria Toxoid}} |
* {{MeshName|Diphtheria Toxoid}} |
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* {{cite web | url = https://druginfo.nlm.nih.gov/drugportal/name/diphtheria%20vaccine | publisher = U.S. National Library of Medicine | work = Drug Information Portal | title = Diphtheria Vaccine }} |
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Latest revision as of 18:44, 6 July 2024
 DT vaccine in Japan | |
| Vaccine description | |
|---|---|
| Target | Corynebacterium diphtheriae |
| Vaccine type | Toxoid |
| Clinical data | |
| MedlinePlus | a607027 |
| Routes of administration | Intramuscular injection |
| ATC code | |
| Legal status | |
| Legal status |
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| Identifiers | |
| ChemSpider |
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  (what is this?) (verify) | |
Diphtheria vaccine is a toxoid vaccine against diphtheria, an illness caused by Corynebacterium diphtheriae.[2] Its use has resulted in a more than 90% decrease in number of cases globally between 1980 and 2000.[3] The first dose is recommended at six weeks of age with two additional doses four weeks apart, after which it is about 95% effective during childhood.[3] Three further doses are recommended during childhood.[3] It is unclear if further doses later in life are needed.[3]
The diphtheria vaccine is very safe.[3] Significant side effects are rare.[3] Pain may occur at the injection site.[3] A bump may form at the site of injection that lasts a few weeks.[4] The vaccine is safe in both pregnancy and among those who have a poor immune function.[4]
The diphtheria vaccine is delivered in several combinations.[5] Some combinations (Td and DT vaccines) include tetanus vaccine, others (known as DPT vaccine or DTaP vaccine depending on the pertussis antigen used) comes with the tetanus and pertussis vaccines, and still others include additional vaccines such as Hib vaccine, hepatitis B vaccine, or inactivated polio vaccine.[3] The World Health Organization (WHO) has recommended its use since 1974.[3] About 84% of the world population is vaccinated.[6] It is given as an intramuscular injection.[3] The vaccine needs to be kept cold but not frozen.[4]
The diphtheria vaccine was developed in 1923.[7] It is on the World Health Organization's List of Essential Medicines.[8]
History
[edit]In 1890, Kitasato Shibasaburō and Emil von Behring at the University of Berlin reported the development of 'antitoxins' against diphtheria and tetanus. Their method involved injecting the respective toxins into animals and then purifying antibodies from their blood. Behring called this method 'serum therapy'. While effective against the pathogen, initial tests on humans were unsuccessful.[9] By 1894, the production of antibodies had been optimised with help from Paul Ehrlich, and the treatment started to show success in humans.[10] The serum therapy reduced mortality to 1–5%, although there were also reports of severe adverse reactions, including at least one death. Behring won the very first Nobel Prize in Physiology or Medicine for this discovery. Kitasato, however, was not awarded.[10]
By 1913, Behring had created Antitoxin-Toxin (antibody-antigen) complexes to produce the diphtheria AT vaccine. In the 1920s, Gaston Ramon developed a cheaper version by using formaldehyde-inactivated toxins.[10] As use of these vaccines spread across the world, the number of diphtheria cases was greatly reduced. In the United States alone, the number of cases fell from 100,000 to 200,000 per year in the 1920s to 19,000 in 1945 and 14 in the period 1996–2018.[11]
Effectiveness
[edit]About 95% of people vaccinated develop immunity, and vaccination against diphtheria has resulted in a more than 90% decrease in number of cases globally between 1980 and 2000.[3] About 86% of the world population was vaccinated as of 2016.[6]
Side effects
[edit]Severe side effects from diphtheria toxoid are rare.[3] Pain may occur at the injection site.[3] A bump may form at the site of injection that lasts a few weeks.[4] The vaccine is safe during pregnancy and among those who have a poor immune function.[4] DTP vaccines may cause additional adverse effects such as fever, irritability, drowsiness, loss of appetite, and, in 6–13% of vaccine recipients, vomiting.[3] Severe adverse effects of DTP vaccines include fever over 40.5 °C/104.9 °F (1 in 333 doses), febrile seizures (1 in 12,500 doses), and hypotonic-hyporesponsive episodes (1 in 1,750 doses).[3][12] Side effects of DTaP vaccines are similar but less frequent.[3] Tetanus toxoid containing vaccines (Td, DT, DTP and DTaP) may cause brachial neuritis at a rate of 0.5 to 1 case per 100,000 toxoid recipients.[13][14]
Recommendations
[edit]The World Health Organization has recommended vaccination against diphtheria since 1974.[3] The first dose is recommended at six weeks of age with two additional doses four weeks apart, after receiving these three doses about 95% of people are immune.[3] Three further doses are recommended during childhood.[3] Booster doses every ten years are no longer recommended if this vaccination scheme of 3 doses + 3 booster doses is followed.[3] Injection of 3 doses + 1 booster dose, provides immunity for 25 years after the last dose.[3] If only three initial doses are given, booster doses are needed to ensure continuing protection.[3]
See also
[edit]References
[edit]- ^ "List of nationally authorised medicinal products - Active substance: diphtheria / tetanus vaccines (adsorbed), diphtheria vaccines (adsorbed)" (PDF). European Medicines Agency. 14 January 2021. Retrieved 28 October 2021.
- ^ Donahue ML, Eberly MD (2022). "Chapter 2: Diphtheria and tetanus". In Jong EC, Stevens DL (eds.). Netter's Infectious Diseases (2nd ed.). Philadelphia: Elsevier. pp. 5–10. ISBN 978-0-323-71159-3.
- ^ a b c d e f g h i j k l m n o p q r s t u v "Diphtheria vaccine: WHO position paper – August 2017" (PDF). Relevé Épidémiologique Hebdomadaire. 92 (31): 417–435. August 2017. hdl:10665/258681. PMID 28776357.
- ^ a b c d e Atkinson W (May 2012). Diphtheria Epidemiology and Prevention of Vaccine-Preventable Diseases (12th ed.). Public Health Foundation. pp. 215–230. ISBN 9780983263135. Archived from the original on 15 September 2016.
- ^ "Diphtheria Vaccination". Centers for Disease Control and Prevention (CDC). Archived from the original on 2 November 2011. Retrieved 8 November 2011.
- ^ a b "Diphtheria". World Health Organization (WHO). 3 September 2014. Archived from the original on 2 April 2015. Retrieved 27 March 2015.
- ^ Macera C (2012). Introduction to Epidemiology: Distribution and Determinants of Disease. Nelson Education. p. 251. ISBN 9781285687148. Archived from the original on 5 March 2016.
- ^ World Health Organization (2023). The selection and use of essential medicines 2023: web annex A: World Health Organization model list of essential medicines: 23rd list (2023). Geneva: World Health Organization. hdl:10665/371090. WHO/MHP/HPS/EML/2023.02.
- ^ "A Diphtheria Cure, 1894". New York Times. 10 May 2010.
- ^ a b c Kaufmann SH (February 2017). "Remembering Emil von Behring: from Tetanus Treatment to Antibody Cooperation with Phagocytes". mBio. 8 (1): e00117–17. doi:10.1128/mbio.00117-17. PMC 5347343. PMID 28246359.
- ^ "Diphtheria". Centers for Disease Control and Prevention. 19 October 2022.
- ^ DuVernoy TS, Braun MM, et al. (The VAERS Working Group) (October 2000). "Hypotonic-hyporesponsive episodes reported to the Vaccine Adverse Event Reporting System (VAERS), 1996-1998". Pediatrics. 106 (4): E52. doi:10.1542/peds.106.4.e52. PMID 11015547. S2CID 12743062.
- ^ "Tetanus". Centers for Disease Control and Prevention (CDC). 15 April 2019.
- ^ "Immunisatio". Australian Government Department of Health. 10 October 2017.
Further reading
[edit]- Ramsay M, ed. (2013). "Chapter 15: Diphtheria". Immunisation against infectious disease. Public Health England.
- Acosta AM, Moro PL, Hariri S, Tiwari TS (2021). "Chapter 7: Diphtheria". In Hall E, Wodi AP, Hamborsky J, Morelli V, Schillie S (eds.). Epidemiology and Prevention of Vaccine-Preventable Diseases (14th ed.). Washington D.C.: U.S. Centers for Disease Control and Prevention (CDC).
External links
[edit]- "Infanrix". U.S. Food and Drug Administration (FDA). 6 November 2019.
- "Daptacel". U.S. Food and Drug Administration (FDA). 22 July 2017.
- Diphtheria Toxoid at the U.S. National Library of Medicine Medical Subject Headings (MeSH)
