Influences on formation of tetanus antibody after simultaneous injection of tetanus immunoglobulin with tetanus vaccine

Influences on Formation of Tetanus Antibody after Simultaneous Injection of Tetanus Immunoglobulin with Tetanus Vaccine
Jonghwan Shin,1 Jinjoo Kim,2 and Kyoungjun Song1
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Abstract
The goal of this study was to determine how much the formation of tetanus antibody is influenced after a single injection of tetanusvaccine (Td) and the simultaneous injection of tetanus vaccine with tetanus immunoglobulin (TIG). All of the healthy adult volunteers were divided into two groups: group 1 (Td only) and group 2 (Td plus TIG). Two hundred thirty seven volunteers were enrolled. When the baseline antibody titer, gender and age were adjusted, the geometric mean titers (GMTs) of the tetanus antibody (group 1 vs group 2)was 0.8438 IU/mL vs 0.5684 IU/mL at 4 weeks (P = 0.002), 0.4074 IU/mL vs 0.3217 IU/mL at 6 months (P = 0.072) and 0.3398 IU/mL vs 0.2761 IU/mL at 12 months (P = 0.140) after injection, respectively. The formation of tetanus antibody after tetanus vaccination is not influenced by TIG at the late period and in adults below the age of 50 yr, but there are significant differences between the two groupsat the early period of 4 weeks after vaccination and for the patients over 60 yr.

Keywords: Tetanus, Tetanus Toxoid, Immunoglobulins
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INTRODUCTION
Despite efforts paid by the World Health Organization and the government of developing countries, tetanus persists as a global health problem. Tetanus prophylaxis after injury had been introduced in US Immunization Practices AdvisoryCommittee (ACIP) guideline and this guideline has been used in emergency departments (EDs) (1). However, some studies have shown that physician compliance with the guideline for tetanus prophylaxis according to the past vaccination history and the kind of wound is very low and their decisions were sometimes incorrect (2-4). The reasons for physician noncompliance with the ACIP guideline are likely dueto a lack of familiarity with the guideline or failure to document the appropriate history (3).

In a busy and overcrowded ED, many emergency physicians are unable to get sufficient medical information of patients on the past tetanus vaccination history and individual immunity. When an injured patient visits the ED, unnecessary injection of tetanus immunoglobulin (TIG) may cause side effects andalso increase the medical expense (5). Further, the opportunity of assessing a rising tetanus antibody titer may be missed after simultaneous injection of tetanus-diphtheria vaccine (Td) and TIG. According to age, the elevation of the tetanus antibody titer after tetanus prophylaxis might be not equivalent because of different levels of basal immunity and the time-interval of the last tetanusvaccination. Therefore, we wanted to determine whether TIG influences the level of tetanus antibody after simultaneous tetanus vaccination according to age and the time-interval of the last tetanus vaccination.

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MATERIALS AND METHODS
Vaccine and immunoglobulin

Tetanus and diphtheria toxoid vaccine (Td-pur, Norvatis, Marburg, Germany) and tetanus immunoglobulin (Hypertet; Green Cross,Seoul, Korea) were used in this study. The Td vaccine was the licensed formulation that has been used for over 5 yr and it contains not less than 20 international unit (IU) per 0.5 mL dose. TIG has anti-tetanus human immunoglobulin 250 IU per 1 mL.

Participants

A total of 237 healthy adult volunteers who were over 20 yr old were enrolled and immunized in one emergency center of an academicteaching hospital. All the participants made lists of answers to questionnaire about the variables of age, gender, previous vaccination or a prophylaxis history, and military service.

Study design and procedures

This study was a randomized, controlled clinical trial. The participants were divided into different age groups: twenties (20-29 yr), thirties (30-39 yr), forties (40-49 yr), fifties...