In the prevaccine era, diphtheria was a feared, highly endemic childhood disease found in temperate climates. Despite a gradual decline in deaths in the developed parts of the world, attributed to improved living standards, diphtheria remained a leading cause of death of children until widespread vaccination was implemented. Despite the decrease in reported cases in the United States, a recent re-emergence in the former Soviet Union in 1994 caused 50,000 cases and roughly 1800 deaths (3). Epidemic diphtheria primarily affected children younger than age 15, but recently has shifted to affect adults who lack natural exposure to toxigenic C. diphtheria in the vaccine era and did not receive booster vaccinations. The factors governing the periodicity of diphtheria outbreaks are not understood. No gender difference has been described in terms of acute infection, although lack of immunity has been noted in elderly women compared to men.

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