Immunogenicity and safety of a DTaP–IPV//PRP~T combination vaccine given with hepatitis B vaccine: a randomized open-label trial

443Bulletin of the World Health Organization | June 2008, 86 (6) Immunogenicity and safety of a DTaP–IPV//PRP~T combination vaccine given with hepatitis B vaccine: a randomized open- label trial Maria Rosario Capeding,a Josefina Cadorna-Carlos,b May Book-Montellano c & Esteban Ortiz d Objective To determine seroprotection and vaccine response rates produced by a diphtheria–tetanus–acellular pertussis–inactivated poliovirus–Haemophilus influenzae type-b conjugate (DTaP–IPV//PRP~T) vaccine containing a polyribosyl-ribitol-phosphate (PRP)– tetanus toxoid conjugate (Pentaxim™) and given with a hepatitis B vaccine. Methods In this multicentre open-label trial, 424 infants who received DTaP–IPV//PRP~T at 6, 10 and 14 weeks of age were also randomized to receive hepatitis B vaccine at either 6, 10 and 14 weeks or 0, 6 and 14 weeks of age. Antibody levels were determined at 6 and 18 weeks of age, and reactogenicity was monitored using parental reports. Findings Immunogenicity was high for all vaccine antigens and was similar to that in a historical control study. After primary vaccination, 98.7% of all infants had an anti-PRP antibody titre ³ 0.15 μg/ml. Seroprotection against poliovirus type-1, -2 and -3 and tetanus was obtained in all infants, and against diphtheria, in 97.1%. Pertussis seroconversion, defined as a ³ fourfold increase in antibody titre, occurred in 95.3% for anti-pertussis toxoid antibody and in 89.0% for anti-filamentous haemagglutinin antibody. The hepatitis B seroprotection rate was 99.5% with administration at 0, 6 and 14 weeks, and 97.8%, at 6, 10 and 14 weeks. However, the antibody titre was higher with the 0, 6 and 14-week schedule (601 mIU/ml versus 207 mIU/ml). The reactogenicity of both vaccines was low. Conclusion The DTaP–IPV//PRP~T vaccine was highly immunogenic. The anti-hepatitis B antibody response was seroprotective with both schedules, though the antibody titre was higher with the 0, 6 and 14-week schedule. Bulletin of the World Health Organization 2008;86:443–451. Une traduction en français de ce résumé figure à la fin de l’article. Al final del artículo se facilita una traducción al español. .ةلاقلما هذهل لماكلا صنلا ةياهن في ةصلاخلا هذهل ةيبرعلا ةمجترلا a Research Institute for Tropical Medicine (RITM), Manila, the Philippines. b University of the East Ramon Magsaysay Memorial Hospital, Quezon City, the Philippines. c Mary Chiles Hospital, Manila, the Philippines. d Sanofi pasteur, Lyon, France. Correspondence to Esteban Ortiz (e-mail: esteban.ortiz@sanofipasteur.com). doi:10.2471/BLT.07.042143 (Submitted: 26 March 2007 – Revised version received: 1 December 2007 – Accepted: 13 January 2008 – Published online: 6 May 2008 ) Introduction The original aim of the WHO Ex- panded Programme on Immunization (EPI) was to protect children against six childhood diseases: tuberculosis, diphtheria, neonatal tetanus, whooping cough, poliomyelitis and measles. Sub- sequently, others were added, including hepatitis B and Haemophilus influenzae type b. Combination vaccines that in- clude several valences help ensure high vaccination coverage. Concerns about the safety and reactogenicity of whole-cell pertussis (wP) vaccines led to the development of “acellular” pertussis (aP) vaccines, comprising purified Bordetella pertussis antigens, which are better tolerated than whole-cell vaccines and have simi- lar immunogenicity.1–3 The protective efficacy of aP vaccines has been docu- mented in controlled trials.4–6 Today, they are used in national immunization programmes in Canada, the United States of America (USA), and various European and Asian countries (e.g. Australia, Japan and the Republic of Korea).7 A recent WHO position paper on pertussis vaccines8 stated that: “The best aP vaccines have shown similar protective efficacy as the best wP vac- cines” and that: “all licensed vaccines have proved to be highly effective in controlling pertussis in infants and young children”. Sanofi pasteur has developed an aP vaccine that contains pertussis toxoid (PT) and filamentous haemagglutinin (FHA) that is used in paediatric com- binations with not only diphtheria (D) and tetanus (T) proteins, but also inactivated poliovirus (IPV) vaccine and Haemophilus influenzae type-b capsular polyribosyl-ribitol-phosphate conjugated to tetanus toxoid (PRP~T). Both the PRP~T antigen and the IPV vaccine are WHO prequalified vac- cines.9 The DTaP–IPV//PRP~T vaccine (known as Pentaxim™ or Pentavac™) used in this study has been evaluated clinically in various trials.10–14 The vac- cine was first licensed in European countries in 1997 and is now licensed in approximately 67 countries world- wide. Few data are available on the im- munogenicity, reactogenicity and safety of aP combination vaccines in many countries that follow EPI immuniza- tion schedules. As a result, the present study was carried out to evaluate these characteristics when the DTaP–IPV// PRP~T vaccine was given to infants 444 Bulletin of the World Health Organization | June 2008, 86 (6) Research Combining DTaP–IPV//PRP~T and HBV vaccines Maria Rosario Capeding et al. at 6, 10 and 14 weeks of age along with concomitant hepatitis B virus vac- cination, administered on either of the two WHO-recommended vaccination schedules followed in the Philippines. The results were compared with those previously obtained in European infants given the same DTaP–IPV//PRP~T vaccine at 2, 3 and 4 months of age. Methods Study design This randomized controlled open study enrolled infants at three medical cen- tres in Manila, the Philippines: the Re- search Institute for Tropical Medicine (RITM), the University of the East Ramon Magsaysay Memorial Medical Center, and the Mary Chiles Hospital. The ethical review board at each cen- tre approved the protocol. Written informed consent was obtained from infants’ parents or legal representatives before enrolment. In addition, mothers of potential study subjects also con- sented to clinical assessment and blood sampling during the third trimester of pregnancy to test for hepatitis B sur- face antigen (HBsAg). In those who were seropositive for HBsAg, the hepa- titis B e antigen (HBeAg) level was also measured. Subjects The study involved healthy full-term infants of ³ 37 weeks gestation who weighed ³ 2.5 kg and whose mother was anti-HBsAg seronegative. All in- fants received the DTaP–IPV//PRP~T vaccine at 6, 10 and 14 weeks of age. In addition, they were randomized within 24 hours of birth, using a ran- dom numbers list, to receive recombi- nant hepatitis B vaccine at either 0, 6 and 14 weeks (Group A) or 6, 10 and 14 weeks of age (Group B). Infants whose mother was HBsAg-seropositive were not enrolled but were given hepa- titis B immunoglobulins and the first dose of the hepatitis B vaccine within 24 hours of birth. Parents or guardians were informed of their child’s sero- logical status and private physicians provided follow-up care. Infants were excluded if they had immune system disease, including HIV infection, major congenital malforma- tions or conditions, serious illness or malignancy, a history of neurological disorders or seizures, a mother with liver disease or an allergy to a vaccine component, or if they had received im- munosuppressive therapy (other than inhaled and topical steroids), immu- noglobulins or other blood products, previous immunization against DTP, H. influenzae type b or poliomyelitis or a vaccine other than bacille Calmette- Guérin (BCG), which is included in the national Philippine vaccination schedule. Vaccines The combined DTaP–IPV//PRP~T vaccine (Pentaxim™, batch W1538) was produced and supplied by sanofi pasteur, Lyon, France. Each 0.5-ml dose contained ³ 30 IU [25 limit of floccu- lation (Lf ) of diphtheria toxoid], ³ 40 IU (10 Lf ) of tetanus toxoid, 25 μg of PT, 25 μg of FHA, 40 D antigen units (DU) of IPV type-1 (Mahoney strain), 8 DU of IPV type-2 (MEF-1 strain), 32 DU of IPV type-3 (Saukett strain), and 10 μg of PRP~T. The lyophilized PRP~T component was reconstituted with the liquid DTaP–IPV vaccine im- mediately before injection. The antigen composition of the study vaccine was identical to that of the historical control vaccine. The recombinant hepatitis B vaccine (Recomvax B/Euvax B, batch UVA3002, LG Life Sciences, Seoul, the Republic of Korea) contained 10 μg of recombinant HBsAg. It is licensed and commercially available in the Philippines. The DTaP–IPV//PRP~T and hepatitis B vaccines were admin- istered by intramuscular injection into the right and left anterior thigh, respectively. Serology Blood samples were taken for anti- body determination when infants were 6 weeks of age, just before the first injection of the combination vaccine, Fig. 1. Study flowchart showing the number of infants enrolled in the study, their random allocations, and the numbers who did or did not complete the vaccination schedules 424 subjects randomized Group A (n = 213) DTaP–IPV//PRP~T at 6, 10 and 14 weeks of age. Hepatitis B vaccine at 0, 6 and 14 weeks of age. Birth Group B (n = 211) DTaP–IPV//PRP~T at 6, 10 and 14 weeks of age. Hepatitis B vaccine at 6, 10 and 14 weeks of age. Full analysis set (n = 204) Lost to follow-up (n = 2) Protocol violation (n = 4) Voluntary withdrawal (n = 3) 6 weeks Full analysis set (n = 193) Lost to follow-up (n = 1) Protocol violation (n = 9) Withdrawal by investigator (n = 1) Voluntary withdrawal (n = 6) Serious adverse event (n = 1) Per protocol (n = 200) Protocol violation (n = 1) Voluntary withdrawal (n = 3) Study completion Per protocol (n = 187) Protocol violation (n = 1) Lost to follow-up (n = 2) Withdrawal by investigator (n = 1) Other reason (n = 1) Serious adverse event (n = 1) DTaP–IPV//PRP~T, diphtheria–tetanus–acellular pertussis–inactivated poliovirus–Haemophilus influenzae type-b conjugate. Research Combining DTaP–IPV//PRP~T and HBV vaccines 445Bulletin of the World Health Organization | June 2008, 86 (6) Maria Rosario Capeding et al. Table 1. Seroprotection and vaccine response ratesa 1 month after the third combined vaccine dose Seroprotection level or vaccine response Historical control group rate (%)b,c Group A rate (%)b,d Group B rate (%)b,e Pooled data for groups A and B rate (%)b,d,e Anti-diphtheria ³ 0.01 IU/ml 100 (95.9–100) 98.0 (94.9–99.4) 96.2 (92.4–98.5) 97.1 (94.9–98.6) Anti-tetanus ³ 0.01 IU/ml 100 (95.9–100) 100 (98.2–100) 100 (98.0–100) 100 (99.0–100) Anti-PT ³ fourfold increase 89.6 (81.7–94.9) 94.3 (89.7–97.2) 96.1 (91.7–98.5) 95.1 (92.2–97.2) Anti-FHA ³ fourfold increase 89.5 (81.5–94.8) 90.9 (85.8–94.6) 86.4 (80.3–91.2) 88.8 (85.0–91.9) Anti-poliovirus type-1 ³ 8 1/dil 97.0 (91.5–99.4) 100 (98.2–100) 100 (98.0–100) 100 (99.0–100) Anti-poliovirus type-2 ³ 8 1/dil 100 (96.4–100) 100 (98.2–100) 100 (98.0–100) 100 (99.0–100) Anti-poliovirus type-3 ³ 8 1/dil 99.0 (94.6–100) 100 (98.1–100) 100 (98.0–100) 100 (99.0–100) Anti-PRP ³ 0.15 µg/ml 98.0 (93.0–99.8) 99.0 (96.4–99.9) 98.3 (95.2–99.7) 98.7 (97.0–99.6) Anti-HBsAgf ³ 10 mIU/ml NA 99.5 (97.2–100) 97.8 (94.6–99.4) – DTaP–IPV//PRP~T, diphtheria–tetanus–acellular pertussis–inactivated poliovirus–Haemophilus influenzae type-b conjugate; FHA, filamentous haemagglutinin; HBsAg, hepatitis B surface antigen; NA, not available; PRP, polyribosyl-ribitol-phosphate; PT, pertussis toxoid. a The rate (%) listed is the percentage of infants with an immune response (i.e. with seroprotection, seroconversion or a vaccine response). b Values in parentheses are 95% confidence intervals. c The historical control group received the DTaP–IPV//PRP~T combination vaccine at 2, 3 and 4 months of age. d Group A received the DTaP–IPV//PRP~T combination vaccine at 6, 10, 14 weeks of age and the recombinant hepatitis B vaccine at 0, 6 and 14 weeks of age. e Group B received the DTaP–IPV//PRP~T vaccine and the recombinant hepatitis B vaccine at 6, 10 and 14 weeks of age. f The anti-HBsAg antibody level was determined when infants were 6 and 18 weeks of age. and at approximately 18 weeks of age, one month after the third vaccination. Serological analyses were performed as described previously12 at a Sanofi pasteur central laboratory in Pennsyl- vania, USA. The levels of antibodies to HBsAg, PT, FHA and tetanus antitoxin were determined by enzyme- linked immunosorbent assay (ELISA). Anti-PRP antibodies were measured using a Farr-type radioimmunoassay.12 Anti-diphtheria antitoxin and anti- poliovirus type-1, -2 and -3 antibodies were measured by seroneutralization. The predefined antibody levels for se- roprotection were: anti-PRP ³ 0.15 μg/ ml and ³ 1.0 μg/ml, anti-poliovirus ³ 8 reciprocal dilution (1/dil), anti- diphtheria ³ 0.01 IU/ml, anti-tetanus ³ 0.01 IU/ml and anti-HBsAg ³ 0.01 mIU/ml. Since there are no accepted correlates of seroprotection for pertus- sis antibodies, the vaccine response for anti-pertussis antigens was defined as a ³ fourfold or a ³ twofold increase in antibody concentration after primary vaccination. Reactogenicity and safety Infants were monitored for 30 min- utes after each injection for immediate local or systemic reactions. Parents or legal guardians recorded solicited local reactions (i.e. injection site redness, swelling and pain or tenderness) and solicited systemic events (i.e. rectal temperature ³ 38 °C, drowsiness, un- usual fussiness, unusual crying, loss of appetite, vomiting and diarrhoea) daily for 8 days following vaccination. Pain or tenderness was scored as severe if the infant cried when the limb was moved or if the pain appeared to pre- vent normal activity. To be severe, cry- ing or irritability had to continue for more than 3 hours. Fever was graded severe if the rectal temperature was ³ 40 °C. The date of onset, intensity and resolution of any unsolicited events were recorded for 30 days after each vaccination. Statistical analysis The mean seroprotection or vaccine re- sponse rate and the antibody geometric mean titre (GMT) were calculated for each vaccine antigen, along with the 95% confidence interval (CI), for each study group and for combined data from the two study groups. Reverse cu- mulative distribution curves (RCDC) for antibody titres were also derived to illustrate immune responses. The primary objective of the study was to show that seroprotection rates for diphtheria, tetanus, different polio- virus types and PRP, and the vaccine response rate for pertussis antigens obtained with the combination vaccine are noninferior to those observed in the French historical control study in which the same DTaP–IPV//PRP~T vaccine was given at 2, 3 and 4 months of age. This control study was chosen because no data were available for use of the study vaccine at 6, 10 and 14 weeks of age. The vaccine was considered non- inferior if the 95% CI of the seropro- tection or vaccine response rate lay entirely above the historical reference value minus a predefined clinically acceptable difference of 10%. Given the expected seroprotection and sero- conversion rates derived from the his- torical control study, a predefined clini- cally relevant difference of 10%, and a power of 90%, it was found that a sample size of 180 subjects per group was required to show noninferiority. In addition, on the assumption that 15% of subjects would be lost to evalua- tion, the intention was to enrol 212 in each group. The statistical analysis was performed using SAS software (SAS Institute, Cary, NC, USA). All subjects who received at least one dose of the combination vaccine were included in the safety assessment. Results Study population The study included 424 infants: 264 at the RITM, 75 at the University of 446 Bulletin of the World Health Organization | June 2008, 86 (6) Research Combining DTaP–IPV//PRP~T and HBV vaccines Maria Rosario Capeding et al. Table 2. GMT for all vaccine antigens before and after primary vaccination Antibody Group Aa GMT Group Bb GMT Pooled data for Groups A and Ba,b GMT before dose 1 after dose 3 before dose 1 after dose 3 before dose 1 after dose 3 Anti-diphtheria (IU/ml) c 0.019 (0.016–0.024) 0.051 (0.044–0.060) 0.018 (0.015–0.023) 0.051 (0.043–0.060) 0.019 (0.016–0.022) 0.051 (0.045–0.057) Anti-tetanus (IU/ml) c 0.676 (0.513–0.890) 2.23 (2.04–2.44) 0.637 (0.480–0.846) 2.13 (1.93–2.34) 0.657 (0.540–0.800) 2.18 (2.04–2.33) Anti-PT (EU/ml) c 3.31 (2.80–3.91) 136 (122–150) 2.96 (2.47–3.54) 150 (136–165) 3.14 (2.78–3.54) 142 (132–153) Anti-FHA (EU/ml) c 5.29 (4.52–6.20) 117 (106–129) 5.16 (4.39–6.06) 113 (102–125) 5.23 (4.67–5.85) 115 (107–123) Anti-poliovirus type-1 (1/dil) c 9.67 (7.89–11.8) 545 (448–663) 8.91 (7.32–10.8) 595 (487–727) 9.29 (8.07–10.7) 569 (495–654) Anti-poliovirus type-2 (1/dil) c 14.4 (11.6–17.8) 800 (651–983) 19.5 (15.4–23.9) 738 (599–909) 16.5 (14.2–19.3) 769 (664–890) Anti-poliovirus type-3 (1/dil) c 10.3 (8.68–12.1) 1988 (1697–2328) 10.4 (8.59–12.5) 1 594 (1356–1873) 10.3 (9.10–11.7) 1788 (1597–2002) Anti-PRP (µg/ml) c 0.208 (0.166–0.259) 1.94 (1.63–2.29) 0.228 (0.183–0.284) 2.09 (1.75–2.51) 0.217 (0.186–0.254) 2.01 (1.78–2.27) Anti-HBsAgd (mIU/ml) c 2.15 (1.51–3.08) 601.0 (508–712) 1.16 (0.808–1.66) 207.0 (166–257) – – DTaP–IPV//PRP~T, diphtheria–tetanus–acellular pertussis–inactivated poliovirus–Haemophilus influenzae type-b conjugate; GMT, geometric mean titre; HBsAg, hepatitis B surface antigen; FHA, filamentous haemagglutinin; PRP, polyribosyl-ribitol-phosphate; PT, pertussis toxoid. a Group A received the DTaP–IPV//PRP~T combination vaccine at 6, 10, 14 weeks of age and the recombinant hepatitis B vaccine at 0, 6 and 14 weeks of age. b Group B received the DTaP–IPV//PRP~T vaccine and the recombinant hepatitis B vaccine at 6, 10 and 14 weeks of age. c Values in parentheses are 95% confidence intervals. d The anti-HBsAg antibody level was determined when infants were 6 and 18 weeks of age. the East Ramon Magsaysay Memorial Medical Center, and 85 at the Mary Chiles Hospital. Of these, 213 were randomized to Group A and 211, to Group B. There were more male than female infants (57% versus 43%). Their mean (±standard deviation) age at enrolment was 1.0 (±0.6) days. Their mean age at the first combination vac- cine dose was 6.4 (±0.5) weeks. Of the 424 enrolled infants, 397 (204 in Group A and 193 in Group B) received at least one dose of the combination vaccine (i.e. the full analysis set) and 387 (200 in Group A and 187 in Group B) received three doses (i.e. the per-protocol set). Fig. 1. Twenty-seven subjects (6.7%, nine in Group A and 18 in Group B) discontinued the study or were excluded from the full analysis set before receiving a first dose of the combination vaccine. Of those who re- ceived a first dose, 10 did not complete the study: four in Group A and six in Group B. All but one of the protocol violations reported (Fig. 1) involved the receipt of DTP and oral polio vac- cine. One subject underwent a blood transfusion before the first combination vaccine dose. Two subjects withdrew because of severe adverse events: one had sepsis neonatorum and the other, cardiopulmonary arrest secondary to a ventricular septal defect. Neither was related to vaccination. Immunogenicity The observed seroprotection and vac- cine response rates 1 month after the third combined DTaP–IPV//PRP~T vaccine dose were high for each vaccine antigen, similar in both study groups, and similar to the corresponding rates observed in the historical control study (Table 1). In both study groups, and for each antigen included in the combina- tion vaccine, the 95% CI of the sero- protection or vaccine response rate lay entirely above the rate for the histori- cal control study minus the predefined 10% limit for noninferiority. Pooled data from the two groups showed that 98.7% had an anti-PRP level ³ 0.15 μg/ ml and 67.2% had a level ³ 1.0 μg/ml. The seroprotection rate was 100% for tetanus and poliovirus type-1, -2 and -3, and 97.1% for diphtheria. The vaccine response rates for anti-PT and anti-FHA, defined as at least a fourfold increase in antibody titre, were 95.1% and 88.8%, respectively. The corre- sponding rates for a twofold increase were 98.8% and 95.5%, respectively. An anti-PT antibody titre ³ 25 equiva- lent international units (EU)/ml was observed in 99.5% and 99.0% in Groups A and B respectively, and an anti-FHA antibody titre ³ 25 EU/ml was observed in 98.5% and 99.4% respectively. There was no significant difference in the antibody GMT for any vaccine antigen between Groups A and B, which enabled the data to be pooled (Table 2). Antibody GMTs increased significantly from before to after pri- mary vaccination for each vaccine antigen. The pooled anti-PRP GMT increased from 0.2 to 2.0 μg/ml. The anti-poliovirus type-1 GMT increased from 9.3 to 569 1/dil, the type-2 GMT increased from 16.5 to 769 1/dil, and the type-3 GMT, from 10.3 to 1788 1/ dil. The anti-PT and anti-FHA GMTs increased from 3.14 to 142 EU/ml and from 5.23 to 115 EU/ml, respectively. The reverse cumulative distribution Research Combining DTaP–IPV//PRP~T and HBV vaccines 447Bulletin of the World Health Organization | June 2008, 86 (6) Maria Rosario Capeding et al. Fig. 2. RCDCs for anti-pertussis toxoid antibody titres after the third combined DTaP–IPV//PRP~T vaccine dose Su bj ec ts (% ) 0 100 1 Titre (EU/ml) Historical control groupa 90 80 70 60 50 40 30 20 10 10 100 1000 Group Ab Group Bc Group A and Group B pooled DTaP–IPV//PRP~T, diphtheria–tetanus–acellular pertussis–inactivated poliovirus–Haemophilus influenzae type-b conjugate; RCDC, reverse cumulative distribution curve. a The historical control group received the DTaP–IPV//PRP~T combination vaccine at 2, 3 and 4 months of age. b Group A received the DTaP–IPV//PRP~T combination vaccine at 6, 10, 14 weeks of age and the recombinant hepatitis B vaccine at 0, 6 and 14 weeks of age. c Group B received the DTaP–IPV//PRP~T vaccine and the recombinant hepatitis B vaccine at 6, 10 and 14 weeks of age. curves (RCDCs) in Fig. 2 and Fig. 3 show anti-PT antibody and anti-FHA antibody titres, respectively, in subjects from Group A, Group B, from both groups pooled together and from the historical control study. Immune re- sponses to PT and FHA were similar in the two study groups. The RCDCs for anti-PT antibody show that responses in Groups A and B were stronger than that in the historical control group. A seroprotective anti-HBsAg titre ³ 10 mIU/ml was observed in at least 97.8% of all infants (Table 1), but the GMT was higher in Group A than Group B, at 601 mIU/ml versus 207 mIU/ml, respectively (Table 2). The RCDCs in Fig. 4 show anti-HBsAg responses in Groups A and B in sera obtained at 6 and 18 weeks of age. Reactogenicity Injection site pain was the most fre- quently recorded solicited local reac- tion. It was observed after 12.0% and 21.2% of combined DTaP–IPV// PRP~T vaccine doses in Groups A and B, respectively, and after 13.7% and 18.9% of hepatitis B vaccine doses in the two groups, respectively. Severe pain was observed in no more than 0.7% (Table 3). Redness, swelling and induration were reported after no more than 3% of any dose. Fever and irritability were the most common solicited systemic events, with fever observed after 12.2% and 11.0% of doses in Groups A and B, respec- tively, and irritability after 11.6% to 16.6%, respectively. Severe fever or ir- ritability was seen after 0.2% to 0.5%. Drowsiness or loss of appetite was reported after 5.4% to 6.5%, with no severe cases. Of the 397 subjects who received one dose or more of the combination vaccine, 213 (53.7%) reported at least one unsolicited adverse event within 30 days. Only two of these events, both of which involved fever after the third dose in infants in Group B, were interpreted by the investigator as related to vaccination. The most fre- quently reported unsolicited systemic adverse events in Group A were upper respiratory tract infection (42 infants), nasopharyngitis (31), pyrexia (30) and cough (26). In Group B, they were upper respiratory tract infection (40 infants), nasopharyngitis (34), pyrexia Fig. 3. RCDCs for anti-pertussis filamentous haemagglutinin titres after the third combined DTaP–IPV//PRP~T vaccine dose Su bj ec ts (% ) 0 100 1 Titre (EU/ml) Historical control groupa 90 80 70 60 50 40 30 20 10 10 100 1000 Group Ab Group Bc Group A and Group B pooled DTaP–IPV//PRP~T, diphtheria–tetanus–acellular pertussis–inactivated poliovirus–Haemophilus influenzae type-b conjugate; RCDC, reverse cumulative distribution curve. a The historical control group received the DTaP–IPV//PRP~T combination vaccine at 2, 3 and 4 months of age. b Group A received the DTaP–IPV//PRP~T combination vaccine at 6, 10, 14 weeks of age and the recombinant hepatitis B vaccine at 0, 6 and 14 weeks of age. c Group B received the DTaP–IPV//PRP~T vaccine and the recombinant hepatitis B vaccine at 6, 10 and 14 weeks of age. 448 Bulletin of the World Health Organization | June 2008, 86 (6) Research Combining DTaP–IPV//PRP~T and HBV vaccines Maria Rosario Capeding et al. Fig. 4. RCDCs for anti-hepatitis B surface antigen titres in sera obtained at 6 and 18 weeks of age from infants in Groups A and B Su bj ec ts (% ) 0 100 0.1 Titre (mlU/ml) Group A (week 18)a 90 80 70 60 50 40 30 20 10 1.0 Group B (week 18)b Group A (week 6)a Group B (week 6)b 10.0 100.0 1000.0 10 000.0 100 000.0 DTaP–IPV//PRP~T, diphtheria–tetanus–acellular pertussis–inactivated poliovirus–Haemophilus influenzae type-b conjugate; RCDC, reverse cumulative distribution curve. a Group A received the DTaP–IPV//PRP~T combination vaccine at 6, 10, 14 weeks of age and the recombinant hepatitis B vaccine at 0, 6 and 14 weeks of age. b Group B received the DTaP–IPV//PRP~T vaccine and the recombinant hepatitis B vaccine at 6, 10 and 14 weeks of age. (26) and cough (20). No serious adverse event was regarded as being related to vaccination. Discussion This study evaluated the immunogenic- ity and safety of a DTaP–IPV//PRP~T combination vaccine given to infants as a primary series at 6, 10 and 14 weeks of age. The results were compared with a historical control group given the same vaccine at 2, 3 and 4 months of age in a clinical trial conducted in France, where the vaccine has been in routine use. Infants were randomized at birth, before administration of the combination vaccine, to receive a com- mercially available recombinant hepa- titis B vaccine at either 0, 6 and 14 weeks or 6, 10 and 14 weeks of age. The study provided essential data on an aP combination vaccine that is given at 6, 10 and 14 weeks in many EPI sched- ules. To our knowledge, this is also the first clinical report on an aP combina- tion vaccine being given together with a monovalent hepatitis B vaccine on a schedule starting either at birth or 6 weeks of age. The immunogenicity of the combi- nation vaccine was high for all antigens, was similar in the present two study groups, and was similar to that in the historical control group. The sero- protection rates and antibody GMTs associated with the IPV vaccine were of particular interest because of the schedule used. Indeed, seroprotec- tion against all three polioviruses was present in all infants after vaccination. Large increases in anti-polio neutral- izing antibody GMTs occurred: from 9.2 to 569 1/dil for type-1 poliovirus, from 16.5 to 769 1/dil for type 2, and from 10.3 to 1788 1/dil for type 3. The response to IPV vaccine antigens reported here provides additional data on the immunogenicity of the IPV vac- cine in tropical countries such as the Philippines, and is consistent with the findings of previous clinical studies in temperate countries.10–17 After the third combination vac- cine dose, the anti-PRP titre was ³ 0.15 μg/ml in 98.7% of infants, and the anti-PRP GMT increased from 0.2 to 2.0 μg/ml. This result, obtained in our study with vaccinations given at 6, 10 and 14 weeks of age, is consistent with those of previous studies that used the same schedule and with those of studies that used the same PRP~T anti- gen but administered doses at 2, 3 and 4 months of age or 2, 4 and 6 months of age.11,12,14,15 As there are no recognized serologi- cal correlates for protection against per- tussis, a fourfold increase in the antibody titre from before to after vaccination was used as the criterion for a vaccine response to pertussis antigens. A fourfold increase in anti-PT and anti-FHA anti- body titre was obtained in 95.1% and 88.8% of infants, respectively, and a two- fold increase was obtained in 98.8% and 95.5%, respectively. Anti-PT and anti- FHA antibody GMTs were similar in the two study groups before vaccination, at 3.1 EU/ml for PT and 5.2 EU/ml for FHA. After vaccination, over 99% of infants had an anti-PT or anti-FHA antibody titre ³ 25 EU/ml. The dis- tributions observed on the RCDCs showed that the FHA responses in- duced in infants in Groups A and B were similar and comparable to that seen in the historical control group (Fig. 2). Both groups in this study also had similar anti-PT antibody distribu- tions but the RCDC was shifted to the right relative to that of the historical control group, indicating a somewhat stronger immune response in the pres- ent study. The immunogenicity ob- served for PT and FHA, as measured by the vaccine response and GMT, is also consistent with that seen in studies in Europe.11,12,14 Previous studies have demonstrated that the aP vaccine used in this study is effective.4,6 Additional evidence has also been provided by surveillance in Sweden following sev- eral years of routine use in the national vaccination programme.18,19 The hepatitis B vaccine dose given at birth ensures protection in popula- tions where hepatitis B is endemic and the risk of perinatal transmission is increased. Administering the vaccine at birth is an important public health measure for infants born to mothers who are HBsAg-seropositive or whose hepatitis B status is unknown and when screening errors occur.20,21 This study’s results confirm that the combination vaccine used is compatible with hepa- titis B vaccination schedules recom- mended by the WHO EPI. After the third hepatitis B vaccine dose, the anti-HBsAg GMT was higher in Group A than Group B. The magnitude Research Combining DTaP–IPV//PRP~T and HBV vaccines 449Bulletin of the World Health Organization | June 2008, 86 (6) Maria Rosario Capeding et al. of anti-HBsAg response is known to be schedule-dependent. This study also confirms the observation made in previous studies that lengthening the interval between the last two doses increases the final anti-HBsAg titre.20–22 However, despite the difference in anti- HBsAg antibody titre seen here, there was no difference in the seroprotection rate between the groups. In this study population, vaccina- tion was associated with a low inci- dence of solicited local and systemic adverse reactions. Severe pain was re- corded after only 0.2–0.7% of doses, and no other severe local reaction was reported. A similar pattern was ob- served for severe fever and irritability, which occurred after no more than 0.5% of doses. In summary, this study demon- strated that the DTaP–IPV//PRP~T combination vaccine was highly immu- Table 3. Incidence of local and systemic adverse reactions solicited from parents and guardians that occurred within 8 days of vaccination Adverse reactions Group A vaccine dosesa (n = 606) Group B vaccine dosesb (n = 579) DTaP–IPV//PRP~T (% of doses) Hepatitis B (% of doses) DTaP–IPV//PRP~T (% of doses) Hepatitis B (% of doses) Local adverse reactions any 12.9 13.9 22.1 19.1 severe 0.3 0.2 0.7 0.5 Pain Any 12.0 13.7 21.2 18.9 severe 0.3 0.2 0.7 0.5 Redness Any 0.5 1.2 0.4 0.2 severe 0 0 0 0 Swelling Any 1.0 0.7 2.8 1.8 severe 0 0 0 0 Induration Any 2.0 0.7 3.0 1.2 severe 0 0 0 0 Systemic adverse reactions any 22.9 25.4 severe 0.5 0.7 Fever Any 12.2 11.0 severe 0 0.5 Drowsiness Any 5.4 5.4 severe 0 0 Irritability Any 11.6 16.6 severe 0.5 0.2 Loss of appetite Any 6.3 6.5 severe 0 0 DTaP–IPV//PRP~T, diphtheria–tetanus–acellular pertussis–inactivated poliovirus–Haemophilus influenzae type-b conjugate. a Group A received the DTaP–IPV//PRP~T combination vaccine at 6, 10, 14 weeks of age and the recombinant hepatitis B vaccine at 0, 6 and 14 weeks of age. b Group B received the DTaP–IPV//PRP~T vaccine and the recombinant hepatitis B vaccine at 6, 10 and 14 weeks of age. nogenic for all antigens, well tolerated and safe when given to infants at 6, 10 and 14 weeks of age, a schedule used frequently in the WHO EPI. More- over, it could be given concomitantly with monovalent hepatitis B vaccine at either 0, 6 and 14 weeks of age or 6, 10 and 14 weeks of age. However, the magnitude of the hepatitis B immune response was greater when the first dose was given at birth. The immuno- genicity and safety of the DTaP–IPV// PRP~T combination vaccine in healthy children in the Philippines were similar to those observed in a European his- torical control study that administered the same vaccine at 2, 3 and 4 months of age. ■ Acknowledgements We thank Agnès Garinga and Pas- cale Chavand for study monitoring, Christèle Deroche and Valèrie Bosch- Castells for the analysis of study data, and Clement Weinberger for assistance in preparing the manuscript. The above are employees of sanofi pasteur in the Philippines or in France. Funding: This study (http://www. c l in ica l t r i a l s .gov/c t / show/NCT 00254917?order=3) was conducted with the support of sanofi pasteur, Lyon, France. Competing interests: Esteban Ortiz, and Valèrie Bosch are employed by Sanofi Pasteur, Lyon, France. Maria Rosario Capeding has received fees from Sanofi Pasteur for speaking at medical congresses. 450 Bulletin of the World Health Organization | June 2008, 86 (6) Research Combining DTaP–IPV//PRP~T and HBV vaccines Maria Rosario Capeding et al. Résumé Immunogénicité et innocuité d’une combinaison vaccinale DTaP-IPV//PRP~T, administrée avec le vaccin contre l’hépatite C : essai randomisé ouvert Objectif Déterminer les taux de séroprotection et de réponse vaccinale produits par un vaccin combiné, associant une composante antidiphtérique-antitétanique-anticoquelucheuse acellulaire et une composante conjuguée poliovirus inactivé/valence anti- Haemophilus influenzae type b (DTaP-IPV//PRP~T/Pentaxim™) et contenant du polyribosylribitol phosphate (PRP) conjugué à l’anatoxine tétanique, qui s’administre avec le vaccin contre l’hépatite B. Méthodes Dans le cadre d’un essai ouvert multicentrique, 424 nourrissons ayant reçu le vaccin DTaP-IPV//PRP~T à 6, 10 et 14 semaines ont également reçu de manière aléatoire l’un des deux schémas vaccinaux contre l’hépatite B suivants : administration à 6, 10 et 14 semaines ou à 0, 6 et 14 semaines. Les titres d’anticorps ont été déterminés à 6 et 18 semaines et la réactogénicité a été surveillée d’après les indications des parents. Résultats L’immunogénicité était élevée pour tous les antigènes vaccinaux et similaire à celle obtenue dans une étude témoin historique. Après la primo-vaccination, 98,7 % des nourrissons présentaient un titre d’anticorps anti-PRP ³ 0,15 µg/ml. On obtenait une séroprotection contre les poliovirus de types 1, 2 et 3 et contre le tétanos chez tous les nourrissons et contre la diphtérie chez 97,1 % d’entre eux. La séroconversion pour la coqueluche, définie comme une augmentation d’un facteur supérieur à quatre du titre d’anticorps, s’est produite chez 95,3 % des nourrissons pour les anticorps dirigés contre l’anatoxine coquelucheuse et chez 89,0 % des nourrissons pour les anticorps dirigés contre l’hémagglutinine filamenteuse. Le taux de séroprotection contre l’hépatite B était de 99,5 % pour la série de doses administrées à 0, 6 et 14 semaines et de 97,8 % pour la série administrée à 6, 10 et 14 semaines. Néanmoins, les titres d’anticorps était plus élevés pour la première série (601 mlU/ ml contre 207 mlU/ml). La réactogénicité des deux vaccins était faible. Conclusion Le vaccin DTaP-IPV//PRP~T est hautement immunogène. La réponse en anticorps contre l’hépatite B est séroprotectrice pour les deux schémas de vaccination, bien que le titre d’anticorps soit plus élevé pour l’administration à 0, 6 et 14 semaines. Resumen Inmunogenicidad y seguridad de una combinación vacunal DTaP-IPV//PRP~T administrada con la vacuna anti-hepatitis B: ensayo aleatorizado al descubierto Objetivo Determinar las tasas de seroprotección inducidas por una vacuna conjugada contra difteria-tétanos-tos ferina acelular- poliovirus inactivado-Haemophilus influenzae tipo B (DTaP–IPV// PRP~T) que contiene un conjugado de poliribosil-ribitol-fosfato (PRP) y anatoxina tetánica (Pentaxim™), administrada junto con otra vacuna contra la hepatitis B. Métodos En este ensayo multicéntrico al descubierto, 424 lactantes que recibieron DTaP–IPV//PRP~T a las 6, 10 y 14 semanas de edad fueron inmunizados también de forma aleatorizada con vacuna contra la hepatitis B, bien a las 6, 10 y 14 semanas, o bien a las 0, 6 y 14 semanas de edad. Se determinaron los niveles de anticuerpos a las 6 y las 18 semanas de edad, y se evaluó la reactogenicidad a partir de lo declarado por los padres. Resultados La inmunogenicidad de todos los antígenos vacunales fue elevada y similar a la observada en un estudio con grupo de referencia histórico. Tras la primovacunación, el 98,7% de los lactantes presentaron unos títulos de anticuerpos anti-PRP ³ 0,15 μg/ml. Se indujo seroprotección contra los poliovirus de tipo 1, 2 y 3 y contra el tétanos en todos los lactantes, y contra la difteria en el 97,1% de los casos. La seroconversión contra la tos ferina, definida como un aumento de al menos el cuádruple de título de anticuerpos, se produjo en un 95,3% de los casos en lo que respecta a los anticuerpos contra el toxoide tosferínico, y en un 89,0% de los casos para el anticuerpo contra la hemaglutinina filamentosa. La tasa de seroprotección contra la hepatitis B fue del 99,5% con la pauta de administración a las 0, 6 y 14 semanas, y del 97,8% a las 6, 10 y 14 semanas. Sin embargo, el título de anticuerpos fue mayor con la pauta de las 0, 6 y 14 semanas (601 mUI/ml frente a 207 mUI/ml). La reactogenicidad de las dos vacunas fue baja. Conclusión La vacuna DTaP–IPV//PRP~T tuvo un efecto inmunogénico muy intenso. La respuesta de anticuerpos contra la hepatitis B fue seroprotectora con las dos pautas empleadas, si bien el título de anticuerpos fue mayor con la pauta de 0, 6 y 14 semanas. صخلم نترقلما حاقللاو لافطلأا للشل ل َّطعلما حاقللاو قوهاشلل يولخلالا حاقللاو زازكلاو قانخلا تاحاقل ةفيلوت في ةملاسلاو عانمتسلاا ةحوتفم تاقاصلب ةاشعم ةسارد :ئيابلا دبكلا باهتلا حاقل عم ب طمنلا نم ةيلزنلا تايمدتسملل حاقلل ةباجتسلاا تلادعمو ةيلصلما ةياقولا تلادعم لىع فرعتلا :فدهلا حاقللاو قوهاشلل يولخلالا حاقللاو زازكلاو قانخلا تاحاقل نع مجنت يتلاو ب طمنلا نم ةيلزنلا تايمدتسملل نترقلما حاقللاو لافطلأا للشل ل َّطعلما – لوتيبير – ليزوبير ليوب عم )ميسكاتنب ( نترقلما زازكلا نافوذ ًاضيأ مضتو .ئيابلا دبكلا باهتلا حاقل عم ىطعتو )PRP( تافسوف 242 تلمش ةقاصللا ةحوتفم زكارلما ةددعتم ةسارد نوثحابلا ىرجأ :ةقيرطلا اويرتخا مث ًاعوبسأ 14و 10و 6 رماعأ في هلاعأ ةروكذلما تاحاقللا اوطعأ ًلافط وأ ًاعوبسأ 14و 10و 6 رماعأ في امأ دبكلا باهتلا حاقل يقلتل ةاشعم ةروصب 18و 6 عيباسلأا في دادضلأا ىوتسم نوثحابلا ساقو ًاعوبسأ 14و 6و 0 رماعأ .نيدلاولا ريراقت مادختساب لعفلا دودرو هراثأ ىدم دصرل رمعلا نم ًاهباشمو ،تاحاقللا تادضتسم عيمج في ًاعفترم عانمتسلاا ناك :تادوجولما ناك ئيدبلا حيقلتلا دعبف .ًاقباس تيرجأ دهاوشلاب ةبقارم ةسارد في ظحول الم Research Combining DTaP–IPV//PRP~T and HBV vaccines 451Bulletin of the World Health Organization | June 2008, 86 (6) Maria Rosario Capeding et al. 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PMID:12192167 doi:10.1097/00006454-200208000-00014 /مارغوركم 0.15 نع يواست وأ ديزت PRP ًادادضأ لافطلأا نم 98.7% ىدل 3و 2و 1 طانملأا دض ةيلصم ةياقو لىع لافطلأا عيمج لصح ماك .ترل لييم بلاقنلاا لصح مايف ،قانخلا دض %97.1 ىدلو لافطلأا للش سويرف نم ليصلما بلاقنلاا فرع دقو .لافطلأا نم %95.3 ىدل قوهاشلا دض ليصلما %89.0 ىدلو ،دادضلأا رايع في فاعضأ ةعبرأ لىع ديزت وأ يواست ةدايز هنأب %99.5 ةيلصلما ةياقولا لدعم غلب دقو .يطيخلا يومدلا صاترلا دادضأ دوجوب في تاحاقللا ءاطعإب %97.8و ًاعوبسأ 14و 6و 0 رماعأ في تاحاقللا ءاطعإب تاحاقللا ءاطعإ ىدل لىعأ ناك دادضلأا رايع نأ لاإ ،ًاعوبسأ 14و 10و 6 رماعأ لباقم ترل لييم/ةدحو وركيم 601 غلب دقف( ًاعوبسأ 14و 6و 0 رماعأ في نم ينتطخلا ىدل ةفيعض ةيلاعفتسلاا تناكو .)ترل لييم/ةدحو وركيم 207 .تاحاقللا دادضأب ةباجتسلااو ،ةيلاع ةيعانمتسا ةيلاعف ةروكذلما تاحاقلل :جاتنتسلاا رايع نأ لاإ ،ينتطخلا لاك في ةيلصم ةياقو تاذ تناك ئيابلا دبكلا باهتلا ًاعوبسأ 14و 6و 0 رماعأ في تاحاقللا اهيف ىطعت يتلا ةطخلا في ناك دادضلأا .ىرخلأا ةطخلا في هيلع تناك مام لىعأ