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Traveler Summary

Key Points

  • Diphtheria is a severe bacterial infection of the throat, which occurs worldwide (especially in developing countries with poor vaccination coverage) and is acquired through inhalation of aerosolized respiratory droplets from infected persons. Pertussis (whooping cough) is a bacterial infection, which occurs worldwide and is acquired through inhalation of aerosolized respiratory droplets or direct contact with respiratory secretions of infected persons. Tetanus (lockjaw) is a bacterial infection affecting the muscles, which occurs worldwide and is acquired through the contamination of wounds or other breaks in the skin.
  • Risk of diphtheria is increased for unvaccinated or inadequately vaccinated travelers going to affected countries, especially during outbreaks. Risk for pertussis is increased, especially for not yet completely vaccinated infants who come in close contact with infected persons. Risk of tetanus is increased in the case of severe injury or exposure to nonsterile instruments during surgical or dental procedures.
  • Symptoms of diphtheria include sore throat, hoarseness, nasal drainage, fever, difficulty swallowing, and a thick coating overlying the tonsils and throat. Symptoms of pertussis include severe unrelenting cough, which (in young children) is followed by sudden outbursts of a high-pitched "whoop" on inhalation. Symptoms of tetanus include spasms of the jaw muscles, painful stiffness in the neck and abdomen, difficulty swallowing, and muscle 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 (cough and sneeze etiquette) and hand-hygiene (frequent, thorough handwashing) measures and proper wound cleaning and care.
  • Diphtheria, tetanus, and pertussis vaccines are routinely given to children as 4 doses through age 18 months, followed by a booster at age 4-6 years. Completely unvaccinated adults may need an entire primary series.
  • Vaccine side effects are most commonly injection-site reactions, headache, tiredness, 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, an acute, contagious bacterial disease, occurs worldwide (especially in developing countries with insufficient vaccination coverage) and is transmitted primarily through inhalation of respiratory droplets of an infected person.

Pertussis, a highly contagious bacterial respiratory disease, occurs worldwide and is transmitted through inhalation of infected aerosolized respiratory droplets or direct contact with respiratory secretions from infected persons.

Tetanus, an acute (often fatal) bacterial disease, occurs worldwide and is transmitted through contamination of open wounds, burns, punctures, or other breaks in the skin with bacteria from soil, dust, or surfaces.

Risk Areas

Diphtheria occurs worldwide but is uncommon in industrialized countries; highest incidence is in developing countries where vaccination coverage is low.

Pertussis is common worldwide, even in countries with robust vaccination programs where resurgence is probably due to waning protection from current pertussis-containing vaccines. Highest incidence is among young children in countries where vaccination coverage is low.

Tetanus is common worldwide, and highest incidence is in densely populated regions with warm, damp climates and rich, organic soil. The tetanus bacteria are widely distributed in the environment (including soil, dust, and animal and human feces) and can also be found in contaminated street drugs. In the U.S., tetanus is uncommon.

Transmission

Diphtheria is transmitted from person to person via inhalation of aerosolized respiratory droplets (e.g., from coughs or sneezes) or close contact with discharge from skin ulcers of an infected person.

Pertussis is transmitted from person to person through inhalation of aerosolized respiratory droplets (e.g., from coughs or sneezes) or direct contact with respiratory secretions.

Tetanus is transmitted predominantly through contamination of wounds, burns, punctures, or other breaks in the skin. Tetanus is not spread from person to person.

Risk Factors

Risk exists for unvaccinated or inadequately vaccinated travelers for diphtheria in developing countries and for tetanus and pertussis anywhere in the world. Travelers going to affected countries are at increased risk of diphtheria infection during outbreaks. Risk for pertussis is increased, especially for not yet completely vaccinated infants who come in close contact with infected persons (e.g., older siblings, parents, or caregivers) who might not even know they have the disease. Risk for tetanus infection is increased for travelers exposed to nonsterile instruments during surgical or dental procedures.

Symptoms

Symptoms of diphtheria commonly appear about 2 to 5 days following exposure and include sore throat, hoarseness, nasal drainage, fever, difficulty swallowing, and the presence of a thick coating in the throat (which can also occur in the nose).

Symptoms of pertussis appear about 7 to 10 days following exposure, beginning with mild upper respiratory symptoms, followed by severe coughing that progresses to sudden outbursts of a high-pitched "whoop" upon inspiration. Vomiting may occur, but fever is absent or minimal.

Symptoms of tetanus appear about 10 days after exposure and 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. Infants may develop breathing problems or respiratory failure due to severe cough associated with pertussis. Death from breathing failure occurs in approximately 10% to 90% of tetanus cases, with highest rates among infants and the elderly.

Need for Medical Assistance

Persons with symptoms of diphtheria, pertussis, or tetanus should seek immediate medical attention for evaluation of the need for postexposure treatment. Diphtheria patients need referral to a center where specific antitoxin administration is available. Antibiotics can lessen the severity of pertussis infection and prevent transmission to close contacts. Tetanus infection requires hospitalization, antibiotics, immune globulin, and anticonvulsants.

Prevention

Nonvaccine

Observe good respiratory-hygiene (cough and sneeze etiquette) and hand-hygiene (frequent, thorough handwashing) measures and proper wound cleaning and care.

Vaccine

Diphtheria (D or d), pertussis (P or p), and tetanus (T) containing-vaccines are routinely given as childhood vaccinations and to pregnant women and certain travelers. DTaP vaccine is used in young children, and Tdap vaccines (which contain a reduced amount of the diphtheria and pertussis components as denoted by the lower case "d" and "p" [compared to the DTaP vaccines]) 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 booster doses.

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 vaccine side effects for both Tdap and DTaP are injection-site reactions (redness and swelling with or without tenderness). Headache and fatigue are common with Tdap, but fever is uncommon. Fever, drowsiness, poor appetite, and vomiting are common with DTaP.

Timing

DTaP vaccine is given as follows:

  • Routine, regardless of travel for children younger than 7 years: 4 doses, 1 each at ages 2, 4, 6, and 15-18 months, followed by a booster dose at age 4-6 years prior to school entry.

Tdap vaccine is given as follows:

  • Adult travelers: every 10 years
  • Routine, regardless of travel for persons aged 7-10 years with incomplete primary vaccination series: 1 dose of Tdap
  • Persons 7 years and older without prior primary series doses or unknown history of a pertussis-containing vaccine: 3 doses (1 dose Tdap followed by 2 doses Td), given as soon as possible.
  • Pregnant women: 1 dose of Tdap during each pregnancy

Nontraveling adults and health care personnel may receive a vaccine preparation called Td for their 10-year booster if Tdap is contraindicated or as an alternative to a repeat Tdap 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 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 in the event of a severe or contaminated wound.