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Passive Immunization

by William D. Surkis, MD, Jerome Santoro, MD

Passive immunization is provided in the following circumstances:

  • When people cannot synthesize antibody

  • When people have been exposed to a disease that they are not immune to or that is likely to cause complications

  • When people have a disease and the effects of the toxin must be ameliorated

For immune globulins and antitoxins available in the US, see Table: Immune Globulins and Antitoxins* Available in the US.

Immune Globulins and Antitoxins* Available in the US

Immunobiologic Agent

Type

Indications

Botulinum antitoxin

Specific equine antibodies

Treatment of botulism

Botulinum antitoxin (BIG)

Specific human antibodies

Treatment of botulism in infants

Cytomegalovirus immune globulin, IV (CMV-IGIV)

Specific human antibodies

Prophylaxis in hematopoietic stem cell and kidney transplant recipients

Diphtheria antitoxin

Specific equine antibodies

Treatment of respiratory diphtheria

Hepatitis B immune globulin (HBIG)

Specific human antibodies

Prophylaxis for hepatitis B postexposure

Immune globulin (IG)

Pooled human antibodies

Prophylaxis for hepatitis A preexposure and postexposure, measles postexposure, immunoglobulin deficiency, rubella during the 1st trimester of pregnancy, varicella (if varicella zoster immune globulin is unavailable)

Immune globulin, intravenous (IVIG)

Pooled human antibodies

Prophylaxis for and treatment of severe bacterial and viral infections (eg, HIV infection in children), primary immunodeficiency disorders, autoimmune thrombocytopenic purpura, chronic B-cell lymphocytic leukemia, Kawasaki disease, autoimmune disorders (eg, myasthenia gravis, Guillain-Barré syndrome, polymyositis/dermatomyositis)

Prophylaxis for graft-vs-host disease

Immune globulin, sc (SCIG)

Pooled human antibodies

Treatment of primary immunodeficiency disorders

Rabies immune globulin (HRIG)

Specific human antibodies

Management of rabies postexposure in people not previously immunized with rabies vaccine (see Rabies)

Respiratory syncytial virus murine monoclonal antibody (RSV-mAb)

Murine monoclonal antibody (palivizumab)

Tetanus immune globulin (TIG)

Specific human antibodies

Treatment of tetanus

Postexposure prophylaxis in people not adequately immunized with tetanus toxoid

Vaccinia immune globulin (VIG)

Specific human antibodies

Treatment of eczema vaccinatum, vaccinia necrosum, and ocular vaccinia

Varicella-zoster immune globulin (VariZIG)

Specific human antibodies

Postexposure prophylaxis in people who have no evidence of immunity, are at increased risk of severe varicella, and have contraindications to the varicella vaccine (see Human immune globulin (IG))

*Immune globulin preparations and antitoxins are given IM unless otherwise indicated.

HRIG is administered around wounds as well as IM.

From General Recommendations on Immunization. Recommendations of the Advisory Committee on Immunization Practices (ACIP). Morbidity and Mortality Weekly Report 43:1, January 28, 1994. Updated through the Center for Biologics Evaluation and Research of the U.S. Food and Drug Administration, 2008.

Human immune globulin (IG)

IG is a concentrated antibody-containing solution prepared from plasma obtained from normal donors. It consists primarily of IgG, although trace amounts of IgA, IgM, and other serum proteins may be present. IG very rarely contains transmissible viruses (eg, hepatitis B or C, HIV) and is stable for many months if stored at 4°C. IG is given IM.

Because maximal serum antibody levels may not occur until about 48 h after IM injection, IG must be given as soon after exposure as possible. Half-life of IG in the circulation is about 3 wk.

IG may be used for prophylaxis in

  • Hepatitis A

  • Measles

  • Immunoglobulin deficiency

  • Varicella (in immunocompromised patients when varicella-zoster IG is unavailable)

  • Rubella exposure during the 1st trimester of pregnancy

IG provides only temporary protection; the antibody content against specific agents varies by as much as 10-fold among preparations. Administration is painful, and anaphylaxis can occur.

IV immune globulin (IVIG) was developed to provide larger and repeated doses of human immune globulin. IVIG is used to treat or prevent severe bacterial and viral infections, autoimmune disorders, and immunodeficiency disorders, particularly the following:

  • Kawasaki disease

  • HIV infection in children

  • Chronic B-cell lymphocytic leukemia

  • Primary immunodeficiencies

  • Immune thrombocytopenia

  • Prevention of graft-vs-host disease

Adverse effects are uncommon, although fever, chills, headache, faintness, nausea, vomiting, hypersensitivity, anaphylactic reactions, coughing, and volume overload have occurred.

Subcutaneous immune globulin (SCIG) is also prepared from pooled human plasma; SCIG is intended for home use in patients with a primary immunodeficiency.

Injection site reactions are common, but systemic adverse effects (eg, fever, chills) are much less common than with IVIG.

Hyperimmune globulin

Hyperimmune globulin is prepared from the plasma of people with high titers of antibody against a specific organism or antigen. It is derived from people convalescing from natural infections or donors artificially immunized.

Hyperimmune globulins are available for hepatitis B, infant botulism, rabies, tetanus, cytomegalovirus, vaccinia, and varicella-zoster. Administration is painful, and anaphylaxis may occur.

Monoclonal antibodies

Specific monoclonal antibodies active against infectious agents are of great theoretical interest, and a number are currently being studied. However, only one product, palivizumab, is currently available; it is active against RSV and is used for prevention of RSV infection in certain high-risk children (see Respiratory Syncytial Virus (RSV) and Human Metapneumovirus Infections : Prevention).

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