Q:

7/9/2013
I understand that Sanofi is stopping the production of tetanus toxoid. We have been using this vaccine for our delayed hypersensitivity skin testing. Any suggestions on alternatives? Would it be okay to use the Td in place?

A:

Thank you for your inquiry.

We have responded previously to a similar question regarding the use of Candida abstract for the assessment of delayed hypersensitivity, and for your convenience, I have copied this response below. I have also copied below references and a website link referring to the use of other antigens, which would be the ones I would choose, for the assessment of delayed hypersensitivity.

There is very little information I could find on the use of diphtheria-tetanus skin testing for assessment of delayed hypersensitivity. In fact, the only article that I was to uncover found that diphtheria-tetanus toxoid was not helpful in the assessment of delayed hypersensitivity (see Kaufman DB, et al., abstract copied below).

However, there are a number of antigens that can substitute for tetanus. The difficulty, is that most of these studies are old and some of the reagents may no longer be available. However, traditionally, antigens such as Candida, trichophyton, streptokinase-streptodornase, and purified protein derivative are those which have been typically employed.

In summary, as you can see from viewing the references below, tetanus/diphtheria does not seem to be the most appropriate choice to replace tetanus. Other agents such as Candida, trichophyton, and PPD, etc. would be more appropriate. Also some of the references give you the concentrations to employ.

Inquiry previously posted on our website:
Delayed hypersensitivity skin testing with candida
Question:
I would like to know what is the concentration of the candin skin test reagent- I need to perform anergy testing on a patient and would like to use my existing candida albican allergenic extract 1:10 w/v for my candida but cannot find a source to tell me how to dilute this for use as an anergy panel. the candin product info does not specify the strength and I asked allermed company and they did not want to tell me the exact strength - just said it was skin test strength. Thank you

Answer:
Thank you for your recent inquiry.

Unfortunately, I could not find a reference that would give you any guidance regarding delayed hypersensitivity testing using an extract designed for immediate hypersensitivity skin tests. However, there is a commercially available product, CANDIN®, which was designed specifically for delayed hypersensitivity testing to candida. Copied below is a selection from the package insert. This was last reviewed, as you can see, in May 2009. I have not personally checked to see if this agent is available at this time. However, your pharmacist could check for its availability.

If it is not available, you might use a reference, which I have copied for you below, to obtain the method for preparation of Candida for intradermal testing. I am not sure that you would be able to make a direct correlation between the concentration used in this extract and the extract you are presently using, but you could certainly make a reasonable estimate of the concentration you might employ.

CANDIN® is indicated for use as a recall antigen for detecting DTH by intracutaneous (intradermal) testing. The product may be useful in evaluating the cellular immune response in patients suspected of having reduced cellular hypersensitivity. Because some persons with normal cellular immunityare not hypersensitive to Candida, a response rate less than 100% to the antigen is to be expected in normal individuals. Therefore, the concurrent use of other licensed DTH skin test antigens is recommended. The product should not be used to diagnose or treat Type 1 allergy to Candida albicans.

CANDIN® should be administered intradermally on the volar surface of the forearm or on the outer aspect of the upper arm. The test dose is 0.1 mL. The skin should be cleansed with 70% alcohol before applying the skin test. The intradermal injection must be given as superficially as possible causing a distinct, sharply defined bleb. An unreliable reaction may result if the product is injected subcutaneously. A positive DTH reaction to CANDIN® consists of induration ≥ 5 mm.
(Last reviewed on RxList: 5/28/2009)

AIDS Res Hum Retroviruses. 2001 Sep 1;17(13):1273-7.
Delayed hypersensitivity skin testing to mumps and Candida albicans antigens is normal in middle-aged HTLV-I- and-II-infected U.S. cohorts.
Murphy EL, Wu Y, Ownby HE, Smith JW, Ruedy RK, Thomson RA, Ameti DI, Wright DJ, Nemo GJ; NHLBI REDS Investigators. The Retrovirus Epidemiology Donor Study.
University of California San Francisco, 94143, USA. murphy.itsa.ucsf.edu
Abstract
It has been reported that human T cell lymphotropic virus (HTLV)-I-infected persons in Japan have decreased delayed hypersensitivity skin test reactivity to tuberculin purified protein derivative (PPD), but HTLV-I- or -II-infected persons do not generally develop opportunistic infections. We administered standardized intradermal testing with PPD, mumps, and Candida albicans antigens to 31 HTLV-I, 48 HTLV-II, and 143 seronegative subjects in the United States. Reactivity at 48 hr was compared among the three groups. Response rates to PPD were very low in all subjects. Fifty-five percent of seronegative subjects did not react to mumps antigen, compared with 55% of HTLV-I [adjusted odds ratio (OR) = 0.79, 95% confidence interval (CI) 0.27-2.33] and 38% of HTLV-II (OR = 0.73, 95% CI 0.33-1.64). Fifty-one percent of seronegatives did not react to Candida albicans antigen, compared with 34% of HTLV-I (OR = 0.37, 95% CI 0.15-0.93) and 46% of HTLV-II (OR = 0.71, 95% CI 0.34-1.52). Anergy was present in 33% of seronegatives, 28% of HTLV-I (OR = 0.60, 95% CI 0.20-1.78), and 19% of HTLV-II (OR = 0.56, 95% CI 0.22-1.44). HTLV-I- and -II-infected persons appear to have intact delayed hypersensitivity skin test responses to mumps and Candida albicans antigens.

References:
Streptokinase-streptodornase (SK-SD) (Lederle, Montreal, Canada) in a final concentration of 80 units of SK and 20 units of SD per ml; Candida albicans (Hollister-Stier, Toronto, Canada) diluted 1/1,000 (v/v); trichophyton mix (Hollister-Stier, Toronto, Canada), diluted 1/500 (v/v); mumps (Eli Lilly & Company, Indianapolis, USA) undiluted and PPD (Connaught, Toronto, Canada) in a dose of 5 TU.

Keystone EC, Demerieux P, Gladman D, Poplonski L, Piper S, and Buchanan R. Enhanced delayed hypersensitivity skin test reactivity with serial testing in healthy volunteers. Clinical and Experimental Immunology 1980; 40(1):202-205.

Candida albicans, mumps, streptokinase-streptodornase, trichophyton, tuberculin.
Neuvonen P, Salo M, Viljanen M, and Helander I. Retesting results and antibody measurements. Allergy 1985; 40(3):208-212.

Candida, mumps, PPD, staphylococcus toxoid, streptokinase-streptodornase, trichophytonJ Allergy Clin Immunol 1975; 55(4):268-275.

Tuberculin PPD, streptokinase-streptodornase, mumps, Candida. Cancer 1975; 45(3):748-756.

Candida at 1:100/volume, trichophyton at 1:30 or 1:100/volume, mumps at 40 colony-forming units/ml. An article in Emergency Medicine.

In “UpToDate,” it mentions Candida antigen (Candin, Allermed Laboratories), PPD, 5 TU/ml (Sanofi Pasteur), and trichophyton (1:500 w/v, Allermed Laboratories).

Am J Dis Child. 1980 May;134(5):479-83.Diphtheria-tetanus skin testing. Its clinical value for delayed hypersensitivity.
Kaufman DB, deMendon├ža WC, Newton J.
Abstract
Skin testing as an in vivo means of evaluating cell-mediated immune function is extremely valuable. However, problems lie in selecting the appropriate antigens and interpreting the results. The suggestion that diphtheria-tetanus would provide a good antigen in infants and children was evaluated by comparing skin test observations with results of skin biopsy examinations. Thirteen subjects, seven of whom were immunodeficient, were evaluated by skin reactions and dermal biopsy specimens. Fifty percent of the immunodeficient patients had positive skin test reactions but had biopsy specimens that were not consistent with delayed-type hypersensitivity (DTH). Although all normal controls on whom biopsies were done had histologic DTH reactions, two had negative or equivocal skin reactions. Our data suggest, on the contrary, that delayed hypersensitivity testing with this antigen is not a good screening test for disorders of immunity or inflammation.

AAAAI - American Academy of Allergy Asthma & Immunology