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Traveler Summary

Key Points

  • Diphtheria is a severe bacterial infection of the throat acquired through oral or respiratory droplets. Pertussis (whooping cough) is a bacterial respiratory infection acquired through inhalation or oral or respiratory droplets. Tetanus (lockjaw) is a bacterial infection affecting the muscles, which is acquired through the contamination of wounds or other breaks in the skin. Diphtheria is present primarily in developing countries, and tetanus and pertussis are present worldwide.
  • Unvaccinated or inadequately vaccinated travelers in close contact with local populations or with high likelihood of injury are at risk.
  • Symptoms of diphtheria include sore throat, hoarseness, nasal drainage, fever, difficulty swallowing, and a thick coating in the throat. Symptoms of pertussis include severe unrelenting cough, which (in young children) is followed by sudden outbursts of a high-pitched “whoop” on inspiration. Symptoms of tetanus include spasms of the jaw muscles, painful stiffness in the neck and abdomen, and difficulty swallowing, followed by muscles spasms throughout the body.
  • Consequences of infections include fatal airway obstruction or heart failure with diphtheria; breathing difficulty, especially in infants with pertussis; and death due to respiratory muscle spasms with tetanus.
  • Prevention includes observing good respiratory hygiene, good handwashing practices, and thorough wound cleaning.
  • Routine vaccination with inactivated (killed) diphtheria, tetanus, pertussis vaccine is given at ages 2, 4, 6, and 15-18 months, followed by a booster dose at age 4-6 years. Completely unvaccinated adults may need an entire primary series.
  • Vaccine side effects are most commonly injection-site reactions and fever.
  • Duration of vaccine protection varies for the different vaccine components. For adult travelers, a Tdap (tetanus, diphtheria, pertussis) booster is recommended every 10 years.
  • Postexposure prevention of tetanus from a wound includes proper wound care and, possibly, a booster dose of a tetanus-containing vaccine.

Introduction

Diphtheria is an acute, contagious bacterial disease primarily affecting the throat. Pertussis ("whooping cough") is a highly communicable bacterial respiratory disease. Tetanus ("lockjaw") is an acute, often fatal, bacterial disease affecting muscles (including the respiratory muscles).

Risk Areas

Diphtheria is found worldwide but is uncommon in industrialized countries because of longstanding, routine use of vaccine. Diphtheria causes significant illness and death in developing countries where vaccination coverage is low.

Pertussis remains a poorly controlled vaccine-preventable disease. Even in countries with vaccination programs, waning protection from current pertussis-containing vaccines appears to have contributed to a resurgence of this disease. Disease rates are highest among young children in countries where vaccination coverage is low. In developed countries, the incidence of pertussis is highest among infants who are too young to be vaccinated, but many older adults are infected as well.

Tetanus is a global health problem. Incidence is highest in densely populated regions with warm, damp climates and rich, organic soil. The tetanus bacteria are widely distributed in the environment and include soil, dust, and animal and human feces. In the U.S., most cases occur in people older than 50 years.

Transmission

Diphtheria is transmitted from person to person through oral or respiratory droplets or close physical contact. In countries with warm climates, contact with discharge from skin lesions can also transmit infection.

Pertussis is spread from person to person through aerosolized respiratory droplets (coughing, sneezing) or direct contact with respiratory secretions. Many infants who get pertussis are infected by older siblings, parents, or caregivers, all who might not even know they have the disease.

Tetanus transmission typically occurs via contamination of wounds, burns, punctures, or other breaks in the skin. Tetanus is not spread from person to person.

Risk Factors

Unvaccinated or inadequately vaccinated travelers are at risk for diphtheria in developing countries and at risk for tetanus and pertussis anywhere in the world.

Symptoms

Diphtheria is characterized by sore throat, hoarseness, nasal drainage, fever, difficulty swallowing, and the presence of a thick coating, most often in the throat.

Pertussis usually starts with mild upper respiratory symptoms. After 1 to 2 weeks, severe coughing begins and, in children, is followed by sudden outbursts of a high-pitched "whoop" upon inspiration. Vomiting may occur, but fever is absent or minimal.

Early symptoms of tetanus include spasms of the jaw muscles (lockjaw), painful stiffness in the neck and abdomen, and difficulty swallowing. Later symptoms include generalized, severe muscle spasms throughout the body.

Consequences of Infection

Fatal airway obstruction due to diphtheria can result if the coating extends into the voice box or windpipe, and cardiac problems may occur, albeit rarely. Infants may develop breathing problems or respiratory failure due to severe cough associated with pertussis. Death from breathing failure occurs in approximately 10% to 20% of tetanus cases.

Need for Medical Assistance

Persons with symptoms of tetanus or diphtheria should seek immediate medical attention. Persons with symptoms of pertussis should seek treatment because antibiotics can lessen the severity of infection and prevent transmission to close contacts. Diphtheria patients need referral to a center where specific antitoxin administration is available.

Prevention

Non-vaccine: Observe good respiratory hygiene (cough and sneeze etiquette) and good handwashing practices. Thoroughly clean any wounds.

Vaccine: DTaP vaccine is used in young children, and Tdap is used for persons 7 years and older. All persons, regardless of travel plans, should have completed a primary series at some time during their lives and be up to date on regular 10-year boosters.

Persons with underlying medical conditions or who have concerns about the vaccine should speak to their health care provider before vaccine administration.

Side Effects:

The most common Tdap vaccine side effects are injection-site reactions, headache, and fatigue. Fever is uncommon.

Timing:

DTaP vaccine is given as follows:

  • Children younger than 7 years: 4 doses, 1 each at ages 2, 4, 6, and 15-18 months followed by a booster at age 4-6 years, prior to school entry.

Tdap vaccine is given as follows:

  • All persons 11 years and older who have not previously received a dose of Tdap at any time. Adults should receive this dose as soon as possible, regardless of the interval since the last tetanus-containing vaccine if it was not Tdap.
  • Travelers, every 10 years
  • As 1 of the doses of a primary series in previously unvaccinated persons 7 years and older
  • Pregnant women: 1 dose of Tdap during each pregnancy

Nontravelers may receive a vaccine preparation called Td for their 10-year booster if they have previously received at least 1 dose of Tdap during their lives.

Travelers going to remote areas where tetanus boosters may not be readily available in case of an injury should receive a booster of Tdap or Td (as appropriate) prior to travel if more than 5 years have elapsed since the last booster dose. Travelers who received their last tetanus-containing vaccine 5 or more years earlier should receive 1 dose of Tdap or Td as part of their wound care if they have a very contaminated wound.