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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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Ahmed N, Rabaan AA, Alwashmi ASS, Albayat H, Mashraqi MM, Alshehri AA, Garout M, Abduljabbar WA, Yusof NY, Yean CY. Immunoinformatic Execution and Design of an Anti-Epstein-Barr Virus Vaccine with Multiple Epitopes Triggering Innate and Adaptive Immune Responses. Microorganisms 2023; 11:2448. [PMID: 37894106 PMCID: PMC10609278 DOI: 10.3390/microorganisms11102448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 08/31/2023] [Accepted: 09/26/2023] [Indexed: 10/29/2023] Open
Abstract
One of the most important breakthroughs in healthcare is the development of vaccines. The life cycle and its gene expression in the numerous virus-associated disorders must be considered when choosing the target vaccine antigen for Epstein-Barr virus (EBV). The vaccine candidate used in the current study will also be effective against all other herpesvirus strains, based on the conservancy study, which verified that the protein is present in all herpesviruses. From the screening, two B-cell epitopes, four MHC-I, and five MHC-II restricted epitopes were chosen for further study. The refined epitopes indicated 70.59% coverage of the population in Malaysia and 93.98% worldwide. After removing the one toxin (PADRE) from the original vaccine design, it was projected that the new vaccine would not be similar to the human host and would instead be antigenic, immunogenic, non-allergenic, and non-toxic. The vaccine construct was stable, thermostable, soluble, and hydrophilic. The immunological simulation projected that the vaccine candidate would be subject to a long-lasting active adaptive response and a short-lived active innate response. With IgM concentrations of up to 450 cells per mm3 and active B-cell concentrations of up to 400 cells per mm3, the B-cells remain active for a considerable time. The construct also discovered other conformational epitopes, improving its ability to stimulate an immune response. This suggests that, upon injection, the epitope will target the B-cell surface receptors and elicit a potent immune response. Furthermore, the discotope analysis confirmed that our conformational B-cell epitope was not displaced during the design. Lastly, the docking complex was stable and exhibited little deformability under heat pressure. These computational results are very encouraging for future testing of our proposed vaccine, which may potentially help in the management and prevention of EBV infections worldwide.
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Affiliation(s)
- Naveed Ahmed
- Department of Medical Microbiology and Parasitology, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian 16150, Malaysia
| | - Ali A. Rabaan
- Molecular Diagnostic Laboratory, Johns Hopkins Aramco Healthcare, Dhahran 31311, Saudi Arabia
- College of Medicine, Alfaisal University, Riyadh 11533, Saudi Arabia
- Department of Public Health and Nutrition, The University of Haripur, Haripur 22610, Pakistan
| | - Ameen S. S. Alwashmi
- Department of Medical Laboratories, College of Applied Medical Sciences, Qassim University, Buraydah 51452, Saudi Arabia
| | - Hawra Albayat
- Infectious Disease Department, King Saud Medical City, Riyadh 12746, Saudi Arabia
| | - Mutaib M. Mashraqi
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, Najran University, Najran 61441, Saudi Arabia
| | - Ahmad A. Alshehri
- Department of Clinical Laboratory Sciences, College of Applied Medical Sciences, Najran University, Najran 61441, Saudi Arabia
| | - Mohammed Garout
- Department of Community Medicine and Health Care for Pilgrims, Faculty of Medicine, Umm Al-Qura University, Makkah 21955, Saudi Arabia;
| | - Wesam A. Abduljabbar
- Department of Medical Laboratory Sciences, Fakeeh College for Medical Sciences, Jeddah 21461, Saudi Arabia
| | - Nik Yusnoraini Yusof
- Institute for Research in Molecular Medicine (INFORMM), Universiti Sains Malaysia, Health Campus, Kubang Kerian 16150, Malaysia
| | - Chan Yean Yean
- Department of Medical Microbiology and Parasitology, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian 16150, Malaysia
- Institute for Research in Molecular Medicine (INFORMM), Universiti Sains Malaysia, Health Campus, Kubang Kerian 16150, Malaysia
- Hospital Universiti Sains Malaysia, Universiti Sains Malaysia, Health Campus, Kubang Kerian 16150, Malaysia
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Gehrt L, Laake I, Englund H, Nieminen H, Feiring B, Lahdenkari M, Palmu AA, Trogstad L, Benn CS, Sørup S. Cohort Profile: Childhood morbidity and potential non-specific effects of the childhood vaccination programmes in the Nordic countries (NONSEnse): register-based cohort of children born 1990-2017/2018. BMJ Open 2023; 13:e065984. [PMID: 36764731 PMCID: PMC9923270 DOI: 10.1136/bmjopen-2022-065984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2023] Open
Abstract
PURPOSE The aim of the NONSEnse project is to investigate the non-specific effects of vaccines and immunisation programmes on the overall health of children by using information from the extensive nationwide registers on health and sociodemographic factors in Denmark, Finland, Norway and Sweden. PARTICIPANTS The cohort covers 9 072 420 children aged 0-17 years, born 1990-2017/2018 and living in Denmark, Finland, Norway or Sweden. All countries use a unique identification number for its permanent residents, which makes it possible to link individual-level information from different registers. FINDINGS TO DATE Data collection and harmonisation according to a common data model was completed in March 2022. As a prerequisite for comparing the effects of childhood vaccinations on the overall health of children across the Nordic countries, we have identified indicators measuring similar levels of infectious disease morbidity across these settings. So far, studies pertaining to non-specific effects of vaccines are limited to investigations that could be undertaken using aggregated data sets that were available before the NONSEnse cohort with individual-level information was completely set up. FUTURE PLANS We are currently performing several studies of the effects on non-targeted infectious disease morbidity across the countries following vaccination against measles, mumps, rubella, diphtheria, tetanus, pertussis, human papillomavirus, rotavirus and influenza. Multiple studies are planned within the next years using different study designs to facilitate triangulation of results and enhance causal inference. REGISTRATION No clinical trials will be conducted within the NONSEnse project.
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Affiliation(s)
- Lise Gehrt
- Bandim Health Project, Research Unit OPEN, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Danish Institute for Advanced Study, University of Southern Denmark, Odense, Denmark
| | - Ida Laake
- Division of Infection Control, Norwegian Institute of Public Health, Oslo, Norway
| | - Hélène Englund
- Department of Public Health Analysis and Data Management, Public Health Agency of Sweden, Solna, Sweden
| | - Heta Nieminen
- Department of Public Health and Welfare, Finnish Institute for Health and Welfare, Helsinki, Finland
| | - Berit Feiring
- Division of Infection Control, Norwegian Institute of Public Health, Oslo, Norway
| | - Mika Lahdenkari
- Department of Information Services, Finnish Institute for Health and Welfare, Helsinki, Finland
| | - Arto A Palmu
- Department of Public Health and Welfare, Finnish Institute for Health and Welfare, Helsinki, Finland
| | - Lill Trogstad
- Division of Infection Control, Norwegian Institute of Public Health, Oslo, Norway
| | - Christine Stabell Benn
- Bandim Health Project, Research Unit OPEN, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Danish Institute for Advanced Study, University of Southern Denmark, Odense, Denmark
| | - Signe Sørup
- Bandim Health Project, Research Unit OPEN, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
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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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Aaby P, Thoma H, Dietz K. Measles in the European Past: Outbreak of Severe Measles in an Isolated German Village, 1861. J Infect 2022; 84:668-674. [PMID: 35182549 DOI: 10.1016/j.jinf.2022.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 02/10/2022] [Accepted: 02/11/2022] [Indexed: 10/19/2022]
Abstract
OBJECTIVES We examined measles mortality in the European past in an outbreak in an isolated German village, Hagelloch, in 1861. METHODS Pfeilsticker's contemporary thesis was used to describe the measles case fatality ratio (CFR) and complications. Data on onset of prodromes and rash was used to determine index cases and secondary cases of measles within the household. The church register provided information on survival in 1862. RESULTS The epidemic affected nearly all children under 14 years of age. The overall CFR was 6.4%(12/187), and 10%(7/70) for children under five years of age; 44% of children were secondary cases (82/187). Secondary cases had higher CFR than index cases (RR=3.03 (95% CI: 0.91-10.07). Boys had higher CFR than girls (RR=4.46 (1.03-19.22)). Boys infected by a girl had higher CFR than boys infected by other boys (RR=6.30 (1.18-85.64)). Children who survived measles virus infection in 1861, did not have higher mortality in the following year compared with those who had not had measles in 1861 (RR=0.24 (0.07-0.82)). CONCLUSIONS Severe measles in the European past had determinants similar to those observed more recently in low-income countries. BRIEF SUMMARY The measles case fatality was 6% in rural Germany in 1861. Mortality was highest for boys infected in the household by a girl. There was no excess mortality after the acute phase of measles infection.
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Affiliation(s)
- Peter Aaby
- Bandim Health Project, OPEN, Institute of Clinical Research, 5000 Odense, Denmark.
| | - Heike Thoma
- Tagesklinik Villingen, Vinzenz von Paul Hospital GmbH, Germany
| | - Klaus Dietz
- Medical Faculty, University of Tübingen, Germany
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Sørup S, Englund H, Laake I, Nieminen H, Gehrt L, Feiring B, Trogstad L, Roth A, Benn CS. Revaccination with measles-mumps-rubella vaccine and hospitalization for infection in Denmark and Sweden - An interrupted time-series analysis. Vaccine 2021; 40:1583-1593. [PMID: 33518465 DOI: 10.1016/j.vaccine.2021.01.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 12/16/2020] [Accepted: 01/08/2021] [Indexed: 01/14/2023]
Abstract
BACKGROUND In a previous cohort study of 4-year-old Danish children, revaccination with the live measles-mumps-rubella vaccine (MMR) was associated with a 16% reduction in the rate of hospitalization lasting two days or longer for non-measles-mumps-rubella infections. AIM To examine if the introduction of revaccination with MMR at 4 years of age in Denmark (spring 2008) and at 7-9 years of age in Sweden (autumn 2009), at a time when there was virtually no measles, mumps or rubella cases, was associated with a reduction in the rate of hospitalization-for-infection lasting two days or longer at the population level. METHODS We included 4-year-olds in Denmark and 7-9-year-olds in Sweden. We obtained the number of hospitalization-for-infection lasting two days or longer from nationwide hospital registers. Person-years at risk were approximated from population statistics for each season and year. We performed an interrupted time series analysis using Poisson regression to estimate the change in hospitalization incidence rates following the introduction of MMR revaccination, adjusting for seasonality. We also performed analyses with control series (3-year-olds in Denmark and 4-year-olds in Sweden). RESULTS Comparing the incidence of hospitalization-for-infection lasting two days or longer after the introduction of MMR revaccination with the expected level without an introduction of MMR revaccination resulted in an incidence rate ratio of 1.07 (95% confidence interval [CI] = 0.89-1.28) for 4-year-olds in Denmark and 0.89 (95% CI = 0.77-1.02) for 7-9-year-olds in Sweden in analyses without controls. Analyses with controls gave similar results. CONCLUSION This population-level study of the introduction of MMR revaccination in Denmark and Sweden had inadequate power to confirm or refute the findings from an individual-level Danish study of an association between MMR revaccination and a lower incidence rate of hospitalization-for-infection lasting two days or longer.
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Affiliation(s)
- Signe Sørup
- Research Center for Vitamins and Vaccines (CVIVA), Statens Serum Institut, Artillerivej 5, DK-2300 Copenhagen S, Denmark; Department of Clinical Epidemiology, Aarhus University, Oluf Palmes Allé 43-45, DK-8200 Aarhus N, Denmark.
| | - Hélène Englund
- Public Health Agency of Sweden, Nobels väg 18, 171 82 Solna, Sweden
| | - Ida Laake
- Division of Infection Control and Environmental Health, The Norwegian Institute of Public Health, PO Box 222 Skøyen, N-0213 Oslo, Norway
| | - Heta Nieminen
- Department of Public Health Solutions, Finnish Institute for Health and Welfare, FinnMedi 1, Biokatu 6, 33520 Tampere, Finland
| | - Lise Gehrt
- Research Center for Vitamins and Vaccines (CVIVA), Statens Serum Institut, Artillerivej 5, DK-2300 Copenhagen S, Denmark; Bandim Health Project, OPEN, Open Patient Data Explorative Network, Odense University Hospital/Department of Clinical Research, University of Southern Denmark, J.B. Winsløws Vej 9 A, 3(rd) Floor, DK-5000 Odense, Denmark
| | - Berit Feiring
- Division of Infection Control and Environmental Health, The Norwegian Institute of Public Health, PO Box 222 Skøyen, N-0213 Oslo, Norway
| | - Lill Trogstad
- Division of Infection Control and Environmental Health, The Norwegian Institute of Public Health, PO Box 222 Skøyen, N-0213 Oslo, Norway
| | - Adam Roth
- Public Health Agency of Sweden, Nobels väg 18, 171 82 Solna, Sweden; Institution for Translational Medicine, Lund University, J Waldenströms g 35, CRC, hus 92, plan 11, 205 02 Malmö, Sweden
| | - Christine Stabell Benn
- Research Center for Vitamins and Vaccines (CVIVA), Statens Serum Institut, Artillerivej 5, DK-2300 Copenhagen S, Denmark; Bandim Health Project, OPEN, Open Patient Data Explorative Network, Odense University Hospital/Department of Clinical Research, University of Southern Denmark, J.B. Winsløws Vej 9 A, 3(rd) Floor, DK-5000 Odense, Denmark
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Øland CB, Mogensen SW, Rodrigues A, Benn CS, Aaby P. Reduced Mortality After Oral Polio Vaccination and Increased Mortality After Diphtheria-tetanus-pertussis Vaccination in Children in a Low-income Setting. Clin Ther 2020; 43:172-184.e7. [PMID: 33277047 DOI: 10.1016/j.clinthera.2020.11.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 11/09/2020] [Accepted: 11/11/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE The diphtheria-tetanus-pertussis vaccine (DTP) and oral polio vaccine (OPV) were introduced in children 3 of 5 months of age in 1981-1983 in Bandim, in the capital of Guinea-Bissau. Because DTP has been linked to deleterious nonspecific effects (NSEs) and OPV to beneficial NSEs, we followed up this cohort to 3 years of age and examined the effects of DTP with OPV on all-cause mortality and the interactions of DTP and OPV with the measles vaccine (MV). METHODS DTP and OPV were offered at 3 monthly community weighing sessions. Vaccination groups were defined by the last vaccine received. We compared overall mortality for different groups in Cox proportional hazards regression models, reporting hazards ratios (HRs) with 95% CIs. FINDINGS The study cohort included 1491 children born in Bandim from December 1980 to December 1983. From 3 to 35 months of age, with censoring for MV, children vaccinated with DTP and/or OPV had higher mortality than both unvaccinated children (HR = l.66; 95% CI, 1.03-2.69) and OPV-only vaccinated children (HR = 2.81; 95% CI, 1.02-7.69); DTP-only vaccinated children had higher mortality than OPV-only vaccinated children (HR = 3.38; 95% CI, 1.15--9.93). In the age group of 3-8 months, before MV is administered, DTP-only vaccination was associated with a higher mortality than DTP with OPV (HR = 3.38; 95% CI, 1.59-7.20). Between 9 and 35 months of age, when MV is given, DTP-vaccinated and MV-unvaccinated children had higher mortality (HR = 2.76; 95% CI, 1.36-5.59) than children who had received MV after DTP, and among children who received DTP with MV or after MV, DTP-only vaccination was associated with a higher mortality than DTP with OPV (HR = 6.25; 95% CI, 2.55-15.37). IMPLICATIONS Because the 2 vaccines had differential effects and the healthiest children were vaccinated first, selection biases are unlikely to explain the estimated impact on child survival. OPV had beneficial NSEs, and administration of OPV with DTP may have reduced the negative effects of DTP.
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Affiliation(s)
| | - Søren Wengel Mogensen
- Bandim Health Project, Indepth Network, Bissau, Guinea-Bissau; Department of Mathematical Sciences, University of Copenhagen, Copenhagen, Denmark
| | | | - Christine S Benn
- Research Centre for Vitamins and Vaccines, Bandim Health Project, Statens Serum Institut, Copenhagen, Denmark; OPEN, Institute of Clinical Research, University of Southern Denmark/Odense University Hospital, Odense, Denmark
| | - Peter Aaby
- Bandim Health Project, Indepth Network, Bissau, Guinea-Bissau; Research Centre for Vitamins and Vaccines, Bandim Health Project, Statens Serum Institut, Copenhagen, Denmark.
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Benn CS, Roth A, Garly ML, Fisker AB, Schaltz-Buchholzer F, Timmermann A, Berendsen M, Aaby P. BCG scarring and improved child survival: a combined analysis of studies of BCG scarring. J Intern Med 2020; 288:614-624. [PMID: 32301189 DOI: 10.1111/joim.13084] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 03/11/2020] [Accepted: 03/15/2020] [Indexed: 11/30/2022]
Abstract
Bacillus Calmette-Guérin (BCG) vaccine against tuberculosis (TB) is recommended at birth in TB-endemic areas. Currently, BCG vaccination programmes use "BCG vaccination coverage by 12 months of age" as the performance indicator. Previous studies suggest that BCG-vaccinated children, who develop a scar, have better overall survival compared with BCG-vaccinated children, who do not develop a scar. We summarized the available studies of BCG scarring and child survival. A structured literature search for studies with original data and analysis of BCG scarring and mortality were performed. Combined analyses on the effect of BCG scarring on overall mortality. We identified six studies covering seven cohorts, all from Guinea-Bissau, West Africa, with evaluation of BCG scarring amongst BCG-vaccinated children and follow-up for mortality. Determinants of BCG scarring were BCG strain, intradermal injection route, size of injection wheal, and co-administered vaccines and micronutrients. In a combined analysis, having a BCG scar vs. no BCG scar was associated with a mortality rate ratio (MRR) of 0.61 (95% CI: 0.51-0.74). The proportion with a BCG scar varied from 52 to 93%; the estimated effect of a BCG scar was not associated with the scar prevalence. The effect was strongest in the first (MRR = 0.48 (0.37-0.62)) and second (MRR = 0.63 (0.44-0.92)) year of life, and in children BCG-vaccinated in the neonatal period (MRR = 0.45 (0.36-0.55)). The effect was not explained by protection against TB. Confounding and genetic factors are unlikely to explain the strong association between BCG scarring and subsequent survival. Including "BCG scar prevalence" as a BCG vaccination programme performance indicator should be considered. The effect of revaccinating scar-negative children should be studied.
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Affiliation(s)
- C S Benn
- From the, Bandim Health Project, Indepth Network, Bissau, Guinea-Bissau.,Research Centre for Vitamins and Vaccines (CVIVA), Statens Serum Institute, Copenhagen S, Denmark.,OPEN, Institute of Clinical Research, University of Southern Denmark/Odense University Hospital, Odense, Denmark
| | - A Roth
- Public Health Agency of Sweden, Solna, Sweden.,Institution for Translational Medicine, Lund University, Malmö, Sweden
| | - M-L Garly
- From the, Bandim Health Project, Indepth Network, Bissau, Guinea-Bissau
| | - A B Fisker
- From the, Bandim Health Project, Indepth Network, Bissau, Guinea-Bissau.,OPEN, Institute of Clinical Research, University of Southern Denmark/Odense University Hospital, Odense, Denmark
| | - F Schaltz-Buchholzer
- From the, Bandim Health Project, Indepth Network, Bissau, Guinea-Bissau.,OPEN, Institute of Clinical Research, University of Southern Denmark/Odense University Hospital, Odense, Denmark
| | - A Timmermann
- Research Unit of Environmental Medicine, University of Southern Denmark, Odense C, Denmark
| | - M Berendsen
- From the, Bandim Health Project, Indepth Network, Bissau, Guinea-Bissau.,OPEN, Institute of Clinical Research, University of Southern Denmark/Odense University Hospital, Odense, Denmark.,Department of Internal Medicine, Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - P Aaby
- From the, Bandim Health Project, Indepth Network, Bissau, Guinea-Bissau.,Research Centre for Vitamins and Vaccines (CVIVA), Statens Serum Institute, Copenhagen S, Denmark
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10
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Galanti MR, Pulkki-Brännström AM, Nilsson M. Tobacco-Free Duo Adult-Child Contract for Prevention of Tobacco Use Among Adolescents and Parents: Protocol for a Mixed-Design Evaluation. JMIR Res Protoc 2020; 9:e21100. [PMID: 33000762 PMCID: PMC7661241 DOI: 10.2196/21100] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 09/15/2020] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Universal tobacco-prevention programs targeting youths usually involve significant adults, who are assumed to be important social influences. Commitment not to use tobacco, or to quit use, as a formal contract between an adolescent and a significant adult is a preventive model that has not been widely practiced or explored and has been formally evaluated even less. In this paper, we present the rationale and protocol for the evaluation of the Swedish Tobacco-free Duo program, a multicomponent school-based program the core of which rests on a formal agreement between an adolescent and an adult. The adolescent's commitment mainly concerns avoiding the onset of any tobacco use while the adult commits to support the adolescent in staying tobacco free, being a role model by not using tobacco themselves. OBJECTIVE To assess (1) whether Tobacco-free Duo is superior to an education-only program in preventing smoking onset among adolescents and promoting cessation among their parents, (2) whether exposure to core components (adult-child agreement) entails more positive effects than exposure to other components, (3) the impact of the program on whole school tobacco use, (4) potential negative side effects, and (5) school-level factors related to fidelity of the program's implementation. METHODS A mixed-design approach was developed. First, a cluster randomized controlled trial was designed with schools randomly assigned to either the comprehensive multicomponent program or its educational component only. Primary outcome at the adolescent level was identified as not having tried tobacco during the 3-year junior high school compulsory grades (12-15 years of age). An intention-to-treat cohort-wise approach and an as-treated approach complemented with a whole school repeated cross-sectional approach was devised as analytical methods of the trial data. Second, an observational study was added in order to compare smoking incidence in the schools participating in the experiment with that of a convenience sample of schools that were not part of the experimental study. Diverse secondary outcomes at both adolescent and adult levels were also included. RESULTS The study was approved by the Umeå Regional Ethics Review Board (registration number 2017/255-31) in 2017. Recruitment of schools started in fall 2017 and continued until June 2018. In total, 43 schools were recruited to the experimental study, and 16 schools were recruited to the observational study. Data collection started in the fall 2018, is ongoing, and is planned to be finished in spring 2021. CONCLUSIONS Methodological, ethical, and practical implications of the evaluation protocol were discussed, especially the advantage of combining several sources of data, to triangulate the study questions. The results of these studies will help revise the agenda of this program as well as those of similar programs. TRIAL REGISTRATION International Standard Randomized Controlled Trial Number (ISRCTN) 52858080; https://doi.org/10.1186/ISRCTN52858080. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/21100.
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Affiliation(s)
- Maria Rosaria Galanti
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden.,Centre for Epidemiology and Community Health, Stockholm, Sweden
| | | | - Maria Nilsson
- Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden
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11
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Gehrt L, Rieckmann A, Kiraly N, Jensen AKG, Aaby P, Benn CS, Sørup S. Timeliness of DTaP-IPV-Hib Vaccination and Development of Atopic Dermatitis Between 4 Months and 1 Year of Age-Register-Based Cohort Study. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 9:1520-1528.e8. [PMID: 33011301 DOI: 10.1016/j.jaip.2020.09.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 08/24/2020] [Accepted: 09/14/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND An Australian study including 4433 children found that delayed Diphtheria-Tetanus-acellular Pertussis-containing vaccination was associated with reduced risk of developing atopic dermatitis (AD) before age 1 year. OBJECTIVE We assessed whether delayed vaccination against diphtheria, tetanus, acellular pertussis, polio, and Haemophilus influenzae type b (Diphtheria, Tetanus, acellular Pertussis - Inactivated Polio vaccine - Haemophilus influenzae type b [DTaP]) was associated with a reduced risk of new cases of AD before age 1 year in Denmark. METHODS We used nationwide registers to follow 883,160 children born in Denmark from 1997 to 2012. Binary regression models adjusting for potential confounding factors were applied to estimate relative risks (adjusted relative risks [aRRs]) of developing AD among children with delayed DTaP vaccination (defined as given 1 month or more after the recommended age) compared with timely vaccinated children. RESULTS Among 143,429 children with a delayed first dose of DTaP, 4,847 (3.4%) developed AD between age 4 months and 1 year, compared with 27,628 (3.7%) among 739,731 children not having delayed DTaP (aRR 0.94; 95% CI, 0.91-0.97). The aRR was 0.94 (95% CI, 0.90-0.99) for children with a delayed second dose, and the aRR was 0.88 (95% CI, 0.82-0.93) when comparing children with delayed first and second doses with all timely vaccinated children. CONCLUSIONS The results support the hypothesis that delayed vaccination with DTaP is associated with reduced risk of developing new cases of AD after age 4 months. The dose-dependent relationship strengthens the evidence of a causal relationship. Some countries are introducing maternal pertussis vaccination and delaying the first dose of DTaP, providing a possibility for further testing the hypothesis.
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Affiliation(s)
- Lise Gehrt
- Research Center for Vitamins and Vaccines (CVIVA), Statens Serum Institut, Copenhagen, Denmark; OPEN, Open Patient data Explorative Network, Odense University Hospital/Department of Clinical Research, University of Southern Denmark, Odense, Denmark.
| | - Andreas Rieckmann
- Research Center for Vitamins and Vaccines (CVIVA), Statens Serum Institut, Copenhagen, Denmark; Section of Epidemiology, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Nicholas Kiraly
- Gastro and Food Allergy, Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, VIC, Australia
| | - Aksel Karl Georg Jensen
- Research Center for Vitamins and Vaccines (CVIVA), Statens Serum Institut, Copenhagen, Denmark; Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | - Peter Aaby
- Research Center for Vitamins and Vaccines (CVIVA), Statens Serum Institut, Copenhagen, Denmark; Bandim Health Project, Indepth Network, Bissau, Guinea-Bissau
| | - Christine Stabell Benn
- Research Center for Vitamins and Vaccines (CVIVA), Statens Serum Institut, Copenhagen, Denmark; OPEN, Open Patient data Explorative Network, Odense University Hospital/Department of Clinical Research, University of Southern Denmark, Odense, Denmark; Danish Institute for Advanced Study, University of Southern Denmark, Odense, Denmark
| | - Signe Sørup
- Research Center for Vitamins and Vaccines (CVIVA), Statens Serum Institut, Copenhagen, Denmark; Department of Clinical Epidemiology, Aarhus University, Aarhus, Denmark
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12
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Benn CS, Fisker AB, Rieckmann A, Sørup S, Aaby P. Vaccinology: time to change the paradigm? THE LANCET. INFECTIOUS DISEASES 2020; 20:e274-e283. [PMID: 32645296 DOI: 10.1016/s1473-3099(19)30742-x] [Citation(s) in RCA: 95] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 11/28/2019] [Accepted: 12/09/2019] [Indexed: 01/06/2023]
Abstract
The existing vaccine paradigm assumes that vaccines only protect against the target infection, that effective vaccines reduce mortality corresponding to the target infection's share of total mortality, and that the effects of vaccines are similar for males and females. However, epidemiological vaccine research has generated observations that contradict these assumptions and suggest that vaccines have important non-specific effects on overall health in populations. These include the observations that several live vaccines reduce the incidence of all-cause mortality in vaccinated compared with unvaccinated populations far more than can be explained by protection against the target infections, and that several non-live vaccines are associated with increased all-cause mortality in females. In this Personal View we describe current observations and contradictions and define six emerging principles that might explain them. First, that live vaccines enhance resistance towards unrelated infections. Second, non-live vaccines enhance the susceptibility of girls to unrelated infections. Third, the most recently administered vaccination has the strongest non-specific effects. Fourth, combinations of live and non-live vaccines given together have variable non-specific health effects. Fifth, vaccinating children with live vaccines in the presence of maternal immunity enhances beneficial non-specific effects and reduces mortality. Finally, vaccines might interact with other co-administered health interventions, for example vitamin A supplementation. The potential implications for child health are substantial. For example, if BCG vaccination was given to children at birth, if higher measles vaccination coverage could be obtained, if diphtheria, tetanus, and pertussis-containing vaccines were not given with or after measles vaccine, or if the BCG strain with the best non-specific effects could be used consistently, then child mortality could be considerably lower. Pursuing these emerging principles could improve our understanding and use of vaccines globally.
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Affiliation(s)
- Christine Stabell Benn
- Bandim Health Project, Indepth Network, Bissau, Guinea-Bissau; Research Centre for Vitamins and Vaccines, Statens Serum Institut, Copenhagen, Denmark; Danish Institute of Advanced Science, University of Southern Denmark, Odense, Denmark.
| | - Ane B Fisker
- Bandim Health Project, Indepth Network, Bissau, Guinea-Bissau; Bandim Health Project, Open Patient data Explorative Network, Institute of Clinical Research, Odense University Hospital, Odense, Denmark
| | - Andreas Rieckmann
- Research Centre for Vitamins and Vaccines, Statens Serum Institut, Copenhagen, Denmark; Section of Epidemiology, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Signe Sørup
- Research Centre for Vitamins and Vaccines, Statens Serum Institut, Copenhagen, Denmark; Department of Clinical Epidemiology, Aarhus University, Aarhus, Denmark
| | - Peter Aaby
- Bandim Health Project, Indepth Network, Bissau, Guinea-Bissau; Bandim Health Project, Open Patient data Explorative Network, Institute of Clinical Research, Odense University Hospital, Odense, Denmark
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13
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Sørup S. Careful consideration of hypotheses and model assumptions in study of non-specific effects of vaccines. Vaccine 2020; 38:2115. [PMID: 32057331 DOI: 10.1016/j.vaccine.2020.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 01/03/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Signe Sørup
- Research Center for Vitamins and Vaccines (CVIVA), Bandim Health Project, Statens Serum Institut, Copenhagen, Denmark; Department of Clinical Epidemiology, Aarhus University, Aarhus, Denmark.
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14
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Rieckmann A, Benn CS. The importance of randomised vs non-randomised trials. Lancet 2019; 394:634. [PMID: 31448732 DOI: 10.1016/s0140-6736(19)31129-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Accepted: 04/12/2019] [Indexed: 12/26/2022]
Affiliation(s)
- Andreas Rieckmann
- Research Center for Vitamins and Vaccines, Bandim Health Project, Statens Serum Institut, 2300 Copenhagen, Denmark; Section of Epidemiology, Department of Public Health, University of Copenhagen, Copenhagen, Denmark.
| | - Christine S Benn
- Research Center for Vitamins and Vaccines, Bandim Health Project, Statens Serum Institut, 2300 Copenhagen, Denmark; Odense Patient Data Explorative Network, University of Southern Denmark, Odense, Denmark
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15
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Aaby P, Benn CS. Developing the concept of beneficial non-specific effect of live vaccines with epidemiological studies. Clin Microbiol Infect 2019; 25:1459-1467. [PMID: 31449870 DOI: 10.1016/j.cmi.2019.08.011] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Revised: 08/08/2019] [Accepted: 08/12/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Epidemiological and immunological studies are increasingly reporting non-specific effects (NSEs) of vaccines; i.e. vaccines may affect the risk and severity of non-targeted infections. We reviewed how epidemiological studies developed the concept of beneficial NSEs of live vaccines. SOURCES This is a personal narrative of how we came to pursue the concept of NSEs in studies of measles vaccine (MV) from the late 1970s. We also searched Pubmed for epidemiological studies of nonspecific/non-specific effects (NSEs) of the most common human vaccines. CONTENT When smallpox vaccine was introduced around 1800, bacillus Calmette-Guérin (BCG) against tuberculosis in the 1920s and oral polio vaccine (OPV) in the 1960s, there were suggestions that these live attenuated vaccines reduced mortality more than expected. However, scientific follow-up was limited and the concept of beneficial NSEs did not become mainstream. We observed beneficial NSEs after MV was introduced in low-income countries in the 1970s. Subsequent observational studies and randomized trials confirmed beneficial NSEs of smallpox vaccine, BCG and OPV. Recently, beneficial NSEs have been claimed for the non-live diphtheria-tetanus-pertussis and rabies vaccines. However, no non-live vaccine has yet been documented to produce beneficial NSEs. IMPLICATIONS Observational and experimental research has shown beneficial NSEs of four live attenuated vaccines: smallpox vaccine, BCG, OPV and MV. With immunological evidence now supporting the epidemiological observations, it is urgent to take both the specific and NSEs into account in the planning of vaccination programmes.
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Affiliation(s)
- P Aaby
- Bandim Health Project, Indepth Network, Bissau, Guinea-Bissau.
| | - C S Benn
- Research Centre for Vitamins and Vaccines (CVIVA), Bandim Health Project, Statens Serum Institut, Copenhagen, Denmark; OPEN, Odense Patient Data Explorative Network, Institute of Clinical Research, Danish Institute of Advanced Science, Odense University Hospital/University of Southern, Odense, Denmark
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