Social factors thought to contribute to transmission of respiratory diphtheria include poverty, overcrowding, and poor skin care and hygiene . From 1972 to 1982, three outbreaks of diphtheria occurred in Seattle’s Skid Road area, with 86% of the 1100 total cases having cutaneous diphtheria. The incidence was highest in the winter and spring, involving only indigent persons and primarily urban alcoholic persons with poor hygiene . Similarly, in Sweden since 1984, diphtheria has been mainly diagnosed among men abusing alcohol [5, 37]. A report from the recent (1993–1994) diphtheria epidemic in St. Petersburg, Russia, reported that 29 (69%) of the 42 diphtheria deaths were among persons classified as chronic alcoholics .