Seven countries in Western Europe collected large, representative serum banks across the entire
age range and tested them for diphtheria anti-toxin (sample size ranged from 2991 to 7715).
Although a variety of assays were used, the results were all standardized to those of a reference
laboratory and expressed in international units. The standardization process, and the
availability of similar, large data sets allowed comparative analyses to be performed in which a
high degree of confidence could be ascribed to observed epidemiological differences. The results
showed that there were large differences in the proportion of adults with insufficient levels of
protection amongst different countries. For instance, roughly 35% of 50- to 60-year-olds were
found to be seronegative (titre [les ] 0·01 IU/ml) in Finland compared with 70–75% in the United
Kingdom. Furthermore, the proportion of seronegative adults would be expected to increase in
some countries, notably Italy and the western part of Germany. In those countries with
vaccination of military recruits there was a marked sex-related difference in the proportion of
seropositive individuals. All countries have high levels of infant vaccine coverage (> 90%) but
the accelerated schedule in the United Kingdom appears to result in lower anti-toxin titres
than elsewhere. In Sweden, booster doses are not offered until 10 years of age which results in
large numbers of children with inadequate levels of protection. Although the United Kingdom
and Sweden both have higher proportions of seronegative children than elsewhere the
likelihood of a resurgence of diphtheria in these countries seems remote.