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Nielsen S, Fisker AB, Sie A, Müller O, Nebie E, Becher H, van der Klis F, Biering-Sørensen S, Byberg S, Thysen SM, da Silva I, Rodrigues A, Martins C, Whittle HC, Aaby P, Benn CS. Contradictory mortality results in early 2-dose measles vaccine trials: interactions with oral polio vaccine may explain differences. Int J Infect Dis 2024; 148:107224. [PMID: 39218141 DOI: 10.1016/j.ijid.2024.107224] [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: 02/02/2024] [Revised: 08/22/2024] [Accepted: 08/23/2024] [Indexed: 09/04/2024] Open
Abstract
OBJECTIVES Between 2003 and 2019, three trials (randomised controlled trials [RCTs]) in Guinea-Bissau randomised infants to an early 2-dose measles vaccine (MV) schedule at 4 and 9 months vs standard MV at 9 months. The RCTs produced contradictory mortality results; the effect being beneficial in the 2-dose group in the first but tending to have higher mortality in the last two RCTs. We hypothesised that increased frequency of campaigns with oral polio vaccine (C-OPV) explained the pattern. METHODS We performed per-protocol analysis of individual-level survival data from the three RCTs in Cox proportional hazards models yielding hazard ratios (HR) for the 2-dose vs the 1-dose MV group. We examined whether timing of C-OPVs and early administration of OPV0 (birth to day 14) affected the HRs for 2-dose/1-dose MV. RESULTS The combined HR(2-dose/1-dose) was 0.79 (95% confidence interval: 0.62-1.00) for children receiving no C-OPV-before-enrolment, but 1.39 (0.97-1.99) for those receiving C-OPV-before-enrolment (homogeneity, P = 0.01). C-OPV-before-enrolment had a beneficial effect in the 1-dose group but tended to have a negative effect in the 2-dose group, especially in females. These effects were amplified further by early administration of OPV0. CONCLUSION In the absence of C-OPVs, an early 2-dose MV strategy had beneficial effects on mortality, but frequent C-OPVs may have benefitted the 1-dose group more than the 2-dose MV group, leading to varying results depending on the intensity of C-OPVs.
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Affiliation(s)
- Sebastian Nielsen
- Bandim Health Project, Indepth Network, Bissau, Guinea-Bissau; OPEN, Odense Patient Data Explorative Network, Institute of Clinical Research, Odense University Hospital/University of Southern Denmark, Odense, Denmark.
| | - Ane B Fisker
- Bandim Health Project, Indepth Network, Bissau, Guinea-Bissau; OPEN, Odense Patient Data Explorative Network, Institute of Clinical Research, Odense University Hospital/University of Southern Denmark, Odense, Denmark
| | - Ali Sie
- Centre de Recherche en Santé, Nouna, Burkina Faso
| | - Olaf Müller
- Institute of Public Health, Ruprecht-Karls-University, Heidelberg, Germany
| | - Eric Nebie
- Centre de Recherche en Santé, Nouna, Burkina Faso
| | - Heiko Becher
- Institute of Global Health, University Hospital Heidelberg, Heidelberg, Germany
| | - Fiona van der Klis
- National Institute of Public Health and the Environment, Bilthoven, The Netherlands
| | | | - Stine Byberg
- Bandim Health Project, Indepth Network, Bissau, Guinea-Bissau
| | - Sanne M Thysen
- Bandim Health Project, Indepth Network, Bissau, Guinea-Bissau
| | | | | | - Cesario Martins
- Bandim Health Project, Indepth Network, Bissau, Guinea-Bissau
| | | | - Peter Aaby
- Bandim Health Project, Indepth Network, Bissau, Guinea-Bissau; OPEN, Odense Patient Data Explorative Network, Institute of Clinical Research, Odense University Hospital/University of Southern Denmark, Odense, Denmark
| | - Christine S Benn
- Bandim Health Project, Indepth Network, Bissau, Guinea-Bissau; OPEN, Odense Patient Data Explorative Network, Institute of Clinical Research, Odense University Hospital/University of Southern Denmark, Odense, Denmark; Danish Institute for Advanced Study, University of Southern Denmark, Odense, Denmark
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2
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Aamand T, Fisker AB, Correia C, Fernandes M, Clipet-Jensen C, Thysen SM. Do Pentavalent (DTwP-Hib-HBV) vaccines have sex-differential nonspecific effects? An observational study. Hum Vaccin Immunother 2023; 19:2288297. [PMID: 38054431 PMCID: PMC10732639 DOI: 10.1080/21645515.2023.2288297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 11/22/2023] [Indexed: 12/07/2023] Open
Abstract
Vaccines may alter the ability to combat infections unrelated to the target disease, i.e. have "nonspecific effects." The non-live Diphtheria-Tetanus-Pertussis vaccine (DTP) has been associated with increased child mortality, especially for females. In 2008, the DTP-containing Pentavalent vaccine replaced DTP vaccine in Guinea-Bissau. We investigate female relative to male mortality after Penta vaccination. In Guinea-Bissau, Bandim Health Project (BHP) registered children's vaccination and vital status at biannual village visits and provided vaccines. Among children Penta-vaccinated by BHP, we compared mortality of males and females in Cox proportional hazards models. Children aged 6 weeks to 8 months entered the analysis at the date of vaccination and were followed for up to 6 months. Between September 2008 and December 2017, 33,989 children aged 6 weeks to 8 months were under surveillance. Of these 12,753 (females: 6,363; males: 6,390) received Penta by the BHP and entered the study contributing with 19,667 observations. The mortality rate following Penta vaccination was 25.2 per 1,000 person years for females and 26.6 for males, resulting in an adjusted Female/Male mortality rate ratio of (F/M aMRR) 1.01 (0.82-1.25). The association between sex and mortality differed by timeliness of vaccination, F/M aMRR: 0.62 (0.41-0.93) for children vaccinated below median age, and F/M aMRR: 1.38 (0.90-2.13) for children vaccinated above median age. We did not find higher overall mortality in females than males after Penta vaccination. Our findings suggest that mortality differences between males and females following Penta vaccination may depend on timeliness of Penta vaccination.
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Affiliation(s)
- Thomas Aamand
- Bandim Health Project, Indepth Network, Bissau, Guinea-Bissau
- Department of Public Health, Aarhus University, Aarhus C, Denmark
| | - Ane Bærent Fisker
- Bandim Health Project, Indepth Network, Bissau, Guinea-Bissau
- Bandim Health Project, OPEN, Department of Clinical Research, Odense University Hospital/University of Southern Denmark, Odense, Denmark
| | | | | | | | - Sanne Marie Thysen
- Bandim Health Project, Indepth Network, Bissau, Guinea-Bissau
- Bandim Health Project, OPEN, Department of Clinical Research, Odense University Hospital/University of Southern Denmark, Odense, Denmark
- Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
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3
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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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4
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Varma A, Thysen SM, Martins JSD, Nanque LM, Jensen AKG, Fisker AB. Overall effect of a campaign with measles vaccine on the composite outcome mortality or hospital admission: A cluster-randomized trial among children aged 9-59 months in rural Guinea-Bissau. Int J Infect Dis 2023; 134:23-30. [PMID: 37182547 DOI: 10.1016/j.ijid.2023.05.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Revised: 05/06/2023] [Accepted: 05/09/2023] [Indexed: 05/16/2023] Open
Abstract
OBJECTIVES Campaigns with measles vaccine (C-MV) are conducted to eradicate measles, but prior studies indicate that MV reduces non-measles mortality and hospital admissions too. We hypothesized that C-MV reduces death/hospital admission by 30%. METHODS Between 2016-2019, we conducted a non-blinded cluster-randomized trial randomizing village clusters in rural Guinea-Bissau to a C-MV targeting children aged 9-59 months. In Cox proportional hazards models, we assessed the effect of C-MV, obtaining hazard ratios (HR) for the composite outcome (death/hospital admission). We also examined potential effect modifiers. RESULTS Among 18,411 children (9636 in 111 intervention clusters/8775 in 110 control clusters), 379 events occurred (208 intervention/171 control) during a median follow-up period of 22 months. C-MV did not reduce the composite outcome (HR 1.12, 95% confidence interval 0.88-1.41). Mortality among enrolled children (5.3 intervention and 4.6 control, per 1000 person-years) was approximately half the pre-trial mortality rate (11.1 intervention and 8.9 control, per 1000 person-years). Neither planned nor explorative analyses of potential effect modifiers explained the contrasting results to prior studies. CONCLUSION C-MV did not reduce overall mortality or hospital admission. This might be explained by changes in disease patterns, baseline differences in health status, and/or modifying effects of other campaigns during follow-up.
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Affiliation(s)
- Anshu Varma
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau; OPEN, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Sanne M Thysen
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau; OPEN, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | | | - Line M Nanque
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau; OPEN, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Aksel K G Jensen
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Ane B Fisker
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau; OPEN, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark.
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5
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Baroncelli S, Galluzzo CM, Orlando S, Luhanga R, Mphwere R, Kavalo T, Amici R, Floridia M, Andreotti M, Ciccacci F, Marazzi MC, Giuliano M. Insufficient measles antibody protection in 6-month-old Malawian infants: Reconsider vaccination schedule? Trop Med Int Health 2023; 28:731-735. [PMID: 37533039 DOI: 10.1111/tmi.13920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2023]
Abstract
Measles vaccination is currently recommended at 9 months, since maternal antibodies are supposed to protect infants until that age. In this study of 6-month-old Malawian infants 98.3% (58/59) had non-protective IgG levels against measles, irrespective of HIV exposure. Anticipating the first dose at 6 months could be considered.
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Affiliation(s)
- Silvia Baroncelli
- National Center for Global Health, Istituto Superiore di Sanità, Rome, Italy
| | | | - Stefano Orlando
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, Rome, Italy
| | | | | | - Thom Kavalo
- DREAM Program, Community of S. Egidio, Blantyre, Malawi
| | - Roberta Amici
- National Center for Global Health, Istituto Superiore di Sanità, Rome, Italy
| | - Marco Floridia
- National Center for Global Health, Istituto Superiore di Sanità, Rome, Italy
| | - Mauro Andreotti
- National Center for Global Health, Istituto Superiore di Sanità, Rome, Italy
| | - Fausto Ciccacci
- Saint Camillus International, University of Health Sciences, Rome, Italy
| | | | - Marina Giuliano
- National Center for Global Health, Istituto Superiore di Sanità, Rome, Italy
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Sørensen MM, Fisker AB, Dalgård C, Jensen KJ, Nielsen F, Benn CS, Grandjean P, Timmermann A. Predictors of serum- per- and polyfluoroalkyl substance (PFAS) concentrations among infants in Guinea-Bissau, West Africa. ENVIRONMENTAL RESEARCH 2023; 228:115784. [PMID: 37011795 DOI: 10.1016/j.envres.2023.115784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 03/07/2023] [Accepted: 03/26/2023] [Indexed: 05/16/2023]
Abstract
BACKGROUND Knowledge about PFAS exposure in Africa is limited. We have previously detected six types of PFAS in the serum of infants from Guinea-Bissau, West Africa. The aim of this study was to identify predictors of the infant serum-PFAS concentrations. METHODS This cross-sectional study was based on a subset of data from a randomized controlled trial of early measles vaccination performed in 2012-2015 in three rural regions of Guinea-Bissau. Blood samples were obtained from 237 children aged 4-to-7 months, and six types of PFAS were quantified in serum. Location of residence was recorded, and information about predictors related to socioeconomic status as well as maternal and child characteristics were obtained through structured interviews with the mothers through routine surveillance. Associations between potential predictors and infant serum-PFAS concentrations were examined in linear regression models while adjusting for potential confounding and mediating factors as identified in a directed acyclic graph. RESULTS Infants from the Cacheu region had the lowest concentrations of perfluorooctanoic acid (PFOA), while infants from the Oio region had the lowest concentrations of all other PFAS. Compared to infants from Oio, infant serum-perfluorooctane sulfonic acid (PFOS) concentrations were 94.1% (95% CI: 52.4, 147.1%) and 81.9% (95% CI: 45.7, 127.1%) higher in Cacheu and Biombo, respectively. Higher maternal age and lower parity were associated with slightly higher child-serum perfluorohexane sulfonic acid (PFHxS) concentrations, while infants with higher socioeconomic status and infants breastfed without supplementary solid foods at inclusion had higher average concentrations of most PFAS, although the confidence intervals were wide and overlapped zero. DISCUSSION Location of residence was the most important determinant of serum-PFAS concentrations among Guinea-Bissau infants, indicating a potential role of diet as affected by the global spread of PFAS, but future studies should explore reasons for the regional differences in PFAS exposure.
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Affiliation(s)
- Marzanna Marianna Sørensen
- Research Unit of Clinical Pharmacology, Pharmacy and Environmental Medicine, University of Southern Denmark, Odense, Denmark
| | - Ane Bærent Fisker
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau; OPEN, Department of Clinical Research, University of Southern Denmark/Odense University Hospital, Odense, Denmark
| | - Christine Dalgård
- Research Unit of Clinical Pharmacology, Pharmacy and Environmental Medicine, University of Southern Denmark, Odense, Denmark
| | - Kristoffer Jarlov Jensen
- Copenhagen Phase IV Unit, Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Flemming Nielsen
- Research Unit of Clinical Pharmacology, Pharmacy and Environmental Medicine, University of Southern Denmark, Odense, Denmark
| | - Christine Stabell Benn
- OPEN, Department of Clinical Research, University of Southern Denmark/Odense University Hospital, Odense, Denmark; Danish Institute for Advanced Study, University of Southern Denmark, Odense, Denmark
| | - Philippe Grandjean
- Research Unit of Clinical Pharmacology, Pharmacy and Environmental Medicine, University of Southern Denmark, Odense, Denmark; Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, MA, United States
| | - Amalie Timmermann
- National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark.
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7
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Zimakoff AC, Jensen A, Vittrup DM, Herlufsen EH, Sørensen JK, Malon M, Svensson J, Stensballe LG. Measles, mumps, and rubella vaccine at age 6 months and hospitalisation for infection before age 12 months: randomised controlled trial. BMJ 2023; 381:e072724. [PMID: 37286215 DOI: 10.1136/bmj-2022-072724] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To test for potential non-specific effects of an additional, early measles, mumps, and rubella (MMR) vaccine at age 5-7 months on risk of infection related hospitalisation before age 12 months. DESIGN Randomised, double blinded, placebo controlled trial. SETTING Denmark, a high income setting with low exposure to MMR. PARTICIPANTS 6540 Danish infants aged 5 to 7 months. INTERVENTIONS Infants were randomly allocated 1:1 to intramuscular injection with standard titre MMR vaccine (M-M-R VaxPro) or placebo (solvent only). MAIN OUTCOME MEASURES Hospitalisations for infection, defined as all hospital contacts of infants referred from primary care for hospital evaluation and with an infection diagnosed, analysed as recurrent events, from randomisation to 12 months of age. In secondary analyses implications of censoring for date of subsequent diphtheria, tetanus, pertussis, polio, Haemophilus influenzae type B, and immunisation with pneumococci conjugate vaccine (DTaP-IPV-Hib+PCV), potential effect modification by sex, prematurity (<37 weeks' gestation), season, and age at randomisation were tested, and the secondary outcomes of hospitalisations ≥12 hours and antibiotic use were evaluated. RESULTS 6536 infants were included in the intention-to-treat analysis. 3264 infants randomised to MMR vaccine experienced 786 hospitalisations for infection before age 12 months compared with 762 for the 3272 infants randomised to placebo. In the intention-to-treat analysis the rate of hospitalisations for infection did not differ between the MMR vaccine and placebo groups (hazard ratio 1.03, 95% confidence interval 0.91 to 1.18). For infants randomised to MMR vaccine compared with those randomised to placebo, the hazard ratio of hospitalisations for infection with a duration of at least 12 hours was 1.25 (0.88 to 1.77), and for prescriptions of antibiotics was 1.04 (0.88 to 1.23). No significant effect modifications were found by sex, prematurity, age at randomisation, or season. The estimate did not change when censoring at the date infants received DTaP-IPV-Hib+PCV after randomisation (1.02, 0.90 to 1.16). CONCLUSION Findings of this trial conducted in Denmark, a high income setting, do not support the hypothesis that live attenuated MMR vaccine administered early to infants aged 5-7 months decreases the rate of hospitalisations for non-targeted infection before age 12 months. TRIAL REGISTRATION EU Clinical Trials Registry EudraCT 2016-001901-18 and ClinicalTrials.gov NCT03780179.
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Affiliation(s)
- Anne Cathrine Zimakoff
- Department of Paediatrics and Adolescent Medicine, Danish National University Hospital "Rigshospitalet," Copenhagen, Denmark
| | - Andreas Jensen
- Department of Paediatrics and Adolescent Medicine, Danish National University Hospital "Rigshospitalet," Copenhagen, Denmark
| | - Dorthe Maria Vittrup
- Child and Adolescent Department, University Hospital Herlev, Copenhagen, Denmark
| | | | - Jesper Kiehn Sørensen
- Department of Paediatrics and Adolescent Medicine, Danish National University Hospital "Rigshospitalet," Copenhagen, Denmark
| | - Michelle Malon
- Department of Paediatrics and Adolescent Medicine, Danish National University Hospital "Rigshospitalet," Copenhagen, Denmark
| | - Jannet Svensson
- Child and Adolescent Department, University Hospital Herlev, Copenhagen, Denmark
| | - Lone Graff Stensballe
- Department of Paediatrics and Adolescent Medicine, Danish National University Hospital "Rigshospitalet," Copenhagen, Denmark
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8
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Benn CS, Amenyogbe N, Björkman A, Domínguez-Andrés J, Fish EN, Flanagan KL, Klein SL, Kollmann TR, Kyvik KO, Netea MG, Rod NH, Schaltz-Buchholzer F, Shann F, Selin L, Thysen SM, Aaby P. Implications of Non-Specific Effects for Testing, Approving, and Regulating Vaccines. Drug Saf 2023; 46:439-448. [PMID: 37074598 PMCID: PMC10116894 DOI: 10.1007/s40264-023-01295-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2023] [Indexed: 04/20/2023]
Abstract
The current framework for testing and regulating vaccines was established before the realization that vaccines, in addition to their effect against the vaccine-specific disease, may also have "non-specific effects" affecting the risk of unrelated diseases. Accumulating evidence from epidemiological studies shows that vaccines in some situations can affect all-cause mortality and morbidity in ways that are not explained by the prevention of the vaccine-targeted disease. Live attenuated vaccines have sometimes been associated with decreases in mortality and morbidity that are greater than anticipated. In contrast, some non-live vaccines have in certain contexts been associated with increases in all-cause mortality and morbidity. The non-specific effects are often greater for female than male individuals. Immunological studies have provided several mechanisms that explain how vaccines might modulate the immune response to unrelated pathogens, such as through trained innate immunity, emergency granulopoiesis, and heterologous T-cell immunity. These insights suggest that the framework for the testing, approving, and regulating vaccines needs to be updated to accommodate non-specific effects. Currently, non-specific effects are not routinely captured in phase I-III clinical trials or in the post-licensure safety surveillance. For instance, an infection with Streptococcus pneumoniae occurring months after a diphtheria-tetanus-pertussis vaccination would not be considered an effect of the vaccination, although evidence indicates it might well be for female individuals. Here, as a starting point for discussion, we propose a new framework that considers the non-specific effects of vaccines in both phase III trials and post-licensure.
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Affiliation(s)
- Christine Stabell Benn
- Bandim Health Project, Open Patient Data Explorative Network (OPEN), Department of Clinical Research, Odense University Hospital and University of Southern Denmark, Odense, Denmark.
- Danish Institute for Advanced Study, University of Southern Denmark, Copenhagen, Denmark.
| | | | - Anders Björkman
- Department of Global Public Health, Karolinska Institutet Stockholm, Stockholm, Sweden
| | - Jorge Domínguez-Andrés
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center Nijmegen, Nijmegen, The Netherlands
| | - Eleanor N Fish
- Department of Immunology, University of Toronto, Toronto, ON, Canada
- Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada
| | - Katie L Flanagan
- Tasmanian Vaccine Trial Centre, Clifford Craig Foundation, Launceston General Hospital, Launceston, TAS, Australia
- School of Medicine, Faculty of Health Sciences, University of Tasmania, Launceston, TAS, Australia
- School of Health and Biomedical Sciences, RMIT University, Melbourne, VIC, Australia
| | - Sabra L Klein
- W. Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Kirsten Ohm Kyvik
- Department of Clinical Research, Odense University Hospital and University of Southern Denmark, Odense, Denmark
| | - Mihai G Netea
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center Nijmegen, Nijmegen, The Netherlands
| | - Naja Hulvej Rod
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Frederik Schaltz-Buchholzer
- Bandim Health Project, Open Patient Data Explorative Network (OPEN), Department of Clinical Research, Odense University Hospital and University of Southern Denmark, Odense, Denmark
| | - Frank Shann
- Department of Paediatrics, University of Melbourne, Parkville, VIC, Australia
| | - Liisa Selin
- Department of Pathology, University of Massachusetts Medical School, Worcester, MA, USA
| | - Sanne M Thysen
- Center for Clinical Research and Prevention, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Peter Aaby
- Bandim Health Project, Open Patient Data Explorative Network (OPEN), Department of Clinical Research, Odense University Hospital and University of Southern Denmark, Odense, Denmark
- Bandim Health Project, Apartado 861, 1004, Bissau Codex, Guinea-Bissau
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9
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Wang Q, Wang W, Winter AK, Zhan Z, Ajelli M, Trentini F, Wang L, Li F, Yang J, Xiang X, Liao Q, Zhou J, Guo J, Yan X, Liu N, Metcalf CJE, Grenfell BT, Yu H. Long-term measles antibody profiles following different vaccine schedules in China, a longitudinal study. Nat Commun 2023; 14:1746. [PMID: 36990986 PMCID: PMC10054217 DOI: 10.1038/s41467-023-37407-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 03/13/2023] [Indexed: 03/31/2023] Open
Abstract
Characterizing the long-term kinetics of maternally derived and vaccine-induced measles immunity is critical for informing measles immunization strategies moving forward. Based on two prospective cohorts of children in China, we estimate that maternally derived immunity against measles persists for 2.4 months. Following two-dose series of measles-containing vaccine (MCV) at 8 and 18 months of age, the immune protection against measles is not lifelong, and antibody concentrations are extrapolated to fall below the protective threshold of 200 mIU/ml at 14.3 years. A catch-up MCV dose in addition to the routine doses between 8 months and 5 years reduce the cumulative incidence of seroreversion by 79.3-88.7% by the age of 6 years. Our findings also support a good immune response after the first MCV vaccination at 8 months. These findings, coupled with the effectiveness of a catch-up dose in addition to the routine doses, could be instrumental to relevant stakeholders when planning routine immunization schedules and supplemental immunization activities.
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Affiliation(s)
- Qianli Wang
- Shanghai Institute of Infectious Disease and Biosecurity, Fudan University, Shanghai, China
| | - Wei Wang
- School of Public Health, Fudan University, Key Laboratory of Public Health Safety, Ministry of Education, Shanghai, China
| | - Amy K Winter
- Department of Epidemiology and Biostatistics, University of Georgia, Athens, GA, USA
| | - Zhifei Zhan
- Hunan Provincial Center for Disease Control and Prevention, Changsha, China
| | - Marco Ajelli
- Laboratory for Computational Epidemiology and Public Health, Department of Epidemiology and Biostatistics, Indiana University School of Public Health, Bloomington, IN, USA
| | - Filippo Trentini
- Dondena Centre for Research on Social Dynamics and Public Policy, Bocconi University, Milan, Italy
| | - Lili Wang
- School of Public Health, Fudan University, Key Laboratory of Public Health Safety, Ministry of Education, Shanghai, China
| | - Fangcai Li
- Hunan Provincial Center for Disease Control and Prevention, Changsha, China
| | - Juan Yang
- School of Public Health, Fudan University, Key Laboratory of Public Health Safety, Ministry of Education, Shanghai, China
| | - Xingyu Xiang
- Hunan Provincial Center for Disease Control and Prevention, Changsha, China
| | - Qiaohong Liao
- School of Public Health, Fudan University, Key Laboratory of Public Health Safety, Ministry of Education, Shanghai, China
| | - Jiaxin Zhou
- School of Public Health, Fudan University, Key Laboratory of Public Health Safety, Ministry of Education, Shanghai, China
| | - Jinxin Guo
- School of Public Health, Fudan University, Key Laboratory of Public Health Safety, Ministry of Education, Shanghai, China
| | - Xuemei Yan
- School of Public Health, Fudan University, Key Laboratory of Public Health Safety, Ministry of Education, Shanghai, China
| | - Nuolan Liu
- School of Public Health, Fudan University, Key Laboratory of Public Health Safety, Ministry of Education, Shanghai, China
| | - C Jessica E Metcalf
- Department of Ecology and Evolutionary Biology, Princeton University, Princeton, NJ, USA
- Princeton School of Public and International Affairs, Princeton University, Princeton, NJ, USA
| | - Bryan T Grenfell
- Department of Ecology and Evolutionary Biology, Princeton University, Princeton, NJ, USA
- Princeton School of Public and International Affairs, Princeton University, Princeton, NJ, USA
| | - Hongjie Yu
- Shanghai Institute of Infectious Disease and Biosecurity, Fudan University, Shanghai, China.
- School of Public Health, Fudan University, Key Laboratory of Public Health Safety, Ministry of Education, Shanghai, China.
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10
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Nielsen S, Fisker AB, da Silva I, Byberg S, Biering-Sørensen S, Balé C, Barbosa A, Bjerregaard-Andersen M, Hansen NS, Do VA, Bæk O, Rasmussen SM, Damkjær L, Hvidt S, Baltzersen O, Rodrigues A, Martins C, Jensen KJ, Whittle HC, Smits G, van der Klis F, Aaby P, Benn CS. Effect of early two-dose measles vaccination on childhood mortality and modification by maternal measles antibody in Guinea-Bissau, West Africa: A single-centre open-label randomised controlled trial. EClinicalMedicine 2022; 49:101467. [PMID: 35747181 PMCID: PMC9156892 DOI: 10.1016/j.eclinm.2022.101467] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 04/26/2022] [Accepted: 05/05/2022] [Indexed: 11/18/2022] Open
Abstract
Background Early 2-dose measles vaccine (MV) at 4 and 9 months of age vs. the WHO strategy of MV at 9 months of age reduced all-cause child mortality in a previous trial. We aimed to test two hypotheses: 1) a 2-dose strategy reduces child mortality between 4 and 60 months of age by 30%; 2) receiving early MV at 4 months in the presence versus absence of maternal measles antibodies (MatAb) reduces child mortality by 35%. Methods Single-centre open-label community-based randomised controlled trial in Guinea-Bissau, with 2:1 block-randomisation by sex to a 2-dose (4 + 9 months) vs. 1-dose (9 months) MV strategy. Healthy children were eligible 4 weeks after the 3rd diphtheria-tetanus-pertussis-containing vaccine. Before randomisation a blood sample was collected to determine MatAb level. The primary outcome was all-cause mortality. Hazard ratios (HR) were derived from Cox regression in the per protocol population. We tested for interactions with national campaigns with oral polio vaccine (C-OPV). Trial registration: NCT01486355. Findings Between August 2011-April 17th 2015, 6,636 children were enroled, 6,598[n2-dose=4,397; n1-dose=2,201] were included in the analysis of the primary outcome, The HR(2-dose/1-dose) between 4 and 60 months was 1.38 (95%CI: 0.92-2.06) [deaths: n2-dose=90; n1-dose=33]. Before the 9-month MV and the HR(1-dose/no dose) was 0.94 (0.45-1.96) [deaths: n2-dose=21; n1-dose=11]. The HR(2-dose/1-dose) was 0.81 (0.29-2.22) for children, who received no C-OPV [deaths/children: n2-dose=10/2,801; n1-dose=6/1,365], and 4.73 (1.44-15.6) for children, who received C-OPV before and after enrolment (p for interaction=0.027) [deaths/children: n2-dose=27/1,602; n1-dose=3/837]. In the 2-dose group receiving early MV at 4 months, mortality was 50% (20-68%) lower for those vaccinated in the presence of MatAb vs. the absence of MatAb [deaths/children: nMatAb=51/3,132; nnoMatAb=31/1,028]. Interpretation The main result contrasts with previous findings but may, though based on a small number of events, be explained by frequent OPV campaigns that reduced the mortality rate, but apparently interacted negatively with early MV. The beneficial non-specific effects of MV in the presence of MatAb should be investigated further. Funding ERC, Danish National Research Foundation, the Danish Council for Development Research, Ministry of Foreign Affairs, Novo Nordisk Foundation, European Union and the Lundbeck Foundation.
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Affiliation(s)
- Sebastian Nielsen
- Bandim Health Project, Indepth Network, Apartado 861, Bissau, Guinea-Bissau
- Bandim Health Project, OPEN, Odense Patient data Explorative Network, Institute of Clinical Research, and Danish Institute of Advanced Science, Odense University Hospital/ University of Southern Denmark, Denmark
| | - Ane B Fisker
- Bandim Health Project, Indepth Network, Apartado 861, Bissau, Guinea-Bissau
- Bandim Health Project, OPEN, Odense Patient data Explorative Network, Institute of Clinical Research, and Danish Institute of Advanced Science, Odense University Hospital/ University of Southern Denmark, Denmark
| | - Isaquel da Silva
- Bandim Health Project, Indepth Network, Apartado 861, Bissau, Guinea-Bissau
| | - Stine Byberg
- Bandim Health Project, Indepth Network, Apartado 861, Bissau, Guinea-Bissau
| | | | - Carlitos Balé
- Bandim Health Project, Indepth Network, Apartado 861, Bissau, Guinea-Bissau
| | - Amarildo Barbosa
- Bandim Health Project, Indepth Network, Apartado 861, Bissau, Guinea-Bissau
| | | | | | - Vu An Do
- Bandim Health Project, Indepth Network, Apartado 861, Bissau, Guinea-Bissau
| | - Ole Bæk
- Bandim Health Project, Indepth Network, Apartado 861, Bissau, Guinea-Bissau
| | | | - Lone Damkjær
- Bandim Health Project, Indepth Network, Apartado 861, Bissau, Guinea-Bissau
| | - Sophus Hvidt
- Bandim Health Project, Indepth Network, Apartado 861, Bissau, Guinea-Bissau
| | - Olga Baltzersen
- Bandim Health Project, Indepth Network, Apartado 861, Bissau, Guinea-Bissau
| | - Amabelia Rodrigues
- Bandim Health Project, Indepth Network, Apartado 861, Bissau, Guinea-Bissau
| | - Cesario Martins
- Bandim Health Project, Indepth Network, Apartado 861, Bissau, Guinea-Bissau
| | - Kristoffer J Jensen
- Bandim Health Project, Indepth Network, Apartado 861, Bissau, Guinea-Bissau
- Bandim Health Project, OPEN, Odense Patient data Explorative Network, Institute of Clinical Research, and Danish Institute of Advanced Science, Odense University Hospital/ University of Southern Denmark, Denmark
| | - Hilton C Whittle
- London School of Hygiene and Topical Medicine, Keppel Street, London, UK
| | - Gaby Smits
- National Institute of Public Health and the Environment, Bilthoven, The Netherlands
| | - Fiona van der Klis
- National Institute of Public Health and the Environment, Bilthoven, The Netherlands
| | - Peter Aaby
- Bandim Health Project, Indepth Network, Apartado 861, Bissau, Guinea-Bissau
- Bandim Health Project, OPEN, Odense Patient data Explorative Network, Institute of Clinical Research, and Danish Institute of Advanced Science, Odense University Hospital/ University of Southern Denmark, Denmark
| | - Christine S. Benn
- Bandim Health Project, Indepth Network, Apartado 861, Bissau, Guinea-Bissau
- Bandim Health Project, OPEN, Odense Patient data Explorative Network, Institute of Clinical Research, and Danish Institute of Advanced Science, Odense University Hospital/ University of Southern Denmark, Denmark
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11
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Rieckmann A, Fisker AB, Øland CB, Nielsen S, Wibaek R, Sørensen TB, Martins CL, Benn CS, Aaby P. Understanding the child mortality decline in Guinea-Bissau: the role of population-level nutritional status measured by mid-upper arm circumference. Int J Epidemiol 2022; 51:1522-1532. [PMID: 35640034 DOI: 10.1093/ije/dyac113] [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: 08/30/2022] [Accepted: 05/10/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Malnutrition is considered an important contributing factor to child mortality, and the mid-upper arm circumference (MUAC) is regarded as one of the better anthropometric predictors of child mortality. We explored whether the decline in child mortality over recent decades could be explained by changes in children's MUAC. METHODS This prospective study analysed individual-level data from 47 731 children from the capital of Guinea-Bissau followed from 3 months until 36 months of age over 2003 to 2016. We used standardization to compare the mortality rate as if only the MUAC distribution had changed between an early period (2003-05) and a late period (2014-16). We adjusted the analyses for age, sex, socioeconomic-related possessions and maternal education. RESULTS A total of 949 deaths were included in the analysis. The adjusted mortality rate was 18.9 [95% confidence interval (CI) 14.3-23.3] deaths per 1000 person-years (pyrs) in the early period and declined to 4.4 (95% CI 2.9-6.0) deaths per 1000 pyrs in the late period, a 77% (95% CI 71-83%) reduction in the mortality rate. At all calendar years, the MUAC distribution in the population was close to the WHO reference population. MUAC below -1 z-score was associated with increased child mortality. The change in MUAC distribution from the early period to the late period (in the early period mortality standardization) corresponded to 1.5 (95% CI 1.0-2.2) fewer deaths per 1000 pyrs, equivalent to 11% (95% CI 7-14%) of the observed change in child mortality. CONCLUSIONS From 2003 to 2016, child mortality in urban Guinea-Bissau declined considerably but, though a low MUAC was associated with increased mortality, changes in the MUAC distribution in the population explained little of the decline. Understanding the driving factors of child mortality decline can help scope tomorrow's interventions.
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Affiliation(s)
- Andreas Rieckmann
- Bandim Health Project, Indepth Network, Bissau, Guinea-Bissau.,Section of Epidemiology, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Ane Bærent Fisker
- Bandim Health Project, Indepth Network, Bissau, Guinea-Bissau.,Bandim Health Project, OPEN, Odense University Hospital/Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Christian Bjerregård Øland
- Bandim Health Project, OPEN, Odense University Hospital/Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Sebastian Nielsen
- Bandim Health Project, OPEN, Odense University Hospital/Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Rasmus Wibaek
- Clinical Research, Steno Diabetes Center Copenhagen, Copenhagen, Denmark
| | - Tina Bonde Sørensen
- Bandim Health Project, OPEN, Odense University Hospital/Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | | | - Christine Stabell Benn
- Bandim Health Project, OPEN, Odense University Hospital/Institute of Clinical Research, University of Southern Denmark, Odense, Denmark.,Danish Institute for Advanced Study, University of Southern Denmark, Odense, Denmark
| | - Peter Aaby
- Bandim Health Project, Indepth Network, Bissau, Guinea-Bissau
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12
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Geckin B, Konstantin Föhse F, Domínguez-Andrés J, Netea MG. Trained immunity: implications for vaccination. Curr Opin Immunol 2022; 77:102190. [PMID: 35597182 DOI: 10.1016/j.coi.2022.102190] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 03/30/2022] [Accepted: 04/08/2022] [Indexed: 01/03/2023]
Abstract
The concept that only adaptive immunity can build immunological memory has been challenged in the past decade. Live attenuated vaccines such as the Bacillus Calmette-Guérin, measles-containing vaccines, and the oral polio vaccine have been shown to reduce overall mortality beyond their effects attributable to the targeted diseases. After an encounter with a primary stimulus, epigenetic and metabolic reprogramming of bone marrow progenitor cells and functional changes of tissue immune cell populations result in augmented immune responses against a secondary challenge. This process has been termed trained immunity. This review describes the mechanisms leading to trained immunity and summarizes the most important developments from the past few years.
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Affiliation(s)
- Büsranur Geckin
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Centre, Nijmegen, The Netherlands; Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Friedrich Konstantin Föhse
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Centre, Nijmegen, The Netherlands; Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Jorge Domínguez-Andrés
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Centre, Nijmegen, The Netherlands; Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Mihai G Netea
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Centre, Nijmegen, The Netherlands; Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands; Department of Immunology and Metabolism, Life & Medical Sciences Institute, University of Bonn, Bonn, Germany.
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13
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Fisker AB, Martins JSD, Jensen AM, Martins C, Aaby P, Thysen SM. Health effects of utilising hospital contacts to provide measles vaccination to children 9-59 months-a randomised controlled trial in Guinea-Bissau. Trials 2022; 23:349. [PMID: 35461287 PMCID: PMC9034539 DOI: 10.1186/s13063-022-06291-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 04/09/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Measles vaccination coverage in Guinea-Bissau is low; fewer than 80% of children are currently measles vaccinated before 12 months of age. The low coverage hampers control of measles. Furthermore, accumulating evidence indicates that measles vaccine has beneficial non-specific effects, strengthening the resistance towards other infections. Thus, even if children are not exposed to measles virus, measles-unvaccinated children may be worse off. To increase vaccination coverage, WHO recommends that contacts with the health system for mild illness are utilised to vaccinate. Currently, in Guinea-Bissau, curative health system contacts are not utilised. METHODS Bandim Health Project registers out-patient consultations and admissions at the paediatric ward of the National Hospital in Guinea-Bissau. Measles-unvaccinated children aged 9-59 months consulting for milder illness or being discharged from the paediatric ward will be invited to participate in a randomised trial. Among 5400 children, randomised 1:1 to receive standard measles vaccine or a saline placebo, we will test the hypothesis that providing a measles vaccine at discharge lowers the risk of admission/mortality (composite outcome) during the subsequent 6 months by 25%. All enrolled children are followed through the Bandim Health Project registration system and through telephone follow-up. The first 1000 enrolled children are furthermore followed through interviews on days 2, 4, 7 and 14 after enrolment. DISCUSSION Utilising missed vaccination opportunities can increase vaccination coverage and may improve child health. However, without further evidence for the safety and potential benefits of measles vaccination, these curative contacts are unlikely to be used for vaccination in Guinea-Bissau. TRIAL REGISTRATION www. CLINICALTRIALS gov NCT04220671 . Registered on 5 January 2020.
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Affiliation(s)
- Ane B Fisker
- Bandim Health Project, Indepth Network, 1004, Bissau, Guinea-Bissau. .,Bandim Health Project, University of Southern Denmark, OPEN, 5000, Odense, Denmark.
| | | | - Andreas M Jensen
- Bandim Health Project, Indepth Network, 1004, Bissau, Guinea-Bissau.,Bandim Health Project, University of Southern Denmark, OPEN, 5000, Odense, Denmark
| | - Cesario Martins
- Bandim Health Project, Indepth Network, 1004, Bissau, Guinea-Bissau
| | - Peter Aaby
- Bandim Health Project, Indepth Network, 1004, Bissau, Guinea-Bissau.,Bandim Health Project, University of Southern Denmark, OPEN, 5000, Odense, Denmark
| | - Sanne M Thysen
- Bandim Health Project, Indepth Network, 1004, Bissau, Guinea-Bissau.,Bandim Health Project, University of Southern Denmark, OPEN, 5000, Odense, Denmark.,Center for Clinical Research and Prevention, Frederiksberg Hospital, 2000, Frederiksberg, Denmark
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14
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Omar M, Muhsen K. A narrative review of nonspecific effects of pediatric vaccines on child mortality and morbidity. Hum Vaccin Immunother 2021; 17:5269-5283. [PMID: 34847820 DOI: 10.1080/21645515.2021.1996150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
We reviewed evidence on nonspecific effects of pediatric vaccines on mortality and morbidity in countries with high child mortality. Literature search of epidemiological studies was conducted for studies published between 2000 and September 2021 using MEDLINE. Consistent evidence exists regarding the potential protective effect of measles vaccine on child survival. Vaccination with Bacillus Calmette-Guérin (BCG) vaccine was related to lower risk of mortality in young children (including low birth weight babies) and inverse associations were found between developing a scar and having a positive tuberculin test after BCG vaccination with mortality. BCG vaccine might also reduce the risk of nontuberculosis infectious diseases. Studies on the association between diphtheria-pertussis-tetanus (DPT) vaccine and child survival showed inconsistent findings, which might be affected by bias and confounding. More evidence is needed to assess the role of these and other vaccines in children's health and to better understand potential biological mechanisms and other influential factors.
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Affiliation(s)
- Muna Omar
- Department of Epidemiology and Preventive Medicine, School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Khitam Muhsen
- Department of Epidemiology and Preventive Medicine, School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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15
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Khampanisong P, Pauly M, Nouanthong P, Vickers MA, Virachith S, Xaydalasouk K, Black AP, Muller CP, Hübschen JM. Waning of Maternal Antibodies against Measles Suggests a Large Window of Susceptibility in Infants in Lao People's Democratic Republic. Pathogens 2021; 10:1316. [PMID: 34684265 PMCID: PMC8538652 DOI: 10.3390/pathogens10101316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 10/08/2021] [Accepted: 10/10/2021] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Measles is an endemic but largely neglected disease in Lao People's Democratic Republic. New-borns are protected by maternal antibodies, but antibody waning before measles vaccination at 9 months of age leaves infants susceptible to infection. In this study, the susceptibility window of infants was determined to generate scientific evidence to assess the national measles immunization strategy. METHODS Between 2015 and 2016, demographic data, medical history, and blood samples were collected from 508 mother-child pairs at the provincial hospital in Vientiane. The samples were screened with a commercial kit detecting anti-measles IgG antibodies. RESULTS The large majority (95.7%) of the mothers were seropositive for anti-measles IgG and antibody titers of the mothers and infants were highly correlated (p < 0.01). While at birth 97.7% of the infants were seropositive, seropositivity rates decreased to 74.2% two months later to reach only 28.2% four months after birth (p < 0.01). Just before the first dose of the measles-rubella vaccine, scheduled at 9 months of age, was actually given, less than 14% of the infants were seropositive. CONCLUSION This alarmingly wide susceptibility gap due to rapid maternal antibody decay leaves infants at risk of measles infection and serious disease complications. A high herd immunity is crucial to protect young infants and can be achieved through improved routine vaccination coverage and (expanded age group) supplementary immunization activities.
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Affiliation(s)
- Phonepaseuth Khampanisong
- Institut Pasteur du Laos, Samsenthai Road, Ban Kao-Gnot, Sisattanak District, Vientiane P.O. Box 3560, Laos; (P.K.); (P.N.); (S.V.); (K.X.); (A.P.B.)
| | - Maude Pauly
- Department of Infection and Immunity, Luxembourg Institute of Health, 29, rue Henri Koch, 4354 Esch-sur-Alzette, Luxembourg; (M.P.); (M.A.V.); (C.P.M.)
| | - Phonethipsavanh Nouanthong
- Institut Pasteur du Laos, Samsenthai Road, Ban Kao-Gnot, Sisattanak District, Vientiane P.O. Box 3560, Laos; (P.K.); (P.N.); (S.V.); (K.X.); (A.P.B.)
| | - Molly A. Vickers
- Department of Infection and Immunity, Luxembourg Institute of Health, 29, rue Henri Koch, 4354 Esch-sur-Alzette, Luxembourg; (M.P.); (M.A.V.); (C.P.M.)
| | - Siriphone Virachith
- Institut Pasteur du Laos, Samsenthai Road, Ban Kao-Gnot, Sisattanak District, Vientiane P.O. Box 3560, Laos; (P.K.); (P.N.); (S.V.); (K.X.); (A.P.B.)
| | - Kinnaly Xaydalasouk
- Institut Pasteur du Laos, Samsenthai Road, Ban Kao-Gnot, Sisattanak District, Vientiane P.O. Box 3560, Laos; (P.K.); (P.N.); (S.V.); (K.X.); (A.P.B.)
| | - Antony P. Black
- Institut Pasteur du Laos, Samsenthai Road, Ban Kao-Gnot, Sisattanak District, Vientiane P.O. Box 3560, Laos; (P.K.); (P.N.); (S.V.); (K.X.); (A.P.B.)
| | - Claude P. Muller
- Department of Infection and Immunity, Luxembourg Institute of Health, 29, rue Henri Koch, 4354 Esch-sur-Alzette, Luxembourg; (M.P.); (M.A.V.); (C.P.M.)
| | - Judith M. Hübschen
- Department of Infection and Immunity, Luxembourg Institute of Health, 29, rue Henri Koch, 4354 Esch-sur-Alzette, Luxembourg; (M.P.); (M.A.V.); (C.P.M.)
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16
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Odita CI, Conan A, Smith-Antony M, Battice J, England S, Barry D, Gessner BD, Knobel DL. Non-specific effects of rabies vaccine on the incidence of self-reported common infectious disease episodes: A randomized controlled trial. Vaccine 2021; 40:1617-1623. [PMID: 34127294 DOI: 10.1016/j.vaccine.2021.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 04/23/2021] [Accepted: 06/02/2021] [Indexed: 11/27/2022]
Abstract
Vaccines may affect recipients' immune systems in ways that change morbidity or mortality rates to unrelated infections in vaccinated populations. It has been proposed that these non-specific effects differ by type of vaccine and by sex, with non-live vaccines enhancing susceptibility of females to unrelated infections, and live vaccines enhancing resistance in both sexes. Rabies vaccine-a non-live vaccine-has been associated with protection against unrelated central nervous system infections. Data from randomized controlled trials are needed to assess this effect against other illnesses. This phase IV, single-site, participant-blinded, randomized, placebo-controlled trial in a population of veterinary students on the rabies-free island of St. Kitts assessed the effect of a primary course of rabies vaccine on the incidence rate of weekly self-reported new episodes of common infectious disease (CID) syndromes, defined as a new episode of any one of the following syndromes in a particular week: upper respiratory illness (URI), influenza-like illness (ILI), diarrheal illness (DIA) or undifferentiated febrile illness (UFI). As a secondary objective, we tested for modification of the effect of rabies vaccine on study outcomes by sex. 546 participants were randomized (274 to rabies vaccine and 272 to placebo). No statistically significant differences between groups were observed for any study outcomes: CID incidence rate ratio (IRR) 0.95 (95% CI 0.77-1.18); URI IRR 1.15 (95% CI 0.86-1.54); ILI IRR 0.83 (95% CI 0.54-1.27); DIA IRR 0.93 (95% CI 0.70-1.24) and UFI IRR 1.09 (95% CI 0.48-2.44). In a secondary analysis, there was little evidence that sex modified the effect of vaccination on any of the evaluated outcomes, although the power to detect this was low. In conclusion, rabies vaccine did not provide protection against mild self-reported illness among a young and healthy group of adults attending veterinary school. Clinical trial registration. ClinicalTrials.gov: NCT03656198.
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Affiliation(s)
- Christianah I Odita
- Department of Veterinary Tropical Diseases, University of Pretoria, Pretoria, South Africa
| | - Anne Conan
- Department of Biomedical Sciences, Ross University School of Veterinary Medicine, Basseterre, Saint Kitts and Nevis; Center for One Health Research and Policy Advice, City University of Hong Kong, Kowloon, Hong Kong Special Administrative Region
| | - Marshalette Smith-Antony
- Department of Biomedical Sciences, Ross University School of Veterinary Medicine, Basseterre, Saint Kitts and Nevis
| | - Juliet Battice
- Department of Biomedical Sciences, Ross University School of Veterinary Medicine, Basseterre, Saint Kitts and Nevis
| | - Shianne England
- Department of Biomedical Sciences, Ross University School of Veterinary Medicine, Basseterre, Saint Kitts and Nevis
| | - Donna Barry
- Department of Biomedical Sciences, Ross University School of Veterinary Medicine, Basseterre, Saint Kitts and Nevis
| | | | - Darryn L Knobel
- Department of Veterinary Tropical Diseases, University of Pretoria, Pretoria, South Africa; Department of Biomedical Sciences, Ross University School of Veterinary Medicine, Basseterre, Saint Kitts and Nevis.
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17
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Byberg S, Aaby P, Rodrigues A, Stabell Benn C, Fisker AB. The mortality effects of disregarding the strategy to save doses of measles vaccine: a cluster-randomised trial in Guinea-Bissau. BMJ Glob Health 2021; 6:e004328. [PMID: 33941513 PMCID: PMC8098964 DOI: 10.1136/bmjgh-2020-004328] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 03/31/2021] [Accepted: 04/16/2021] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Measles vaccine (MV) may improve health beyond measles protection. To avoid wastage from multi-dose vials, children in Guinea-Bissau are only measles vaccinated when aged 9-11 months and when six or more children are present. We assessed health impacts of providing MV to all measles-unvaccinated children 9-35 months. METHODS We cluster-randomised 182 village clusters under demographic surveillance in rural Guinea-Bissau to an 'MV-for-all-policy' arm where we offered MV regardless of age and number of children present at our bi-annual village visits, or a 'Restrictive-MV-policy' arm where we followed national policy. Measles-unvaccinated children aged 9-35 months were eligible for enrolment and followed to 5 years of age. In intention-to-treat analyses, we compared mortality using Cox regression analyses with age as underlying timescale. The primary analysis was for children aged 12-35 months at eligibility assessment. Interactions with several background factors were explored. RESULTS Between 2011 and 2016, we followed 2778 children in the primary analysis. MV coverage by 3 years was 97% among children eligible for enrolment under the MV-for-all-policy, and 48% under the Restrictive-MV-policy. Mortality was 59% lower than anticipated and did not differ by trial arm (MV-for-all-policy: 45/1405: Restrictive-MV-policy: 44/1373; HR: 0.95 (95% CI 0.64 to 1.43)). The effect of MV-for-all changed over time: The HR was 0.53 (95% CI 0.27 to 1.07) during the first 1½ years of enrolment but 1.47 (95% CI 0.87 to 2.50) later (p=0.02, test of interaction). Explorative analyses indicated that the temporal change may be related to interactions with other childhood interventions. CONCLUSION The MV-for-all-policy increased MV coverage but had no overall effect on overall mortality. TRIAL REGISTRATION NUMBER NCT01306006.
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Affiliation(s)
- Stine Byberg
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau
- Bandim Health Project, OPEN, University of Southern Denmark, Copenhagen, Denmark
- Research Center for Vitamins and Vaccines, Statens Serum Institut, Copenhagen, Denmark
- Steno Diabetes Center Copenhagen, Gentofte, Denmark
| | - Peter Aaby
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau
- Bandim Health Project, OPEN, University of Southern Denmark, Copenhagen, Denmark
- Research Center for Vitamins and Vaccines, Statens Serum Institut, Copenhagen, Denmark
| | | | - Christine Stabell Benn
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau
- Bandim Health Project, OPEN, University of Southern Denmark, Copenhagen, Denmark
- Research Center for Vitamins and Vaccines, Statens Serum Institut, Copenhagen, Denmark
- Danish Institute for Advanced Study, University of Southern Denmark, Odense, Denmark
| | - Ane Baerent Fisker
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau
- Bandim Health Project, OPEN, University of Southern Denmark, Copenhagen, Denmark
- Research Center for Vitamins and Vaccines, Statens Serum Institut, Copenhagen, Denmark
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18
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Timmermann CAG, Jensen KJ, Nielsen F, Budtz-Jørgensen E, van der Klis F, Benn CS, Grandjean P, Fisker AB. Serum Perfluoroalkyl Substances, Vaccine Responses, and Morbidity in a Cohort of Guinea-Bissau Children. ENVIRONMENTAL HEALTH PERSPECTIVES 2020; 128:87002. [PMID: 32772733 PMCID: PMC7416537 DOI: 10.1289/ehp6517] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
BACKGROUND Perfluoroalkyl substances (PFAS) are a group of widely used persistent chemicals with suspected immunotoxic effects. OBJECTIVES The present study aimed to examine the association between infant PFAS exposure and antibody responses to measles vaccination as well as morbidity in a low-income country. METHODS In a randomized controlled trial, children from Guinea-Bissau, West Africa, were followed from inclusion (4-7 months of age) through 2 years of age. Half the children received two measles vaccinations (at inclusion and at 9 months of age), and the other half received only one (at 9 months of age). In a subset of 237 children, six PFAS were quantified in serum at inclusion, and measles antibody concentrations were assessed at inclusion and at approximately 9 months and 2 years of age. At inclusion and at the 9-month visit, mothers were interviewed about infant morbidity. RESULTS All but one child had detectable serum concentrations of all six PFAS, although levels were lower than seen elsewhere. A doubling in perfluorooctane sulfonic acid (PFOS) and perfluorodecanoic acid (PFDA) were associated with 21% (95% CI: 2, 37%) and 25% (95% CI: 1, 43%), respectively, lower measles antibody concentrations at the 9-month visit among the children who had received a measles vaccine at inclusion. Elevated serum PFAS concentrations were also associated with reduced prevaccination measles antibody concentrations and increased morbidity. DISCUSSION The present study documents that PFAS exposure has reached West Africa and that infants show PFAS-associated increases in morbidity and decreases in measles-specific antibody concentrations before and after vaccination. These findings support the evidence on PFAS immunotoxicity at comparatively low serum concentrations. https://doi.org/10.1289/EHP6517.
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Affiliation(s)
| | - Kristoffer Jarlov Jensen
- Research Center for Vitamins and Vaccines, Bandim Health Project, Statens Serum Institut, Copenhagen, Denmark
- Experimental and Translational Immunology, Department of Health Technology, Technical University of Denmark, Kgs Lyngby, Denmark
| | - Flemming Nielsen
- Research Unit of Environmental Medicine, University of Southern Denmark, Odense, Denmark
| | | | - Fiona van der Klis
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, Netherlands
| | - Christine Stabell Benn
- Research Center for Vitamins and Vaccines, Bandim Health Project, Statens Serum Institut, Copenhagen, Denmark
- Open Patient data Explorative Network, University of Southern Denmark/Odense University Hospital, Odense, Denmark
| | - Philippe Grandjean
- Research Unit of Environmental Medicine, University of Southern Denmark, Odense, Denmark
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Ane Bærent Fisker
- Research Center for Vitamins and Vaccines, Bandim Health Project, Statens Serum Institut, Copenhagen, Denmark
- Open Patient data Explorative Network, University of Southern Denmark/Odense University Hospital, Odense, Denmark
- Bandim Health Project, Indepth Network, Bissau, Guinea-Bissau
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19
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Smits G, Stabell Benn C, Whittle H, van Binnendijk R, Aaby P, van der Klis F. Maternal Measles Antibodies and Their Influence on All-cause Mortality Following Measles Vaccination: An Alternative to Measure Very Low Maternal Antibody Levels. Clin Infect Dis 2020; 68:1758-1760. [PMID: 30329030 DOI: 10.1093/cid/ciy900] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 10/15/2018] [Indexed: 01/08/2023] Open
Abstract
It was previously shown by hemagglutination inhibition that measles vaccination in the presence of maternal measles antibodies was associated with reduced all-cause mortality. We confirmed this serological association using a multiplexed immunoassay as a sensitive alternative and estimated a threshold concentration (28.7 mIU/mL) that correlates with lower all-cause mortality (P = .02).
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Affiliation(s)
- Gaby Smits
- Centre for Immunology of Infectious Diseases and Vaccines, National Institute of Public Health and the Environment, Bilthoven, The Netherlands
| | - Christine Stabell Benn
- Research Center for Vitamins and Vaccines, Bandim Health Project, Statens Serum Institut, Copenhagen.,OPEN, Institute of Clinical Research, and DIAS, University of Southern Denmark/Odense University Hospital, Denmark
| | - Hilton Whittle
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, United Kingdom
| | - Rob van Binnendijk
- Centre for Immunology of Infectious Diseases and Vaccines, National Institute of Public Health and the Environment, Bilthoven, The Netherlands
| | - Peter Aaby
- Projécto de Saúde Bandim, INDEPTH Network, Bissau, Guinea-Bissau
| | - Fiona van der Klis
- Centre for Immunology of Infectious Diseases and Vaccines, National Institute of Public Health and the Environment, Bilthoven, The Netherlands
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20
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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: 107] [Impact Index Per Article: 26.8] [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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21
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Mutsaerts EAML, Nunes MC, Bhikha S, Ikulinda BT, Boyce W, Jose L, Koen A, Moultrie A, Cutland CL, Grobbee DE, Klipstein-Grobusch K, Madhi SA. Immunogenicity and Safety of an Early Measles Vaccination Schedule at 6 and 12 Months of Age in Human Immunodeficiency Virus (HIV)-Unexposed and HIV-Exposed, Uninfected South African Children. J Infect Dis 2020; 220:1529-1538. [PMID: 31282539 DOI: 10.1093/infdis/jiz348] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 07/04/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Measles morbidity and mortality rates are greatest in children <12 months old, with increased susceptibility in human immunodeficiency virus (HIV)-exposed children. We evaluated the immunogenicity and safety of an early 2-dose measles vaccine regimen administered at 6 and 12 months of age in South Africa. METHODS HIV-unexposed (HU) (n = 212) and HIV-exposed, uninfected (HEU) (n = 71) children received measles vaccination (CAM-70) at 6 and 12 months of age. Measles immunoglobulin G titers were measured by means of enzyme-linked immunosorbent assay before and 1 month after each vaccine dose. RESULTS The majority of children (88.2% HU and 95.8% HEU; P = .04) were seronegative (<150 mIU/mL) to measles at 4.2 months of age. This was particularly evident among infants of mothers born from 1992 onwards (year of public nationwide measles vaccine availability). One month after the first measles vaccine, 42.3% of HU and 46.4% of HEU children were seropositive (≥330 mIU/mL). After the second dose, the proportion seropositive increased to 99.0% in HU and 95.3% in HEU children. Safety profiles were similar between HU and HEU children. CONCLUSIONS Early 2-dose measles vaccination at 6 and 12 months of age was safe and induced antibody responses in HU and HEU children, which could partly offset the early loss of maternally derived antibodies in infants born to predominantly measles-vaccinated mothers. CLINICAL TRIALS REGISTRATION NCT03330171.
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Affiliation(s)
- Eleonora A M L Mutsaerts
- Medical Research Council, Respiratory and Meningeal Pathogens Research Unit.,Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Marta C Nunes
- Medical Research Council, Respiratory and Meningeal Pathogens Research Unit.,Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sutika Bhikha
- Medical Research Council, Respiratory and Meningeal Pathogens Research Unit.,Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Benit T Ikulinda
- Medical Research Council, Respiratory and Meningeal Pathogens Research Unit.,Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Welekazi Boyce
- Medical Research Council, Respiratory and Meningeal Pathogens Research Unit.,Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Lisa Jose
- Medical Research Council, Respiratory and Meningeal Pathogens Research Unit.,Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Anthonet Koen
- Medical Research Council, Respiratory and Meningeal Pathogens Research Unit.,Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Andrew Moultrie
- Medical Research Council, Respiratory and Meningeal Pathogens Research Unit.,Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Clare L Cutland
- Medical Research Council, Respiratory and Meningeal Pathogens Research Unit.,Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Diederick E Grobbee
- Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Kerstin Klipstein-Grobusch
- Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.,Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, the Netherlands
| | - Shabir A Madhi
- Medical Research Council, Respiratory and Meningeal Pathogens Research Unit.,Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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22
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Steiniche MM, Thysen SM, Jensen AKG, Rodrigues A, Martins C, Meyrowitsch DW, Aaby P, Fisker AB. The effect of early measles vaccination on morbidity and growth: A randomised trial from Guinea-Bissau. Vaccine 2020; 38:2487-2494. [PMID: 32061387 DOI: 10.1016/j.vaccine.2020.01.096] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 01/25/2020] [Accepted: 01/31/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Measles vaccine (MV) has beneficial non-specific effects protecting against non-measles infections in some situations. Within a trial of the effect of MV on mortality, we assessed effects of early MV on the secondary outcomes consultations and growth, overall, and by sex and exposure to campaigns with oral polio vaccine (OPV). MATERIALS AND METHODS Children were randomly assigned to MV at 4.5 + 9 months or MV at 9 months as recommended. At enrolment and 9 months children had their mid-upper-arm-circumference (MUAC) and weight measured. Consultations (out/inpatient) were registered at monthly home visits. Weight-for-age and MUAC-for-age Z-scores were obtained using the WHO growth reference and compared by group in linear regression models. Consultation rates between enrolment and 9 months were compared in Cox proportional hazards models, providing consultation Hazard Ratios (HRs) for early MV versus no early MV. We tested whether the effect of early MV was modified by OPV campaigns by splitting observation time at exposure to OPV campaigns. RESULTS Among 3548 children enrolled between 2012 and 2015, early MV had no effect on MUAC-for-age (mean difference comparing early MV vs. no MV -0.01, 95% CI -0.06-0.04), weight-for-age (mean difference -0.03, 95% CI -0.07-0.02) or rates of consultations (HR = 1.03, 95% CI 0.92-1.16). The rate of consultations for children enrolled was lower after exposure to OPV campaigns (HR = 0.81, 95% CI 0.71-0.92). The effect of MV differed before exposure to OPV campaigns (HR = 1.12, 95% CI 0.98-1.29) and after OPV campaigns (HR = 0.83, 95% CI 0.67-1.03) (test for interaction: p = 0.03). Associations did not differ by sex. CONCLUSION Early MV had no overall effect on consultation rates and growth between enrolment and 9 months of age. However, early MV tended to have beneficial effects for children subsequently exposed to OPV campaigns. As beneficial effects were observed in subgroups, the results should be interpreted with caution. CLINICAL TRIALS REGISTRATION NCT01644721.
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Affiliation(s)
- Mette Møller Steiniche
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau; Research Center for Vitamins and Vaccines (CVIVA), Statens Serum Institut, Copenhagen S, Denmark
| | - Sanne Marie Thysen
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau; Research Center for Vitamins and Vaccines (CVIVA), Statens Serum Institut, Copenhagen S, Denmark; Center for Global Health (GloHAU), Department of Public Health, Aarhus University, Aarhus C, Denmark
| | - Aksel Karl Georg Jensen
- Research Center for Vitamins and Vaccines (CVIVA), Statens Serum Institut, Copenhagen S, Denmark; Section of Biostatistics, University of Copenhagen, Copenhagen K, Denmark
| | | | - Cesario Martins
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau
| | - Dan Wolf Meyrowitsch
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen K, Denmark
| | - Peter Aaby
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau
| | - Ane Bærent Fisker
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau; Research Center for Vitamins and Vaccines (CVIVA), Statens Serum Institut, Copenhagen S, Denmark; OPEN, Institute of Clinical Research, University of Southern Denmark/Odense University Hospital, Odense C, Denmark.
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23
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Benn CS, Martins CL, Andersen A, Fisker AB, Whittle HC, Aaby P. Measles Vaccination in Presence of Measles Antibody May Enhance Child Survival. Front Pediatr 2020; 8:20. [PMID: 32117827 PMCID: PMC7020693 DOI: 10.3389/fped.2020.00020] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Accepted: 01/14/2020] [Indexed: 11/13/2022] Open
Abstract
Background: In trials of early two-dose measles vaccination (MV), with the first dose being given before 9 months of age, vaccination in the presence of maternal antibody reduced mortality 2- to 3-fold compared with MV in the presence of no measles antibody. We tested this finding in two historical studies in which the children had received one dose of MV. Methods: We used data from a surveillance study of seroconversion after standard-titer MV (Schwarz strain) (Study 1) and a trial of early medium-titer MV (Edmonston-Zagreb strain) in which a pre-vaccination blood sample had been collected (Study 2). Both studies had control children, who were enrolled under similar conditions, but did not receive effective MV. Study 1 was a natural experiment where all children measles vaccinated during 1 month did not seroconvert and had therefore received an ineffective vaccine. In Study 2, the controls were randomized to an inactivated polio vaccine (IPV). We compared mortality for children with undetectable levels of measles antibody (<31.25 mIU) at baseline with children with detectable levels (≥31.25 mIU). Results: In both studies, children who were measles vaccinated in the presence of measles antibody had lower mortality compared with children who were measles vaccinated in presence of no measles antibody, the combined mortality rate ratio (MRR) being 0.51 (0.27-0.96). In the control groups, a detectable level of measles antibody vs. an undetectable level was not associated with lower mortality, the MRR being 1.40 (0.31-6.38). Conclusion: The results supported previous findings: measles vaccination in the presence of measles antibody had beneficial effects on child survival. Since maternal antibody levels are declining, it may be time to consider giving MV earlier and/or to provide MV to adolescent girls to boost antibody levels.
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Affiliation(s)
- Christine S Benn
- Bandim Health Project, Indepth Network, Bissau, Guinea-Bissau.,Research Centre for Vitamins and Vaccines, Bandim Health Project, Statens Serum Institut, Copenhagen, Denmark.,Odense Patient Data Explorative Network, Odense University Hospital, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | | | - Andreas Andersen
- Bandim Health Project, Indepth Network, Bissau, Guinea-Bissau.,Research Centre for Vitamins and Vaccines, Bandim Health Project, Statens Serum Institut, Copenhagen, Denmark
| | - Ane B Fisker
- Bandim Health Project, Indepth Network, Bissau, Guinea-Bissau.,Research Centre for Vitamins and Vaccines, Bandim Health Project, Statens Serum Institut, Copenhagen, Denmark.,Odense Patient Data Explorative Network, Odense University Hospital, Institute of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Hilton C Whittle
- Department of Infectious and Tropical Diseases, The London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - 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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24
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Nic Lochlainn LM, de Gier B, van der Maas N, Strebel PM, Goodman T, van Binnendijk RS, de Melker HE, Hahné SJM. Immunogenicity, effectiveness, and safety of measles vaccination in infants younger than 9 months: a systematic review and meta-analysis. THE LANCET. INFECTIOUS DISEASES 2019; 19:1235-1245. [PMID: 31548079 PMCID: PMC6838664 DOI: 10.1016/s1473-3099(19)30395-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 04/20/2019] [Accepted: 06/13/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND Measles is an important cause of death in children, despite the availability of safe and cost-saving measles-containing vaccines (MCVs). The first MCV dose (MCV1) is recommended at 9 months of age in countries with ongoing measles transmission, and at 12 months in countries with low risk of measles. To assess whether bringing forward the age of MCV1 is beneficial, we did a systematic review and meta-analysis of the benefits and risks of MCV1 in infants younger than 9 months. METHODS For this systematic review and meta-analysis, we searched MEDLINE, EMBASE, Scopus, Proquest, Global Health, the WHO library database, and the WHO Institutional Repository for Information Sharing database, and consulted experts. We included randomised and quasi-randomised controlled trials, outbreak investigations, and cohort and case-control studies without restriction on publication dates, in which MCV1 was administered to infants younger than 9 months. We did the literature search on June 2, 2015, and updated it on Jan 14, 2019. We assessed: proportion of infants seroconverted, geometric mean antibody titre, avidity, cellular immunity, duration of immunity, vaccine efficacy, vaccine effectiveness, and safety. We used random-effects models to derive pooled estimates of the endpoints, where appropriate. We assessed methodological quality using the Grading of Recommendations, Assessment, Development, and Evaluation guidelines. FINDINGS Our search identified 1156 studies, of which 1071 were screened for eligibility. 351 were eligible for full-text screening, and data from 56 studies that met all inclusion criteria were used for analysis. The proportion of infants who seroconverted increased from 50% (95% CI 29-71) for those vaccinated with MCV1 at 4 months of age to 85% (69-97) for those were vaccinated at 8 months. The pooled geometric mean titre ratio for infants aged 4-8 months vaccinated with MCV1 compared with infants vaccinated with MCV1 at age 9 months or older was 0·46 (95% CI 0·33-0·66; I2=99·9%, p<0·0001). Only one study reported on avidity and suggested that there was lower avidity and a shorter duration of immunity following MCV1 administration at 6 months of age than at 9 months of age (p=0·0016) or 12 months of age (p<0·001). No effect of age at MCV1 administration on cellular immunity was found. One study reported that vaccine efficacy against laboratory-confirmed measles virus infection was 94% (95% CI 74-98) in infants vaccinated with MCV1 at 4·5 months of age. The pooled vaccine effectiveness of MCV1 in infants younger than 9 months against measles was 58% (95% CI 9-80; I2=84·9%, p<0·0001). The pooled vaccine effectiveness estimate from within-study comparisons of infants younger than 9 months vaccinated with MCV1 were 51% (95% CI -44 to 83; I2=92·3%, p<0·0001), and for those aged 9 months and older at vaccination it was 83% (76-88; I2=93·8%, p<0·0001). No differences in the risk of adverse events after MCV1 administration were found between infants younger than 9 months and those aged 9 months of older. Overall, the quality of evidence ranged from moderate to very low. INTERPRETATION MCV1 administered to infants younger than 9 months induces a good immune response, whereby the proportion of infants seroconverted increases with increased age at vaccination. A large proportion of infants receiving MCV1 before 9 months of age are protected and the vaccine is safe, although higher antibody titres and vaccine effectiveness are found when MCV1 is administered at older ages. Recommending MCV1 administration to infants younger than 9 months for those at high risk of measles is an important step towards reducing measles-related mortality and morbidity. FUNDING WHO.
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Affiliation(s)
- Laura M Nic Lochlainn
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, Netherlands
| | - Brechje de Gier
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, Netherlands
| | - Nicoline van der Maas
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, Netherlands
| | - Peter M Strebel
- Expanded Programme on Immunization, Department of Immunization, Vaccines, and Biologicals, World Health Organization, Geneva, Switzerland
| | - Tracey Goodman
- Expanded Programme on Immunization, Department of Immunization, Vaccines, and Biologicals, World Health Organization, Geneva, Switzerland
| | - Rob S van Binnendijk
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, Netherlands
| | - Hester E de Melker
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, Netherlands
| | - Susan J M Hahné
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, Netherlands.
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25
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Javelle E, Colson P, Parola P, Raoult D. Measles, the need for a paradigm shift. Eur J Epidemiol 2019; 34:897-915. [DOI: 10.1007/s10654-019-00569-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 10/03/2019] [Indexed: 01/24/2023]
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26
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Effect of measles vaccination in infants younger than 9 months on the immune response to subsequent measles vaccine doses: a systematic review and meta-analysis. THE LANCET. INFECTIOUS DISEASES 2019; 19:1246-1254. [PMID: 31548081 PMCID: PMC6838663 DOI: 10.1016/s1473-3099(19)30396-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Figures] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 04/20/2019] [Accepted: 06/13/2019] [Indexed: 01/25/2023]
Abstract
BACKGROUND Vaccinating infants with a first dose of measles-containing vaccine (MCV1) before 9 months of age in high-risk settings has the potential to reduce measles-related morbidity and mortality. However, there is concern that early vaccination might blunt the immune response to subsequent measles vaccine doses. We systematically reviewed the available evidence on the effect of MCV1 administration to infants younger than 9 months on their immune responses to subsequent MCV doses. METHODS For this systematic review and meta-analysis, we searched for randomised and quasi-randomised controlled trials, outbreak investigations, and cohort and case-control studies without restriction on publication dates, in which MCV1 was administered to infants younger than 9 months. We did the literature search on June 2, 2015, and updated it on Jan 14, 2019. We included studies reporting data on strength or duration of humoral and cellular immune responses, and on vaccine efficacy or vaccine effectiveness after two-dose or three-dose MCV schedules. Our outcome measures were proportion of seropositive infants, geometric mean titre, vaccine efficacy, vaccine effectiveness, antibody avidity index, and T-cell stimulation index. We used random-effects meta-analysis to derive pooled estimates of the outcomes, where appropriate. We assessed the methodological quality of included studies using Grading of Recommendation Assessment, Development and Evaluation (GRADE) guidelines. FINDINGS Our search retrieved 1156 records and 85 were excluded due to duplication. 1071 records were screened for eligibility, of which 351 were eligible for full-text screening and 21 were eligible for inclusion in the review. From 13 studies, the pooled proportion of infants seropositive after two MCV doses, with MCV1 administered before 9 months of age, was 98% (95% CI 96-99; I2=79·8%, p<0·0001), which was not significantly different from seropositivity after a two-dose MCV schedule starting later (p=0·087). Only one of four studies found geometric mean titres after MCV2 administration to be significantly lower when MCV1 was administered before 9 months of age than at 9 months of age or later. There was insufficient evidence to determine an effect of age at MCV1 administration on antibody avidity. The pooled vaccine effectiveness estimate derived from two studies of a two-dose MCV schedule with MCV1 vaccination before 9 months of age was 95% (95% CI 89-100; I2=12·6%, p=0·29). Seven studies reporting on measles virus-specific cellular immune responses found that T-cell responses and T-cell memory were sustained, irrespective of the age of MCV1 administration. Overall, the quality of evidence was moderate to very low. INTERPRETATION Our findings suggest that administering MCV1 to infants younger than 9 months followed by additional MCV doses results in high seropositivity, vaccine effectiveness, and T-cell responses, which are independent of the age at MCV1, supporting the vaccination of very young infants in high-risk settings. However, we also found some evidence that MCV1 administered to infants younger than 9 months resulted in lower antibody titres after one or two subsequent doses of MCV than when measles vaccination is started at age 9 months or older. The clinical and public-health relevance of this immunity blunting effect are uncertain. FUNDING WHO.
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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: 51] [Impact Index Per Article: 10.2] [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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Thysen SM, Fernandes M, Benn CS, Aaby P, Fisker AB. Cohort profile : Bandim Health Project's (BHP) rural Health and Demographic Surveillance System (HDSS)-a nationally representative HDSS in Guinea-Bissau. BMJ Open 2019; 9:e028775. [PMID: 31189684 PMCID: PMC6575866 DOI: 10.1136/bmjopen-2018-028775] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Revised: 03/25/2019] [Accepted: 05/15/2019] [Indexed: 12/15/2022] Open
Abstract
PURPOSE Bandim Health Project (BHP) monitors health and survival of women and children in a nationally representative rural Health and Demographic Surveillance System (HDSS) in Guinea-Bissau. The HDSS was set up in 1989-1990 to collect data on health interventions and child mortality. PARTICIPANTS The HDSS covers 182 randomly selected clusters across the whole country. The cohort is open, and women and children enter the cohort, when they move into the selected clusters, and leave the cohort, when they move out or die, or when children reach 5 years of age. Data are collected through biannual or more frequent household visits. At all village visits, information on pregnancies, vital status, vaccination status, arm circumference, use of bed nets and other basic information is collected for women and children. Today, more than 25 000 women and 23 000 children below the age of 5 years are under surveillance. FINDINGS TO DATE Research from the BHP has given rise to the hypothesis that vaccines, in addition to their targeted effects, have important non-specific effects altering the susceptibility to other infections. Initially, it was observed that mortality among children vaccinated with the live BCG or measles vaccines was much lower than the mortality among unvaccinated children, a difference, which could not be explained by prevention of tuberculosis and measles infections. In contrast, mortality tended to be higher for children who had received the non-live Diphtheria-Tetanus-Pertussis vaccine compared with children who had not received this vaccine. Since the effect differed for the different vaccines, no bias explained the contrasting findings. FUTURE PLANS New health interventions are introduced with little assessment of real-life effects. Through the HDSS, we can describe both the implementation of interventions (eg, the vaccination programme) and their effects. Furthermore, the intensive follow-up allows the implementation of randomised trials testing potential better vaccination programmes.
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Affiliation(s)
- Sanne Marie Thysen
- OPEN, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau
- Research Center for Vitamins and Vaccines, Bandim Health Project, Statens Serum Institut, Copenhagen, Denmark
- Center for Global Health, Aarhus University, Aarhus, Denmark
| | | | - Christine Stabell Benn
- OPEN, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau
- Research Center for Vitamins and Vaccines, Bandim Health Project, Statens Serum Institut, Copenhagen, Denmark
| | - Peter Aaby
- OPEN, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau
| | - Ane Bærent Fisker
- OPEN, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Bandim Health Project, INDEPTH Network, Bissau, Guinea-Bissau
- Research Center for Vitamins and Vaccines, Bandim Health Project, Statens Serum Institut, Copenhagen, Denmark
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Non-live pentavalent vaccines after live measles vaccine may increase mortality. Vaccine 2018; 36:6039-6042. [PMID: 30195487 DOI: 10.1016/j.vaccine.2018.08.083] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Revised: 08/29/2018] [Accepted: 08/31/2018] [Indexed: 11/21/2022]
Abstract
Live measles vaccine (MV) may have beneficial off-target/non-specific effects (NSEs) reducing child mortality beyond prevention of measles infection. In contrast, the non-live pentavalent (Diphtheria-Tetanus-Pertussis-H. influenzae Type B-Hepatitis B) vaccine has no beneficial NSEs. The NSEs are strongest for the most recent vaccine. Hence, sequence of vaccination may affect survival. In Guinea-Bissau, we followed 7094 measles-vaccinated children prospectively from first home visit after 9 months (when MV is scheduled) to 5 years of age. We compared survival by sequence of MV and third Pentavalent vaccine (Penta3; scheduled at 3½ months) in Cox proportional-hazards models. Compared with being vaccinated in-sequence (Penta3-then-MV), having received out-of-sequence Penta3-after-MV before the visit was associated with an adjusted Hazard Ratio (aHR) of 1.19 (95%CI: 0.84-1.69); Receiving missing Penta doses on the visit date tended to be associated with higher mortality (aHR = 1.87 (0.96-3.65)) while not receiving missing doses of Penta was not (aHR = 0.93 (0.57-1.54)), test for interaction p = 0.09.
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Fisker AB, Thysen SM. Implementation and assessment of vaccination programmes: the importance of vaccination sequence for overall health outcomes. Hum Vaccin Immunother 2018; 14:2900-2903. [PMID: 30020019 DOI: 10.1080/21645515.2018.1496771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
In addition to their effect on the target infections, accumulating evidence indicates that vaccines have non-specific effects. Live measles vaccine (MV) has beneficial NSEs reducing mortality by more than can be explained by preventing measles infection. In contrast, non-live diphtheria-tetanus-pertussis vaccine (DTP) has negative NSEs; in spite of protecting against diphtheria, tetanus and pertussis, it is associated with increased mortality. The most recent vaccine has the strongest effect on child health, and therefore sequence of vaccines is important. There is consistent evidence that DTP with or after MV is associated with increased mortality compared with having MV as the most recent vaccine, but the sequence of vaccines is not considered in the current evaluation and implementation of vaccination programmes. To maximise the impact of current vaccination programmes on child health, increased emphasis should be placed on receiving MV after DTP. Increasing time with live MV as the most recent vaccine through better adherence to the schedule, and modified recommendations for catch-up vaccinations for children who do not follow the recommended schedule are likely to result in improvements in child health.
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Affiliation(s)
- Ane Bærent Fisker
- a Bandim Health Project, Indepth Network , Apartado , Guinea-Bissau.,b Research Center for Vitamins and Vaccines (CVIVA), Bandim Health Project , Statens Serum Institut , Artillerivej , Denmark.,c OPEN, Odense Patient data Explorative Network , Odense University Hospital/Institute of Clinical Research, University of Southern Denmark , Odense C , Denmark
| | - Sanne Marie Thysen
- a Bandim Health Project, Indepth Network , Apartado , Guinea-Bissau.,b Research Center for Vitamins and Vaccines (CVIVA), Bandim Health Project , Statens Serum Institut , Artillerivej , Denmark.,d Center for Global Health, Department of Public Health , Aarhus University , Aarhus C , Denmark
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de Bree LCJ, Koeken VACM, Joosten LAB, Aaby P, Benn CS, van Crevel R, Netea MG. Non-specific effects of vaccines: Current evidence and potential implications. Semin Immunol 2018; 39:35-43. [PMID: 30007489 DOI: 10.1016/j.smim.2018.06.002] [Citation(s) in RCA: 158] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 06/05/2018] [Accepted: 06/08/2018] [Indexed: 12/17/2022]
Abstract
Besides protection against specific microorganisms, vaccines can induce heterologous or non-specific effects (NSE). Epidemiological data suggest that vaccination with live-attenuated vaccines such as Bacillus Calmette-Guérin (BCG), measles vaccine, and oral polio vaccine results in increased overall childhood survival, and several of these observations have been confirmed in randomized trials. Immunological mechanisms mediating NSE include heterologous lymphocyte effects and induction of innate immune memory (trained immunity). Trained immunity induces long-term functional upregulation of innate immune cells through epigenetic and metabolic reprogramming. An overview of the epidemiological evidence of non-specific effects of vaccines and the latest insights regarding the biological mechanisms behind this phenomenon is presented, and future research priorities and potential implications are discussed.
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Affiliation(s)
- L C J de Bree
- Department of Internal Medicine and Radboud Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands; Research Center for Vitamins and Vaccines, Bandim Health Project, Statens Serum Institut, Copenhagen, Denmark; Odense Patient Data Explorative Network, University of Southern Denmark, Odense University Hospital, Odense, Denmark
| | - Valerie A C M Koeken
- Department of Internal Medicine and Radboud Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Leo A B Joosten
- Department of Internal Medicine and Radboud Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Peter Aaby
- Research Center for Vitamins and Vaccines, Bandim Health Project, Statens Serum Institut, Copenhagen, Denmark; Odense Patient Data Explorative Network, University of Southern Denmark, Odense University Hospital, Odense, Denmark
| | - Christine Stabell Benn
- Research Center for Vitamins and Vaccines, Bandim Health Project, Statens Serum Institut, Copenhagen, Denmark; Odense Patient Data Explorative Network, University of Southern Denmark, Odense University Hospital, Odense, Denmark
| | - Reinout van Crevel
- Department of Internal Medicine and Radboud Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Mihai G Netea
- Department of Internal Medicine and Radboud Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands; Department for Genomics & Immunoregulation, Life and Medical Sciences Institute (LIMES), University of Bonn, Bonn, Germany.
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