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Rieckmann A, Nielsen S, Dworzynski P, Amini H, Mogensen SW, Silva IB, Chang AY, Arah OA, Samek W, Rod NH, Ekstrøm CT, Benn CS, Aaby P, Fisker AB. Discovering Subgroups of Children With High Mortality in Urban Guinea-Bissau: Exploratory and Validation Cohort Study. JMIR Public Health Surveill 2024; 10:e48060. [PMID: 38592761 DOI: 10.2196/48060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 12/22/2023] [Accepted: 01/23/2024] [Indexed: 04/10/2024] Open
Abstract
BACKGROUND The decline in global child mortality is an important public health achievement, yet child mortality remains disproportionally high in many low-income countries like Guinea-Bissau. The persisting high mortality rates necessitate targeted research to identify vulnerable subgroups of children and formulate effective interventions. OBJECTIVE This study aimed to discover subgroups of children at an elevated risk of mortality in the urban setting of Bissau, Guinea-Bissau, West Africa. By identifying these groups, we intend to provide a foundation for developing targeted health interventions and inform public health policy. METHODS We used data from the health and demographic surveillance site, Bandim Health Project, covering 2003 to 2019. We identified baseline variables recorded before children reached the age of 6 weeks. The focus was on determining factors consistently linked with increased mortality up to the age of 3 years. Our multifaceted methodological approach incorporated spatial analysis for visualizing geographical variations in mortality risk, causally adjusted regression analysis to single out specific risk factors, and machine learning techniques for identifying clusters of multifactorial risk factors. To ensure robustness and validity, we divided the data set temporally, assessing the persistence of identified subgroups over different periods. The reassessment of mortality risk used the targeted maximum likelihood estimation (TMLE) method to achieve more robust causal modeling. RESULTS We analyzed data from 21,005 children. The mortality risk (6 weeks to 3 years of age) was 5.2% (95% CI 4.8%-5.6%) for children born between 2003 and 2011, and 2.9% (95% CI 2.5%-3.3%) for children born between 2012 and 2016. Our findings revealed 3 distinct high-risk subgroups with notably higher mortality rates, children residing in a specific urban area (adjusted mortality risk difference of 3.4%, 95% CI 0.3%-6.5%), children born to mothers with no prenatal consultations (adjusted mortality risk difference of 5.8%, 95% CI 2.6%-8.9%), and children from polygamous families born during the dry season (adjusted mortality risk difference of 1.7%, 95% CI 0.4%-2.9%). These subgroups, though small, showed a consistent pattern of higher mortality risk over time. Common social and economic factors were linked to a larger share of the total child deaths. CONCLUSIONS The study's results underscore the need for targeted interventions to address the specific risks faced by these identified high-risk subgroups. These interventions should be designed to work to complement broader public health strategies, creating a comprehensive approach to reducing child mortality. We suggest future research that focuses on developing, testing, and comparing targeted intervention strategies unraveling the proposed hypotheses found in this study. The ultimate aim is to optimize health outcomes for all children in high-mortality settings, leveraging a strategic mix of targeted and general health interventions to address the varied needs of different child subgroups.
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Affiliation(s)
- Andreas Rieckmann
- Section of Epidemiology, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Sebastian Nielsen
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau
- Bandim Health Project, Research unit Odense Patient Data Explorative Network (OPEN), Department of Clinical Research, Odense University Hospital and University of Southern Denmark, Odense, Denmark
| | - Piotr Dworzynski
- Novo Nordisk Foundation Center for Basic Metabolic Research, University of Copenhagen, Copenhagen, Denmark
| | - Heresh Amini
- Department of Environmental Medicine and Climate Science, Icahn School of Medicine at Mount Sinai, New York, NY, United States
- Institute for Climate Change, Environmental Health, and Exposomics, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | | | - Isaquel Bartolomeu Silva
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau
- Bandim Health Project, Research unit Odense Patient Data Explorative Network (OPEN), Department of Clinical Research, Odense University Hospital and University of Southern Denmark, Odense, Denmark
| | - Angela Y Chang
- Danish Institute for Advanced Study, University of Southern Denmark, Odense, Denmark
- The Interdisciplinary Centre on Population Dynamics, University of Southern Denmark, Odense, Denmark
| | - Onyebuchi A Arah
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, CA, United States
- Department of Statistics and Data Science, College of Letters and Science, University of California, Los Angeles, Los Angeles, CA, United States
- Research Unit for Epidemiology, Department of Public Health, University of Aarhus, Aarhus, Denmark
| | - Wojciech Samek
- Department of Artificial Intelligence, Fraunhofer Heinrich Hertz Institute, Berlin, Germany
- Department of Electrical Engineering and Computer Science, Technical University of Berlin, Berlin, Germany
- Berlin Institute for the Foundations of Learning and Data, Berlin, Germany
| | - Naja Hulvej Rod
- Section of Epidemiology, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Claus Thorn Ekstrøm
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Christine Stabell Benn
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau
- Bandim Health Project, Research unit Odense Patient Data Explorative Network (OPEN), Department of Clinical Research, Odense University Hospital and University of Southern Denmark, Odense, Denmark
- Danish Institute for Advanced Study, University of Southern Denmark, Odense, Denmark
| | - Peter Aaby
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau
- Bandim Health Project, Research unit Odense Patient Data Explorative Network (OPEN), Department of Clinical Research, Odense University Hospital and University of Southern Denmark, Odense, Denmark
| | - Ane Bærent Fisker
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau
- Bandim Health Project, Research unit Odense Patient Data Explorative Network (OPEN), Department of Clinical Research, Odense University Hospital and University of Southern Denmark, Odense, Denmark
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Schaltz-Buchholzer F, Nielsen S, Sørensen MK, Stjernholm EB, Fabricius RA, Umbasse P, Monteiro I, Cá EJC, Aaby P, Benn CS. Effects of Neonatal BCG-Japan Versus BCG-Russia Vaccination on Overall Mortality and Morbidity: Randomized Controlled Trial From Guinea-Bissau (BCGSTRAIN II). Open Forum Infect Dis 2024; 11:ofae057. [PMID: 38500576 PMCID: PMC10946234 DOI: 10.1093/ofid/ofae057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 01/29/2024] [Indexed: 03/20/2024] Open
Abstract
Background Vaccination with the Danish strain of bacille Calmette-Guérin (BCG) has been associated with pronounced reductions in all-cause neonatal mortality and morbidity. Developing a skin reaction postvaccination is associated with markedly reduced mortality risk. It is unknown whether the beneficial nonspecific effects are maintained across different BCG strains. Methods This was an open-label randomized controlled trial in Guinea-Bissau, comparing BCG-Japan (n = 8754) versus BCG-Russia (n = 8752) for all-cause hospital admission risk by 6 weeks of age (primary outcome) and 6 months of age. Additional secondary outcomes were in-hospital case-fatality risk (CFR), all-cause mortality, and BCG skin reaction prevalence. Participants were followed through telephone calls at 6 weeks and 6 months, with a subgroup also visited at home. We assessed admission and mortality risk in Cox models providing incidence rate ratios (IRRs) and mortality rate ratios. CFR and skin reactions were assessed by binomial regression providing risk ratios. Analyses were done overall and stratified by sex. Results BCG strain was not associated with admission risk, the BCG-Japan/BCG-Russia IRR being 0.92 (95% confidence interval [CI], .81-1.05) by 6 weeks and 0.92 (95% CI, .82-1.02) by 6 months. By 6 months of age, there were significantly fewer BCG-Japan infants with no skin reaction (1%) than for BCG-Russia (2%), the risk ratio being 0.36 (95% CI, .16-.81). BCG-Japan skin reactions were also larger. Conclusions Both vaccines induced a skin reaction in almost all participants. The BCG strains had comparable effects on morbidity and mortality, but BCG-Japan was associated with more and larger skin reactions that are indicators of lower mortality risk. Clinical Trials Registration NCT03400878.
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Affiliation(s)
- Frederik Schaltz-Buchholzer
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau
- Bandim Health Project, Odense Patient Data Explorative Network (OPEN), Department of Clinical Research, University of Southern Denmark and Odense University Hospital, Odense, Denmark
| | - Sebastian Nielsen
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau
- Bandim Health Project, Odense Patient Data Explorative Network (OPEN), Department of Clinical Research, University of Southern Denmark and Odense University Hospital, Odense, Denmark
| | | | | | | | - Paulo Umbasse
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau
| | - Ivan Monteiro
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau
| | | | - Peter Aaby
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau
| | - Christine Stabell Benn
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau
- Bandim Health Project, Odense Patient Data Explorative Network (OPEN), Department of Clinical Research, University of Southern Denmark and Odense University Hospital, Odense, Denmark
- Danish Institute of Advanced Study, University of Southern Denmark, Odense, Denmark
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Munkwase G. Implications of vaccine non-specific effects on licensure of new vaccines. Vaccine 2024; 42:1013-1021. [PMID: 38242737 DOI: 10.1016/j.vaccine.2024.01.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 01/14/2024] [Accepted: 01/16/2024] [Indexed: 01/21/2024]
Abstract
Immune memory was for a long time thought to be an exclusive feature of the adaptive immune system. Emerging evidence has shown that the innate immune system may exhibit memory which has been termed as trained immunity or innate immune memory. Trained immunity following vaccination may produce non-specific effects leading to reduction in morbidity and mortality from heterologous pathogens. This review looked at trained immunity as a mechanism for vaccine induced non-specific effects, mechanisms underlying trained immunity and known vaccine non-specific effects. A discussion is also made on the implications these vaccine non-specific effects may have on overall risk-benefit ratio evaluation by National Medicines Regulatory Authorities (NMRAs) during licensure of new vaccines. Epigenetic remodeling and "rewiring" of cellular metabolism in the innate immune cells especially monocytes, macrophages, and Natural Killer (NK) cells have been suggested to be the mechanisms underlying trained immunity. Trained immunity in other innate cells has largely remained elusive up to date. Non-specific effects have been extensively documented with Bacille Calmette-Guerin (BCG), measles vaccine and oral polio vaccine but it remains unclear if other vaccines may exhibit similar effects. All known vaccine non-specific effects have come from observations in epidemiological studies conducted post-vaccine licensure and roll out in target populations. It remains to be seen if early identification of non-specific effects especially those with protective benefits during the clinical development of new vaccines may contribute to the overall risk-benefit ratio evaluation during licensure by NMRAs.
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Affiliation(s)
- Grant Munkwase
- National Drug Authority, Plot 93, Buganda Road, Kampala, Uganda; African Leadership in Vaccinology Expertise (ALIVE), Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa.
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Aamand T, Fisker AB, Correia C, Fernandes M, Clipet-Jensen C, Thysen SM. Do Pentavalent (DTwP-Hib-HBV) vaccines have sex-differential nonspecific effects? An observational study. Hum Vaccin Immunother 2023; 19:2288297. [PMID: 38054431 PMCID: PMC10732639 DOI: 10.1080/21645515.2023.2288297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 11/22/2023] [Indexed: 12/07/2023] Open
Abstract
Vaccines may alter the ability to combat infections unrelated to the target disease, i.e. have "nonspecific effects." The non-live Diphtheria-Tetanus-Pertussis vaccine (DTP) has been associated with increased child mortality, especially for females. In 2008, the DTP-containing Pentavalent vaccine replaced DTP vaccine in Guinea-Bissau. We investigate female relative to male mortality after Penta vaccination. In Guinea-Bissau, Bandim Health Project (BHP) registered children's vaccination and vital status at biannual village visits and provided vaccines. Among children Penta-vaccinated by BHP, we compared mortality of males and females in Cox proportional hazards models. Children aged 6 weeks to 8 months entered the analysis at the date of vaccination and were followed for up to 6 months. Between September 2008 and December 2017, 33,989 children aged 6 weeks to 8 months were under surveillance. Of these 12,753 (females: 6,363; males: 6,390) received Penta by the BHP and entered the study contributing with 19,667 observations. The mortality rate following Penta vaccination was 25.2 per 1,000 person years for females and 26.6 for males, resulting in an adjusted Female/Male mortality rate ratio of (F/M aMRR) 1.01 (0.82-1.25). The association between sex and mortality differed by timeliness of vaccination, F/M aMRR: 0.62 (0.41-0.93) for children vaccinated below median age, and F/M aMRR: 1.38 (0.90-2.13) for children vaccinated above median age. We did not find higher overall mortality in females than males after Penta vaccination. Our findings suggest that mortality differences between males and females following Penta vaccination may depend on timeliness of Penta vaccination.
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Affiliation(s)
- Thomas Aamand
- Bandim Health Project, Indepth Network, Bissau, Guinea-Bissau
- Department of Public Health, Aarhus University, Aarhus C, Denmark
| | - Ane Bærent Fisker
- Bandim Health Project, Indepth Network, Bissau, Guinea-Bissau
- Bandim Health Project, OPEN, Department of Clinical Research, Odense University Hospital/University of Southern Denmark, Odense, Denmark
| | | | | | | | - Sanne Marie Thysen
- Bandim Health Project, Indepth Network, Bissau, Guinea-Bissau
- Bandim Health Project, OPEN, Department of Clinical Research, Odense University Hospital/University of Southern Denmark, Odense, Denmark
- Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
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Welaga P, Mutua MK, Ahmed Hanifi SM, Ansah P, Aaby P, Nielsen S. Effect of national immunisation campaigns with oral polio vaccine on all-cause mortality in children in rural northern Ghana: 20 years of demographic surveillance cohort data. EClinicalMedicine 2023; 66:102322. [PMID: 38143803 PMCID: PMC10746391 DOI: 10.1016/j.eclinm.2023.102322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 11/01/2023] [Accepted: 11/02/2023] [Indexed: 12/26/2023] Open
Abstract
Background Studies from Guinea-Bissau and Bangladesh have shown that campaigns with oral polio vaccine (C-OPV) may be associated with 25-31% lower child mortality. Between 1996 and 2015, Ghana had 50 national C-OPVs and numerous campaigns with vitamin A supplementation (VAS), and measles vaccine (MV). We investigated whether C-OPVs had beneficial non-specific effects (NSEs) on child survival in northern Ghana. Methods We used data from a health and demographic surveillance system in the Navrongo Health Research Centre in rural northern Ghana to examine mortality from day 1-5 years of age. We used Cox models with age as underlying time scale to calculate hazard ratios (HR) for the time-varying covariate "after-campaign" mortality versus "before-campaign" mortality, adjusted for temporal change in mortality, other campaign interventions and stratified for season at risk. Findings From 1996 to 2015, 75,610 children were followed for 280,156 person-years between day 1 and 5 years of age. In initial analysis, assuming a common effect across all ages, we did not find that OPV-only campaigns significantly reduced all-cause mortality, the HR being 0.96 (95% CI: 0.88-1.05). However, we subsequently found the HR differed strongly by age group, being 0.92 (0.75-1.13), 1.29 (1.10-1.51), 0.79 (0.66-0.94), 0.67 (0.53-0.86) and 1.03 (0.78-1.36) respectively for children aged 0-2, 3-5, 6-8, 9-11 and above 12 months of age (p < 0.001). Triangulation of the evidence from this and previous studies suggested that increased frequency of C-OPVs and a different historical period could explain these results. Interpretation In Ghana, C-OPVs had limited effects on overall child survival. However, triangulating the evidence suggested that NSEs of C-OPVs depend on age of first exposure and routine vaccination programs. C-OPVs had beneficial effects for children that were not exposed before 6 months of age. These non-specific effects of OPV should be exploited to further reduce child mortality. Funding DANIDA; Else og Mogens Wedell Wedellsborgs Fond.
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Affiliation(s)
- Paul Welaga
- School of Public Health, CK Tedam University of Technology and Applied Sciences, P. O. Box 24, Navrongo, Ghana
- Navrongo Health Research Centre, P. O. Box 114, Navrongo, Ghana
| | - Martin Kavao Mutua
- African Population and Health Research Center, P.O Box 10787 – 00100, Nairobi, Kenya
| | - Syed Manzoor Ahmed Hanifi
- Health Systems and Population Studies Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Bangladesh
| | - Patrick Ansah
- Navrongo Health Research Centre, P. O. Box 114, Navrongo, Ghana
| | - Peter Aaby
- Bandim Health Project, Indepth Network, Apartado 861, Bissau, Guinea-Bissau
- OPEN, Institute for Clinical Research, University of Southern Denmark/Odense University Hospital, Odense, Denmark
| | - Sebastian Nielsen
- Bandim Health Project, Indepth Network, Apartado 861, Bissau, Guinea-Bissau
- OPEN, Institute for Clinical Research, University of Southern Denmark/Odense University Hospital, Odense, Denmark
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Benn CS, Aaby P. Measles vaccination and reduced child mortality: Prevention of immune amnesia or beneficial non-specific effects of measles vaccine? J Infect 2023; 87:295-304. [PMID: 37482223 DOI: 10.1016/j.jinf.2023.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 07/17/2023] [Accepted: 07/18/2023] [Indexed: 07/25/2023]
Abstract
Measles vaccine (MV) has been observed to reduce all-cause mortality more than explained by prevention of measles infection. Recently, prevention of "measles-induced immune amnesia" (MIA) has been proposed as an explanation for this larger-than-anticipated beneficial effect of measles vaccine (MV). According to the "MIA hypothesis", immune amnesia leads to excess non-measles morbidity and mortality, that may last up to five years after measles infection, but may be prevented by MV. However, the benefits of MV-vaccinated children could also be due to beneficial non-specific effects (NSEs) of MV, reducing the risk of non-measles infections (The "NSE hypothesis"). The epidemiological studies do provide some support for MIA, as exposure to measles infection before 6 months of age causes long-term MIA, and over 6 months of age for 2-3 months. However, in children over 6 months of age, the MIA hypothesis is contradicted by several epidemiological patterns: First, in community studies that adjusted for MV status, children surviving acute measles infection had lower mortality than uninfected controls (44%(95%CI: 0-69%)). Second, in six randomised trials and six observational studies comparing MV-vaccinated and MV-unvaccinated children, the benefit of MV changed minimally from 54%(43-63%) to 49%(37-59%) when measles cases were censored in the survival analysis, making it unlikely that prevention of measles and its long-term consequences explained much of the reduced mortality. Third, several studies conducted in measles-free contexts still showed significantly lower mortality after MV (55%(40-67%)). Fourth, administration of MV in the presence of maternal measles antibody (MatAb) is associated with much stronger beneficial effect for child survival than administration of MV in the absence of MatAb (55%(35-68%) lower mortality). The MIA hypothesis alone cannot explain the strongly beneficial effects of MV on child survival. Conversely, the hypothesis that MV has beneficial non-specific immune training effects is compatible with all available data. Consideration should be given to continuing MV even when measles has been eradicated.
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Affiliation(s)
- Christine S Benn
- Bandim Health Project, Indepth Network, Apartado 861, Bissau, Guinea-Bissau; Bandim Health Project, OPEN, Department of Clinical Research, University of Southern Denmark/Odense University Hospital, Denmark; Danish Institute for Advanced Study (DIAS), University of Southern Denmark, Denmark
| | - Peter Aaby
- Bandim Health Project, Indepth Network, Apartado 861, Bissau, Guinea-Bissau; Bandim Health Project, OPEN, Department of Clinical Research, University of Southern Denmark/Odense University Hospital, Denmark.
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Varma A, Thysen SM, Martins JSD, Nanque LM, Jensen AKG, Fisker AB. Overall effect of a campaign with measles vaccine on the composite outcome mortality or hospital admission: A cluster-randomized trial among children aged 9-59 months in rural Guinea-Bissau. Int J Infect Dis 2023; 134:23-30. [PMID: 37182547 DOI: 10.1016/j.ijid.2023.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 05/06/2023] [Accepted: 05/09/2023] [Indexed: 05/16/2023] Open
Abstract
OBJECTIVES Campaigns with measles vaccine (C-MV) are conducted to eradicate measles, but prior studies indicate that MV reduces non-measles mortality and hospital admissions too. We hypothesized that C-MV reduces death/hospital admission by 30%. METHODS Between 2016-2019, we conducted a non-blinded cluster-randomized trial randomizing village clusters in rural Guinea-Bissau to a C-MV targeting children aged 9-59 months. In Cox proportional hazards models, we assessed the effect of C-MV, obtaining hazard ratios (HR) for the composite outcome (death/hospital admission). We also examined potential effect modifiers. RESULTS Among 18,411 children (9636 in 111 intervention clusters/8775 in 110 control clusters), 379 events occurred (208 intervention/171 control) during a median follow-up period of 22 months. C-MV did not reduce the composite outcome (HR 1.12, 95% confidence interval 0.88-1.41). Mortality among enrolled children (5.3 intervention and 4.6 control, per 1000 person-years) was approximately half the pre-trial mortality rate (11.1 intervention and 8.9 control, per 1000 person-years). Neither planned nor explorative analyses of potential effect modifiers explained the contrasting results to prior studies. CONCLUSION C-MV did not reduce overall mortality or hospital admission. This might be explained by changes in disease patterns, baseline differences in health status, and/or modifying effects of other campaigns during follow-up.
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Affiliation(s)
- Anshu Varma
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau; OPEN, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Sanne M Thysen
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau; OPEN, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | | | - Line M Nanque
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau; OPEN, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Aksel K G Jensen
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Ane B Fisker
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau; OPEN, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark.
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Baroncelli S, Galluzzo CM, Orlando S, Luhanga R, Mphwere R, Kavalo T, Amici R, Floridia M, Andreotti M, Ciccacci F, Marazzi MC, Giuliano M. Insufficient measles antibody protection in 6-month-old Malawian infants: Reconsider vaccination schedule? Trop Med Int Health 2023; 28:731-735. [PMID: 37533039 DOI: 10.1111/tmi.13920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2023]
Abstract
Measles vaccination is currently recommended at 9 months, since maternal antibodies are supposed to protect infants until that age. In this study of 6-month-old Malawian infants 98.3% (58/59) had non-protective IgG levels against measles, irrespective of HIV exposure. Anticipating the first dose at 6 months could be considered.
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Affiliation(s)
- Silvia Baroncelli
- National Center for Global Health, Istituto Superiore di Sanità, Rome, Italy
| | | | - Stefano Orlando
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | | | | | - Thom Kavalo
- DREAM Program, Community of S. Egidio, Blantyre, Malawi
| | - Roberta Amici
- National Center for Global Health, Istituto Superiore di Sanità, Rome, Italy
| | - Marco Floridia
- National Center for Global Health, Istituto Superiore di Sanità, Rome, Italy
| | - Mauro Andreotti
- National Center for Global Health, Istituto Superiore di Sanità, Rome, Italy
| | - Fausto Ciccacci
- Saint Camillus International, University of Health Sciences, Rome, Italy
| | | | - Marina Giuliano
- National Center for Global Health, Istituto Superiore di Sanità, Rome, Italy
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Zimakoff AC, Jensen A, Vittrup DM, Herlufsen EH, Sørensen JK, Malon M, Svensson J, Stensballe LG. Measles, mumps, and rubella vaccine at age 6 months and hospitalisation for infection before age 12 months: randomised controlled trial. BMJ 2023; 381:e072724. [PMID: 37286215 DOI: 10.1136/bmj-2022-072724] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To test for potential non-specific effects of an additional, early measles, mumps, and rubella (MMR) vaccine at age 5-7 months on risk of infection related hospitalisation before age 12 months. DESIGN Randomised, double blinded, placebo controlled trial. SETTING Denmark, a high income setting with low exposure to MMR. PARTICIPANTS 6540 Danish infants aged 5 to 7 months. INTERVENTIONS Infants were randomly allocated 1:1 to intramuscular injection with standard titre MMR vaccine (M-M-R VaxPro) or placebo (solvent only). MAIN OUTCOME MEASURES Hospitalisations for infection, defined as all hospital contacts of infants referred from primary care for hospital evaluation and with an infection diagnosed, analysed as recurrent events, from randomisation to 12 months of age. In secondary analyses implications of censoring for date of subsequent diphtheria, tetanus, pertussis, polio, Haemophilus influenzae type B, and immunisation with pneumococci conjugate vaccine (DTaP-IPV-Hib+PCV), potential effect modification by sex, prematurity (<37 weeks' gestation), season, and age at randomisation were tested, and the secondary outcomes of hospitalisations ≥12 hours and antibiotic use were evaluated. RESULTS 6536 infants were included in the intention-to-treat analysis. 3264 infants randomised to MMR vaccine experienced 786 hospitalisations for infection before age 12 months compared with 762 for the 3272 infants randomised to placebo. In the intention-to-treat analysis the rate of hospitalisations for infection did not differ between the MMR vaccine and placebo groups (hazard ratio 1.03, 95% confidence interval 0.91 to 1.18). For infants randomised to MMR vaccine compared with those randomised to placebo, the hazard ratio of hospitalisations for infection with a duration of at least 12 hours was 1.25 (0.88 to 1.77), and for prescriptions of antibiotics was 1.04 (0.88 to 1.23). No significant effect modifications were found by sex, prematurity, age at randomisation, or season. The estimate did not change when censoring at the date infants received DTaP-IPV-Hib+PCV after randomisation (1.02, 0.90 to 1.16). CONCLUSION Findings of this trial conducted in Denmark, a high income setting, do not support the hypothesis that live attenuated MMR vaccine administered early to infants aged 5-7 months decreases the rate of hospitalisations for non-targeted infection before age 12 months. TRIAL REGISTRATION EU Clinical Trials Registry EudraCT 2016-001901-18 and ClinicalTrials.gov NCT03780179.
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Affiliation(s)
- Anne Cathrine Zimakoff
- Department of Paediatrics and Adolescent Medicine, Danish National University Hospital "Rigshospitalet," Copenhagen, Denmark
| | - Andreas Jensen
- Department of Paediatrics and Adolescent Medicine, Danish National University Hospital "Rigshospitalet," Copenhagen, Denmark
| | - Dorthe Maria Vittrup
- Child and Adolescent Department, University Hospital Herlev, Copenhagen, Denmark
| | | | - Jesper Kiehn Sørensen
- Department of Paediatrics and Adolescent Medicine, Danish National University Hospital "Rigshospitalet," Copenhagen, Denmark
| | - Michelle Malon
- Department of Paediatrics and Adolescent Medicine, Danish National University Hospital "Rigshospitalet," Copenhagen, Denmark
| | - Jannet Svensson
- Child and Adolescent Department, University Hospital Herlev, Copenhagen, Denmark
| | - Lone Graff Stensballe
- Department of Paediatrics and Adolescent Medicine, Danish National University Hospital "Rigshospitalet," Copenhagen, Denmark
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Benn CS, Amenyogbe N, Björkman A, Domínguez-Andrés J, Fish EN, Flanagan KL, Klein SL, Kollmann TR, Kyvik KO, Netea MG, Rod NH, Schaltz-Buchholzer F, Shann F, Selin L, Thysen SM, Aaby P. Implications of Non-Specific Effects for Testing, Approving, and Regulating Vaccines. Drug Saf 2023; 46:439-448. [PMID: 37074598 PMCID: PMC10116894 DOI: 10.1007/s40264-023-01295-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2023] [Indexed: 04/20/2023]
Abstract
The current framework for testing and regulating vaccines was established before the realization that vaccines, in addition to their effect against the vaccine-specific disease, may also have "non-specific effects" affecting the risk of unrelated diseases. Accumulating evidence from epidemiological studies shows that vaccines in some situations can affect all-cause mortality and morbidity in ways that are not explained by the prevention of the vaccine-targeted disease. Live attenuated vaccines have sometimes been associated with decreases in mortality and morbidity that are greater than anticipated. In contrast, some non-live vaccines have in certain contexts been associated with increases in all-cause mortality and morbidity. The non-specific effects are often greater for female than male individuals. Immunological studies have provided several mechanisms that explain how vaccines might modulate the immune response to unrelated pathogens, such as through trained innate immunity, emergency granulopoiesis, and heterologous T-cell immunity. These insights suggest that the framework for the testing, approving, and regulating vaccines needs to be updated to accommodate non-specific effects. Currently, non-specific effects are not routinely captured in phase I-III clinical trials or in the post-licensure safety surveillance. For instance, an infection with Streptococcus pneumoniae occurring months after a diphtheria-tetanus-pertussis vaccination would not be considered an effect of the vaccination, although evidence indicates it might well be for female individuals. Here, as a starting point for discussion, we propose a new framework that considers the non-specific effects of vaccines in both phase III trials and post-licensure.
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Affiliation(s)
- Christine Stabell Benn
- Bandim Health Project, Open Patient Data Explorative Network (OPEN), Department of Clinical Research, Odense University Hospital and University of Southern Denmark, Odense, Denmark.
- Danish Institute for Advanced Study, University of Southern Denmark, Copenhagen, Denmark.
| | | | - Anders Björkman
- Department of Global Public Health, Karolinska Institutet Stockholm, Stockholm, Sweden
| | - Jorge Domínguez-Andrés
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center Nijmegen, Nijmegen, The Netherlands
| | - Eleanor N Fish
- Department of Immunology, University of Toronto, Toronto, ON, Canada
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Katie L Flanagan
- Tasmanian Vaccine Trial Centre, Clifford Craig Foundation, Launceston General Hospital, Launceston, TAS, Australia
- School of Medicine, Faculty of Health Sciences, University of Tasmania, Launceston, TAS, Australia
- School of Health and Biomedical Sciences, RMIT University, Melbourne, VIC, Australia
| | - Sabra L Klein
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Kirsten Ohm Kyvik
- Department of Clinical Research, Odense University Hospital and University of Southern Denmark, Odense, Denmark
| | - Mihai G Netea
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center Nijmegen, Nijmegen, The Netherlands
| | - Naja Hulvej Rod
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Frederik Schaltz-Buchholzer
- Bandim Health Project, Open Patient Data Explorative Network (OPEN), Department of Clinical Research, Odense University Hospital and University of Southern Denmark, Odense, Denmark
| | - Frank Shann
- Department of Paediatrics, University of Melbourne, Parkville, VIC, Australia
| | - Liisa Selin
- Department of Pathology, University of Massachusetts Medical School, Worcester, MA, USA
| | - Sanne M Thysen
- Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Peter Aaby
- Bandim Health Project, Open Patient Data Explorative Network (OPEN), Department of Clinical Research, Odense University Hospital and University of Southern Denmark, Odense, Denmark
- Bandim Health Project, Apartado 861, 1004, Bissau Codex, Guinea-Bissau
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Aaby P, Nielsen S, Fisker AB, Pedersen LM, Welaga P, Hanifi SMA, Martins CL, Rodrigues A, Chumakov K, Benn CS. Stopping oral polio vaccine (OPV) after defeating poliomyelitis in low-and-middle-income countries: Harmful unintended consequences? Open Forum Infect Dis 2022; 9:ofac340. [PMID: 35937644 PMCID: PMC9348612 DOI: 10.1093/ofid/ofac340] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Indexed: 11/18/2022] Open
Abstract
Background The live vaccines bacille Calmette-Guérin (BCG) and measles vaccine have beneficial nonspecific effects (NSEs) reducing mortality, more than can be explained by prevention of tuberculosis or measles infection. Live oral polio vaccine (OPV) will be stopped after polio eradication; we therefore reviewed the potential NSEs of OPV. Methods OPV has been provided in 3 contexts: (1) coadministration of OPV and diphtheria-tetanus-pertussis (DTP) vaccine at 6, 10, and 14 weeks of age; (2) at birth (OPV0) with BCG; and (3) in OPV campaigns (C-OPVs) initiated to eradicate polio infection. We searched PubMed and Embase for studies of OPV with mortality as an outcome. We used meta-analysis to obtain the combined relative risk (RR) of mortality associated with different uses of OPV. Results First, in natural experiments when DTP was missing, OPV-only compared with DTP + OPV was associated with 3-fold lower mortality in community studies (RR, 0.33 [95% confidence interval {CI}, .14–.75]) and a hospital study (RR, 0.29 [95% CI, .11–.77]). Conversely, when OPV was missing, DTP-only was associated with 3-fold higher mortality than DTP + OPV (RR, 3.23 [95% CI, 1.27–8.21]). Second, in a randomized controlled trial, BCG + OPV0 vs BCG + no OPV0 was associated with 32% (95% CI, 0–55%) lower infant mortality. Beneficial NSEs were stronger with early use of OPV0. Third, in 5 population-based studies from Guinea-Bissau and Bangladesh, the mortality rate was 24% (95% CI, 17%–31%) lower after C-OPVs than before C-OPVs. Conclusions There have been few clinical polio cases reported in this century, and no confounding factors or bias would explain all these patterns. The only consistent interpretation is that OPV has beneficial NSEs, reducing nonpolio child mortality.
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Affiliation(s)
- Peter Aaby
- Bandim Health Project, Indepth Network , Apartado 861, Bissau, Guinea-Bissau
| | - Sebastian Nielsen
- Bandim Health Project, Indepth Network , Apartado 861, Bissau, Guinea-Bissau
- OPEN, Odense Patient data Explorative Network, Institute of Clinical Research, University of Southern Denmark , Denmark
| | - Ane B Fisker
- Bandim Health Project, Indepth Network , Apartado 861, Bissau, Guinea-Bissau
- OPEN, Odense Patient data Explorative Network, Institute of Clinical Research, University of Southern Denmark , Denmark
| | - Line M Pedersen
- Bandim Health Project, Indepth Network , Apartado 861, Bissau, Guinea-Bissau
- OPEN, Odense Patient data Explorative Network, Institute of Clinical Research, University of Southern Denmark , Denmark
| | - Paul Welaga
- Navrongo Health Research Centre , P. O. Box 114, Navrongo , Ghana
| | - Syed M A Hanifi
- Health Systems and Population Studies Division, International Centre for Diarrhoeal Disease Research , Bangladesh (icddr, b)
| | - Cesario L Martins
- Bandim Health Project, Indepth Network , Apartado 861, Bissau, Guinea-Bissau
| | - Amabelia Rodrigues
- Bandim Health Project, Indepth Network , Apartado 861, Bissau, Guinea-Bissau
| | - Konstantin Chumakov
- Office of Vaccines Research and Review, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring , MD , USA
| | - Christine S Benn
- OPEN, Odense Patient data Explorative Network, Institute of Clinical Research, University of Southern Denmark , Denmark
- Danish Institute of Advanced Science, Odense University Hospital/University of Southern Denmark , Denmark
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