Safety and immunogenicity of a pentavalent meningococcal conjugate vaccine containing serogroups A, C, Y, W, and X in healthy adults: a phase 1, single-centre, double-blind, randomised, controlled study

BACKGROUND

Invasive meningococcal disease is an important public health problem, especially in sub-Saharan Africa. After introduction of MenAfriVac in 2010, Neisseria meningitidis serogroup A disease has been almost eliminated from the region. However, serogroups C, W, Y, and X continue to cause disease outbreaks. We assessed the NmCV-5 pentavalent meningococcal conjugate vaccine targeting A, C, Y, W, and X serogroups in a first-in-man, phase 1 study.

METHODS

We did a single-centre, double-blind, randomised controlled trial at a research clinic in Baltimore (MD, USA). Participants were healthy adults aged 18-45 years with no history of meningococcal vaccination or previous meningococcal infection. We randomly assigned participants (1:1:1) by an SAS-generated random schedule to a single, 0·5 mL, intramuscular injection of aluminium-phosphate adjuvanted NmCV-5, non-adjuvanted NmCV-5, or control (the quadrivalent meningococcal conjugate vaccine Menactra). The randomisation sequence used a permuted block design with randomly chosen block sizes of three and six. The vaccines were prepared, labelled, and administered with procedures to ensure participants and study personnel remained masked to treatment. After vaccination, participants were observed in the clinic for 60 min for adverse reactions. Participants recorded daily temperature and injection site or systemic reactions at home and returned to the clinic for follow-up visits on days 7, 28, and 84 for safety assessments; blood samples were also collected on day 7 for safety laboratory assessment. A phone call contact was made 6 months after vaccination. Serum was collected before vaccination and 28 days after vaccination for immunological assessment with a rabbit complement-dependent serum bactericidal antibody (rSBA) assay. The primary objective was an intention-to-treat assessment of safety, measuring local and systemic reactogenicity over 7 days, unsolicited adverse events through 28 days, and serious adverse events over 6 months. The secondary objective for the assessment of immunogenicity, was a per-protocol analysis of rSBA before and 28 days after vaccination. This trial is registered with ClinicalTrials.gov, number NCT02810340.

FINDINGS

Between Aug 17, 2016, and Feb 16, 2017, we assigned 20 participants to each vaccine. All vaccines were well-tolerated. Pain was the most common local reaction, occurring in 12 (60%), ten (50%), and seven (35%) participants in the adjuvanted NmCV-5, non-adjuvanted NmCV-5, and control groups, respectively. Headache was the most common systemic reaction, occurring in five (25%), three (15%), and three (15%), respectively. Most solicited reactogenicity adverse reactions were mild (60 [74%] of 81) and all were self-limiting. None of the differences in proportions of individuals with each solicited reaction was significant (p>0·300 for all comparisons) between the three vaccination groups. There were no serious adverse events and 19 unsolicited non-serious adverse events in 14 (23%) participants. Both adjuvanted and non-adjuvanted NmCV-5 elicited high rSBA titres against all five meningococcal serogroups. The pre-vaccination geometric mean titres (GMTs) ranged from 3·36 to 53·80 for the control, from 6·28 to 187·00 for the adjuvanted vaccine, and from 4·29 to 350·00 for the non-adjuvanted vaccine, and the post-vaccination GMT ranged from 3·14 to 3214 for the control, from 1351 to 8192 for the adjuvanted vaccine, and from 1607 to 11 191 for the non-adjuvanted vaccine. Predicted seroprotective responses (ie, an increase in rSBA titres of eight times or more) for the adjuvanted and non-adjuvanted NmCV-5 were similar to control responses for all five serogroups.

INTERPRETATION

The adjuvanted and non-adjuvanted NmCV-5 vaccines were well tolerated and did not produce concerning adverse effects and resulted in immune responses that are predicted to confer protection against all five targeted serogroups of invasive meningococcal disease. Further clinical testing of NmCV-5 is ongoing, and additional clinical trials are necessary to confirm the safety and immunogenicity of NmCV-5 in target populations.

FUNDING

UK Department for International Development.

Consolidation intraperitoneal chemotherapy in epithelial ovarian cancer patients following negative second-look laparotomy

Fifty-six patients with Stage III ovarian carcinoma who had a negative second-look laparotomy following optimum cytoreduction, cisplatin, and cyclophosphamide chemotherapy were enrolled in a pilot study to receive consolidation intraperitoneal (IP) chemotherapy. Forty-one patients received three courses of IP cisplatin (80 mg/m2). Fifteen patients with cisplatin-induced toxicity received three courses of IP mitoxantrone (10 mg/m2). Toxicity was minimal, with only 2 patients suffering peritonitis and 1 patient developing an enterotomy at the time of catheter removal. Median follow-up for the IP cisplatin and IP mitoxantrone group has been 24 and 30 months, respectively. Ten of the 41 patients (24%) who received IP cisplatin and 4/15 (26%) of the IP mitoxantrone patients have recurred (P = ns). Median time to recurrence was 18 months for both groups. This study indicates that consolidation intraperitoneal chemotherapy following negative second-look laparotomy is feasible with either cisplatin or mitoxantrone. However, many of these patients still recurred and prospective trials will be required to determine which (if any) consolidation intraperitoneal treatment is best following a negative second-look laparotomy.

Papillary villoglandular carcinoma of the cervix

Three cases of papillary villoglandular carcinoma of the cervix are presented. Each patient was multiparous and presented with abnormal vaginal bleeding. The mean age at presentation was 35 years (range 28-42 years). All patients were staged as FIGO IB and underwent radical Wertheim hysterectomy and bilateral pelvic lymphadenectomy. Disease was limited to the cervix in two patients and extended to involve the lower uterine segment in one patient. There was no evidence of microscopic spread to the lymph nodes. Previous reports that examined patients with papillary villoglandular carcinoma of the cervix found them to have a favorable prognosis. Treatment implications are discussed.

Management of endometriosis with oral medroxyprogesterone acetate

Efficacy of oral medroxyprogesterone acetate (MPA) was assessed in 35 women with an established diagnosis of endometriosis (33 pelvic and 2 abdominal). MPA was given in a dosage of 30 mg daily for 90 days. Results indicated improvement or remission in all cases, even though breakthrough bleeding occurred in 8. Twenty-six were treated for associated infertility. Twelve of these became pregnant following treatment. Pregnancy rate in those women whose husbands were fertile was 90%. Side effects included spotting and breakthrough bleeding. The patients usually remained amenorrheic and anovulatory while receiving MPA. Posttreatment resumption of ovulation was prompt. The findings indicate that oral MPA is a useful therapeutic agent in the management of minimal to moderate endometriosis, particularly when it is associated with infertility.

Persistent behavioural and electroencephalographic changes after single doses of nitrazepam and amylobarbitone sodium

In a double-blind cross-over trial the effects of nitrazepam (5 and 10 mg.), amylobarbitone sodium (100 and 200 mg.), and placebo were compared in normal healthy young people. Though they reported a good night's sleep and adjudged themselves to be alert after all four drug treatments, behavioural tests showed their performance to be significantly impaired 13 hours after treatment with nitrazepam or amylobarbitone, and E.E.G. records showed more drowsiness and light sleep 18 hours after treatment with nitrazepam than with amylobarbitone or placebo. E.E.G. fast activity was more plentiful after drugs in either dosage than with placebo.