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Otaki Y, Ogawa E, Higuchi T, Takeshita K, Takeuchi N, Ishiwada N, Ito K. Invasive Haemophilus influenzae type b infection in a patient with transient hypogammaglobulinemia of infancy. J Infect Chemother 2021; 27:1756-1759. [PMID: 34376350 DOI: 10.1016/j.jiac.2021.07.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 07/28/2021] [Accepted: 07/31/2021] [Indexed: 11/19/2022]
Abstract
We describe a patient with invasive Haemophilus influenzae type b (Hib) infection despite being completely immunized by a conjugate Hib vaccine. Although Hib vaccination has contributed to significant reduction in invasive Hib infection, there are some case reports of invasive Hib infections despite immunization. Immunoglobulin (Ig) deficiency is the main cause of primary vaccine failure, and IgG2 subclass deficiency is known to be the leading cause. A previously healthy 13-month-old boy visited the outpatient clinic with a 5-day history of fever (40.0 °C), cough, and vomiting, and was diagnosed with bacterial meningitis, purulent pericarditis, and arthritis. Hib was recovered from blood, cerebrospinal fluid, and pericardial fluid. Immunological examination revealed subnormal IgG and IgA titers at 13 and 17 months of age. Serum IgG2 titer was recovered at 17 months of age despite being low at 13 months. Comprehensive gene analysis for primary immunodeficiency syndromes (primary antibody deficiency, common variable immunodeficiency, and toll-like receptor abnormalities) were negative. The antibody titer against Hib [anti-polyribosylribitol phosphate (PRP) antibody] was lower than the long-term protective titer (1.0 μg/ml) at 13 months of age, but was reactively increased to 2.38 μg/mL two months after booster immunization. Transient hypogammaglobulinemia of infancy (THI) is described as an accentuation and prolongation of the physiologic Ig nadir that is normally observed during infancy and defined as low IgG and IgA levels in the first three years of life. We speculate that he developed an invasive Hib infection as a result of primary Hib vaccine failure caused by THI.
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Affiliation(s)
- Yuji Otaki
- Division of General Pediatrics, Aichi Children's Health and Medical Center
| | - Eiki Ogawa
- Division of General Pediatrics, Aichi Children's Health and Medical Center
| | - Toru Higuchi
- Division of General Pediatrics, Aichi Children's Health and Medical Center
| | - Kenichi Takeshita
- Department of Infectious Diseases, Medical Mycology Research Center, Chiba University
| | - Noriko Takeuchi
- Department of Infectious Diseases, Medical Mycology Research Center, Chiba University
| | - Naruhiko Ishiwada
- Department of Infectious Diseases, Medical Mycology Research Center, Chiba University
| | - Kenta Ito
- Division of General Pediatrics, Aichi Children's Health and Medical Center.
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Abstract
Introduction: Controlling the preventable infectious diseases is the main goal of vaccination. Among the vaccines, combined vaccines are of great importance for their social, public health, and economic values. It is stated that the combined vaccines are as efficient and safe as the monovalent vaccines. However, a concern has raised about the efficacy and safety of the combined vaccines due to the outbreaks of vaccine-preventable diseases and occurrence of serious adverse events. Areas covered: A retrospective literature search was conducted in the Google Scholar and PubMed databases to evaluate the efficacy and safety of the combined vaccines from 1980 to 2020 using appropriate keywords. Expert opinion: Several studies have shown efficacy and safety issues related to the combined vaccines. Different factors contribute to the inefficacy and lack of safety in the vaccines including formulation problems, limited data in the pre-licensure studies and challenges related to imperfection of the post-licensure surveillance systems. For surmounting the mentioned obstacles, there is a need to provide new formulations of the vaccines, revise the vaccines҆ safety and efficacy acceptance standards in the pre-licensure studies, improvement of post-licensure surveillance systems, and education of healthcare staff.
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3
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Abreu TC, Boshuizen H, Mollema L, Berbers GAM, Korthals Altes H. Association between season of vaccination and antibody levels against infectious diseases. Epidemiol Infect 2020; 148:e276. [PMID: 33148351 PMCID: PMC7770373 DOI: 10.1017/s0950268820002691] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 10/02/2020] [Accepted: 10/15/2020] [Indexed: 11/19/2022] Open
Abstract
Vaccination has reduced the disease burden of vaccine-preventable diseases. However, the extent to which seasonal cycles of immunity could influence vaccine-induced immunity is not well understood. A national cross-sectional serosurveillance study performed in the Netherlands (Pienter-2) yielded data to investigate whether season of vaccination was associated with antibody responses induced by DT-IPV (diphtheria, tetanus and poliomyelitis), MMR (measles, mumps and rubella) and meningococcus C (MenC) vaccines in children. In total, 434 children met the inclusion criteria to study DT-IPV immunity, 811 for MMR and 311 for MenC. Differences in log(antibody levels) by season of vaccination were investigated with linear multivariable regression analyses. Seroconversion rates varied according to season of vaccination for rubella (90% of autumn-vaccinated children vs. 99% of winter-vaccinated had concentrations above cut-off levels). Summer-vaccinated boys showed a slower decline of tetanus antibodies (6% per month), in comparison with winter-vaccinated boys. In conclusion, season of vaccination showed little association with immunological protection. However, a number of associations were seen with a P-value of about 0.03; and adding data from a just-completed nationwide serological study might add more power to the current study. Further immunological and longitudinal investigations could help understand the mechanisms of seasonal influence in vaccine-induced responses.
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Affiliation(s)
- T. C. Abreu
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| | - H. Boshuizen
- Centre for Nutrition, Prevention and Health Services, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| | - L. Mollema
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| | - G. A. M. Berbers
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| | - H. Korthals Altes
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
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Giufrè M, Lindh E, Cardines R, Pezzotti P, Cerquetti M. Invasive Haemophilus influenzae type b (Hib) disease in children in Italy, after 20 years of routine use of conjugate Hib vaccines. Vaccine 2020; 38:6533-6538. [PMID: 32859435 DOI: 10.1016/j.vaccine.2020.08.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 08/07/2020] [Accepted: 08/10/2020] [Indexed: 11/26/2022]
Abstract
Haemophilus influenzae serotype b (Hib) was the leading cause of bacterial meningitis in children before the implementation of infant immunization with conjugate Hib vaccines. Despite the effectiveness of the vaccine, invasive Hib disease cases (i.e. isolation of Hib from a normally sterile site) are still reported in children. All invasive Hib disease cases in children ≤ 15 years reported through the National Surveillance System of Invasive Bacterial Disease, during 2012-2018 in Italy, were analyzed. Hib PCR-confirmed isolates were subjected to MLST and PFGE analysis. The number of copies of the capb locus, a virulence factor potentially contributing to true vaccine failures (TVFs), was determined by Southern blot analysis. Vaccine effectiveness (VE) was determined using a multiple Poisson regression model. 31 cases of invasive Hib disease in children were reported. Fourteen children were vaccinated (TVFs), 14 were unvaccinated and 2 partially vaccinated (vaccination status was unknown for 1 case). The median age of children was 12 months (range 3 months-15 years). A decrease in vaccination coverage was observed in 2014-2016 (source Ministry of Health), and a rise in incidence was documented from 2016 until 2018, especially in children < 5 years. Vaccine effectiveness was estimated to be 83% (95% CI:45-95). 24 isolates were available. The predominant ST was ST6 (70.8%). Cluster analysis of ST6 isolates by PFGE identified five variants. Six isolates (25%) contained multiple copies of the capb locus distributed among TVFs (30%) and unvaccinated children (16.7%). Our data show that both failures to vaccinate and TVFs are associated with invasive Hib disease in children in Italy, during the vaccination era. Most cases in children ≤ 2 years were vaccine-preventable, since they occurred in unvaccinated subjects (13/21 cases, 62%). No host predisposing factors for TVF were recognized. TVFs were not significantly associated with either specific genotypes or amplification status of the capb locus.
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Affiliation(s)
- Maria Giufrè
- Department of Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy.
| | - Erika Lindh
- Department of Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy; European Program for Public Health Microbiology Training (EUPHEM), European Centre for Disease Prevention and Control, (ECDC), Stockholm, Sweden
| | - Rita Cardines
- Department of Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - Patrizio Pezzotti
- Department of Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - Marina Cerquetti
- Department of Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy
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Monge S, Mollema L, de Melker H, Sanders E, van der Ende A, Knol M. Clinical Characterization of Invasive Disease Caused by Haemophilus influenzae Serotype b in a High Vaccination Coverage Setting. J Pediatric Infect Dis Soc 2019; 8:261-264. [PMID: 29579288 DOI: 10.1093/jpids/piy020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 01/31/2018] [Indexed: 11/14/2022]
Abstract
This national study characterized invasive Haemophilus influenzae serotype b infections. Vaccinated (n = 41) and nonvaccinated (n = 10) cases were similar regarding presentation as meningitis (68.8% vs 90.0%; P = .25), predisposing factors (29.3% vs 20.0%; P = .76), admission to intensive care unit or death (22.0% vs 10.0%; P = 1.00), or sequelae (21.6% vs 10.0%; P = .81). Haemophilus influenzae serotype b occurred in vaccinated, healthy children with comparable disease course.
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Affiliation(s)
- Susana Monge
- Centre for Infectious Disease Control Netherlands (CIb), National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands.,European Programme for Intervention Epidemiology Training, European Centre for Disease Prevention and Control, Stockholm, Sweden
| | - Liesbeth Mollema
- Centre for Infectious Disease Control Netherlands (CIb), National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| | - Hester de Melker
- Centre for Infectious Disease Control Netherlands (CIb), National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| | - Elisabeth Sanders
- Centre for Infectious Disease Control Netherlands (CIb), National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
| | - Arie van der Ende
- Department of Medical Microbiology and The Netherlands Reference Laboratory for Bacterial Meningitis, Academic Medical Center, University of Amsterdam
| | - Mirjam Knol
- Centre for Infectious Disease Control Netherlands (CIb), National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands
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Wing R, Manno M. Gone but not forgotten: a case of respiratory distress. Clin Pediatr (Phila) 2015; 54:697-9. [PMID: 25896724 DOI: 10.1177/0009922815581834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Robyn Wing
- Hasbro Children's Hospital/Brown University, Providence, RI, USA
| | - Mariann Manno
- University of Massachusetts Children's Medical Center, Worcester, MA, USA
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Impaired Antigen-Specific Immune Response to Vaccines in Children with Antibody Production Defects. CLINICAL AND VACCINE IMMUNOLOGY : CVI 2015; 22:875-82. [PMID: 26018535 DOI: 10.1128/cvi.00148-15] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 05/19/2015] [Indexed: 12/16/2022]
Abstract
The impaired synthesis of antigen-specific antibodies, which is indispensable for an adaptive immune response to infections, is a fundamental pathomechanism that leads to clinical manifestations in children with antibody production defects. The aim of this study was to evaluate the synthesis of antigen-specific antibodies following immunization in relation to peripheral blood B cell subsets in young children with hypogammaglobulinemia. Twenty-two children, aged from 8 to 61 months, with a deficiency in one or more major immunoglobulin classes participated in the study. Postvaccination antibodies against tetanus and diphtheria toxoids, the surface antigen of the hepatitis B virus, and the capsular Haemophilus influenzae type b polysaccharide antigen were assessed along with an immunophenotypic evaluation of peripheral blood B lymph cell maturation. A deficiency of antibodies against the tetanus toxoid was assessed in 73% of cases and that against the diphtheria toxoid was assessed in 68% of cases, whereas a deficiency of antibodies against the surface antigen of the hepatitis B virus was revealed in 59% of the children included in the study. A defective response to immunization with a conjugate vaccine with the Haemophilus influenzae type b polysaccharide antigen was demonstrated in 55% of hypogammaglobulinemic patients. Increased proportions of transitional B lymph cells and an accumulation of plasmablasts accompanied antibody deficiencies. The defective response to vaccine protein and polysaccharide antigens is a predominating disorder of humoral immunity in children with hypogammaglobulinemia and may result from a dysfunctional state of the cellular elements of the immune system.
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Genel F, Kutukculer N. Prospective, randomized comparison of OM-85 BV and a prophylactic antibiotic in children with recurrent infections and immunoglobulin A and/or G subclass deficiency. Curr Ther Res Clin Exp 2014; 64:600-15. [PMID: 24944407 DOI: 10.1016/j.curtheres.2003.09.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2003] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Patients with immunoglobulin (Ig)A and/or IgG subclass deficiency may be asymptomatic or may have recurrent, mainly respiratory infections. OBJECTIVE This study compared the clinical efficacy and tolerability of prophylactic therapy with either the oral immunomodulator bacterial extract OM-85 BV or benzathine penicillin G (BPG) in the prevention of recurrent infections in symptomatic patients. METHODS In this 26-month, prospective, randomized study conducted at the Department of Pediatric Immunology, Ege University (Izmir, Turkey), children aged 1 to 12 years with recurrent infections and IgA and/or IgG subclass deficiency were enrolled. After an initial 12-month control period, patients were randomized to receive OM-85 BV or BPG. OM-85 BV (3.5-mg capsule) was given once daily for the first 10 days of each month for the first 3 months of the study. IM injections of BPG were given at a dose of 1.2 million units (for patients with body weight > 27 kg) or at a half-dose (for patients with body weight ≤27 kg) every 3 weeks for 12 months. In nonresponders (ie, those who continued to have recurrent infections at 12-month follow-up), IV immunoglobulin (IVIG) replacement therapy at 400 mg/kg body weight was given every 4 weeks for an additional 12 months. The results of IVIG therapy were assessed by the authors using clinical observation. Adverse effects and adverse drug reactions were documented by the authors for each vaccine, prophylactic therapy, and IVIG. RESULTS A total of 91 children (56 boys, 35 girls; mean [SD] age at the start of the control period, 46.4 [31.0] months) were enrolled. Of these, 44 were randomized to the OM-85 BV group and 47 to the BPG group. The year before prophylactic therapy, the mean (SD) number of reported infections was 10.7 (3.6) and the mean (SD) number of antibiotic courses was 9.7 (3.6) (OM-85 BV group: mean [SD] number of reported infections, 10.5 [3.3]; mean (SD) number of antibiotic courses, 9.3 [3.3]; BPG group: mean [SD] number of reported infections, 10.8 [3.9], mean (SD) number of antibiotic courses, 10.1 [3.9]). At 12 months, the number of infections and antibiotic courses decreased significantly in the entire study population, but the between-group difference was not significant. Five patients in each group (OM-85 BV group, 11.4%; BPG group, 10.6%) were considered nonresponders and received IVIG treatment. Compared with responders, nonresponders were significantly younger (mean [SD] age, 34.40 [21.70] months vs 52.65 [30.52] months; P = 0.036) and had lower serum IgG (P<0.001), IgG1 (P = 0.006), IgG2 (P = 0.003), IgG3 (P = 0.035), and IgM (P = 0.008) levels and antibody responses to tetanus toxoid and Haemophilus influenzae type b (Hib) vaccines (P = 0.036 and 0.013, respectively). At 12-month follow-up, a protective effect of the prophylactic IVIG therapy was seen, with a statistically significant reduction in the number of infections to 3.3 (2.4) and in the number of antibiotic courses to 2.7 (2.5) (both P = 0.005). CONCLUSIONS In this study population of children with recurrent infections and IgA and/or IgG subclass deficiency, prophylactic therapy with either OM-85 BV or an antibiotic significantly decreased the number of infections per year. In addition, nonresponders benefited from IVIG replacement therapy.
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Affiliation(s)
- Ferah Genel
- Department of Pediatric Immunology, Ege University Faculty of Medicine, Izmir, Turkey
| | - Necil Kutukculer
- Department of Pediatric Immunology, Ege University Faculty of Medicine, Izmir, Turkey
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Purohit P, Al-Obaid IA, Omar NGAD. The first reported case of possible Haemophilus influenzae type b vaccine failure from Kuwait and literature-review. J Infect Public Health 2014; 7:99-105. [DOI: 10.1016/j.jiph.2013.07.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2013] [Revised: 06/11/2013] [Accepted: 07/06/2013] [Indexed: 11/28/2022] Open
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Crum-Cianflone NF, Collins G, Defang G, Iverson E, Eberly LE, Duplessis C, Maguire J, Ganesan A, Agan BK, Lalani T, Whitman T, Brandt C, Faix D, Blair PJ, Burgess T. Immunoglobulin G subclass levels and antibody responses to the 2009 influenza A (H1N1) monovalent vaccine among human immunodeficiency virus (HIV)-infected and HIV-uninfected adults. Clin Exp Immunol 2012; 168:135-41. [PMID: 22385248 DOI: 10.1111/j.1365-2249.2011.04550.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Immunoglobulin (Ig)G levels are important for antibody vaccine responses and IgG subclass deficiencies have been associated with severe 2009 influenza A (H1N1) infections. Studies have demonstrated variations in immune responses to the H1N1 vaccine, but the aetiology of this is unknown. We determined the associations between pre-vaccination overall and influenza-specific IgG subclass levels and 2009 H1N1-specific antibody responses post-vaccination (robust versus poor at day 28) stratified by human immunodeficiency virus (HIV) status. Logistic regression models were utilized to evaluate whether pre-vaccination IgG subclass levels were associated with the antibody response generated post-vaccination. We evaluated 48 participants as part of a clinical study who were stratified by robust versus poor post-vaccination immune responses. Participants had a median age of 35 years; 92% were male and 44% were Caucasian. HIV-infected adults had a median CD4 count of 669 cells/mm(3) , and 79% were receiving highly active anti-retroviral therapy. HIV-infected participants were more likely to have IgG2 deficiency (<240 mg/dl) than HIV-uninfected individuals (62% versus 4%, P < 0·001). No association of pre-vaccination IgG subclass levels (total or influenza-specific) and the antibody response generated by HIN1 vaccination in either group was found. In summary, pre-vaccination IgG subclass levels did not correlate with the ability to develop robust antibody responses to the 2009 influenza A (H1N1) monovalent vaccine. IgG2 deficiencies were common among HIV-infected individuals but did not correlate with poor influenza vaccine responses. Further investigations into the aetiology of disparate vaccine responses are needed.
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Affiliation(s)
- N F Crum-Cianflone
- Infectious Disease Clinical Research Program, Uniformed Services University of the Health Sciences Naval Medical Research Center, Bethesda, MD 20892, USA.
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11
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Immunoglobulin deficiency in children with Hib vaccine failure. Vaccine 2011; 29:9137-40. [DOI: 10.1016/j.vaccine.2011.09.107] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2011] [Revised: 09/18/2011] [Accepted: 09/23/2011] [Indexed: 11/22/2022]
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12
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Haemophilus influenzae infections in the H. influenzae type b conjugate vaccine era. J Clin Microbiol 2011; 49:3728-32. [PMID: 21900515 DOI: 10.1128/jcm.05476-11] [Citation(s) in RCA: 164] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The widespread use of Haemophilus influenzae type b (Hib) conjugate vaccines has nearly eradicated invasive Hib disease where the vaccines are used. This success was accompanied by a shift in capsular serotypes of invasive H. influenzae disease, with nontypeable strains replacing type b strains as the most common bloodstream isolate, but there is no convincing evidence of a true increase in the incidence of non-serotype b invasive infections. H. influenzae causes predominantly mucosal infections. The introduction of vaccines for otitis media and global shifts in antimicrobial susceptibility emphasize the importance of continued surveillance of H. influenzae colonization and disease patterns.
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Ladhani S, Heath PT, Slack MPE, McIntyre PB, Diez-Domingo J, Campos J, Dagan R, Ramsay ME. Haemophilus influenzae serotype b conjugate vaccine failure in twelve countries with established national childhood immunization programmes. Clin Microbiol Infect 2009; 16:948-54. [PMID: 19889054 DOI: 10.1111/j.1469-0691.2009.02945.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The present study describes the clinical and immunological features of children with Hib vaccine failure, who were identified through national surveillance between 1996 and 2001 in Europe, Israel and Australia. True vaccine failure was defined as invasive Hib disease occurring ≥2 weeks after one dose, given after the first birthday, or ≥1 week after ≥2 doses, given at <1 year of age. Of the 423 cases (representing 0.2 cases per 100,000 child-years at risk) reported, 330 (78%) had received three doses in the first year of life and developed disease at a median age of 28 months. Of the remaining 93, 48 had received two doses in infancy, 34 had received four doses including a booster, and 11 had received a single dose after 12 months of age. These children developed disease at a median age of 12, 33 and 71 months, respectively. In total, 47 out of 258 children (18%) with available information had an underlying medical problem (including prematurity) and 53 out of 161 (33%) had immunoglobulin deficiency. Convalescent Hib antibody concentrations were above the putative protective concentration of 1.0 mg/L in 147/194 (76%) children; low concentrations were associated with both the presence of an underlying medical problem and young age at the time of Hib disease. Almost all children who received an additional vaccine dose developed antibodies at protective concentrations. Thus, Hib vaccine failure is rare, but can occur with any immunization schedule. Children with Hib vaccine failure should have immunoglobulin and convalescent Hib antibody concentrations measured after infection and receive additional vaccination, if required.
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Affiliation(s)
- S Ladhani
- Immunisation Department, Centre for Infections, Health Protection Agency, London, UK.
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14
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Kutukculer N, Gulez N. The outcome of patients with unclassified hypogammaglobulinemia in early childhood. Pediatr Allergy Immunol 2009; 20:693-8. [PMID: 19196447 DOI: 10.1111/j.1399-3038.2008.00845.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Symptomatic hypogammaglobulinemia in childhood may be the initial finding of primary immunodeficiency (PID) or may be due to delay in maturation of immunoglobulin synthesis. The aim of this study was to review the clinical and laboratory records of patients with unclassified hypogammaglobulinemia and to evaluate whether these children experience changes in serum immunoglobulin concentrations during long-term followup and have an exact diagnosis in natural course of disease. We reviewed the data of 412 patients who were diagnosed as PID with symptomatic hypogammaglobulinemia. Thirty-seven patients with hypogammaglobulinemia [19 males (51.4%) and 18 females (48.6%), with a followup of 34.1 +/- 22.0 months] who were not classified according to European Society for Immunodeficiencies diagnostic criteria were included in this study. The mean age at the beginning of the symptoms was 21.4 +/- 20.6 months and the mean age at admission was 51.5 +/- 25.8 months. The commonest clinical presentations were recurrent upper (94.6%) and/or lower (40.5%) respiratory infections, urinary infection (27%) and gastroenteritis (10.8%). Percentage of consanguinity was 8%. Of the initial 37 patients, 18 (48.6%) spontaneously corrected their immunoglobulin abnormalities during followup. Clinical symptoms of these patients were also improved. IgG, IgA and IgM levels reached to normal levels at ages 62.5 +/- 21.8, 72.0 +/- 11.2, 55.2 +/- 7.8 months, respectively. In remaining 19 patients with undefined/unclassified hypogammaglobulinemia, three partial IgA deficiency, seven IgG subclass deficiency, two selective IgM deficiency and two common variable immunodeficiency (CVID) were diagnosed by long-term monitoring of immunoglobulin levels. Five (13.5%) of the 37 unclassified patients could not be exactly diagnosed while two of them might have a T-cell defect and three of them still had low IgG and IgA levels but adequate antibody responses against vaccine antigens. In conclusion, it is important to monitor symptomatic patients with hypogammaglobulinemia periodically. Some children may spontaneously correct their immunoglobulin abnormalities not in the first 30 months of age, but during the first decade of life and some of them may have a severe PID like CVID.
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Affiliation(s)
- Necil Kutukculer
- Division of Pediatric Immunology, Department of Pediatrics, Faculty of Medicine, Ege University, Izmir, Turkey.
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15
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Hib epiglottitis despite fully vaccinated status. Br J Gen Pract 2009; 59:597-8. [PMID: 22751236 DOI: 10.3399/bjgp09x453828] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2008] [Accepted: 02/13/2009] [Indexed: 10/31/2022] Open
Abstract
The introduction of an effective vaccine has markedly reduced the incidence of invasive Haemophilus influenzae type b (Hib) disease. However, vaccination failure can occur, and this report describes one such case in a previously healthy 4-year-old girl, who became severely unwell with Hib epiglottitis. She had received a full course of Hib vaccine administered via the buttocks. This site has been associated with reduced immunogenicity compared to vaccination by injection into the thigh or deltoid muscles. Current recommendations are to avoid gluteal injection for all vaccinations.
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Pop-Jora D, Dabernat H, Levy C, Lécuyer A, Cohen R, Grimprel E. Surveillance des méningites à Haemophilus Influenzae de l'enfant en France, 2001-2006. Arch Pediatr 2008; 15 Suppl 3:S148-53. [DOI: 10.1016/s0929-693x(08)75498-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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17
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Kimman TG, Vandebriel RJ, Hoebee B. Genetic variation in the response to vaccination. Public Health Genomics 2007; 10:201-17. [PMID: 17895626 DOI: 10.1159/000106559] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Vaccines are the most powerful means to prevent and diminish the burden of infectious disease. However, there are limitations to their use: vaccines are not yet available for all infectious diseases (including human immunodeficiency virus and respiratory syncytial virus), they sometimes lack efficacy, the response to vaccination is limited by maternal antibodies in very young infants, and the response to vaccination is variable or may even be absent in some individuals. This review focuses on genetic factors that determine the variable response to vaccination. The highly polymorphic human leukocyte antigen system, which is involved in antigen presentation, has been researched most in this aspect, and clearly affects the response to vaccination. Other, but less polymorphic pathways involved are the Toll-like receptor pathway, which is involved in antigen recognition and stimulation of the immune system, and the cytokine immunoregulatory network. The heritability, or the proportion of total variance that is due to additive genetic factors, appears to be particularly large for vaccine-induced antibody responses in young infants compared with cell-mediated responses and antibody responses in older, immunologically more mature individuals. Both antibody and cell-mediated responses are not only affected by loci within, but also strongly by loci outside the human leukocyte antigen system. Because most genes that are important in influencing immune responses to vaccination are still unknown, clearly more work is required. A better understanding of the factors that determine an effective response to vaccination may lead to the identification of specific genes and pathways as targets for the development of novel more uniformly effective vaccines.
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Affiliation(s)
- T G Kimman
- Laboratorie for Vaccine-Preventable Diseases, National Institute of Public Health and Environment, Bilthoven, The Netherlands.
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Kutukculer N, Yeniay BS, Aksu G, Berdeli A. Arg753Gln polymorphism of the human toll-like receptor-2 gene in children with recurrent febrile infections. Biochem Genet 2007; 45:507-14. [PMID: 17554618 DOI: 10.1007/s10528-007-9091-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2006] [Accepted: 03/19/2007] [Indexed: 12/26/2022]
Abstract
Polymorphisms in toll-like receptors (TLRs) have been reported to increase susceptibility for some diseases. TLR-2 gene polymorphisms in Turkish children with recurrent respiratory tract infections and without well-known humoral immunodeficiencies were examined. The study consisted of 52 children with recurrent infections (study group) and 91 healthy children with a maximum of two infections in a year (control group). Recurrent infection was defined as the presence of at least six febrile bacterial infection episodes in a year. Not only TLR-2 gene polymorphisms but also immunoglobulins (IgG, IgM, IgA), IgG subsets (G1, G2, G3), and specific antibody levels (anti-tetanus and anti-hemophilus influenza) were determined to exclude humoral immunodeficiencies. The Arg753Gln and Arg677Trp polymorphisms were genotyped by polymerase chain reaction restriction fragment length polymorphism. The Arg753Arg genotype was significantly decreased in the study group compared to the control (P < 0.05). Children with recurrent infections were also found to be more frequently Arg753Gln heterozygous (P < 0.05), and their Gln allele distribution was higher than that of the control subjects (23% vs. 4.9%; P < 0.001). In contrast to these results, we did not detect any case with Arg677Trp polymorphism in both groups. These results have indicated that there is a strong significant relationship between susceptibility to recurrent bacterial infections and Arg753Gln polymorphism of the TLR-2 gene.
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Affiliation(s)
- Necil Kutukculer
- Department of Pediatrics, Faculty of Medicine, Ege University, Bornova, Izmir 35100, Turkey.
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Kutukculer N, Karaca NE, Demircioglu O, Aksu G. Increases in serum immunoglobulins to age-related normal levels in children with IgA and/or IgG subclass deficiency. Pediatr Allergy Immunol 2007; 18:167-73. [PMID: 17338791 DOI: 10.1111/j.1399-3038.2006.00491.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Immunoglobulins (Ig) A and G subclass deficiencies are common immune system disorders which cause morbidity especially between 2 and 6 yr of age. Prognosis of these defects and therapeutic approach is unclear. The aim of the present retrospective study was to review the clinical and laboratory records of 87 children with IgA and/or IgG subclass deficiency to determine whether these patients experience changes in serum Ig concentrations during follow-up and to give more clinic and laboratory information to the families about the course of these diseases. Among 87 patients studied, the most frequent defect was partial IgA deficiency combined with IgG3 subclass deficiency (41%). The other groups were as follows; partial IgA deficiency (32%), selective IgA deficiency (8%), partial IgA combined with IgG2-G4 subclass deficiency (6%), and IgG subclass deficiency (13%). The commonest clinical presentations were recurrent upper respiratory tract infections (76%), pneumonia (14%), acute gastroenteritis (3%), urinary tractus infection (3%), sinusitis (2%), and acute otitis media (2%). Atopy was widely represented in the patients studied (24%). The number of patients who were given prophylactic treatment with benzathine penicilline, prophylactic oral antibiotic, or oral bacterial extract to prevent infections was 68 (78%). Frequency of recurrent infections decreased from 7.9 +/- 4.9 per year to 2.5 +/- 2.3 in 68 patients receiving any prophylactic regimen; however, decrease in frequency of infections did not show any significant difference between different prophylactic groups. None of the patients in the selective IgA deficiency group had reached normal serum levels of IgA. At the age of 58.3 +/- 21.4 months, 52% of patients in partial IgA deficiency group and 51% of patients in partial IgA + IgG subclass deficiency group, serum IgA increased to normal ranges. Serum IgG subclass levels increased to normal range for age in 67% of patients in partial IgA + IgG subclass deficiency group and in 30% of patients in isolated IgG subclass deficiency group. The mean age for reaching age-related normal IgG subclass levels for these patients was 69.0 +/- 14.5 months. In conclusion, findings of this study suggest that IgA and/or IgG subclass deficiency may be either progressive or reversible disorders and emphasize the value of monitoring Ig levels in affected individuals.
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Affiliation(s)
- Necil Kutukculer
- Ege University, The Medical School, Department of Pediatrics, Izmir, Turkey.
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20
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Corvec S, Hazart I, Reynaud A, Picherot G, Drugeon H. [Vaccination failure: case report of Haemophilus influenzae b meningitis in a 14-month-old child]. ACTA ACUST UNITED AC 2005; 53:92-6. [PMID: 15708653 DOI: 10.1016/j.patbio.2004.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2004] [Accepted: 02/09/2004] [Indexed: 11/19/2022]
Abstract
BACKGROUND The generalization of the vaccination against H. influenzae b (Hib), according to its integration in the French vaccinal calendar, led to the incidence decrease of the purulent meningitis with Hib in young children, which became a so rare event. CASE REPORT We described the case of a 14-months-old child showing a bacterial purulent meningitis with Hib, despite of a well driven vaccination. DISCUSSION The epidemiology of bacterial meningitis was upset by the generalization of the anti-H. influenzae b vaccination. The use of combined vaccines specially reduced the incidence and the gravity of this pathology. Nevertheless, in spite of the excellent vaccinal coverage, the limited but real persistence of epiglottis or meningitis due to H. influenzae b should keep in mind of the biologists and the clinicians. Indeed, the chronic nasopharyngal carriage, the existence of not vaccinated or not answering people allow to consider the persistent risk of H. influenzae b bacterial meningitis.
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Affiliation(s)
- S Corvec
- Laboratoire de Bactériologie-Virologie-Hygiène Hospitalière, institut de biologie de Nantes, CHU de Nantes, 9 quai Moncousu, 44093 Nantes cedex 01, France.
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Abstract
Haemophilus influenzae type b (Hib) is one of the leading causes of invasive bacterial infection in young children worldwide. During childhood, acquisition of antibody directed against the polysaccharide capsule of the organism, presumably as a result of asymptomatic carriage, confers protection and disease is much less common after the age of 4 years. Like other polysaccharides, the polyribosyl ribitol phosphate (PRP) of the Hib capsule is a T-independent antigen and not immunogenic when administered as a vaccine in infancy. Because the highest rates of disease occur in the first 2 years of life, efficacious Hib vaccines have been designed by covalently linking the PRP capsule to a carrier protein that recruits T-cell help for the polysaccharide immune response and induces anti-PRP antibody production even in the first 6 months of life. Introduction of Hib protein-polysaccharide conjugate vaccines into many industrialized countries over the past 15 years has resulted in the virtual elimination of invasive Hib disease. However, despite the success of the vaccine programme several factors may interfere with the effectiveness of the vaccine in the routine programme, as observed in the UK recently. Such factors may include interference with other concomitant vaccines, waning immunity in the absence of booster doses of vaccine, and reduced natural boosting as a result of decreased transmission of the organism. However, the burden of disease remains highest in resource-poor countries and urgent efforts are needed to provide the benefits of this vaccine for children living in regions where it cannot be used for economic and logistical reasons.
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Affiliation(s)
- Dominic F Kelly
- Department of Paediatrics, John Radcliffe Hospital, University of Oxford, Headington, Oxford, UK
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Krueger M, Fluegge K, Krause MF, Berner R. Fatal Haemophilus influenzaetype b sepsis in a 10-month-old infant despite complete vaccination and adequate Hib antibodies. Eur J Pediatr 2004; 163:412-3. [PMID: 15085427 DOI: 10.1007/s00431-004-1449-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2003] [Accepted: 03/11/2004] [Indexed: 11/29/2022]
Affiliation(s)
- Marcus Krueger
- Department of Paediatrics, University Hospital of Freiburg, Mathildenstrasse 1, 79106 Freiburg, Germany.
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23
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Nigrovic LE, Malley R. Evaluation of the febrile child 3 to 36 months old in the era of pneumococcal conjugate vaccine: focus on occult bacteremia. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2004. [DOI: 10.1016/j.cpem.2003.11.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Prinz DM, Smithson SL, Kieber-Emmons T, Westerink MAJ. Induction of a protective capsular polysaccharide antibody response to a multiepitope DNA vaccine encoding a peptide mimic of meningococcal serogroup C capsular polysaccharide. Immunology 2003; 110:242-9. [PMID: 14511238 PMCID: PMC1783044 DOI: 10.1046/j.1365-2567.2003.01732.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Systemic infection by encapsulated organisms, such as Neisseria meningitidis, is a major cause of morbidity and mortality worldwide, especially in individuals less than 2 years of age. Antibodies directed at the capsular polysaccharide are shown to be protective against disease by inducing complement-dependent bactericidal activity. The current polysaccharide vaccine has been shown to be poorly immunogenic in high-risk groups and this is probably related to its T-independent properties. An alternative approach to eliciting a T-dependent serum immunoglobulin G (IgG) antibody response to encapsulated pathogens is DNA vaccination. We assessed the immunogenicity of a multiepitope DNA vaccine encoding a T-cell helper epitope and a peptide mimic of N. meningitidis serogroup C. The DNA construct induced a significant anti-polysaccharide antibody response that was bactericidal. Mice immunized with the DNA construct were subsequently protected against challenge with a lethal dose of N. meningitidis serogroup C.
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Affiliation(s)
- Deborah M Prinz
- Departments of Pathology and Medicine, Medical College of Ohio, Toledo, OH 43614, USA.
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25
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Campos J, Aracil B, Román F, Pérez-Vázquez M. Molecular epidemiology of Haemophilus influenzae type b isolated from children with clinical cases of conjugate vaccine failures. J Clin Microbiol 2003; 41:3915-8. [PMID: 12904417 PMCID: PMC179828 DOI: 10.1128/jcm.41.8.3915-3918.2003] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
We analyzed eight invasive Haemophilus influenzae strains isolated from individual children vaccinated appropriately for their ages. Five of the strains were type b and three were nontypeable strains. Children infected with nontypeable strains had a protective level of anti-H. influenzae type b antibodies, while only one of the children whose cases represented true vaccine failure did.
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Affiliation(s)
- José Campos
- Centro Nacional de Microbiología, Instituto de Salud Carlos III, Ministry of Health, Madrid, Spain.
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McVernon J, Johnson PDR, Pollard AJ, Slack MPE, Moxon ER. Immunologic memory in Haemophilus influenzae type b conjugate vaccine failure. Arch Dis Child 2003; 88:379-83. [PMID: 12716702 PMCID: PMC1719572 DOI: 10.1136/adc.88.5.379] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
AIMS To compare the convalescent antibody response to invasive Haemophilus influenzae type b (Hib) disease between conjugate vaccine immunised and unimmunised children, to look for evidence of priming for immunologic memory. METHODS Unmatched case-control study in the UK and Eire 1992-2001 and Victoria, Australia 1988-1990. A total of 93 children were identified as having invasive Hib disease following three doses of conjugate vaccine in infancy through post licensure surveillance throughout the UK and Eire; 92 unvaccinated children admitted to an Australian paediatric hospital with invasive Hib disease were used as historical controls. Convalescent serum was taken for measurement of Hib antibody concentration, and clinical information relating to potential disease risk factors was collected. The geometric mean concentrations of convalescent Hib antibodies were compared between immunised and unimmunised children, using raw and adjusted data. RESULTS Hib conjugate vaccine immunised children had higher serum Hib antibody responses to disease (geometric mean concentration (GMC) 10.81 microg/ml (95% CI 6.62 to 17.66) than unimmunised children (1.06 microg/ml (0.61 to 1.84)) (p < 0.0001). However, following adjustment for the significant confounding influences of age at presentation and timing of serum collection, a difference persisted only in children presenting with meningitis (vaccinated GMC 3.78 microg/ml (2.78 to 5.15); unvaccinated GMC 1.48 microg/ml (0.90 to 2.21); p = 0.003). CONCLUSIONS Higher antibody responses to invasive Hib disease in vaccinated children with meningitis reflect priming for immunologic memory by the vaccine. Although a majority of children in the UK are protected from Hib disease by immunisation, the relative roles of immunologic memory and other immune mechanisms in conferring protection remain unclear.
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Affiliation(s)
- J McVernon
- Oxford Vaccine Group, University of Oxford Department of Paediatrics, John Radcliffe Hospital, Oxford, UK.
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Abstract
The use of potency control testing is a valuable tool for testing the actual relative strength of manufactured assembly lots of vaccine. Biological-based manufacturing methods are inherently variable and potency testing is a tool to ensure lot-to-lot consistency of commercial vaccines. A strong historical link to clinical efficacy has been established where correlation to efficacy and adequate test validation have been achieved. The link to immunogenicity and efficacy has traditionally been strongest with attenuated vaccines and toxoids. Control potency test failure does predict that a serial or batch of vaccine would most likely provide insufficient immunogenicity in typical field applications. Because of the complexity of pathogenic processes and associated immune responses, potency tests may not always directly predict the effectiveness of a vaccine. Thus, vaccines that pass control potency testing may not always provide adequate efficacy. This is particularly true of adjuvanted, inactivated vaccines. In the development of vaccine formulations and control tests for vaccines, the nature of the desired protective immune responses to the targeted pathogen (when known) should be considered. These considerations could provide better alternatives in the assays chosen as correlates of immunity and may more accurately predict efficacy and assure batch-to-batch consistency. Also, the effects of the dose and duration of antigen exposure as well as the nature of antigen presentation and generation of extrinsic cytokines could be characterised and correlated to vaccine potency as additional indicators of vaccine efficacy.
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Affiliation(s)
- David Scott McVey
- Biologicals Development, Veterinary Medicine Research and Development, Pfizer Animal Health, Pfizer, Inc., Eastern Point Road, 8118D-2001, Groton, CT 06340, USA.
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28
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Meats E, Feil EJ, Stringer S, Cody AJ, Goldstein R, Kroll JS, Popovic T, Spratt BG. Characterization of encapsulated and noncapsulated Haemophilus influenzae and determination of phylogenetic relationships by multilocus sequence typing. J Clin Microbiol 2003; 41:1623-36. [PMID: 12682154 PMCID: PMC153921 DOI: 10.1128/jcm.41.4.1623-1636.2003] [Citation(s) in RCA: 293] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
A multilocus sequence typing (MLST) scheme has been developed for the unambiguous characterization of encapsulated and noncapsulated Haemophilus influenzae isolates. The sequences of internal fragments of seven housekeeping genes were determined for 131 isolates, comprising a diverse set of 104 serotype a, b, c, d, e, and f isolates and 27 noncapsulated isolates. Many of the encapsulated isolates had previously been characterized by multilocus enzyme electrophoresis (MLEE), and the validity of the MLST scheme was established by the very similar clustering of isolates obtained by these methods. Isolates of serotypes c, d, e, and f formed monophyletic groups on a dendrogram constructed from the differences in the allelic profiles of the isolates, whereas there were highly divergent lineages of both serotype a and b isolates. Noncapsulated isolates were distinct from encapsulated isolates and, with one exception, were within two highly divergent clusters. The relationships between the major lineages of encapsulated H. influenzae inferred from MLEE data could not be discerned on a dendrogram constructed from differences in the allelic profiles, but were apparent on a tree reconstructed from the concatenated nucleotide sequences. Recombination has not therefore completely eliminated phylogenetic signal, and in support of this, for encapsulated isolates, there was significant congruence between many of the trees reconstructed from the sequences of the seven individual loci. Congruence was less apparent for noncapsulated isolates, suggesting that the impact of recombination is greater among noncapsulated than encapsulated isolates. The H. influenzae MLST scheme is available at www.mlst.net, it allows any isolate to be compared with those in the MLST database, and (for encapsulated isolates) it assigns isolates to their phylogenetic lineage, via the Internet.
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Affiliation(s)
- Emma Meats
- Department of Infectious Disease Epidemiology, Imperial College London, St. Mary's Hospital, London W2 1PG, United Kingdom
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29
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Affiliation(s)
- Mark Steinhoff
- Johns Hopkins University School of Medicine, School of Hygiene, Baltimore, MD 21205, USA.
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30
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Nigrovic LE, Kuppermann N, Malley R. Development and validation of a multivariable predictive model to distinguish bacterial from aseptic meningitis in children in the post-Haemophilus influenzae era. Pediatrics 2002; 110:712-9. [PMID: 12359784 DOI: 10.1542/peds.110.4.712] [Citation(s) in RCA: 127] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Children with meningitis are routinely admitted to the hospital and administered broad-spectrum antibiotics pending culture results because distinguishing bacterial meningitis from aseptic meningitis is often difficult. OBJECTIVE To develop and validate a simple multivariable model to distinguish bacterial meningitis from aseptic meningitis in children using objective parameters available at the time of patient presentation. DESIGN Retrospective cohort study of all children with meningitis admitted to 1 urban children's hospital from July 1992 through June 2000, randomly divided into derivation (66%) and validation sets (34%). PATIENTS Six hundred ninety-six previously healthy children aged 29 days to 19 years, of whom 125 (18%) had bacterial meningitis and 571 (82%) had aseptic meningitis. INTERVENTION Multivariable logistic regression and recursive partitioning analyses identified the following predictors of bacterial meningitis from the derivation set: Gram stain of cerebrospinal fluid (CSF) showing bacteria, CSF protein > or =80 mg/dL, peripheral absolute neutrophil count > or =10 000 cells/mm3, seizure before or at time of presentation, and CSF absolute neutrophil count > or =1000 cells/mm3. A Bacterial Meningitis Score (BMS) was developed on the derivation set by attributing 2 points for a positive Gram stain and 1 point for each of the other variables. MAIN OUTCOME MEASURE The accuracy of the BMS when applied to the validation set. RESULTS A BMS of 0 accurately identified patients with aseptic meningitis without misclassifying any child with bacterial meningitis in the validation set. The negative predictive value of a score of 0 for bacterial meningitis was 100% (95% confidence interval: 97%-100%). A BMS > or =2 predicted bacterial meningitis with a sensitivity of 87% (95% confidence interval: 72%-96%). CONCLUSIONS The BMS accurately identifies children at low (BMS = 0) or high (BMS > or =2) risk of bacterial meningitis. Outpatient management may be considered for children in the low-risk group.
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Affiliation(s)
- Lise E Nigrovic
- Department of Medicine, Children's Hospital and Harvard Medical School, Boston, Massachusetts 02115, USA
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Pelton SI, Klein JO. The future of pneumococcal conjugate vaccines for prevention of pneumococcal diseases in infants and children. Pediatrics 2002; 110:805-14. [PMID: 12359799 DOI: 10.1542/peds.110.4.805] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Seven-valent pneumococcal conjugate vaccine (PCV7) was licensed in February 2000. In June 2000, the Advisory Committee on Immunization Practices and the American Academy of Pediatrics recommended the universal administration of pneumococcal conjugate vaccine for all children 23 months of age and younger and for children 24 to 59 months of age who are at high risk for serious pneumococcal disease. Since then, >23 million doses have been administered in the United States. Postlicensure surveillance of invasive pneumococcal disease (IPD) in the United States from the Active Bacterial Core Surveillance program at the Centers for Disease Control and Prevention and the Northern California Kaiser Permanente Vaccine Study Center has reported a decline in IPD and in pneumococcal disease incidence as a result of vaccine serotypes, respectively. During this period, issues critical to the long-term success of PCV7 have become more relevant: Will PCV7 be as effective in groups of children who are at high risk for IPD as in healthy children? Will nonvaccine types replace vaccine serotypes in the nasopharynx and in disease? Why are the results of the clinical trials different for IPD and for acute otitis media? How many doses of PCV7 and what concentrations of antibody are necessary for protection? Will universal administration of PCV7 to children younger than 2 years reduce antimicrobial drug resistance and alter prescribing patterns of physicians for febrile infants? Have there been unanticipated adverse events or benefits observed? The purpose of this report is to review the current data available to address these questions and to identify gaps that will require additional knowledge to determine the ultimate value of pneumococcal conjugate vaccines in reducing the burden of pneumococcal disease in infants and children.
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Affiliation(s)
- Stephen I Pelton
- Department of Pediatrics, Boston University School of Medicine, and Maxwell Finland Laboratory for Infectious Diseases, Boston Medical Center, Boston, Massachusetts 02118, USA.
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Meissner HC, Pickering LK. Control of disease attributable to Haemophilus influenzae type b and the national immunization program. Pediatrics 2002; 110:820-3. [PMID: 12359800 DOI: 10.1542/peds.110.4.820] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- H Cody Meissner
- Division of Pediatric Infectious Disease, New England Medical Center, Tufts University School of Medicine, Boston, MA 02111, USA.
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Breukels MA, Jol-van der Zijde E, van Tol MJD, Rijkers GT. Concentration and avidity of anti-Haemophilus influenzae type b (Hib) antibodies in serum samples obtained from patients for whom Hib vaccination failed. Clin Infect Dis 2002; 34:191-7. [PMID: 11740707 DOI: 10.1086/338259] [Citation(s) in RCA: 40] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2001] [Revised: 09/04/2001] [Indexed: 11/03/2022] Open
Abstract
Haemophilus influenzae type b (Hib) conjugate vaccines are extremely effective in protecting infants and children from invasive Hib infections; however, vaccine failures do occur. The anti-Hib antibody production was studied both quantitatively and qualitatively in 12 patients who experienced Hib failure, all of whom had normal serum immunoglobulin concentrations and all of whom were without clinical risk factors for invasive Hib disease. Both anti-Hib antibody concentration and immunoglobulin-G2 anti-Hib antibody avidity were significantly lower in patients who experienced Hib failure, at onset of disease and after reconvalescence, when compared with controls. This finding suggests that the patients who developed invasive Hib disease--despite having received 3-4 Hib conjugate vaccinations--were inadequately primed by these vaccinations.
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Affiliation(s)
- Mijke A Breukels
- Department of Pediatric Immunology, Wilhelmina Children's Hospital, University Medical Center, 3584 EA, Utrecht, The Netherlands.
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