What is the role of Tetanus Immunoglobulin (TIG) in tetanus prevention and treatment?

Role of Tetanus Immunoglobulin (TIG) in Tetanus Prevention and Treatment

Tetanus Immunoglobulin (TIG) plays a critical role in both prevention and treatment of tetanus by providing immediate passive immunity to neutralize tetanus toxin in individuals with inadequate active immunity.

Preventive Use of TIG

Wound Management

• TIG is indicated for prophylaxis in patients with tetanus-prone wounds who have unknown or incomplete tetanus vaccination history (<3 doses) 1.
• Tetanus-prone wounds include those contaminated with dirt, feces, soil, saliva, puncture wounds, avulsions, and wounds from missiles, crushing, burns, and frostbite 1.
• The standard prophylactic dose is 250 units administered intramuscularly for both adults and children 1, 2.
• When TIG and tetanus toxoid-containing vaccines are administered concurrently, they must be given at separate anatomical sites using separate syringes 1.

Decision Algorithm for TIG Administration

• For clean, minor wounds:

  • No TIG needed regardless of vaccination history 1.

• For tetanus-prone wounds:

  • Unknown or <3 doses of tetanus toxoid-containing vaccine: Administer both tetanus toxoid-containing vaccine AND TIG 1.
  • ≥3 doses of tetanus toxoid-containing vaccine:
    • Last dose <5 years ago: No TIG needed 1.
    • Last dose ≥5 years ago: No TIG needed (only tetanus toxoid-containing vaccine) 1.

Special Populations

• Persons with HIV infection or severe immunodeficiency who have contaminated wounds should receive TIG regardless of their tetanus immunization history 1.
• In mass-casualty settings with limited TIG supply, priority should be given to persons aged >60 years and immigrants from regions other than North America or Europe who are less likely to have adequate antitetanus antibodies 1.
• Pregnant women follow the same TIG guidelines as non-pregnant adults 1, 3.

Treatment of Active Tetanus

• For patients with active tetanus, TIG is administered to neutralize circulating tetanus toxin that has not yet bound to nerve tissue 2, 4.
• Intrathecal administration of TIG has shown superior outcomes compared to intramuscular administration in treating active tetanus, with a relative risk of mortality of 0.71 (95% CI, 0.62-0.81) 5.
• In mild tetanus cases, intrathecal TIG (250 IU) significantly reduces:
  • Disease progression rate 6
  • Duration of hospital and ICU stay 6
  • Need for tracheostomies 6
  • Sedative requirements for controlling spasms 6

Clinical Considerations and Pitfalls

• TIG provides immediate passive protection but does not replace the need for active immunization with tetanus toxoid 2, 7.
• Following a tetanus toxoid booster, there is no significant increase in antitoxin levels within the first 4 days, supporting the need for TIG in high-risk situations 7.
• If TIG is unavailable, intravenous immune globulin may be substituted 1.
• Antibodies in TIG may interfere with the response to live viral vaccines (measles, mumps, polio, rubella), so these vaccines should be deferred for approximately 3 months after TIG administration 2.
• TIG should never be administered intravenously due to risk of precipitous blood pressure drop and anaphylaxis-like reactions 2.
• The gluteal region should be avoided as an injection site due to risk of sciatic nerve injury 2.

Limitations and Contraindications

• Persons with a history of Arthus reaction following a previous dose of tetanus toxoid-containing vaccine should not receive a tetanus toxoid-containing vaccine until >10 years after the most recent dose, regardless of wound condition 1.
• Postexposure chemoprophylaxis with antimicrobials against tetanus is not recommended 1.
• Skin tests should not be performed before TIG administration as they can be misinterpreted 2.