Five commercially available enzyme-linked immunosorbent assays for the measurement of anti-tetanus toxoid immunoglobulin G (IgG) antibodies were evaluated for performance. The data suggest that there are manufacturer-dependent differences in sensitivity and accuracy for the determination of tetanus toxoid IgG antibodies that could result in different diagnostic interpretations.The measurement of anti-tetanus toxoid immunoglobulin G (IgG) levels is of value in (i) determining the rates of immunity within broad populations or the immune status of individuals who may be at risk of infection (15), (ii) assessing responses to vaccination and immunization schedule efficacy (2,5,15), and (iii) evaluating individuals for potential immunodeficiency disorders (1, 3).The World Health Organization guidelines suggest that IgG antibody titers above 0.01 IU/ml afford minimal protection against infection and titers above 0.1 IU/ml provide substantial protection (2).Significant differences in performance against international reference preparations and clinical interpretation of a number of patient samples have been found previously in commercial anti-tetanus toxoid enzyme-linked immunosorbent assays (ELISAs) (14). The present study confirms these findings, increases the number of commercial assays evaluated, and extends the comparison of their performance in terms of diagnostic interpretations.Normal human serum samples were obtained from Research Sample Bank, Inc., Pompano Beach, FL, and Golden West Biologicals Inc., Temecula, CA, and stored at Ϫ20°C prior to testing. The reference sample NIBSC 76/589 (NIBSC, Hertfordshire, United Kingdom) was used to evaluate the calibration of the ELISA kits. It was chosen because it is correlated against the mouse in vivo neutralization test, the concentration was more appropriate for the measuring ranges of clinically relevant ELISA kits, and it has been used previously (14). For use, NIBSC 76/589 was reconstituted according to the manufacturer's instructions (working concentration of 1 IU/ ml), serially diluted with distilled water to a final concentration of 0.03 IU/ml, and further diluted immediately into the appropriate sample diluents.Anti-tetanus toxoid IgG antibodies were measured according to the manufacturers' instructions by using the following ELISA kits, with the measuring ranges in parentheses: Euroimmun, Lübeck, Germany (0.01 to 10 IU/ml); Scimedx Corp., Denville, NJ (0.1 to 5 IU/ml); Serion-Verion, Würzburg, Germany (0.1 to 5 IU/ml); The Binding Site, Birmingham, United Kingdom (the TBS assay; 0.01 to 7 IU/ml); and Genzyme Virotech, Rüsselsheim, Germany (0.1 to 5 IU/ml). Results were generated in accordance with the manufacturer's instructions. Assays were considered valid when quality control parameters were in the range specified in the manufacturer's product insert. Intraassay precision was measured by using three serum samples (low, medium, and high levels) and assayed in seven-well repeats at the same time. For interassay precision, the same measurements were performed ...