1344 Letters to the Editor / American Journal of Infection Control 42 (2014) 1343-4

Immune response to Reply: Immune response to

diphtheria booster diphtheria booster
vaccination vaccination

To the Editor: We are thankful for the reader’s comments regarding our
recently published study describing the baseline immunity against
We read the recently published article by Wiboonchutikul et al1
diphtheria and immunologic response to diphtheria booster
with great interest. The authors investigated diphtheria immunity
vaccination in Thai health care workers.1
in health care workers at enrollment and after diphtheria tetanus
The reader questioned our unexplained method regarding the
toxoid booster vaccinations. However, we think that some points in
time point of obtaining the serum samples to investigate the immu-
this study should be clarified.
nity after booster doses. We collected blood samples for measure-
Although the first booster was administered to all participants
ment of diphtheria antibody 1 month after booster vaccination with
after baseline blood collection, the second booster was adminis-
the tetanus-diphtheria (Td) vaccine. A serum collecting time point of
tered 6 weeks thereafter to the participants who demonstrated no
approximately 1 month after receipt of the diphtheria toxoid vaccine
seroprotection. Serum samples for investigating baseline immunity
in adults to assess immunogenicity has also clearly been described in
had been obtained prior to the first booster; however, it is not clear
previous studies.2,3 Antibody against diphtheria was found to reach
when the serum samples were obtained after booster vaccinations.
plateau levels at 30 days after receiving the Td vaccine.4
It is well known that vaccine antibody response changes
We found that the proportion of nonimmune participants at the
depending on the postvaccination sampling time. In accordance
baseline in our study was low (10.8%), and the correlation between
with this knowledge, serum collection time after booster vaccina-
age and diphtheria antibody levels was poor. The small sample size,
tion was clearly described in previous studies regarding diphtheria
which was already acknowledged in the discussion section of our
immunity.2,3 Therefore, we think that the results of this study
article, may limit the power of our study. However, a recent study in
would be more accurate if the authors explained when they ob-
generally healthy Thai individuals also found a very high proportion
tained the serum samples after the booster vaccinations.
of participants with immunity against diphtheria (94.8%), even in
In addition, the rate of baseline nonimmune subjects is quite
older adults.5 These findings suggest that Thailand has a high pro-
low (10%). If this rate was higher, their data would be more
portion of immune individuals in the population, and the effect of age
powerful and meaningful. Also, the effect of age might be evaluated
on baseline diphtheria immunity may differ from other countries.
more accurately if older adults also participated.

References
References
1. Wiboonchutikul S, Manosuthi W, Sangsajja C, Thientong V, Likanonsakul S,
1. Wiboonchutikul S, Manosuthi W, Sangsajja C, Thientong V, Likanonsakul S,
Srisopha S, et al. Baseline immunity to diphtheria and immunologic response
Srisopha S, et al. Baseline immunity to diphtheria and immunologic response
after booster vaccination with reduced diphtheria and tetanus toxoid vaccine in
after booster vaccination with reduced diphtheria and tetanus toxoid vaccine in
Thai health care workers. Am J Infect Control 2014;42:e81-3.
Thai health care workers. Am J Infect Control 2014;42:e81-3.
2. Blatter M, Friedland LR, Weston WM, Li P, Howe B. Immunogenicity and safety of
2. Rønne T, Valentelis R, Tarum S, Griskevica A, Wachmann CH, Aggerbeck H, et al.
a tetanus toxoid, reduced diphtheria toxoid and three-component acellular
Immune response to diphtheria booster vaccine in the Baltic states. J Infect Dis
pertussis vaccine in adults 19-64 years of age. Vaccine 2009;27:765-72.
2000;181(Suppl 1):S213-9.
3. Thierry-Carstensen B, Jordan K, Uhlving HH, Dalby T, Sørensen C, Jensen AM,
3. Nakajima H, Kariya H, Ohata R, Ogura H. Investigation of immunity
et al. A randomised, double-blind, non-inferiority clinical trial on the safety and
level against diphtheria and reinforcement of immunity by booster
immunogenicity of a tetanus, diphtheria and monocomponent acellular
vaccination for infection control staff in Okayama prefecture. Jpn J Infect Dis
pertussis (TdaP) vaccine in comparison to a tetanus and diphtheria (Td) vaccine
2008;61:104-6.
when given as booster vaccinations to healthy adults. Vaccine 2012;30:5464-71.
4. Sutter RW, Hardy IR, Kozlova IA, Tchoudnaia LM, Gluskevich TG, Marievsky V,
DOI of original article: http://dx.doi.org/10.1016/j.ajic.2014.09.002 et al. Immunogenicity of tetanus-diphtheria toxoids (Td) among Ukrainian
Source of support: None. adults: implications for diphtheria control in the Newly Independent States of
Conflicts of interest: None to report. the Former Soviet Union. J Infect Dis 2000;181(Suppl 1):S197-202.
5. Bansiddhi H, Vuthitanachot V, Vuthitanachot C, Prachayangprecha S,
Theamboonlers A, Poovorawan Y. Seroprevalence of antibody against diphtheria
Hasan Tahsin Gozdas, MD* among the population in Khon Kaen Province, Thailand. Asia Pac J Public Health;
Department of Infectious Diseases and Clinical Microbiology 2012 [Epub ahead of print].
_
Dr. Münif Islamo lu Kastamonu State Hospital
g
DOI of original article: http://dx.doi.org/10.1016/j.ajic.2014.08.020
Kastamonu, Turkey
Conflicts of interest: None to report.
Oguz Karabay, MD
Surasak Wiboonchutikul, MD*
Department of Infectious Diseases and Clinical Microbiology
Weerawat Manosuthi, MD
Faculty of Medicine, Sakarya University
Bamrasnaradura Infectious Diseases Institute
Sakarya, Turkey
Department of Disease Control, Ministry of Public Health
* Nonthaburi, Thailand
Address correspondence to Hasan Tahsin Gozdas, MD,
Department of Infectious Diseases and Clinical Microbiology,
_ * Address correspondence to Surasak Wiboonchutikul, MD,
Dr. Münif Islamo lu Kastamonu State Hospital, Kastamonu, 37100
g
Bamrasnaradura Infectious Diseases Institute, Department of
Turkey.
Disease Control, Ministry of Public Health,
E-mail address: dr.htgozdas@yahoo.com.tr (H.T. Gozdas).
Nonthaburi, 11000, Thailand.
E-mail address: srsw135@yahoo.com (S. Wiboonchutikul).
http://dx.doi.org/10.1016/j.ajic.2014.08.020
http://dx.doi.org/10.1016/j.ajic.2014.09.002