- Email: [email protected]
Assessment of the immunogenicity and reactogenicity of a quadrivalent diphtheria, tetanus, acellular pertussis and hepatitis B (DTPa-HBV) vaccine administered in a single injection with Haemophilus influenzae type b conjugate vaccine, to infants at 2, 4 and 6 months of age
PII: SO264-410X(98)00114-5
Vacane, Vol. 16, No. 20, pp. 1976-I 981, 1998 0 1998 Elsevier Science Ltd. All rights reserved Printed in Great Britain 0264-410X198 $19+0.00
ELSEVIER
Assessment of the immunogenicity and reactogenicity of a quadrivalent diphtheria, tetanus, acellular pertussis and hepatitis B (DTPa-HBV) vaccine administered in a single injection with Haemophilus influenzae type b conjugate vaccine, to infants at 2,4 and 6 months of age Javier Aristegui”, Rafael Dal-R&@, Elisa Garrote*, Antonio GonzBlez?_, Juan-Pedro Arrate” and Albert0 P&-ez* This double-blind, randomised study was pegormed to assess the immunogenic@ and reactogenicity of three lots of a quadrivalent diphtheria-tetanus-acellular pertussishepatitis B vaccine (DTPa-HBV) co-administered with three lots of Haemophilus influenzae type b conjugate (Hib) vaccine in one injection, as a primary vaccination course in healthy infants at 2, 4 and 6 months of age. 269 infants (8-11 weeks of age) were randomly allocated to three groups to receive DTPa-HBVIHib vaccines, concomitantly with oral polio vaccine. Blood samples for antibody determinations were taken before vaccination and 1 month after the third dose in 262 subjects. Local and general symptoms were recorded by parents on diary cards. All vaccinees had post-vaccination protective anti-D and anti-T (2 0.1 IU ml-‘) antibodies, and 98% had protective antiHBs antibody titres (210 mIU mll’). There were no statistically significant differences between groups in post-vaccination anti-D, anti-T anti-HBs antibody geometric mean titres (GMT), these being 3.49 IU ml-‘, 5.92 IU ml-’ and 1109 mIU ml-‘, respectively All subjects responded to three pertussis components, i.e. pertussis toxin (PT), jilamentous haemagglutinin (FHA) and pertactin (PRN). Although statistically significant digerences in GMTs of anti-PT anti-FM and anti-PBN were found between groups, these were not believed to be of any clinical relevance as the minimum GMTs were 60, 193 and 230 EL.U ml-’ for anti-PT, anti-FHA and anti-Pm, respectively. There were no statistically significant differences in anti-PRP antibody GMT (4.05 ug ml-7 between groups, 100% and 85% of subjects having titres 20.15 and 1.0 ug ml-, respectively. No symptoms were reported for one third of the subjects. Fever ( > 38°C) was reported after 16% of doses, with < 1% having > 39.5”C. Almost all local and general symptoms were mild or moderate, and lasted less than 48 h. No subject dropped out due to a severe adverse reaction. The administration of an experimental mix of DTPa-HBV and Hib vaccines in a single injection is safe, well-tolerated and immunogenic for all vaccine components. 0 1998 Elsevier Science Ltd. All rights reserved Keywords: DTPa-HBV;
Hib: vaccines; single injection: infants
*Department of Pediatrics, Basurto Hospital, c/ Avda Montevideo 18, 48013 Bilbao, Spain and iMedical Department, SmithKline Beecham Pharmaceuticals, c/ Valle de la Fuenfria 3, 28034 Madrid, Spain. *To whom correspondence should be addressed. Tel.: (34-l) 334-52-78; Fax: (34-l) 334-51-41. (Received 13 October 1997; revised version received 20 February 1998; accepted 12 March 1998)
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Vaccine 1998 Volume 16 Number 20
Assessment of OTPa-HBV vaccine in infants: J. Arktegui et al. Combination vaccines are designed to reduce the number of injections at each visit, thereby decreasing discomfort, simplifying logistics for storage, syringes, transportation and training, and reducing costs’,‘. Therefore delivering multiple vaccine antigens in a single injection is considered as a high priority for parents, physicians and manufacturers3. In paediatric vaccination schedules there are currently three major vaccines which can be considered for combinations: (a) diphtheria-tetanus-pertussis (DTP) vaccine, (b) Hepattitis B (HBV) vaccine and (c) Haemophilus injluenzae type b (Hib) vaccine. In addition, inactivated poliovirus vaccine is another important constituent for a future combined vaccine. DTP is one of the cornerstones of the WHO’s worldwide Expanded Programme on Immunization (EPI). Where initiated, most of the countries are using conventional whole-cell pertussis-diphtheria-tetanus toxoid (DTPw) vaccin,es, although many western countries such as Germany, Italy and the US are increasingly using the diphtheria-tetanus-acellular pertussis (DTPa) vaccines, which have been shown to be less reactogenic and at least similar in efficacy to DTPw~-~. In 1996 HBV had been introduced as part of the routine infant or adolescent immunisation programmes in more than 80 countries, following the WHO initiative to integrate Hepatitis B (HBV) vaccine into all national paediatric immunisation programmes by 1997’. Infant vaccination with Hib conjugate has been so successful in a number of western countries that invasive Hib disease is no longer a major public health problem in those countries”. As simultaneous administration of all vaccines in childhood is an importanmt strate to ensure that vaccinations are received on tscheduleY, a vaccine that could protect against diphtheria, tetanus, pertussis, hepatitis B and Hib when administered in one single injection would be an important step towards ensuring a wide childhood coverage against diseases caused by these five infective agents. The present study was designed to assess the immunogenicity and reactogenicity of three combined vaccine lots of a DTPa-HBV co-administered with three lots of Hib conjugate vaccine reconstituted as an experimental mix in one single injection, as a primary vaccination course to healthy infants.
immunogenicity of the antigen components contained in the two study vaccines, administered as primary vaccination at 2, 4 and 6 months of age. A secondary objective was to evaluate the reactogenicity of DTPaHBV/Hib mixture. Study population
Healthy infants, as evidenced by medical history and physical examination, aged between 8 and 12 weeks old at the time of first vaccination were included in this study. Children were randomly allocated to one of the three groups using an algorithm of pseudo random numbers. Infants with evidence of previous DTP, HBV and Hib vaccination, or previous pertussis disease were excluded. Only children born from mothers who were found HBsAg-negative during pregnancy were included. They had not received any previous or concurrent vaccination or immunoglobulin, except for oral polio vaccine, which all infants received, or BCG. The following adverse experiences associated with pertussis immunization constituted absolute contraindication to further administration of pertussis vaccine: rectal temperature 24OS”C within 48 h of vaccination; seizures; encephalopathy; hypersensitivity reaction; persistent, inconsolable screaming or crying for more than 3 h within 48 h after vaccination. Study vaccines
All study vaccines were manufactured by SmithKline Beecham Biologicals, Rixensart, Belgium. Each 0.5 ml dose of DTPa-HBV vaccine contained 25 /lg pertussis toxoid (PT), 25 pg filamentous haemagglutinin (FHA), 8 c(g pertactin (PRN), 230 IU diphtheria toxoid, 240 IU tetanus toxoid and 10 c(g HBV surface antigen adsorbed onto 0.5 mg aluminum salts, with 2.5 mg phenoxyethanol as preservative. The lyophilised Hib vaccine contained 10 pg polyribose-ribitol-phosphate (PRP) conjugated to -30 /lg tetanus toxoid with 10 mg lactose as stabiliser, and was reconstituted in the 0.5 ml volume of the DTPa-HBV vaccine. Vaccines were allocated as follows: Group 1 DTPa-HBV (lot no. 16707B2) and Hib (002A44), Group 2 DTPa-HBV (16708B2) and Hib (OOlA41), and Group 3 DTPaHBV (16710A2) and Hib (003A41). Reactogenicity
MATERIALS AND METHODS Study design
This was a double-blind, parallel, randomised comparative study with three groups of healthy infants. The study protocol was approved by the Research Ethics Committee of the Hospital de Basurto, Bilbao, Spain, and was conducted following the Good Clinical Practice guidelines. Written informed consent was obtained from the parents or guardians of all subjects prior to enrolment. Objectives
The primary objective was to assess the clinical consistency of three consecutive production lots of a combined DTPa-HBV vaccine when co-administered with three lots of an Hib vaccine (DTPa-HBV/Hib), reconstituted in one s#ingle injection, in terms of
assessment
All vaccines were administered intramuscularly on the anterolateral thigh. Subjects were closely monitored for 30 min after each dose. Solicited local reactions (pain on digital pressure, swelling and redness at the injection site) and general symptoms (fever, rectal temperature of 238°C; unusual, unexplained crying for more than 60 min; vomiting, diarrhoea, loss of appetite and restlessness) were recorded on diary cards by the parents on the day of vaccination, and on each of the three subsequent days. Redness and swelling were measured and recorded as severe if > 20 mm in diameter, while local pain and the general symptoms other than fever were assessed by the parents as mild (easily tolerated), moderate (sufficient to interfere with daily activities) or severe (sufficient to prevent normal activity). Fever > 39.5”C was considered as severe. Any symptoms not specifically solicited, or symptoms reported after the 4-day
Vaccine 1998 Volume 16 Number 20
1977
Assessment
of DTPa-HBV
vaccine in infants: J. Aristegui et al.
follow-up period were classified as unsolicited symptoms. Unsolicited symptoms were recorded throughout the vaccination course up to 30 days after the third dose. Serological
analyses
For antibody determinations, blood samples were drawn before the first dose and 1 month after the administration of the third dose. All blood samples were labelled and maintained at -20°C until serological analyses were performed at SmithKline Beecham Biologicals (Rixensart, Belgium), in a coded fashion. Anti-diphtheria’ and anti-tetanus”’ antibody titres were measured by ELISA and expressed in IU ml-‘. Although seroprotection is considered to occur at 0.01 IU ml-‘, a cut-off value of 0.1 IU ml-’ was conservatively applied to ensure a good correlation between the ELISA and the values obtained using in vivo neutralisation tests”‘.“. Titres below cut-off were considered as negative. Antibodies to the pertussis antigens (PT, FHA, PRN) were determined by ELISA and expressed in ELISA Units ml-’ (EL.U ml-‘), with a cut-off of 5 EL.U ml-‘, titres below cut-off being considered as negative. The assay was calibrated using the pooled US FDA reference sera (lot 3 for PT and FHA; lot 4 for PRN). There being no generally accepted protective level for these antibodies, vaccine response was defined as induction of an antibody response to the individual pertussis antigens, taking into account the prevaccination serological status of the subject. For initially seronegative subjects, an antibody response was indicated by a post-vaccination antibody titre 25 EL.U ml-‘. For initially seropositive subjects, an antibody response was indicated by a post-vaccination antibody titre at least equal to the pre-vaccination titre, thus taking into account the expected decrease in maternal antibody titre (half-life for decay of maternal pertussis antibodies is approximately 40 days’“) in the period between pre- and post-vaccination blood sampling. Anti-HBs antibody titres were determined using a commercially radioimmunoassay kit available (AUSAB, Abbott Laboratories, Chicago, IL) with a cut-off of 10 mIU ml-‘. Titres 210 mIU ml-’ are generally considered as protective13. Total antibodies to the Hib polysaccharide PRP were assayed using a radio-labelled antigen binding assayI with a cut-off of 0.15 pg ml-‘. An anti-PRP titre 20.15 /lg ml-’ has been described as being seroprotective for unconjugated Hib vaccines, for which titres 21.0 pg ml-’ are associated with long term protection’5. Sample size and statistical
analysis
The primary endpoint was the comparison of the antibody response to pertussis components, diphtheria and tetanus toxoids, and the seroprotection rates for HBV between the three lots after the third vaccine dose. The sample size was fixed to 75 evaluable subjects per group which allows the detection, with an alpha level of 5% and a power of 80%, of a difference between seroprotection rates from 95% to 78% between the three groups”. To cover unforeseen dropouts, the intention was to enrol 90 subjects per group. The male/female ratio and the mean age between groups and sexes were compared between groups using
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Vaccine 1998 Volume 16 Number 20
Fisher’s exact test and one-way ANOVA, respectively. The immunogenic@ of the study vaccines were investigated by monitoring the antibody levels to each vaccine antigen component in pre- and post-vaccination blood samples. Seropositivity rates (%) for each vaccine antigen were compared using Fisher’s exact test. Geometric Mean Titres (GMT) were calculated, with the 95% confidence interval (CI) for all vaccine components at each point that blood samples were taken. For GMT calculation, antibody titres below the assay cut-off were given an arbitrary value of one half of the cut-off value. Comparison of GMT between groups were performed using a one-way ANOVA test. For each group, the incidence per dose of each solicited symptom over the 4-day follow-up period was calculated. The incidence of fever and local symptoms was compared between vaccine lots using Fisher’s exact test. Unsolicited symptoms were tabulated and their relationship to vaccination given by the investigator. Significance was assumed at p ~0.05. The Bonferroni method was used to adjust p-values on multiple comparisons”. All statistical analyses were performed using SAS software version 6.08 (Statistical Analysis Systems Institute Inc., Cary, NC).
RESULTS Two hundred and seventy infants were enrolled and randomly allocated to one of three groups (90 infants/ group) to receive a three-dose primary vaccination course of DTPa-HBV/Hib in a single injection, at 2, 4 and 6 months of age. Oral polio vaccine was given simultaneously. Two hundred and sixty nine infants received the 1st vaccine dose as consent for one subject (Group 3) was withdrawn before receiving it. Seven subjects were excluded due to protocol violation (n = l), being lost to follow-up (2), migration from study area (2), or failing to provide a final blood sample (2), leaving 262 subjects (86 in Group 1; 87 in Group 2; 89 in Group 3) evaluable for the immunogenicity analysis. There were no statistically significant differences between groups in relation to mean age and male/ female ratio. The mean age (*SD) and the male/ female ratio of the total cohort was 9.3 f 0.5 weeks old (range: S-11) and 0.9311, respectively. Reactogenicity
analysis
Eight hundred and two DTPa-HBViHib vaccine doses were administered to 269 infants, and 801 diary cards (99.9% compliance) were returned. Following DTPa-HBV/Hib administration, 28%, 30% and 41% of doses 1, 2 and 3 were not associated with symptoms, respectively. Solicited general reactions were reported after 63%. 66% and 49% of doses 1, 2 and 3, respectively. Similarly, solicited local symptoms were recorded after 37%, 34% and 33% of doses 1, 2 and 3, respectively. The onset of all symptoms was within the first 48 h after vaccination. The vast majority ( ~95%) were described as mild or moderate, and resolved within 48 h. Fever ( > 38°C) was reported after 16.2% of doses (Table I), but there were only six cases (< 1%) of fever > 39.5”C. None of the subjects enrolled dropped out of the study due to a severe adverse reaction. All of the 46 unsolicited symptoms
Assessment
considered to be related IO DTPa-HBV/Hib were local signs, such as induration, redness and swelling, which were reported after the 4-day follow up period.
Immunogenicity
analysis
There were no statistically significant differences between groups in the pre-vaccination serological status with respect to any of the vaccine antigens. Pre-vaccination, 10% of subjects were anti-HBs positive, whereas for the other antibodies seropositivity rates were 45% (PRP), 5’7% (tetanus), 62% (PT), 71% (PRN), 82% (diphtheria) and 95% (FHA). In infants of this age, prevaccination seropositivity is most probably due to the presence of maternal antibodies. As no statistically significant differences in postvaccination anti-diphtheria, anti-tetanus, anti-HBs or anti-PRP antibody GMTs were found between groups, pooled data for seroprotective rates and GMTs for all three lots are shown in Z&&s 2 and 3. All subjects had protective titres against diphtheria and tetanus one month after the 3rd dose. Almost all (257/262, 98%) subjects had anti-HBs titres 2 10 mIU ml-’ one month after the third dose, with a GMT of 1109 mIU ml-‘. Table 1 lncidences of local and systemic solicited symptoms, and those graded as severe from the 801 diary cards returned
Symptom
Total incidence
‘Severe’
n
(%f
n
(%)
Local Pain Redness Swelling Systemic Fever Diarrhoea Loss of appetite Restlessness Unusual crying Vomiting
127 103 83
(15.9) (12.9) (10.4)
2 3 9
130 47 127 233 205 45
(16.2) (5.9) ‘15.9)
6 3 6 9 12 0
Table 2
rates (“Y) and geometric
Seroprotective
;:::;; (5.6)
(0.2) (0.4) (1.1)
I:::; 1:::; (1.5) 0
of DTPa-HBV vaccine in infants: J. Aristegui et al.
Anti-PRP titres 20.15 pg ml-’ and 2 1.0 pg ml-’ were obtained in 100% and 85% of subjects, respectively, with a GMT of 4.05 /lg ml-‘. All vaccinees responded to the three pertussis components (PT, FHA, PRN) one month after the full vaccination course. Statistically significant differences (~~10.01) in post-vaccination GMTs of anti-PT, antiFHA and anti-PRN antibodies were detected between Groups 1 and 2, Groups 2 and 3, and Groups 2 and 3, respectively (Table 4). However, the anti-PT, anti-FHA and anti-PRN GMTs had a minimum S-, 7- and 2.5fold increase, respectively, in all three groups. DISCUSSION This study shows that the three DTPa-HBV vaccine lots were immunogenic when administered as an experimental mix with an Hib (tetanus-PRP) conjugate vaccine in a single injection as a 3-dose primary vaccination course to infants at 2, 4 and 6 months of age, with simultaneous administration of oral polio vaccine. The safety profile of DTPa-HBV/Hib showed that around l/3 of doses were accompanied by local symptoms and approximately 60% with general symptoms. Fever (rectal temperature > 38”C), which is considered to be the most clinically relevant general symptom’R, was observed following 16.2% of doses, but fever > 39.5”C occurred in less than 1% of cases. These figures are similar to (fever) or higher (local reactions) than those found after a primary vaccination course of the same DTPa vaccine in infants of 3, 4 and 5 months of agelR, but much lower than those reported after the administration of a tetravalent DTPw-HBV vaccine with the same HBV component to infants”**“. Most of the adverse events reported were mild or moderate, and resolved within 48 h. One month after administration of the third dose of DTPa-HBV/Hib, all subjects had protective ( 20.1 IU ml-‘) antibody titres against both diphtheria and tetanus, with anti-diphtheria and anti-tetanus GMTs of 3.5 and 5.9 IU ml-‘, respectively. These values are
mean titres (GMT) for anti-diphtheria
and anti-tetanus
antibodies
by group
20.1 IU ml-’ Group Anti-diphtheria 1 2 3 All Anti-tetanus 1 2 3 All
Timing
n
n
%
GMT (95% Cl)
Pre PHI Pre Plll Pre Pill Pre Pill
86 86 87 87 89 89 262 262
69 86 72 87 75 89 216 262
80.2 100 82.8 100 84.3 100 82.4 100
0.31 3.21 0.27 3.36 0.29 3.91 0.29 3.49
(0.24-0.41) (2.77-3.72) (0.21-0.35) (2.89-3.91) (0.24-0.37) (3.38-4.57) (0.25-0.34) (3.20-3.80)
Pre Pill Pre Plll Pre Pill Pre Pill
86 86 87 87 89 89
55 86 52 87 43 89 150 262
64 100 59.8 100 48.3 100 57.3 100
0.20 5.63 0.17 5.81 0.13 6.33 0.16 5.92
(0.15-0.27) (4.87-6.52) (0.13-0.22) (5.08-6.66) (0.10-0.17) (5.66-7.08) (0.15-0.27) (5.49-6.38)
Pre: pre-vaccination. PIII: post-vaccination, approxirnately 95% Cl: 95% confidence interval.
262
1 month after the 3rd vaccine dose.
Vaccine 1998 Volume 16 Number 20
1979
Assessment of DTPa-HBV vaccine in infants: J. Aristegui et Table 3 Seroprotectiverates (%)and geometric mean titres (GMT)
al.
for anti-HBs and anti-PRP antibodies
by group
2 10 mlU ml-’ Group Anti-HBs 1 2 3 All
Timing
n
n
%
GMT (95% Cl)
Pre Pill Pre Pill Pre Plll Pre Pill
86 86 87 87 89 89 262 262
8 64 13 84 6 89 27 257
9.3 97.7 14.9 96.6 6.7 100 10.3 98.1
9 1033 9 1096 7 1202 8 1109
20.15 Group Anti-PRP 1 2 3 All
mcg ml-’
n
n
%
n
%
GMT (95% Cl)
Pre Pill Pre Pill Pre Pill Pre PIII
86 86 87 87 89 89 262 262
49 86 35 87 34 89 118 262
57 100 40.2 100 38.2 100 45 100
32 74 20 70 15 78 67 222
37.2 86 23 80.5 16.9 87.6 25.6 84.7
0.40 4.21 0.25 3.21 0.21 4.89 0.28 4.05
Pre- and post-vaccination
geometric
mlK”“> following a similar dosing schedule at 2, 4 and 6 months of age, respectively. All subjects had anti-PRP concentrations 20.15 /lg ml-’ one month after receiving the third dose of DTPa-HBV/Hib, and 85% had anti-PRP levels 2 1.0 ttg ml-‘. These values are currently used as indicators of clinical and long-term protection a ainst invasive R Haemoplzilus inftuenzae type b disease4. , respectively, although it should be noted that they were originally established for non-conjugated Hib polysaccharide vaccines and do not take into account non-humoral immune responses which ma play a role in protection against invasive Hib disease-J . These results are at least as high as of those found with a 3-dose primary course of four commercial PRP-conjugate vaccines administered at 2, 4 and 6 months of age as separate injectionsz4, and are somewhat higher than those found in a German study performed in infants who received the same vaccines (DTPa-HBV/Hib) at 3, 4 and 5 months of age. In the latter study only 71% of subjects had anti-PRP titres 2 1.0 /lg ml-’ one month after the last dose”. In that study it was shown that children primed with similar DTPa-HBV and tetanus-PRP conjugate
mean titres (GMT, EL.U ml-‘) of pertussis antigens with 95% confidence
Antibody
Group (n)
Pre-vaccination
Anti-PT
1 2 3 1 2 3 1 2 3
8 7 9 30 25 29 10 9 11
Anti-PRN
(86) (87) (89) (84) (87) (87) (86) (87) (89)
(6-l 0) (6-9) (7-l 1) (24-37) (19-32) (23-37) (8-13) (7-l 2) (8-14)
GMT (95% Cl)
Vaccine 1998 Volume 16 Number 20
intervals (Cl)
Post-vaccination 80 60 73 218 193 275 250 230 336
GMT (95% Cl)
(69-93)b (52-68)b (64-84) (191-250) (167-222)’ (241-315)’ (216-290) (198-269)’ (287-394)‘=
n: number of subjects tested; 95% Cl: 95% confidence interval; PT: pertussis toxin; FHA: filamentous haemagglutinin; serological determinations were not performed due to insufficient serum. “p = 0.01. ‘p = 0.001. “p = 0.002.
1980
(0.29-0.56) (3.22-5.52) (0.18-0.35) (2.48-4.17) (0.16-0.29) (3.73-6.41) (0.23-0.33) (3.47-4.72)
1 month after the 3rd vaccine dose.
similar too those obtained with a combined DTPw-HBV vaccine , which has recently been approved by the European Medicines Evaluation Agency (London). For the pertussis antigens, all subjects responded to the three vaccine components, but there were statistically significant differences between lots for the post-vaccination GMTs of anti-PT, anti-FHA and anti-PRN antibodies. However, the clinical relevance of these differences is doubtful since the GMTs obtained for all three lots and for all three antibodies (anti-PT, antiFHA and anti-PRN) were similar to, or even higher than, those observed in trials where this DTPa vaccine was demonstrated to have an efficacy rate of 84-89%6.‘8*2’. Seroprotective titres against hepatitis B (2 10 mIU ml-‘) were elicited in 98% of subjects after administration of all three vaccine doses, with a GMT of 1109 mIU ml-‘. These figures are similar, but with a lower GMT, to those obtained when the same recombinant vaccine (HBV) was given concomitantly with a DTPw vae!;e (seroprotection rate = 99%; GMT = 1812 mIU DTPw-HBV vaccine ml ) or as a combined (seroprotection rate = 100%; GMT = 2318 mIU
Anti-FHA”
2 1.O mcg ml-’
Timing
Pre: pre-vaccination. PIII: post-vaccination, approximately 95% Cl: 95% confidence interval.
Table 4
(6-13) (757-1410) (7-14) (770-1561) (5-10) (921-1571) (7-10) (929-1325)
PRN: pertactin. “Four
Assessment
vaccines had a good primary humoral response, and induced immunological memory, as a rapid and large immune response was observed after exposure to plain PRP, indicating that protection against circulating wildtype Hib had been generatedz3. The use of a combined DTPa-HBV-Hib vaccine would help to ensure a high coverage against five infective agents in those western countries which are currently immunizing their infants against them. Moreover, in countries such as Southern European ones, with well established universal vaccination programmes against HBV’, and where the introduction of systematic vaccination against Hib has been strongly advocatedx, the immunization of infants in a single injection against diphtheria, tetanus, B pertussis, hepatitis B and Haemophilus inj?uenzae type b would be an invaluable tool to ensure that complete vaccination is received on schedule.
10
11
12
13
14
15
ACKNOWLEDGEMENTS Study supported by a grant of SmithKline Biologicals, Rixensart, B’elgium
9
Beecham
16
17
REFERENCES King, G.E. and Hadler. SC. Centers for Disease Control: current issues in pediatrics. Simultaneous administration of childhood vaccines: an important public health policy that is safe and efficacious. Pediatr. Infect. Dis. J. 1994, 13, 394-407. Van Damme, P., Kane, M. and Meheus, A. on behalf of the Viral Hepatitis Prevention Board. Integration of hepatitis B vaccination into national immunisation programmes. Br. Med. J. 1997, 314, 1033-l 037. Edwards, K.M. and Decker, M.D. Challenges for licensure of new diphtheria, tetanus toxoid, acellular pertussis (DTaP) combination vaccines: counterpoint. Pediatr. Infect. Dis. J. 1996, 15,1070-1073. Centres for Disease Control and Prevention. Pertussis vaccination: use of acellular pertussis vaccines among infants and young children. Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1997, 46 @R-7), pp. l-25. Edwards, K.M. and Decker, M.D. Acellular pertussis vaccines for infants. N. Ena/. J. Med. 1996, 334. 391-392. Greco, D., Salm&o, S., Mastrantonib, P. et al. A controlled trial of two acellular vaccines and one whole-cell vaccine against pertussis. N. Engl. J. Med. 1996, 334, 341-348. Gustafson, L., Hallander, H.O., Olin, P., Reizenstein, E. and Storsaeter, J. A controlled trial of two-component acellular, a five-component acellular, and a whole-cell pertussis vaccine. N. Engl. J. Med. 1996, 334, 349-355. J., Ruiz-Contreras, J. et a/. Barquet, N., Aristegui, Hib-EuroSud’95: the South exists. Vaccine 1996, 14, 1569-l 572.
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of DTPa-HEW vaccine in infants: J. Aristegui
et al.
Camargo, M.E., Silveira, L., Furuta, J.A., Oliveira, E.P.T. and Germak, O.A. lmmunoenzymatic assay of anti-diphtheric toxin antibodies in human serum. J. C/in. Microbial. 1984, 20, 772-774. Melville-Smith, M.E., Seagroatt, V.A. and Watkins, J.T. A comparison of enzyme linked immunosorbent assay (ELISA) with the toxin neutralisation test in mice as a method for the estimation of tetanus antitoxin in human sera. J. Biol. Stand. 1983, 11, 137-144. Melville-Smith, M.E. and Balfour, E. Estimation of Corynebacterium diphtheriae antitoxin in human sera: a comparison of enzyme-linked immunosorbant assay with the toxin neutralisation test. J. Med. Microbial. 1988, 25, 279-283. Van Savage, J., Decker, M., Edwards, K.M., Sell, S.H. and Karzon, D.T. Natural history of pertussis antibody in the infant and effect on vaccine response. J. Infect. Dis. 1990, 161, 487-492. Frisch-Niggemeyer, W., Ambrosch, F. and Hoffman, H. The assessment of immunity against hepatitis B after vaccination. J. Biol. Stand. 1986, 14, 255-258. Kuo, J.S.-C., Moji, N., Schwalbe, R.S. and McCoy, D.W. A radioactive antigen-binding assay for the measurement of antobody to Haemophilus influenzae type b capsular polysaccharide. J. Immunol. Methods 1981, 43, 35-37. Kaythy, H. Difficulties in establishing a serological correlate of protection after immunization with Haemophilus influenzae conjugate vaccines. Biologicals 1994, 22, 397-402. Schwartz, D., Flamant, R. and Lellouch, J. L’essai therapeutique chez /‘Hornme. Flammarion MBdecine-Sciences, Paris, 1985. Altman, D.G. Practical Statistics for Medical Research. Chapman and Hall, London, 1991. Schmitt, H.J., Schuind, A., Knuf, M. et al. Clinical experience of a tricomponent acellular pertussis vaccine combined with diphtheria and tetanus toxoids for primary vaccination in 22,505 infants. J. Pediafr. 1996, 129, 695-701. Aristegui, J., Garrote, E., Gonz&lez, A., Arrate, J.P., Perez, A. and Vandepapeliere, P. Immune response to a combined Hepatitis B, Diphtheria, Tetanus and whole-cell Pertussis vaccine administered to infants at 2, 4 and 6 months of age. Vaccine 1997, 15, 7-9. Diez-Delgado, J., Dal-R& R., Llorente, M., Gonzalez, A. and Lopez, J. Hepatitis B component does not interfere with the immune response to diphtheria, tetanus and whole-cell Bordetella pertussis components of a quadrivalent (DTPwHBV) vaccine: a controlled trial in healthy infants. Vaccine 1997,15,1418-1422. Schmitt, H.J., Wirsing von Kbnig, C.H., Neiss. A. et al. Efficacy of acellular pertussis vaccine in early childhood after household exposure. JAMA 1996,275,37-41. Greenberg, D.P., Vadheim, CM., Marcy, S.M. et al. Safety and immunogenicity of a recombinant hepatitis B vaccine administered to infants at 2, 4 and 6 months of age. Vaccine 1996, 14, 811-816. Zepp, F., Schmitt, H.J., Kaufhold, A. et al. Evidence for induction of polysaccharide specific B-cell-memory in the 1st year of life: plain Haemophilus influenzae type b-PRP (Hib) boosters children primed with a tetanus-conjugate Hib-DTPaHBV combined vaccine. Eur. J. Pediatr. 1997, 156, 18-24. Decker, M.D., Edwards, K.M., Bradley, R. and Palmer, P. Comparative trial in infants of four conjugate Haemophilus influenzae type b vaccines. J. Pediatr. 1997, 120, 184- 189.
Vaccine 1998 Volume 16 Number 20
1981
Vacane, Vol. 16, No. 20, pp. 1976-I 981, 1998 0 1998 Elsevier Science Ltd. All rights reserved Printed in Great Britain 0264-410X198 $19+0.00
ELSEVIER
Assessment of the immunogenicity and reactogenicity of a quadrivalent diphtheria, tetanus, acellular pertussis and hepatitis B (DTPa-HBV) vaccine administered in a single injection with Haemophilus influenzae type b conjugate vaccine, to infants at 2,4 and 6 months of age Javier Aristegui”, Rafael Dal-R&@, Elisa Garrote*, Antonio GonzBlez?_, Juan-Pedro Arrate” and Albert0 P&-ez* This double-blind, randomised study was pegormed to assess the immunogenic@ and reactogenicity of three lots of a quadrivalent diphtheria-tetanus-acellular pertussishepatitis B vaccine (DTPa-HBV) co-administered with three lots of Haemophilus influenzae type b conjugate (Hib) vaccine in one injection, as a primary vaccination course in healthy infants at 2, 4 and 6 months of age. 269 infants (8-11 weeks of age) were randomly allocated to three groups to receive DTPa-HBVIHib vaccines, concomitantly with oral polio vaccine. Blood samples for antibody determinations were taken before vaccination and 1 month after the third dose in 262 subjects. Local and general symptoms were recorded by parents on diary cards. All vaccinees had post-vaccination protective anti-D and anti-T (2 0.1 IU ml-‘) antibodies, and 98% had protective antiHBs antibody titres (210 mIU mll’). There were no statistically significant differences between groups in post-vaccination anti-D, anti-T anti-HBs antibody geometric mean titres (GMT), these being 3.49 IU ml-‘, 5.92 IU ml-’ and 1109 mIU ml-‘, respectively All subjects responded to three pertussis components, i.e. pertussis toxin (PT), jilamentous haemagglutinin (FHA) and pertactin (PRN). Although statistically significant digerences in GMTs of anti-PT anti-FM and anti-PBN were found between groups, these were not believed to be of any clinical relevance as the minimum GMTs were 60, 193 and 230 EL.U ml-’ for anti-PT, anti-FHA and anti-Pm, respectively. There were no statistically significant differences in anti-PRP antibody GMT (4.05 ug ml-7 between groups, 100% and 85% of subjects having titres 20.15 and 1.0 ug ml-, respectively. No symptoms were reported for one third of the subjects. Fever ( > 38°C) was reported after 16% of doses, with < 1% having > 39.5”C. Almost all local and general symptoms were mild or moderate, and lasted less than 48 h. No subject dropped out due to a severe adverse reaction. The administration of an experimental mix of DTPa-HBV and Hib vaccines in a single injection is safe, well-tolerated and immunogenic for all vaccine components. 0 1998 Elsevier Science Ltd. All rights reserved Keywords: DTPa-HBV;
Hib: vaccines; single injection: infants
*Department of Pediatrics, Basurto Hospital, c/ Avda Montevideo 18, 48013 Bilbao, Spain and iMedical Department, SmithKline Beecham Pharmaceuticals, c/ Valle de la Fuenfria 3, 28034 Madrid, Spain. *To whom correspondence should be addressed. Tel.: (34-l) 334-52-78; Fax: (34-l) 334-51-41. (Received 13 October 1997; revised version received 20 February 1998; accepted 12 March 1998)
1976
Vaccine 1998 Volume 16 Number 20
Assessment of OTPa-HBV vaccine in infants: J. Arktegui et al. Combination vaccines are designed to reduce the number of injections at each visit, thereby decreasing discomfort, simplifying logistics for storage, syringes, transportation and training, and reducing costs’,‘. Therefore delivering multiple vaccine antigens in a single injection is considered as a high priority for parents, physicians and manufacturers3. In paediatric vaccination schedules there are currently three major vaccines which can be considered for combinations: (a) diphtheria-tetanus-pertussis (DTP) vaccine, (b) Hepattitis B (HBV) vaccine and (c) Haemophilus injluenzae type b (Hib) vaccine. In addition, inactivated poliovirus vaccine is another important constituent for a future combined vaccine. DTP is one of the cornerstones of the WHO’s worldwide Expanded Programme on Immunization (EPI). Where initiated, most of the countries are using conventional whole-cell pertussis-diphtheria-tetanus toxoid (DTPw) vaccin,es, although many western countries such as Germany, Italy and the US are increasingly using the diphtheria-tetanus-acellular pertussis (DTPa) vaccines, which have been shown to be less reactogenic and at least similar in efficacy to DTPw~-~. In 1996 HBV had been introduced as part of the routine infant or adolescent immunisation programmes in more than 80 countries, following the WHO initiative to integrate Hepatitis B (HBV) vaccine into all national paediatric immunisation programmes by 1997’. Infant vaccination with Hib conjugate has been so successful in a number of western countries that invasive Hib disease is no longer a major public health problem in those countries”. As simultaneous administration of all vaccines in childhood is an importanmt strate to ensure that vaccinations are received on tscheduleY, a vaccine that could protect against diphtheria, tetanus, pertussis, hepatitis B and Hib when administered in one single injection would be an important step towards ensuring a wide childhood coverage against diseases caused by these five infective agents. The present study was designed to assess the immunogenicity and reactogenicity of three combined vaccine lots of a DTPa-HBV co-administered with three lots of Hib conjugate vaccine reconstituted as an experimental mix in one single injection, as a primary vaccination course to healthy infants.
immunogenicity of the antigen components contained in the two study vaccines, administered as primary vaccination at 2, 4 and 6 months of age. A secondary objective was to evaluate the reactogenicity of DTPaHBV/Hib mixture. Study population
Healthy infants, as evidenced by medical history and physical examination, aged between 8 and 12 weeks old at the time of first vaccination were included in this study. Children were randomly allocated to one of the three groups using an algorithm of pseudo random numbers. Infants with evidence of previous DTP, HBV and Hib vaccination, or previous pertussis disease were excluded. Only children born from mothers who were found HBsAg-negative during pregnancy were included. They had not received any previous or concurrent vaccination or immunoglobulin, except for oral polio vaccine, which all infants received, or BCG. The following adverse experiences associated with pertussis immunization constituted absolute contraindication to further administration of pertussis vaccine: rectal temperature 24OS”C within 48 h of vaccination; seizures; encephalopathy; hypersensitivity reaction; persistent, inconsolable screaming or crying for more than 3 h within 48 h after vaccination. Study vaccines
All study vaccines were manufactured by SmithKline Beecham Biologicals, Rixensart, Belgium. Each 0.5 ml dose of DTPa-HBV vaccine contained 25 /lg pertussis toxoid (PT), 25 pg filamentous haemagglutinin (FHA), 8 c(g pertactin (PRN), 230 IU diphtheria toxoid, 240 IU tetanus toxoid and 10 c(g HBV surface antigen adsorbed onto 0.5 mg aluminum salts, with 2.5 mg phenoxyethanol as preservative. The lyophilised Hib vaccine contained 10 pg polyribose-ribitol-phosphate (PRP) conjugated to -30 /lg tetanus toxoid with 10 mg lactose as stabiliser, and was reconstituted in the 0.5 ml volume of the DTPa-HBV vaccine. Vaccines were allocated as follows: Group 1 DTPa-HBV (lot no. 16707B2) and Hib (002A44), Group 2 DTPa-HBV (16708B2) and Hib (OOlA41), and Group 3 DTPaHBV (16710A2) and Hib (003A41). Reactogenicity
MATERIALS AND METHODS Study design
This was a double-blind, parallel, randomised comparative study with three groups of healthy infants. The study protocol was approved by the Research Ethics Committee of the Hospital de Basurto, Bilbao, Spain, and was conducted following the Good Clinical Practice guidelines. Written informed consent was obtained from the parents or guardians of all subjects prior to enrolment. Objectives
The primary objective was to assess the clinical consistency of three consecutive production lots of a combined DTPa-HBV vaccine when co-administered with three lots of an Hib vaccine (DTPa-HBV/Hib), reconstituted in one s#ingle injection, in terms of
assessment
All vaccines were administered intramuscularly on the anterolateral thigh. Subjects were closely monitored for 30 min after each dose. Solicited local reactions (pain on digital pressure, swelling and redness at the injection site) and general symptoms (fever, rectal temperature of 238°C; unusual, unexplained crying for more than 60 min; vomiting, diarrhoea, loss of appetite and restlessness) were recorded on diary cards by the parents on the day of vaccination, and on each of the three subsequent days. Redness and swelling were measured and recorded as severe if > 20 mm in diameter, while local pain and the general symptoms other than fever were assessed by the parents as mild (easily tolerated), moderate (sufficient to interfere with daily activities) or severe (sufficient to prevent normal activity). Fever > 39.5”C was considered as severe. Any symptoms not specifically solicited, or symptoms reported after the 4-day
Vaccine 1998 Volume 16 Number 20
1977
Assessment
of DTPa-HBV
vaccine in infants: J. Aristegui et al.
follow-up period were classified as unsolicited symptoms. Unsolicited symptoms were recorded throughout the vaccination course up to 30 days after the third dose. Serological
analyses
For antibody determinations, blood samples were drawn before the first dose and 1 month after the administration of the third dose. All blood samples were labelled and maintained at -20°C until serological analyses were performed at SmithKline Beecham Biologicals (Rixensart, Belgium), in a coded fashion. Anti-diphtheria’ and anti-tetanus”’ antibody titres were measured by ELISA and expressed in IU ml-‘. Although seroprotection is considered to occur at 0.01 IU ml-‘, a cut-off value of 0.1 IU ml-’ was conservatively applied to ensure a good correlation between the ELISA and the values obtained using in vivo neutralisation tests”‘.“. Titres below cut-off were considered as negative. Antibodies to the pertussis antigens (PT, FHA, PRN) were determined by ELISA and expressed in ELISA Units ml-’ (EL.U ml-‘), with a cut-off of 5 EL.U ml-‘, titres below cut-off being considered as negative. The assay was calibrated using the pooled US FDA reference sera (lot 3 for PT and FHA; lot 4 for PRN). There being no generally accepted protective level for these antibodies, vaccine response was defined as induction of an antibody response to the individual pertussis antigens, taking into account the prevaccination serological status of the subject. For initially seronegative subjects, an antibody response was indicated by a post-vaccination antibody titre 25 EL.U ml-‘. For initially seropositive subjects, an antibody response was indicated by a post-vaccination antibody titre at least equal to the pre-vaccination titre, thus taking into account the expected decrease in maternal antibody titre (half-life for decay of maternal pertussis antibodies is approximately 40 days’“) in the period between pre- and post-vaccination blood sampling. Anti-HBs antibody titres were determined using a commercially radioimmunoassay kit available (AUSAB, Abbott Laboratories, Chicago, IL) with a cut-off of 10 mIU ml-‘. Titres 210 mIU ml-’ are generally considered as protective13. Total antibodies to the Hib polysaccharide PRP were assayed using a radio-labelled antigen binding assayI with a cut-off of 0.15 pg ml-‘. An anti-PRP titre 20.15 /lg ml-’ has been described as being seroprotective for unconjugated Hib vaccines, for which titres 21.0 pg ml-’ are associated with long term protection’5. Sample size and statistical
analysis
The primary endpoint was the comparison of the antibody response to pertussis components, diphtheria and tetanus toxoids, and the seroprotection rates for HBV between the three lots after the third vaccine dose. The sample size was fixed to 75 evaluable subjects per group which allows the detection, with an alpha level of 5% and a power of 80%, of a difference between seroprotection rates from 95% to 78% between the three groups”. To cover unforeseen dropouts, the intention was to enrol 90 subjects per group. The male/female ratio and the mean age between groups and sexes were compared between groups using
1978
Vaccine 1998 Volume 16 Number 20
Fisher’s exact test and one-way ANOVA, respectively. The immunogenic@ of the study vaccines were investigated by monitoring the antibody levels to each vaccine antigen component in pre- and post-vaccination blood samples. Seropositivity rates (%) for each vaccine antigen were compared using Fisher’s exact test. Geometric Mean Titres (GMT) were calculated, with the 95% confidence interval (CI) for all vaccine components at each point that blood samples were taken. For GMT calculation, antibody titres below the assay cut-off were given an arbitrary value of one half of the cut-off value. Comparison of GMT between groups were performed using a one-way ANOVA test. For each group, the incidence per dose of each solicited symptom over the 4-day follow-up period was calculated. The incidence of fever and local symptoms was compared between vaccine lots using Fisher’s exact test. Unsolicited symptoms were tabulated and their relationship to vaccination given by the investigator. Significance was assumed at p ~0.05. The Bonferroni method was used to adjust p-values on multiple comparisons”. All statistical analyses were performed using SAS software version 6.08 (Statistical Analysis Systems Institute Inc., Cary, NC).
RESULTS Two hundred and seventy infants were enrolled and randomly allocated to one of three groups (90 infants/ group) to receive a three-dose primary vaccination course of DTPa-HBV/Hib in a single injection, at 2, 4 and 6 months of age. Oral polio vaccine was given simultaneously. Two hundred and sixty nine infants received the 1st vaccine dose as consent for one subject (Group 3) was withdrawn before receiving it. Seven subjects were excluded due to protocol violation (n = l), being lost to follow-up (2), migration from study area (2), or failing to provide a final blood sample (2), leaving 262 subjects (86 in Group 1; 87 in Group 2; 89 in Group 3) evaluable for the immunogenicity analysis. There were no statistically significant differences between groups in relation to mean age and male/ female ratio. The mean age (*SD) and the male/ female ratio of the total cohort was 9.3 f 0.5 weeks old (range: S-11) and 0.9311, respectively. Reactogenicity
analysis
Eight hundred and two DTPa-HBViHib vaccine doses were administered to 269 infants, and 801 diary cards (99.9% compliance) were returned. Following DTPa-HBV/Hib administration, 28%, 30% and 41% of doses 1, 2 and 3 were not associated with symptoms, respectively. Solicited general reactions were reported after 63%. 66% and 49% of doses 1, 2 and 3, respectively. Similarly, solicited local symptoms were recorded after 37%, 34% and 33% of doses 1, 2 and 3, respectively. The onset of all symptoms was within the first 48 h after vaccination. The vast majority ( ~95%) were described as mild or moderate, and resolved within 48 h. Fever ( > 38°C) was reported after 16.2% of doses (Table I), but there were only six cases (< 1%) of fever > 39.5”C. None of the subjects enrolled dropped out of the study due to a severe adverse reaction. All of the 46 unsolicited symptoms
Assessment
considered to be related IO DTPa-HBV/Hib were local signs, such as induration, redness and swelling, which were reported after the 4-day follow up period.
Immunogenicity
analysis
There were no statistically significant differences between groups in the pre-vaccination serological status with respect to any of the vaccine antigens. Pre-vaccination, 10% of subjects were anti-HBs positive, whereas for the other antibodies seropositivity rates were 45% (PRP), 5’7% (tetanus), 62% (PT), 71% (PRN), 82% (diphtheria) and 95% (FHA). In infants of this age, prevaccination seropositivity is most probably due to the presence of maternal antibodies. As no statistically significant differences in postvaccination anti-diphtheria, anti-tetanus, anti-HBs or anti-PRP antibody GMTs were found between groups, pooled data for seroprotective rates and GMTs for all three lots are shown in Z&&s 2 and 3. All subjects had protective titres against diphtheria and tetanus one month after the 3rd dose. Almost all (257/262, 98%) subjects had anti-HBs titres 2 10 mIU ml-’ one month after the third dose, with a GMT of 1109 mIU ml-‘. Table 1 lncidences of local and systemic solicited symptoms, and those graded as severe from the 801 diary cards returned
Symptom
Total incidence
‘Severe’
n
(%f
n
(%)
Local Pain Redness Swelling Systemic Fever Diarrhoea Loss of appetite Restlessness Unusual crying Vomiting
127 103 83
(15.9) (12.9) (10.4)
2 3 9
130 47 127 233 205 45
(16.2) (5.9) ‘15.9)
6 3 6 9 12 0
Table 2
rates (“Y) and geometric
Seroprotective
;:::;; (5.6)
(0.2) (0.4) (1.1)
I:::; 1:::; (1.5) 0
of DTPa-HBV vaccine in infants: J. Aristegui et al.
Anti-PRP titres 20.15 pg ml-’ and 2 1.0 pg ml-’ were obtained in 100% and 85% of subjects, respectively, with a GMT of 4.05 /lg ml-‘. All vaccinees responded to the three pertussis components (PT, FHA, PRN) one month after the full vaccination course. Statistically significant differences (~~10.01) in post-vaccination GMTs of anti-PT, antiFHA and anti-PRN antibodies were detected between Groups 1 and 2, Groups 2 and 3, and Groups 2 and 3, respectively (Table 4). However, the anti-PT, anti-FHA and anti-PRN GMTs had a minimum S-, 7- and 2.5fold increase, respectively, in all three groups. DISCUSSION This study shows that the three DTPa-HBV vaccine lots were immunogenic when administered as an experimental mix with an Hib (tetanus-PRP) conjugate vaccine in a single injection as a 3-dose primary vaccination course to infants at 2, 4 and 6 months of age, with simultaneous administration of oral polio vaccine. The safety profile of DTPa-HBV/Hib showed that around l/3 of doses were accompanied by local symptoms and approximately 60% with general symptoms. Fever (rectal temperature > 38”C), which is considered to be the most clinically relevant general symptom’R, was observed following 16.2% of doses, but fever > 39.5”C occurred in less than 1% of cases. These figures are similar to (fever) or higher (local reactions) than those found after a primary vaccination course of the same DTPa vaccine in infants of 3, 4 and 5 months of agelR, but much lower than those reported after the administration of a tetravalent DTPw-HBV vaccine with the same HBV component to infants”**“. Most of the adverse events reported were mild or moderate, and resolved within 48 h. One month after administration of the third dose of DTPa-HBV/Hib, all subjects had protective ( 20.1 IU ml-‘) antibody titres against both diphtheria and tetanus, with anti-diphtheria and anti-tetanus GMTs of 3.5 and 5.9 IU ml-‘, respectively. These values are
mean titres (GMT) for anti-diphtheria
and anti-tetanus
antibodies
by group
20.1 IU ml-’ Group Anti-diphtheria 1 2 3 All Anti-tetanus 1 2 3 All
Timing
n
n
%
GMT (95% Cl)
Pre PHI Pre Plll Pre Pill Pre Pill
86 86 87 87 89 89 262 262
69 86 72 87 75 89 216 262
80.2 100 82.8 100 84.3 100 82.4 100
0.31 3.21 0.27 3.36 0.29 3.91 0.29 3.49
(0.24-0.41) (2.77-3.72) (0.21-0.35) (2.89-3.91) (0.24-0.37) (3.38-4.57) (0.25-0.34) (3.20-3.80)
Pre Pill Pre Plll Pre Pill Pre Pill
86 86 87 87 89 89
55 86 52 87 43 89 150 262
64 100 59.8 100 48.3 100 57.3 100
0.20 5.63 0.17 5.81 0.13 6.33 0.16 5.92
(0.15-0.27) (4.87-6.52) (0.13-0.22) (5.08-6.66) (0.10-0.17) (5.66-7.08) (0.15-0.27) (5.49-6.38)
Pre: pre-vaccination. PIII: post-vaccination, approxirnately 95% Cl: 95% confidence interval.
262
1 month after the 3rd vaccine dose.
Vaccine 1998 Volume 16 Number 20
1979
Assessment of DTPa-HBV vaccine in infants: J. Aristegui et Table 3 Seroprotectiverates (%)and geometric mean titres (GMT)
al.
for anti-HBs and anti-PRP antibodies
by group
2 10 mlU ml-’ Group Anti-HBs 1 2 3 All
Timing
n
n
%
GMT (95% Cl)
Pre Pill Pre Pill Pre Plll Pre Pill
86 86 87 87 89 89 262 262
8 64 13 84 6 89 27 257
9.3 97.7 14.9 96.6 6.7 100 10.3 98.1
9 1033 9 1096 7 1202 8 1109
20.15 Group Anti-PRP 1 2 3 All
mcg ml-’
n
n
%
n
%
GMT (95% Cl)
Pre Pill Pre Pill Pre Pill Pre PIII
86 86 87 87 89 89 262 262
49 86 35 87 34 89 118 262
57 100 40.2 100 38.2 100 45 100
32 74 20 70 15 78 67 222
37.2 86 23 80.5 16.9 87.6 25.6 84.7
0.40 4.21 0.25 3.21 0.21 4.89 0.28 4.05
Pre- and post-vaccination
geometric
mlK”“> following a similar dosing schedule at 2, 4 and 6 months of age, respectively. All subjects had anti-PRP concentrations 20.15 /lg ml-’ one month after receiving the third dose of DTPa-HBV/Hib, and 85% had anti-PRP levels 2 1.0 ttg ml-‘. These values are currently used as indicators of clinical and long-term protection a ainst invasive R Haemoplzilus inftuenzae type b disease4. , respectively, although it should be noted that they were originally established for non-conjugated Hib polysaccharide vaccines and do not take into account non-humoral immune responses which ma play a role in protection against invasive Hib disease-J . These results are at least as high as of those found with a 3-dose primary course of four commercial PRP-conjugate vaccines administered at 2, 4 and 6 months of age as separate injectionsz4, and are somewhat higher than those found in a German study performed in infants who received the same vaccines (DTPa-HBV/Hib) at 3, 4 and 5 months of age. In the latter study only 71% of subjects had anti-PRP titres 2 1.0 /lg ml-’ one month after the last dose”. In that study it was shown that children primed with similar DTPa-HBV and tetanus-PRP conjugate
mean titres (GMT, EL.U ml-‘) of pertussis antigens with 95% confidence
Antibody
Group (n)
Pre-vaccination
Anti-PT
1 2 3 1 2 3 1 2 3
8 7 9 30 25 29 10 9 11
Anti-PRN
(86) (87) (89) (84) (87) (87) (86) (87) (89)
(6-l 0) (6-9) (7-l 1) (24-37) (19-32) (23-37) (8-13) (7-l 2) (8-14)
GMT (95% Cl)
Vaccine 1998 Volume 16 Number 20
intervals (Cl)
Post-vaccination 80 60 73 218 193 275 250 230 336
GMT (95% Cl)
(69-93)b (52-68)b (64-84) (191-250) (167-222)’ (241-315)’ (216-290) (198-269)’ (287-394)‘=
n: number of subjects tested; 95% Cl: 95% confidence interval; PT: pertussis toxin; FHA: filamentous haemagglutinin; serological determinations were not performed due to insufficient serum. “p = 0.01. ‘p = 0.001. “p = 0.002.
1980
(0.29-0.56) (3.22-5.52) (0.18-0.35) (2.48-4.17) (0.16-0.29) (3.73-6.41) (0.23-0.33) (3.47-4.72)
1 month after the 3rd vaccine dose.
similar too those obtained with a combined DTPw-HBV vaccine , which has recently been approved by the European Medicines Evaluation Agency (London). For the pertussis antigens, all subjects responded to the three vaccine components, but there were statistically significant differences between lots for the post-vaccination GMTs of anti-PT, anti-FHA and anti-PRN antibodies. However, the clinical relevance of these differences is doubtful since the GMTs obtained for all three lots and for all three antibodies (anti-PT, antiFHA and anti-PRN) were similar to, or even higher than, those observed in trials where this DTPa vaccine was demonstrated to have an efficacy rate of 84-89%6.‘8*2’. Seroprotective titres against hepatitis B (2 10 mIU ml-‘) were elicited in 98% of subjects after administration of all three vaccine doses, with a GMT of 1109 mIU ml-‘. These figures are similar, but with a lower GMT, to those obtained when the same recombinant vaccine (HBV) was given concomitantly with a DTPw vae!;e (seroprotection rate = 99%; GMT = 1812 mIU DTPw-HBV vaccine ml ) or as a combined (seroprotection rate = 100%; GMT = 2318 mIU
Anti-FHA”
2 1.O mcg ml-’
Timing
Pre: pre-vaccination. PIII: post-vaccination, approximately 95% Cl: 95% confidence interval.
Table 4
(6-13) (757-1410) (7-14) (770-1561) (5-10) (921-1571) (7-10) (929-1325)
PRN: pertactin. “Four
Assessment
vaccines had a good primary humoral response, and induced immunological memory, as a rapid and large immune response was observed after exposure to plain PRP, indicating that protection against circulating wildtype Hib had been generatedz3. The use of a combined DTPa-HBV-Hib vaccine would help to ensure a high coverage against five infective agents in those western countries which are currently immunizing their infants against them. Moreover, in countries such as Southern European ones, with well established universal vaccination programmes against HBV’, and where the introduction of systematic vaccination against Hib has been strongly advocatedx, the immunization of infants in a single injection against diphtheria, tetanus, B pertussis, hepatitis B and Haemophilus inj?uenzae type b would be an invaluable tool to ensure that complete vaccination is received on schedule.
10
11
12
13
14
15
ACKNOWLEDGEMENTS Study supported by a grant of SmithKline Biologicals, Rixensart, B’elgium
9
Beecham
16
17
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