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Diphtheria is a potentially fatal bacterial infection of the respiratory tract or skin and can cause difficulties in breathing. The disease is highly contagious and remains a problem in the developing world. Diphtheria cases are mainly from: Southeast Asia, South America, Africa, Western pacific and India. It can affect people of all ages, but the groups who are most at risk include unimmunised children and older adults who may not have been vaccinated as children. All travellers who have not had the diphtheria vaccine are at risk.

How is it contracted?
The disease is transmitted by sneezing, coughing or by direct contact with respiratory secretions, or by direct contact with skin lesions of an infected person. 

Signs and symptoms
Symptoms start to develop 2 to 10 days after infection and very early symptoms may be similar to the common cold [55]. Diphtheria can cause serious inflammation of the respiratory tract, and is usually identified by a greyish-white membrane seen at the back of the throat. As the infection progresses, symptoms may include: difficulty in breathing or swallowing, sore throat, headaches, chills and fever. In severe cases the airway can become blocked resulting in suffocation. It also causes inflammation of the heart (myocarditis) leading to possible heart failure, and damage to the nervous systems, which can result in paralysis. A type of disease called malignant diphtheria can also develop which is very serious, with additional symptoms including bleeding and kidney failure. 

The skin can also become infected with diphtheria, called ‘cutaneous diphtheria’ which is usually a milder disease. The only symptom is a persistent, poorly healing ulcer most commonly on lower legs, feet and hands. This type of diphtheria is more common in tropical places and is unlikely to be fatal. Most of the recent cases of diphtheria in travellers, who have returned to the UK, have been cutaneous infections.

An estimated 5-10% of people who get the infection will die from complications of diphtheria, such as breathing difficulties, inflammation of the heart (myocarditis) or problems with the nervous system [56]. Multi-organ failure can occur even if recovery appears to have been made weeks earlier. For those that survive, recovery is slow and particular caution should be advised after myocarditis which can lead to long-term heart problems. Complete recovery from neurological damage is usual in those who survive. Systemic complications and fatalities are rare with the cutaneous form of infection.

Treatment for diphtheria, both respiratory and skin, is with antibiotics and antitoxin. Patients will usually be placed in isolation upon admission to hospital and assisted breathing may be required for those who suffer from airway obstruction. 

Recommendations for Travellers
In the UK, children normally receive these vaccinations as part of the national immunisation schedule. Adults and teenagers can be vaccinated via a course of one injection of a combined diphtheria, tetanus and polio vaccine. Travellers should ensure that they have had a primary course of vaccine, and receive a booster every 10 years with further travel to high risk areas.

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Diphtheria. Here’s the point...

While rare in travellers, it does happen and between 1986 and 2012, 25 cases were imported into the UK from the Indian sub-continent, 10 from South East Asia, 7 from Africa, 2 from Pacific islands and 1 each from the Middle East, Russia, and western Europe [59]. Vaccination is highly effective in preventing the disease and a convenient single dose combination vaccine is available that offers protection against diphtheria, tetanus and polio.