Wisconsin Division of Public Health Disease Surveillance Manual (EpiNet, February 2005)

I. IDENTIFICATION

A. CLINICAL DESCRIPTION: An upper respiratory tract illness characterized by sore throat, low-grade fever, and an adherent membrane of the tonsils, pharynx, and/or nose.

B. REPORTING CRITERIA: Clinical diagnosis.

C. LABORATORY CRITERIA FOR CONFIRMATION: (Any new tests, etc.?)

• Isolation of Corynebacterium diphtheriae from clinical specimen.
• Histopathologic diagnosis of diphtheria.
• Polymerase Chain Reaction (PCR) testing done at CDC.

D. WISCONSIN CASE DEFINITION: A clinically compatible illness that is either laboratory confirmed or epidemiology linked to a laboratory-confirmed case.

II. ACTIONS REQUIRED / PREVENTION MEASURES

A. WISCONSIN DISEASE SURVEILLANCE CATEGORY I: Report IMMEDIATELY BY TELEPHONE to the patient's local health officer upon identification of a case or suspected case. Complete and mail an Acute and Communicable Disease Case Report (DPH 4151) to the local health officer within 24 hours. Notify Regional Immunization Program Representative IMMEDIATELY.

B. EPIDEMIOLOGY REPORTS REQUIRED:

1. Acute and Communicable Diseases Case Report (DPH 4151).

C. PREVENTION MEASURES:

• Diphtheria toxoid is routinely administered with tetanus toxoid and pertussis vaccine at 2, 4, 6, 15-18 months of age and school entry (4-6 years of age). Maintain active protection among adults by administering a booster dose of Td every 10 years.
• Ensure that those at higher risk of patient exposure, such as health care workers, are fully immunized and receive a booster dose of Td every 10 years.

D. PUBLIC HEALTH INTERVENTIONS:

• Isolate case until two cultures taken not less than 24 hours apart and not less than 24 hours after cessation of antimicrobial therapy are negative. If cultures cannot be obtained, isolation may end after 14 days of appropriate treatment.
• Culture all close contacts and keep under surveillance for seven days.
• Identify contacts that handle food or milk or have contacts with unimmunized children. Exclude these contacts from high-risk occupations until negative cultures are obtained.
• Treat all contacts (a single dose of penicillin IM or a 7-10 day course of erythromycin PO ) regardless of their immunization status.
• Give a booster dose of a preparation containing diphtheria toxoid to previously immunized contacts and a primary series to unimmunized contacts.

 III. CONTACTS FOR CONSULTATION

A. BCDP / IMMUNIZATION SECTION: (608) 266-3031.

B. REGIONAL STAFF: See Epinet Introduction: “REGIONAL OFFICE CONTACTS”.

C. WSLH / BACTERIOLOGY: (608) 263-3421.

IV. RELATED REFERENCES

1. Heymann DL, ed. DIPHTHERIA. In: Control of Communicable Diseases Manual. 18 th ed. Washington , DC : American Public Health Association, 2004:171-176.

2. Pickering LK, ed. Diphtheria In: Red Book: 2003 Report of the Committee on Infectious Diseases. 26 th ed. Elk Grove Village , IL : American Academy of Pediatrics, 2003:263-266.

V. DISEASE TRENDS

Diphtheria is rare in the U.S. : fewer than five cases have been reported annually during recent years. No cases have been reported in Wisconsin since 1982. However, an epidemic of diphtheria has been occurring in Russia and the Ukraine since the beginning of the 1990s because of disruption of immunization programs for children and adults. The epidemic is still growing and spreading to neighboring countries. Serosurveys in the U.S. indicate that > 40% of adults lack protective levels of diphtheria antitoxin. All adults, particularly travelers, should receive a booster dose of Td every 10 years.