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Juvet LK, Robertson AH, Laake I, Mjaaland S, Trogstad L. Safety of Influenza A H1N1pdm09 Vaccines: An Overview of Systematic Reviews. Front Immunol 2021; 12:740048. [PMID: 34777351 PMCID: PMC8581668 DOI: 10.3389/fimmu.2021.740048] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 10/12/2021] [Indexed: 01/08/2023] Open
Abstract
Background In 2009, a new influenza A H1N1 virus emerged causing a global pandemic. A range of monovalent influenza A H1N1pdm09 vaccines with or without adjuvants were developed. After the mass vaccination campaigns safety concerns related to H1N1pdm09 vaccines were reported. More than a decade later, reported AEFIs are still under scrutiny. We performed a systematic review aiming to synthesize the evidence on the safety of the H1N1pdm09 vaccines on reported outcomes from existing systematic reviews. Methods Four electronic databases, PubMed, EMBASE, Epistimonikos and the Cochrane Database of Systematic Reviews were searched for articles on H1N1pdm09 vaccination published from 2009 to January 2021. Systematic reviews assessing short- or long-term adverse events after H1N1pdm09 vaccination were considered for inclusion. Data was extracted from all selected reviews. Outcomes were grouped and results from each included review were presented narratively and in tables. Results 16 systematic reviews met the inclusion criteria. Reported outcomes were short-term events (3 reviews), fetal/pregnancy outcomes (8 reviews), Guillain-Barré syndrome (GBS) (4 reviews), narcolepsy (2 reviews) demyelinating diseases (1 review based on one study only) and inflammatory bowel disease (IBD) (1 review). Short-term serious adverse events were rare, 3 cases amongst 16725 subjects in 18 randomized controlled trials (0.018%). No deaths were reported. The risks of local events were generally higher for adjuvanted vaccines as compared to unadjuvanted vaccines. Maternal H1N1pdm09 vaccination in any trimester was not associated with an increase in preterm birth, small for gestational age, congenital malformations or fetal death. For GBS, results were conflicting. The main systematic review on narcolepsy found a 5-14-fold increased risk in children, and a 2-7- fold increased risk in adults after vaccination with Pandemrix. The attributable risk of narcolepsy one year after vaccination was 1 case per 18 400 vaccine doses in children/adolescents, and 1 case per 181 000 vaccine doses in adults. Conclusion Adjuvanted vaccines had more local but not serious adverse events compared to unadjuvanted vaccines. Vaccination with Pandemrix was strongly associated with narcolepsy, particularly in children. No increased risks of pregnancy outcomes were seen after pandemic vaccination. The findings on GBS were inconclusive.
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Affiliation(s)
- Lene Kristine Juvet
- Division of Infection Control and Environmental Health, Norwegian Institute of Public Health, Oslo, Norway
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Cuningham W, Geard N, Fielding JE, Braat S, Madhi SA, Nunes MC, Christian LM, Lin SY, Lee CN, Yamaguchi K, Bisgaard H, Chawes B, Chao AS, Blanchard-Rohner G, Schlaudecker EP, Fisher BM, McVernon J, Moss R. Optimal timing of influenza vaccine during pregnancy: A systematic review and meta-analysis. Influenza Other Respir Viruses 2019; 13:438-452. [PMID: 31165580 PMCID: PMC6692549 DOI: 10.1111/irv.12649] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Revised: 05/01/2019] [Accepted: 05/03/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Pregnant women have an elevated risk of illness and hospitalisation from influenza. Pregnant women are recommended to be prioritised for influenza vaccination during any stage of pregnancy. The risk of seasonal influenza varies substantially throughout the year in temperate climates; however, there is limited knowledge of how vaccination timing during pregnancy impacts the benefits received by the mother and foetus. OBJECTIVES To compare antenatal vaccination timing with regard to influenza vaccine immunogenicity during pregnancy and transplacental transfer to their newborns. METHODS Studies were eligible for inclusion if immunogenicity to influenza vaccine was evaluated in women stratified by trimester of pregnancy. Haemagglutination inhibition (HI) titres, stratified by trimester of vaccination, had to be measured at either pre-vaccination and within one month post-vaccination, post-vaccination and at delivery in the mother, or in cord/newborn blood. Authors searched PubMed, Scopus, Web of Science and EMBASE databases from inception until June 2016 and authors of identified studies were contacted for additional data. Extracted data were tabulated and summarised via random-effect meta-analyses and qualitative methods. RESULTS Sixteen studies met the inclusion criteria. Meta-analyses found that compared with women vaccinated in an earlier trimester, those vaccinated in a later trimester had a greater fold increase in HI titres (1.33- to 1.96-fold) and higher HI titres in cord/newborn blood (1.21- to 1.64-fold). CONCLUSIONS This review provides comparative analysis of the effect of vaccination timing on maternal immunogenicity and protection of the infant that is informative and relevant to current vaccine scheduling for pregnant women.
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Affiliation(s)
- Will Cuningham
- Menzies School of Health Research, Charles Darwin University, Casuarina, Northern Territory, Australia.,Victorian Infectious Diseases Reference Laboratory, Epidemiology Unit, Peter Doherty Institute for Infection and Immunity, The Royal Melbourne Hospital and The University of Melbourne, Melbourne, Victoria, Australia.,Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Nicholas Geard
- Victorian Infectious Diseases Reference Laboratory, Epidemiology Unit, Peter Doherty Institute for Infection and Immunity, The Royal Melbourne Hospital and The University of Melbourne, Melbourne, Victoria, Australia.,Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia.,Computing and Information Systems, Melbourne School of Engineering, The University of Melbourne, Melbourne, Victoria, Australia
| | - James E Fielding
- Victorian Infectious Diseases Reference Laboratory, Epidemiology Unit, Peter Doherty Institute for Infection and Immunity, The Royal Melbourne Hospital and The University of Melbourne, Melbourne, Victoria, Australia.,Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Sabine Braat
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia.,Melbourne Clinical and Translational Sciences (MCATS) Platform, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Shabir A Madhi
- Medical Research Council: Respiratory and Meningeal Pathogens Research Unit, Faculty of Health Science, University of the Witwatersrand, Johannesburg, South Africa.,Department of Science/National Research Foundation: Vaccine Preventable Diseases, Faculty of Health Science, University of the Witwatersrand, Johannesburg, South Africa
| | - Marta C Nunes
- Medical Research Council: Respiratory and Meningeal Pathogens Research Unit, Faculty of Health Science, University of the Witwatersrand, Johannesburg, South Africa.,Department of Science/National Research Foundation: Vaccine Preventable Diseases, Faculty of Health Science, University of the Witwatersrand, Johannesburg, South Africa
| | - Lisa M Christian
- The Department of Psychiatry & Behavioral Health and The Institute for Behavioral Medicine Research, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Shin-Yu Lin
- Department of OBS & GYN, National Taiwan University Hospital, Taipei, Taiwan
| | - Chien-Nan Lee
- Department of OBS & GYN, National Taiwan University Hospital, Taipei, Taiwan
| | - Koushi Yamaguchi
- Division of Immunology and Microbiology, Center of Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Hans Bisgaard
- COPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Bo Chawes
- COPSAC, Copenhagen Prospective Studies on Asthma in Childhood, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - An-Shine Chao
- Department of Obstetrics & Gynecology, Chang Gung Memorial Hospital & Chang Gung University, Taipei, Taiwan
| | - Geraldine Blanchard-Rohner
- Department of Pediatrics, Children's Hospital of Geneva, University Hospitals of Geneva and Faculty of Medicine, Geneva, Switzerland
| | - Elizabeth P Schlaudecker
- Division of Infectious Diseases, Global Health Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Barbra M Fisher
- Department of Obstetrics and Gynecology, Section of Maternal-Fetal Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Jodie McVernon
- Victorian Infectious Diseases Reference Laboratory, Epidemiology Unit, Peter Doherty Institute for Infection and Immunity, The Royal Melbourne Hospital and The University of Melbourne, Melbourne, Victoria, Australia.,Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Robert Moss
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
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Ahmad SM, Alam MJ, Khanam A, Rashid M, Islam S, Kabir Y, Raqib R, Steinhoff MC. Vitamin A Supplementation during Pregnancy Enhances Pandemic H1N1 Vaccine Response in Mothers, but Enhancement of Transplacental Antibody Transfer May Depend on When Mothers Are Vaccinated during Pregnancy. J Nutr 2018; 148:1968-1975. [PMID: 30517724 DOI: 10.1093/jn/nxy228] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 08/17/2018] [Indexed: 12/29/2022] Open
Abstract
Background In the growing embryo, the vitamin A requirement is tightly regulated. Maternal vitamin A deficiency during pregnancy may alter maternal immune function to accommodate the fetus. Objective Our primary objective was to determine the effect of oral vitamin A supplementation (VAS) during pregnancy and until 6 mo postpartum on pandemic H1N1-vaccine responses in mothers and their infants at 6 mo of age. Methods In this randomized controlled clinical trial, pregnant women (n = 112) during the second trimester (mean ± SD: 14 ± 1 wk) were assigned to receive either an oral dose of 10,000 IU vitamin A or placebo weekly until 6 mo postpartum. During the third trimester, mothers received a single dose of inactivated pandemic H1N1-influenza vaccine. Hemagglutination-inhibition (HAI) titer was measured in cord, infant, and maternal blood samples. Multivariate regressions with adjustments were used for data analysis. Results Seventy-six percent of women had low plasma retinol concentrations (<1.05 μmol/L) in their second trimester. VAS of mothers increased vitamin A concentrations in cord blood by 21.4% and in colostrum by 40.7%. At 6 mo postpartum, women in the vitamin A group had 38.7% higher HAI titers and a higher proportion of HAI titer of ≥1:40 of the cutoff compared with the placebo group. A total of 54.5% of infants had an HAI titer ≥1:40 at 6 mo of age, but there was no difference in HAI titer in infants between groups. Overall, HAI in cord blood did not differ between groups, but in the placebo group, cord blood HAI was negatively associated with maternal "vaccination-to-delivery intervals" (rs = -0.401; P = 0.5), and maternal VAS increased cord blood HAI 6-fold if antenatal immunization was administered ≥10 wk before delivery. Conclusions In a community with low vitamin A status, weekly maternal VAS during pregnancy and postpartum increases the breast-milk vitamin A concentration and enhances prenatal H1N1-vaccine responses in mothers, but the benefits of maternal VAS in transplacental antibody transfer may depend on the time of gestation when mothers were vaccinated. This trial was registered at clinicaltrials.gov as NCT00817661.
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Affiliation(s)
- Shaikh M Ahmad
- Infectious Diseases Division, International Center for Diarrheal Disease Research, Bangladesh (icddr,b), Mohakhali, Dhaka, Bangladesh
| | - Md J Alam
- Infectious Diseases Division, International Center for Diarrheal Disease Research, Bangladesh (icddr,b), Mohakhali, Dhaka, Bangladesh
| | - Afsana Khanam
- Infectious Diseases Division, International Center for Diarrheal Disease Research, Bangladesh (icddr,b), Mohakhali, Dhaka, Bangladesh
| | - Mamunur Rashid
- Infectious Diseases Division, International Center for Diarrheal Disease Research, Bangladesh (icddr,b), Mohakhali, Dhaka, Bangladesh
| | - Sharmin Islam
- Infectious Diseases Division, International Center for Diarrheal Disease Research, Bangladesh (icddr,b), Mohakhali, Dhaka, Bangladesh
| | - Yearul Kabir
- Department of Biochemistry and Molecular Biology, University of Dhaka, Dhaka, Bangladesh
| | - Rubhana Raqib
- Infectious Diseases Division, International Center for Diarrheal Disease Research, Bangladesh (icddr,b), Mohakhali, Dhaka, Bangladesh
| | - Mark C Steinhoff
- Global Health Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
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Harder T, Remschmidt C, Haller S, Eckmanns T, Wichmann O. Use of existing systematic reviews for evidence assessments in infectious disease prevention: a comparative case study. Syst Rev 2016; 5:171. [PMID: 27724950 PMCID: PMC5057474 DOI: 10.1186/s13643-016-0347-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 09/21/2016] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Given limited resources and time constraints, the use of existing systematic reviews (SR) for the development of evidence-based public health recommendations has become increasingly important. Recently, a five-step approach for identifying, analyzing, appraising and using existing SRs based on recent guidance by the US Agency for Healthcare Research and Quality (AHRQ) was proposed within the Project on a Framework for Rating Evidence in Public Health (PRECEPT). However, case studies are needed to test whether this approach is useful, what challenges arise and how problems can be solved. METHODS In two case studies, the five-step approach was applied to integrate existing SRs in the development of evidence-based public health recommendations. Case study A focused on the role of neonatal sepsis as a risk factor for adverse neurodevelopmental outcome. Case study B examined the efficacy, effectiveness and safety of influenza vaccination during pregnancy. For each step, we report the approach of the review team, discuss challenges and describe solutions. RESULTS For case study A, one existing SR was identified, while in case study B four SRs were eligible for analysis. We found that comparison of inclusion criteria alone was sufficient to judge on relevance of SRs in case study A, but not B. Although methodological quality of all identified SRs was acceptable, risk of bias assessments of individual studies included in the SRs had to be repeated in both case studies. Particular challenges appeared in case study B where multiple SRs addressed the same research question. With the help of spreadsheets comparing the characteristics of the existing SR we decided to use the most comprehensive one for our evidence synthesis and supplemented the results with those from the other SRs. CONCLUSIONS In both case studies using the complete SR was not possible. The five-step approach provided useful and structured guidance and should be routinely applied when using existing SRs as a basis for evidence-based recommendations in public health. In situations where more than one SR has to be considered, the development of spreadsheets comparing characteristics, inclusion criteria, risk of bias, included studies and outcomes seems useful.
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Affiliation(s)
- Thomas Harder
- Immunization Unit, Robert Koch Institute, Seestrasse 10, 13353 Berlin, Germany
| | | | - Sebastian Haller
- Unit for Healthcare-Associated Infections, Surveillance of Antimicrobial Resistance and Consumption, Robert Koch Institute, Seestrasse 10, 13353 Berlin, Germany
| | - Tim Eckmanns
- Unit for Healthcare-Associated Infections, Surveillance of Antimicrobial Resistance and Consumption, Robert Koch Institute, Seestrasse 10, 13353 Berlin, Germany
| | - Ole Wichmann
- Immunization Unit, Robert Koch Institute, Seestrasse 10, 13353 Berlin, Germany
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McMillan M, Porritt K, Kralik D, Costi L, Marshall H. Influenza vaccination during pregnancy: a systematic review of fetal death, spontaneous abortion, and congenital malformation safety outcomes. Vaccine 2015; 33:2108-17. [PMID: 25758932 DOI: 10.1016/j.vaccine.2015.02.068] [Citation(s) in RCA: 102] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Revised: 01/20/2015] [Accepted: 02/25/2015] [Indexed: 01/07/2023]
Abstract
BACKGROUND Pregnant women are considered the most important risk group for influenza vaccination. Despite this, the potential risk of harm from the vaccine on the fetus is a key factor in low uptake of the vaccine. This systematic review aimed to synthesize the best available evidence on the safety of influenza vaccination during pregnancy on fetal development. METHODS AND FINDINGS A search of the literature was undertaken from the inception of each database up to March 2014. Both observational and clinical trials were considered. Fetal outcomes were present in 19 observational studies, and 14 of those were primarily investigating the monovalent influenza A (H1N1) 2009 vaccine. There was significant methodological and clinical heterogeneity of the included studies and a narrative summary and tabling of results was performed. Fetal death outcomes for women in later pregnancy ranged from OR 0.34 to 2.95 with 95% confidence intervals crossing or below the null value. Spontaneous abortion less than 24 weeks ranged from HR 0.45 to OR 1.23, with 95% confidence intervals crossing or below the null value. Congenital malformations for women vaccinated during their first trimester ranged from OR 0.67 to 2.18 and imprecise confidence intervals crossed the null value. Included in this review were some high quality studies, although overall the studies have a high risk of selection and confounding bias. CONCLUSIONS Results do not indicate that maternal influenza vaccination is associated with an increased risk of fetal death, spontaneous abortion, or congenital malformations. Statistical imprecision and clinical and methodological heterogeneity of the observational studies mean it is not possible to totally exclude adverse effects. Further studies investigating women vaccinated during their first trimester should be the highest priority to allow for more precise estimates, especially for spontaneous abortion, and congenital abnormality outcomes.
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Affiliation(s)
- M McMillan
- School of Pediatrics and Reproductive Health, The University of Adelaide, Adelaide 5005, SA, Australia.
| | - K Porritt
- Joanna Briggs Institute, Faculty of Health Sciences, The University of Adelaide, Adelaide 5005, SA, Australia.
| | - D Kralik
- Women's and Children's Hospital, 72 King William Road, North Adelaide 5006, SA, Australia
| | - L Costi
- Women's and Children's Hospital, 72 King William Road, North Adelaide 5006, SA, Australia.
| | - H Marshall
- Vaccinology and Immunology Research Trials Unit (VIRTU), Women's and Children's Hospital and School of Pediatrics and Reproductive Health & Robinson Institute, The University of Adelaide, Adelaide 5005, SA, Australia.
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