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

Elsevier PII: S0264410X(96)00130-2

ELSEVIER

Vaccine, Vol. 15, No. 1, pp. 7-9, 1997 Copyright 0 1997 Elsevier Science Ltd. All rights reserved Printed in Great Britain 0264-41 OX/97 $17+0.00

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 Javier Aristegui*, Elisa Garrote *, Antonio Gonziileztg, Juan-Pedro Albert0 Perez* and Pierre Vandepapeli&re$

Arrate*,

The objective of this study was to evaluate the immune response and reactagenicity of a communed hepatitis B, diphtheria, tetanus and whole-cell Bordetella pertussis (DTPw-HBV) vaccine administered to healthy infants at 2, 4 and 6 months of age. A total of 179 infants (6-12 weeks of age) received three doses of DTPw-HBV vaccine. Blood samples for antibody determinations were taken before vaccination, 2 months after the second dose and I month after the third dose. solicited and unsolicited symptoms were recorded by parents in a diary card. All vaccinees had protective levels of anti-HBs [geometric mean titre (GMT): 1526 mlU ml-‘], anti-diphtheria and antitetanus antibodies, I month after the third dose. Ninety-two percent of the subjects exhibited a response to the B. pertussis component. Most (99.4%) solicited reactions occurred within the first 48 h and the majority were mild or moderate. The safety, immunogenicity of this tetruvalent vaccine was demonstrated when it was administered in infunts following the 0, 2, 4-month dosing schedule. Copyright 0 1997 Elsevier Science Ltd. Keywords:

DTPw-Hepatitis

B; vaccine;

immunogenicity

The first hepatitis B vaccine was introduced in 1981. Since that time, there has been a growing worldwide effort to immunize against hepatitis B virus (HBV)’ , In the 1980s the United States and other countries with a low endemicity of HBV, developed vaccination strategies which focused on ~munization for specific population groups at high risk2,3. This strategy has not been as successful in decreasing the incidence of hepatitis 3 in these countries. For example, in the United States between 250000 to 300000 new HBV infections occur each year3. Some of the reasons for the lack of success include complexity of delivery programs and difficulty in accessing high-risk individuals4.5. Therefore, organizations such as the US Immunization Practices Advisory Committee, the American Academy of Pediatrics and the World Health Organiz*Department of Pediatrics, Basurto Hospital, Bilbao, Spain. ~Medical Department, SmithKline Beecham SA, Valle de la Fuenfria, 3-3 D, 28034, Madrid, Spain. $SmithKline Beecham Biologicals, Rixensart, Belgium. $To whom correspondence should be addressed. (Received 28 January 1996; revised 28 May 1996; accepted 4 June 1996)

ation (WHO) have recommended universal vaccination of infants2’3*6. This strategy will be facilitated by the development of a vaccine combining hepatitis B surface antigen with a diphtheria, tetanus, whole-cell pertussis (DTPw) vaccine. The objective of this trial was to evaluate the immunogenicity and reactogenicity of a combined tetravalent diphtheria, tetanus, whole-cell Bordetellu pertussis, hepatitis B (DTPw-HBV) vaccine administered to healthy infants at 2, 4 and 6 months of age.

MATERIAL

AND METHODS

Study population

Healthy infants were recruited from the pediatric department of the Hospital de Basurto, Bilbao, Spain. Infants were enrolled if they had not yet received any vaccinations except for oral polio and BCG vaccines. They were not included if they had a history of any significant disease or a central nervous system disorder or if their mothers tested positive for hepatitis B surface antigen during pregnancy.

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Immune response to a combined DTPw-HBV vaccine: J. Arisfegui et al. Vaccine The DT~-~~V vaccine used in this study was developed and manufactured by SmithKline Beecham Biologicals, Rixensart, Belgium. Three production lots of the same formulation were administered, One dose (0.5 ml) contains 10 pug of hepatitis B surface antigen, 2 30 IU diphtheria toxoid, 2 60 IU tetanus toxoid and 15 OU of whole cell B. pertussis, adsorbed on aluminum salts and preserved with 25 pug ml-’ of thiomersal and 50 pg of phenoxyetanol. Study design The study was approved by the Clinical Trials Committee of Hospital Basurto, Bilbao, Spain. All parents gave written informed consent. Enrolled infants were randomized into one of three groups to receive a vaccine from a different production lot under double blind conditions. Prevaccination samples were taken in the period between birth and the first vaccine dose. Vaccine doses were administered (intramuscularly in the anterolateral thigh) at 2, 4 and 6 months of age. Post vaccination blood samples were taken 2 months after administration of the second dose and 1 month after the third dose. Parents were then asked to observe their infants on the day of each vaccination and for the three subsequent days. They were instructed to complete a diary card to record local or general reactions, infants’ body temperature (taken rectally) and any other symptom observed. Any one of the following reactions-body temperature 40.4X?, persistent screaming or crying for 3 h within 48 h after vaccination, seizures, encephafopathy, hypersensitivity reaction-constituted a contra-indication to whole-cell B. pertussis vaccination and were exclusion criteria for subsequent doses. Laboratory analyses Anti-HBs antibody titres were measured by radioimmunoassay (AUSAB, Abbott) and were titred against a WHO reference standard7. Titres were expressed in mIU ml-‘. Anti-tetanus IgG and anti-diphtheria IgG antibody titres were measured by an indirect solid-phase enzyme immunoassay and expressed in IU ml-’ x,9. Anti-B. pertussis antibody titres were measured by ELISA (IgC EIA, commercial kit, Labsystems) and expressed in ElU ml-‘. This method is based on an indirect solid-phase enzyme immunoassay in which sonicated formalin-killed phase 1 B. pertussis bacteria (a mixure of serotypes I, 2 and 3) are bound to the solid phase”. Statistical analysis Geometric mean titres and 95% confidence intervals, of antibodies against diphtheria, tetanus, B. pertussis and hepatitis B were calculated. The percentage of subjects who had protective levels of anti-HBs (2 10 mIU ml- ‘), anti-diphtheria (titres 20.1 IU ml- ‘) and anti-tetanus (titres 2 0.1 IU ml- ‘) were determined. Titres below the cut-off were given arbitrary values of one-half of the assay cut-off for GMT calculations. Antibody response for 3. pertussis was defined as a post-vaccination antibody titre equal to or above the assay cut-off for initially seronegative subjects. For

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initially seropositive subjects the induction of antibodies was indicated by a post-vaccination titre equal to or above the titre present prior to vaccination. Fisher’s exact test was used to compare the ratio of males to female, the incidence of local and general symptoms and the percentage of subjects with protective titres (and the percentage who responded to the B. pertussis component) between groups. ANOVA one-way was used to compare the mean age and GMT between groups. RESULTS One hundred and seventy-nine subjects received three vaccine doses and had a final blood sample drawn. There were no statistically significant differences between the three groups regarding to age (8.3 f 0.35 weeks), male to female ratio (lOO/SO) or prevaccination antibody status of the subjects. A total of 167 infants were included in the immunogenicity analysis (12 infants that were not vaccinated or did not have blood drawn according to the protocol schedule and one other subject that inadvertently received a commercial DTPw vaccine were excluded). The immune responses to the vaccine components are summarized in Table 1. One month after the three-dose vaccination course, all subjects had rotective levels of anti-HBs (GMT: 1526 mIU ml- P), anti-diphtheria (GMT: 2.104 IU ml-‘) and anti-tetanus (GMT: 4.982 IU ml -‘I antibodies. A positive response to the B. pertussis component of the vaccine was elicited in 92.2% (154/167) of the infants (the 13 nonresponders were initially seropositive for anti-B. pertussis antibodies). All vaccinees had anti-B. pertussis titres 2 15 ElU ml-’ 1 month after the third dose. The percentage of subjects who were protected (for hepatitis B. diphtheria and tetanus) or who responded (for B. pertussis) increased from dose 2 to dose 3 for all components except for tetanus. which remained unchanged (with all infants having protective levels after two doses). For all four antigen components, GMT increased at least 2.5-fold from the second dose to the third dose. No differences could be detected between vaccine lots for any of the four components. The reactogenicity analysis was based on data for 537 doses of the combined DTPw-HBV vaccine administered. All doses were accompanied by documentation of the reactogenicity. Most (99.4%) local and systemic solicited reactions reported had an initial onset within the first 48 h and all resolved spontaneously. Most reactions were rated as either mild or moderate in intensity. There was no significant difference between groups with regard to the incidence of local (P=O. 10) or systemic reactions (P=O.61). Pain at the injection site (following 59.2% of the doses) was the most frequently reported local reaction. The primary systemic solicited reaction was unusual crying (following 73.9% of the doses). It is important to note that the unusual crying reported by the parents was not the type of high-pitched, screaming lasting 3 h, which may be indicative of a neurological disorder, but rather crying more frequently or longer than usual. Only 12.3% of the local and systemic reactions reported were rated as severe. Most (92%) of the systemic reactions reported as severe were considered to be unrelated with the study vaccine by the investigator.

immune response to a combined DTPw-HBV vacine: J. Aristegui et al. Table 1

immune response

to hepatitis B, tetanus diphtheria, Subjects with protective

and whole-cell

8. peffussis vaccine components

(data from all three groups)

CL 95%

titer

N

n

%

GMT

Lower limit

Upper limit

Pre PII Pill

167 167

22 159 167

95.2 13.2 100.0

265 10 mlU mlUml-’ ml-’ 1526 mlU ml-’

207 8 1273

&I 1830

Anti-diphtheria Pre PII Pill

167 167 167

39 151 167

23.4 90.4 100.0

0.072 IU ml-’ 0.567 IU ml-’ 2.104 IU ml-’

0.065 0.471 1.850

0.081 0.681 2.393

Anti-tetanus Pre Pll Pill

166 167 167

51 167 167

30.7 100.0 100.0

0.113 IU ml-’ 1.879 IU ml-’ 4.982 IU ml-’

0.091 1.615 4.403

0.141 2.186 5.638

Anti-pe~u~is Pre Post II Post Ill

167 167 167

--a 151a 154a

-a 90.4= 92.2a

27 EIU ml-’ 36 EIU ml-’ 134 EIU ml-’

24 32 122

31 40 147

Vaccine component Anti-HBs

N, Number of subjects tested; Pre, prevaccination blood sample; Post II/Post Ill, blood sample taken 2 months after the second dose/l month after the third dose; CL 95% lower, upper, lower and upper 95% confidence limits; GMT, geometric mean titres. aSubjects with positive response

DISCUSSION This combined DTPw-HBV vaccine induced a strong immune response to all vaccine components: all vaccinees were protected against hepatitis B, diphthe~a, and tetanus and most of the subjects responded to the pertussis component. This fulfills and even exceeds the official WHO recommendation to reach at least 95% of protection against hepatitis B after three doses of vaccine’. The frequency of most local and general reactions reported in the present study was similar to that of recent US study in which infants received, among others, hepatitis B vaccine administered simultaneously with DTPw vaccine’ ’ _ It is now accepted that to achieve a significant control of hepatitis B in developed countries a strategy of universal vaccination may be considered’*“. In fact, some European countries have already established vaccination programs against hepatitis B in infants12.‘3. The main advantage of the DTPw-HBV combined vaccine is avoidance of multiple injections. A survey of both pediatricians and family physicians considered multiple injections as an issue affecting the decision to immunize infants with hepatitis B vaccine14. So, some communities may consider the use of this combined DTPw-HBV vaccine into the routine vaccination schedule as a positive step towards immunization of infants against hepatitis B virus.

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ACKNOWLEDGEMENTS

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This study was supported by a grant of SmithKline Beecham Biologicals, Rixensart, Belgium

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REFERENCES 1 2

Blumberg, B.S. Feasibility of controlling or eradicating the hepatitis B virus. Am. J. Med. 1989, 87S3A, 3A2S-3A4S American Academy of Pediatrics, Committee on Infectious Diseases Universal hepatitis B vaccination. fediatrics 1992,89, 795-800

Hepatitis B virus: a transmission in the United States through universal childhood vaccination. Recommendations of the ACIP. Morbid. Mo~af. Wkly ffep. 1991, 40RR-13, l-25 Immunization Practices Advisory Committee Protection against viral hepatitis-recommendations of the ACIP. Morbid. Mortal. Wkly Rep. 1990, 39RR-2, l-20 Halsey, N.A. Discussion of Immunization Practices Advisory Committee/American Academy of Pediatrics recommendations for universal infant hepatitis B vaccination. Pediatr. Infect. Dis. J. 1993, 12,446-449 World Health Organization. Informal Consultation On Quadrivalent Diphtheria, Tetanus, Pertussis, Hepatitis B Vaccine. Final Report. WHO, Geneva, 7-8 May 1992, pp. 1-12 Hollinger, F.B., Adam, E., Heiberg, D. and Melnick, J.L. Response to hepatitis B vaccine in a young adult population. In: Viraf Hepatitis and Liver Disease-Proceedings of the 1981 fntefnational symposjum (Eds Szmuness, W., Alter, H.J. and Maynard, J.E.). Franklin Institute Press Inc, Philadelphia, PA, 1982, pp, 451466 Melville-Smith, M.E., Seagroatt, V.A. and Watkins, J.T. A comparison of enzyme linked immunosorbent assay (ELISA) with the toxin neutrabation 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, A. Estimation of Corynebacterium diphtheria antitoxin in human sera: a comparison of enzyme linked immunosorbent assay (ELISA) with the toxin neutralisation test. J. Med. Microbial. 1988, 25, 279-283 Labsystems. Sordetella pertussis IgG EIA kit-Instructions for use. Labsystems. 9 Feb. i 991, product No. 61 05 201 Vadheim, CM., Greenberg, D.P., Partridge, S., Jing, J., Ward, J. and Kaiser-UCLA Vaccine Study Group. Effectiveness and safety of an ffaemoph~~us ~~ffuenzae type b conjugate vaccine (PRP-T) in young infants. Pediatrics 1993, 92(2)? 272-278 D’Amelio. R., Matricardi, P.M., Biselli, R. et al. Changing epidemiology of hepatitis B in Italy: public health implications. Am. J. Epidemiol. 1992, 135, 1012-1018 Minist&e des Affaires Sociales de la Sante et de la Ville. Nouvelles measures sur la vaccination contre I’hepatite B. 6 July 1994. Minist&e de L’Education Nationale. Vaccination des &&es des colleges contre I’Hepatite virale B. Paris, 16 November 1994 Freed, G.L. Universal Hepatitis B immunization of infants: reactions of pediatricians and family physicians over time. Pediatrics 1994, 93, 747-751 Immunization

Practices Advisory Committee

comprehensive strategy for eliminating

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