Mortality After Diphtheria Immunizations

By Tara Jane Collins

Diphtheria is a serious infection that consists of inflammation of the nose and throat. It caused sore throat, fever, and difficulty breathing. Before immunizations, diphtheria had high mortality rates that ranged from 30 to 50 percent, most commonly among children (Carmichael 1993, 680). However, today diphtheria is considered rare due to developments in treatment and prevention. An antitoxin for diphtheria was developed in 1894, but it wasn’t regularly used until the 1900s (Lambeth 1927, 38). Due to immunization developments, mortality rates have decreased and cases of diphtheria are non-existent. This is a variety of research, cases, and records for the Medical Officer of Health that document these mortality reductions and show that antitoxins and immunizations were effective at reducing rates of diphtheria. 

The development of the diphtheria antitoxin started in the 1890s when Emil Behring and Erich Wernicke derived an antitoxin from sheep. After testing their antitoxin on animals, the men injected two infected children at the von Bergmann’s Hospital in Berlin. The children were cured due to the antitoxin (Staerk & Oedingen 1997, 607-610). This finding sparked other research in diphtheria treatment, including a skin test for diphtheria developed by Bela Schick, which was later named the Schick Test (Baker 2000, 199). This involves injecting a small amount of diphtheria toxin into the skin. If the person is susceptible to the disease, the skin will turn red at the injection site (Lambeth 1928, 40).

After the Schick test was developed, a study done in New York City by William Park and Abraham Zingher was done to test the efficacy of the diphtheria antitoxin. Park and Zingher went to public schools and used children for their studies. First, they got parental consent for the children to participate. 90,000 children who received parental consent were immunized and compared to 90,000 children who didn’t receive parental consent and didn’t get immunized. The children that didn’t get immunized had 4 times as many cases of diphtheria as the children who were immunized (Baker 2000, 200). These findings from Park and Zingher sparked a huge campaign for diphtheria immunization. The New York City Health Department created the Diphtheria Prevention Commission in 1929, which included posters in stores, film trailers being shown in theaters, leaflets in foreign languages, lectures and radio broadcasts, and even a billboard (Baker 2000, 200). This campaign caused the mortality rate for diphtheria in New York to be cut almost in half, to 6.75 per 100,000 (Baker 2000, 200). New York City is just one example of a city where mortality rates were reduced due to the diphtheria vaccination. 

British advertisement for diphtheria immunization.
Found on Wikipedia.

Reports from the Medical Officers of Health in London also show that mortality rates after diphtheria immunizations dropped sharply. According to one report, due to the antitoxin, mortality rates were reduced by 60 percent between 1825 and 1927 in the Parish and Borough of Lambeth (Lambeth 1927, 38). Another report involves 208 cases of diphtheria, 201 admitted to the Borough Hospital and 7 treated at home. 18 deaths occurred at a mortality rate of 8.7 percent. This report claims the deaths were due to not getting the vaccine in time due to waiting for the results of throat swabs. The author recommended that every patient should have gotten the antitoxin as a “precautionary measure” (Croydon 1923, 18). He claims that if the antitoxin was given to these patients earlier, the mortality rate might have been lower. This was also the case in 1945 in Twickenham when there was one death and it was a 2-year-old, who was the only one of 4 cases that didn’t get immunized (Twickenham 1946, 28-9). Another report shows the mortality rates of the largest cities in America where immunization is common. Detroit’s was 0.6 per 100,000 and New York was 0.9, while neither Rochester and Portland didn’t have a single death from diphtheria in 1935. This is “undoubtedly due to the extensive employment of active immunization” (Dagenham 1937, 64).

Diphtheria immunizations were being promoted in public schools, and according to one report, there was a campaign for children getting immunized before entering school. The author explains that this led to a small incidence rate among the students, affirming that the policy is the right thing to do (Croyden 1949, 115). Due to the decrease in mortality rates because of immunizations, the number of vaccines given were increasing. In 1934, 303 cases of diphtheria were admitted to the Municipal Hospital, 12 more cases than last year. 16 deaths were reported, and the author made it known that the following year, there was an increase in parents immunizing their children (Willesden 1935, 69). The increase was also due to health organization publicizing the need for immunizations. In 1941, health centers in London were visiting schools and issues leaflets to parents. This caused a great increase in children getting immunized, boosting the 501 children that did it in 1940 to 4933 children getting immunized in 1941 (Ealing 1943, 26). During the 1940s, a study done required all children to submit medical examinations to their schools. The percentages of the children who were immunized were calculated from 1945-50 and all percentages were relatively high (lowest was 69.4 and the highest was 83.9). Then incidence and mortality rates of diphtheria were calculated from 1941 to 1949 in England and Wales and also in Leyton. There was a steady decrease as the years progressed, in Leyton incidence rates were in the double digits and there weren’t more than 2 deaths (Leyton 1950, 84). This shows that the incidence and mortality rates were decreasing due to the immunization treatment. 

Before immunization treatments, diphtheria was a serious infection that led to the deaths of many people, specifically children. However, with the discovery of the antitoxin, diphtheria mortality started to decrease in the 1900s. The treatment served as a cure and a preventive measure. Today, diphtheria is a rare condition that people regularly get vaccinations for, and because of this, the mortality rate is almost none. 

Diphtheria Antitoxin and Mortality
Sketch portraying mortality reduction in diphtheria due to antitoxins. Posted by the Virginia Commonwealth University. Found on Flickr.

Bibliography

Primary Sources

1: Lambeth. “Report of the Medical Officer of Health for Lambeth Borough.” Wellcome Trust, 1928. 38.

2: Croydon. “Report of the Medical Officer of Health for Croydon.” Wellcome Trust, 1924. 18.

3: Croydon. “Report of the Medical Officer of Health for Croydon.” Wellcome Trust, 1949. 115.

4: Willesden. “Report of the Medical Officer of Health for Willesden.” Wellcome Trust, 1935. 69.

5: Dagenham. “Report of the Medical Officer of Health for Dagenham.” Wellcome Trust, 1937. 64.

6: Leyton. “Report of the Medical Officer of Health for Leyton.” Wellcome Trust, 1950. 84.

7: Twickenham. “Report of the Medical Officer of Health for Twickenham.” Wellcome Trust, 1946. 28.

8: Twickenham. “Report of the Medical Officer of Health for Twickenham.” Wellcome Trust, 1946. 29.

9: Lambeth. “Report of the Medical Officer of Health for Lambeth Borough.” Wellcome Trust, 1928. 40.

10: Ealing. “Report of the Medical Officer of Heath for Ealing.” Wellcome Trust, 1943. 26.

Secondary Sources

Baker, J.P. “Immunization and the American way.” American journal of public health vol. 90, no. 2 (2000). 199-207.

Carmichael, Ann. “Diphtheria.” Chapter. In The Cambridge World History of Human Disease (1993), 680–83.

Staerk, Joseph W., Oedingen, Christina. “First cure of diphtheria by antitoxin as early as 1891.” Annals of Science vol 54, no. 6 (1997). 607-610.