ATC Class:J07AM52

VA Class:IM500

AHFS Class:

• Antitoxins and Immune Globulins 80:04

Generic Name(s):

• Tetanus Immune Globulin

Tetanus immune globulin (TIG) is a specific immune globulin (hyperimmune globulin)104,106 that contains tetanus antitoxin and is used to provide temporary passive immunity to tetanus.104,106,110 TIG commercially available in the US is prepared from plasma of donors immunized with tetanus toxoid;104 other tetanus antitoxin preparations (e.g., equine tetanus antitoxin) may be available in other countries.101

Tetanus

Tetanus immune globulin (TIG) is used to provide passive immunity to tetanus as part of a postexposure prophylaxis regimen following a tetanus-prone wound and also is used in the treatment of tetanus.100,101,103,104,110,112,113,115

Postexposure Prophylaxis

Passive immunization with TIG is used in conjunction with active immunization with a preparation containing tetanus toxoid adsorbed for postexposure prophylaxis of tetanus in individuals with tetanus-prone wounds who are inadequately vaccinated against tetanus or whose tetanus immunization history is unknown or uncertain.100,101,103,104,110,112,113,115 The US Public Health Service Advisory Committee on Immunization Practices (ACIP) and American Academy of Pediatrics (AAP) state that TIG is not necessary for postexposure prophylaxis in patients with clean, minor wounds (regardless of their immunization status) or for patients with tetanus-prone wounds who have previously received 3 or more doses of a preparation containing tetanus toxoid adsorbed or tetanus toxoid fluid (no longer commercially available in the US).100,101,103 Any individual whose tetanus immunization status is unknown or uncertain should be considered to have had no previous doses of tetanus toxoid adsorbed or tetanus toxoid fluid.100,104,112,113,115

In the event of injury and possible exposure to tetanus, the need for active immunization with a preparation containing tetanus toxoid adsorbed with or without passive immunization with TIG depends on the individual's vaccination status and the likelihood of contamination with tetanus bacilli (e.g., condition of wound, source of contamination).100,101,110,112,113,115 Tetanus-prone wounds include, but are not limited to, wounds contaminated with dirt, feces, soil, or saliva; puncture wounds; avulsions; and wounds resulting from crushing, burns, or frostbite.100,101,103,110,111 Tetanus also has been associated with apparently clean, superficial wounds, surgical procedures, insect bites, animal bites, dental infections, chronic sores and infections, and IV drug abuse.110,111 Tetanus is not transmitted person-to-person.110,111

Table 1 summarizes the ACIP guidelines for active and passive immunization against tetanus in routine wound management.

When passive immunization against tetanus is indicated for postexposure prophylaxis, TIG is the preferred form of tetanus immunoglobulin for postexposure prophylaxis.101,104,110 Tetanus antitoxin (equine) (no longer commercially available in the US but may be used in other countries) provides a shorter duration of protection than TIG and is associated with a high risk of adverse reactions (e.g., serum sickness).101 Tetanus antitoxin (equine) should only be used when TIG is not available and only after appropriate sensitivity testing and, if necessary, desensitization.101

Administration of a prophylactic dose of TIG should not be considered a substitute for active immunization with a preparation containing tetanus toxoid adsorbed, nor a substitute for adequate medical and surgical care of contaminated or potentially contaminated wounds.101 Wound care is an essential part of postexposure prophylaxis or treatment of tetanus100,101,104,110,111 and is necessary regardless of vaccination status.100,101,104,110 Cleansing of the wound and removal of necrotic tissue and foreign material should be performed,101,110 especially if dirt or necrotic tissue is present.101,110 Anti-infectives are not indicated for tetanus postexposure prophylaxis.100,110

The ACIP states that recommendations concerning use of TIG in patients with altered immunocompetence, including those with human immunodeficiency virus (HIV) infection or those who are severely immunocompromised because of congenital immunodeficiency, leukemia, lymphoma, aplastic anemia, generalized malignancy, or therapy with alkylating agents, antimetabolites, radiation, or corticosteroids, are the same as those for patients who are not immunocompromised.105 The AAP states that TIG should be used in the management of tetanus prone wounds in all HIV-infected individuals, regardless of their tetanus immunization history.101

For additional information on tetanus-prone wounds and associated risks of tetanus and recommendations for postexposure prophylaxis of tetanus, see Uses in Diphtheria and Tetanus Toxoids Adsorbed/Tetanus and Diphtheria Toxoids Adsorbed 80:08.

Treatment

TIG is used for the treatment of tetanus101,104,110,111,115 in conjunction with anti-infective agents active against Clostridium tetani (e.g., metronidazole, penicillin G), sedatives, and muscle relaxants.101,111,115 TIG has been used in conjunction with anti-infective therapy (e.g., penicillin G) for the treatment of neonatal tetanus†.108,109 Evidence of effectiveness of TIG in the treatment of active tetanus infection is limited and the optimum therapeutic dosage of TIG for treatment of tetanus infection has not been established.101,104 Although TIG can neutralize unbound exotoxin, it does not affect toxin already bound to nerve endings.110

TIG is the preferred form of tetanus immunoglobulin for the treatment of active tetanus.100,101,110 Immune globulin IV (IGIV) contains tetanus antitoxin and may be used if TIG is unavailable.101,110 Tetanus antitoxin (equine) (no longer commercially available in the US but may be used in other countries) should only be used when TIG is not available and only after appropriate sensitivity testing and, if necessary, desensitization.101 Intrathecal TIG or tetanus antitoxin (equine) is not of proven benefit in the treatment of tetanus.101,102

Recovery from tetanus does not result in naturally acquired tetanus immunity.100,104,110 As soon as possible, active immunization against tetanus should be initiated or completed using a preparation containing tetanus toxoid adsorbed.100,104,110 (See Diphtheria and Tetanus Toxoids Adsorbed/Tetanus and Diphtheria Toxoids Adsorbed 80:08.)

Administration

Tetanus immune globulin (TIG) is administered by deep IM injection.104 TIG should not be administered IV101,104 or intrathecally.101 In the treatment of tetanus, some clinicians recommend infiltration of part of the TIG dose locally around the wound;101,110 however, efficacy of this approach has not been proven.101

IM injections of TIG preferably should be made into the anterolateral aspect of the thigh or the deltoid muscle.104 Because of the risk of injury to the sciatic nerve, the gluteal muscle should be not be used as an injection site.104 Although the manufacturer recommends that aspiration (i.e., pulling back on the syringe plunger after needle insertion and before injection) be performed to ensure that a blood vessel has not been entered,104 the US Public Health Service Advisory Committee on Immunization Practices (ACIP) states that this procedure is not required because large blood vessels are not present at recommended IM injection sites.106

When passive immunization with TIG is indicated in addition to active immunization with a preparation containing tetanus toxoid adsorbed for postexposure prophylaxis of tetanus, TIG may be given simultaneously with the tetanus toxoid adsorbed preparation using different syringes and different injection sites.101,104,106

Dosage

Postexposure Prophylaxis of Tetanus

The usual dosage of TIG for postexposure prophylaxis of tetanus in adults is 250 units as a single dose.101,104

Although safety and efficacy have not been definitely established in children†,104 the manufacturer states that the usual dosage of TIG in children 7 years of age or older for postexposure prophylaxis of tetanus is 250 units as a single dose.104 For children younger than 7 years of age, the manufacturer states that the dosage for routine prophylaxis may be calculated using body weight (4 units/kg); however, it may be advisable to administer 250 units regardless of the child's size since theoretically the amount of toxin produced by Clostridium tetani in a child's body would be the same as that produced in an adult's body.104

Treatment of Tetanus

For the treatment of tetanus in adults, a TIG dosage of 3000-6000 units usually is recommended.101,110 However, the optimum therapeutic dosage of TIG for the treatment of active tetanus has not been established,101 and the manufacturer states that dosage should be adjusted according to the severity of the infection.104

Although safety and efficacy have not been definitely established in children†,104 a TIG dosage of 3000-6000 units usually is recommended.101,110

Some clinicians suggest that a portion of the TIG dose be infiltrated locally around the wound,101,110 although efficacy of this approach has not been established.101

In the treatment of neonatal tetanus†, neonates have received 500 units of TIG in conjunction with anti-infective therapy (e.g., a 10-day regimen of penicillin G).108,109

Adverse Effects

Adverse effects reported with tetanus immune globulin (TIG) include slight soreness at the site of injection and low-grade fever.104

Sensitization to repeated injections of human immune globulin occurs rarely,104 and there have been isolated occurrences of angioneurotic edema, nephrotic syndrome, and anaphylactic shock.104

Precautions and Contraindications

The manufacturer states that there are no known contraindications to TIG.104

Hypersensitivity Reactions

TIG should be administered with caution to individuals who have exhibited previous systemic allergic reactions to immune globulin preparations.104 Use of skin testing (i.e., intradermal injection of concentrated IgG solutions) to evaluate possible hypersensitivity is unreliable since localized areas of inflammation may occur as the result of localized tissue irritation and can be misinterpreted as a positive allergy reaction.104

Although systemic reactions to human immune globulin preparations are rare, epinephrine and other appropriate agents should be readily available in case anaphylaxis or other serious allergic reaction occurs.104

Risk of Transmissible Agents in Plasma-derived Preparations

Because TIG is prepared from pooled human plasma, it is a potential vehicle for transmission of human viruses, including the causative agents of viral hepatitis and human immunodeficiency virus (HIV) infection, and theoretically may carry a risk of transmitting the causative agent of Creutzfeldt-Jakob disease (CJD) or variant CJD (vCJD).104,107 The risk for transmission of recognized blood-borne viruses is considered to be low because plasma donors are screened for certain viruses (hepatitis B virus [HBV], hepatitis C virus [HCV], HIV) and because of the viral inactivation and removal properties inherent in the Cohn cold ethanol precipitation method used for purification of immune globulin products.104 In addition, TIG undergoes chemical (solvent/detergent) and/or heat-treatment procedures to reduce viral infectious potential.104 Improved donor screening, viral-inactivation procedures (e.g., solvent/detergent treatment), and/or filtration procedures have reduced, but not completely eliminated, the risk of pathogen transmission with plasma-derived preparations.104 However, because no purification method has been shown to be totally effective in removing the risk of viral infectivity from plasma-derived products and because new blood-borne viruses may emerge which may not be inactivated by the manufacturing process or the chemical (solvent/detergent) treatment procedure currently used, patients should be advised of the risks and benefits of TIG.104 Any infection believed to have been transmitted by TIG should be reported to the manufacturer at 800-520-2807.104

For further information on precautions related to transmissible agents in plasma-derived preparations, see Risk of Transmissible Agents in Plasma-derived Preparations under Cautions: Precautions and Contraindications, in Albumin Human 16:00.

Individuals with Altered Immunocompetence

Recommendations regarding the use of TIG in individuals with altered immunocompetence are the same as those for individuals who are not immunocompromised.105

The US Public Health Service Advisory Committee on Immunization Practices (ACIP) states that recommendations concerning use of TIG in individuals with altered immunocompetence, including HIV-infected individuals or those severely immunocompromised because of congenital immunodeficiency, leukemia, lymphoma, aplastic anemia, generalized malignancy, or therapy with alkylating agents, antimetabolites, radiation, or corticosteroids, are the same as those for patients who are not immunocompromised.105

Administration Precautions

TIG should not be administered in the same syringe or at the same injection site as tetanus toxoid adsorbed.100,101,104,106 (See Drug Interactions: Inactivated Vaccines and Toxoids.)

Serious systemic reactions (e.g., precipitous decrease in blood pressure) have occurred following IV administration of immune globulin intended for IM administration; therefore, inadvertent IV administration of TIG should be avoided.104

Individuals with Bleeding Disorders

Because bleeding may occur following IM administration in individuals with thrombocytopenia or a bleeding disorder (e.g., hemophilia) or in those receiving anticoagulant therapy, TIG should be used in such individuals only if benefits outweigh risks.104,106

The ACIP states that IM injections can be used in individuals who have bleeding disorders or are receiving anticoagulant therapy if a clinician familiar with the patient's bleeding risk determines that the injection can be administered with reasonable safety.106 In these cases, a fine needle (23 gauge) should be used to administer the dose and firm pressure applied to the injection site (without rubbing) for at least 2 minutes.106 If patient is receiving antihemophilia therapy, the IM dose should be administered shortly after a scheduled dose of such therapy.106 In addition, the individual and/or their family should be advised about the risk of hematoma from IM injections.106

Duration of Immunity

TIG provides only short-term protection against tetanus.104,110 Therefore, active immunization against tetanus using a preparation containing tetanus toxoid adsorbed should be initiated or completed as soon as possible.100,110

Pediatric Precautions

Safety and efficacy of TIG have not been established in children.104 However, recommendations regarding use of TIG in children (including for postexposure prophylaxis of tetanus) usually are the same as those for adults.101

Pregnancy

Pregnancy

Animal reproduction studies have not been performed with TIG and it is not known whether TIG can cause harm when administered to pregnant women.104 TIG should be used during pregnancy only when clearly needed.104

The ACIP states that pregnancy is not generally considered a contraindication to the use of TIG for treatment or postexposure prophylaxis of tetanus.103,115

Inactivated Vaccines and Toxoids

Immune globulins, including tetanus immune globulin (TIG), are not expected to have a clinically important effect on the immune response to inactivated vaccines or toxoids; therefore, inactivated vaccines (e.g., parenteral inactivated influenza vaccine, parenteral inactivated typhoid vaccine [Typhim Vi^®]), recombinant vaccines, polysaccharide vaccines, and toxoids may be administered simultaneously with (using different syringes and different injection sites) or at any interval before or after administration of TIG.106

Tetanus Toxoid Adsorbed

If indicated, active immunization against tetanus should be initiated at the same time as passive immunization with TIG; however, TIG and the preparation containing tetanus toxoid adsorbed should be given at separate sites using different syringes.101,104,112,113,115

Live Vaccines

Antibodies present in immune globulin preparations, including TIG, may interfere with the immune response to certain live virus vaccines (e.g., measles, mumps, and rubella virus vaccine live [MMR], rotavirus vaccine live oral, varicella virus vaccine live).101,104,106

There is no evidence that immune globulin preparations interfere with the immune response to yellow fever virus vaccine live, typhoid vaccine live oral, influenza virus vaccine live intranasal, or poliovirus vaccine live oral (OPV; no longer commercially available in the US) and these vaccines may be administered simultaneously with or at any time before or after administration of TIG.106

Measles, Mumps, and Rubella Vaccine

Immune globulin preparations, including TIG, may interfere with the immune response to measles and rubella antigens contained in MMR; the effect of TIG on the immune response to mumps antigen is unknown.106 The US Public Health Service Advisory Committee on Immunization Practices (ACIP) states that MMR should not be administered simultaneously with or within 3 months before or after TIG.104,106

In general, vaccine virus replication and stimulation of active immunity occur within 1-2 weeks after administration of a live virus vaccine.106 Therefore, if TIG is administered less than 14 days after MMR, revaccination is necessary at least 3 months after the TIG dose, unless serologic testing indicates that there was an adequate antibody response to all 3 antigens contained in MMR.106

Rotavirus Vaccine

TIG may interfere with the immune response to rotavirus vaccine.106 Safety and efficacy data are not available regarding use of rotavirus vaccine live oral in infants who have received an immune globulin within 42 days.114 Although there is potential for decreased antibody response to rotavirus vaccine, the ACIP and American Academy of Pediatrics (AAP) state that the vaccine may be administered simultaneously with or at any time before or after administration of blood or antibody-containing preparations.117,118

Varicella Vaccine

TIG may interfere with the immune response to varicella virus vaccine live.106 Varicella vaccine should not be administered simultaneously with or within 3 months before or after TIG.106

In general, vaccine virus replication and stimulation of active immunity occur within 1-2 weeks after administration of a live virus vaccine.106 Therefore, if TIG is administered less than 14 days after varicella virus vaccine live, revaccination is necessary at least 3 months after the TIG dose, unless serologic testing indicates that there was an adequate antibody response to the vaccine.106

Pharmacology

Tetanus immune globulin (TIG) is used to provide passive immunity to tetanus.100,101,104,110,112,113,115 TIG contains tetanus antitoxin antibodies which neutralize the exotoxin produced by Clostridium tetani , the causative organism of tetanus.104,115 TIG can only neutralize unbound exotoxin; it does not affect toxin already bound to nerve endings.110 The half-life of TIG is approximately 28 days.

Tetanus Infection

Tetanus is a potentially fatal disease caused by a neurotoxic exotoxin (tetanospasmin) produced by C. tetani .101,110,111 C. tetani spores are ubiquitous in the environment and are found in soil and in animal (e.g., horses, sheep, cattle, dogs, cats, rats, guinea pigs, chickens) and human intestinal tracts.100,101,110,111 The spores can contaminate open wounds, especially puncture wounds or those with devitalized tissue; anaerobic wound conditions allow the spores to germinate and produce exotoxins that disseminate through the blood and lymphatic system.101,110 Following infection of a wound, the incubation period for tetanus is usually 8-10 days (range 3-21 days).101,110,111

Tetanus occurs worldwide, almost exclusively in individuals who are unvaccinated or inadequately vaccinated against the disease.101,111 An average of 31 cases was reported each year in the US from 2000 through 2007 (case fatality rate 10%);110 a low of 20 cases was reported in 2003.110 Most cases of tetanus in the US occur following acute injuries or wounds (puncture wounds, lacerations, abrasions) and usually occur in adults 40 years of age or older; however, an increase in the disease recently has been reported in younger adults (e.g., heroin abusers).110,116

The most common form of tetanus is generalized tetanus characterized by rigidity and convulsive muscle spasms that usually involve the jaw (lockjaw) and neck and then become generalized.101,110,111 Neonatal tetanus (tetanus neonatorum) occurs in infants born under nonsterile conditions to women inadequately vaccinated against tetanus; infection usually involves a contaminated umbilical stump and occurs because the infant does not have passively acquired maternal antibodies against tetanus.100,101,110,111,115 Symptoms of neonatal tetanus usually occur during the first 2 weeks of life.101,110 Obstetric tetanus occurs within 6 weeks after delivery or termination of pregnancy because of contaminated wounds or abrasions or unclean deliveries or abortions.115

Chemistry and Stability

Chemistry

Tetanus immune globulin (TIG) is a sterile, concentrated, nonpyrogenic solution of immunoglobulins prepared by cold alcohol fractionation from plasma of adults hyperimmunized with tetanus toxoid.104 TIG contains 15-18% protein.104 Commercially available TIG meets standards established by the Center for Biologics Evaluation and Research of the US Food and Drug Administration, and contains not less than 250 tetanus antitoxin units per dose.104

TIG has a pH of 6.4-7.2 and undergoes a chemical (solvent/detergent) procedure during manufacture to reduce the risk of transmission of viral infection.104 TIG contains glycine as a stabilizing agent, but does not contain thimerosal or any other preservative.104

Stability

TIG should be refrigerated at 2-8°C; freezing should be avoided.104 TIG that has been frozen should not be used.104

Only references cited for selected revisions after 1984 are available electronically.

100. Centers for Disease Control Immunization Practices Advisory Committee (ACIP). Diphtheria, tetanus, and pertussis: recommendations for vaccine use and other preventive measures. MMWR Recomm Rep . 1991; 40(RR-10):1-28.

101. American Academy of Pediatrics. Red Book: 2009 Report of the Committee on Infectious Diseases. 28th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2009.

102. Abrutyn E, Berlin JA. Intrathecal therapy in tetanus: a meta-analysis. JAMA . 1991;266: 2262-7. [PubMed 1833565]

103. Centers for Disease Control. Update on adult immunization: recommendations of the Immunization Practices Advisory Committee (ACIP). MMWR Recomm Rep . 1991; 40(RR-12):18,49,70,87.

104. Talecris Biotherapeutics. HyperTET^® S/D (tetanus immune globulin [human]) solvent/detergent treated prescribing information. Research Triangle Park, NC; 2008 May.

105. Centers for Disease Control and Prevention. Recommendations of the Advisory Committee on Immunization Practices (ACIP): use of vaccines and immune globulins in persons with altered immunocompetence. MMWR Recomm Rep . 1993; 42( RR-4):1-18. [Fulltext MMWR]

106. Centers for Disease Control and Prevention. General recommendations on immunization: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep . 2006; 55(RR-15):1-48. [Fulltext MMWR]

107. Department of Health and Human Services, Food and Drug Administration, Center for Biologics Evaluation and Research (CBER). Guidance for industry. Revised preventive measures to reduce the possible risk of transmission of Creutzfeldt-Jakob disease (CJD) and variant Creutzfeldt-Jakob disease (vCJD) by blood and blood products. January 2002. From FDA website. [Web]

108. Craig AS, Reed GW, Mohon RT et al. Neonatal tetanus in the United States: a sentinel event in the foreign-born. Pediatr Infect Dis J . 1997; 16:955-9. [PubMed 9380471]

109. Centers for Disease Control and Prevention. Neonatal tetanus—Montana, 1998. MMWR Morb Mortal Wkly Rep . 1998; 47:928-30. [PubMed 9822366]

110. Centers for Disease Control and Prevention. Epidemiology and prevention of vaccine-preventable diseases. 11th ed. Washington, DC: Public Health Foundation; 2009.

111. Centers for Disease Control and Prevention. Health information for international travel, 2010. Atlanta, GA: US Department of Health and Human Services; 2010. Updates available from CDC website ([Web]).

112. Kretsinger K, Broder KR, Cortese MM et al. Preventing tetanus, diphtheria, and pertussis among adults: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine recommendations of the Advisory Committee on Immunization Practices (ACIP) and recommendation of ACIP, supported by the Healthcare Infection Control Practices Advisory Committee (HICPAC), for use of Tdap among health-care personnel. MMWR Recomm Rep . 2006; 55:1-37. [Fulltext MMWR]

113. Broder KR, Cortese MM, Iskander JK et al. Preventing tetanus, diphtheria, and pertussis among adolescents: use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccines recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep . 2006; 55:1-34. [Fulltext MMWR]

114. Merck & Co. RotaTeq^® (rotavirus vaccine, live, oral, pentavalent) prescribing information. Whitehouse Station, NJ; 2009 Dec.

115. Murphy TV, Slade BA, Broder KR et al. Prevention of pertussis, tetanus, and diphtheria among pregnant and postpartum women and their infants recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep . 2008; 57:1-51. [Fulltext MMWR][PubMed 18509304]

116. Pascual FB, McGinley EL, Zanardi LR et al. Tetanus surveillance--United States, 1998--2000. MMWR Surveill Summ . 2003; 52:1-8. [PubMed 12825541]

117. Cortese MM, Parashar UD, Centers for Disease Control and Prevention (CDC). Prevention of rotavirus gastroenteritis among infants and children: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep . 2009; 58:1-25. [PubMedCentral]

118. Committee on Infectious Diseases, American Academy of Pediatrics. Prevention of rotavirus disease: updated guidelines for use of rotavirus vaccine. Pediatrics . 2009; 123:1412-20. [PubMed 19332437]