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Song KR, Chapagain RH, Tamrakar D, Shrestha R, Kanodia P, Chaudhary S, Wartel TA, Yang JS, Kim DR, Lee J, Park EL, Cho H, Lee J, Thaisrivichai P, Vemula S, Kim BM, Gupta B, Saluja T, Pansuriya RK, Ganapathy R, Baik YO, Lee YJ, Jeon S, Park Y, Her HL, Park Y, Lynch JA. Safety and immunogenicity of the Euvichol-S oral cholera vaccine for prevention of Vibrio cholerae O1 infection in Nepal: an observer-blind, active-controlled, randomised, non-inferiority, phase 3 trial. Lancet Glob Health 2024; 12:e826-e837. [PMID: 38614631 PMCID: PMC11027156 DOI: 10.1016/s2214-109x(24)00059-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 01/25/2024] [Accepted: 02/01/2024] [Indexed: 04/15/2024]
Abstract
BACKGROUND In October, 2017, WHO launched a strategy to eliminate cholera by 2030. A primary challenge in meeting this goal is the limited global supply capacity of oral cholera vaccine and the worsening of cholera outbreaks since 2021. To help address the current shortage of oral cholera vaccine, a WHO prequalified oral cholera vaccine, Euvichol-Plus was reformulated by reducing the number of components and inactivation methods. We aimed to evaluate the immunogenicity and safety of Euvichol-S (EuBiologics, Seoul, South Korea) compared with an active control vaccine, Shanchol (Sanofi Healthcare India, Telangana, India) in participants of various ages in Nepal. METHODS We did an observer-blind, active-controlled, randomised, non-inferiority, phase 3 trial at four hospitals in Nepal. Eligible participants were healthy individuals aged 1-40 years without a history of cholera vaccination. Individuals with a history of hypersensitivity reactions to other preventive vaccines, severe chronic disease, previous cholera vaccination, receipt of blood or blood-derived products in the past 3 months or other vaccine within 4 weeks before enrolment, and pregnant or lactating women were excluded. Participants were randomly assigned (1:1:1:1) by block randomisation (block sizes of two, four, six, or eight) to one of four groups (groups A-D); groups C and D were stratified by age (1-5, 6-17, and 18-40 years). Participants in groups A-C were assigned to receive two 1·5 mL doses of Euvichol-S (three different lots) and participants in group D were assigned to receive the active control vaccine, Shanchol. All participants and site staff (with the exception of those who prepared and administered the study vaccines) were masked to group assignment. The primary immunogenicity endpoint was non-inferiority of immunogenicity of Euvichol-S (group C) versus Shanchol (group D) at 2 weeks after the second vaccine dose, measured by the seroconversion rate, defined as the proportion of participants who had achieved seroconversion (defined as ≥four-fold increase in V cholerae O1 Inaba and Ogawa titres compared with baseline). The primary immunogenicity endpoint was assessed in the per-protocol analysis set, which included all participants who received all their planned vaccine administrations, had no important protocol deviations, and who provided blood samples for all immunogenicity assessments. The primary safety endpoint was the number of solicited adverse events, unsolicited adverse events, and serious adverse events after each vaccine dose in all ages and each age stratum, assessed in all participants who received at least one dose of the Euvichol-S or Shanchol. Non-inferiority of Euvichol-S compared with Shanchol was shown if the lower limit of the 95% CI for the difference between the seroconversion rates in Euvichol-S group C versus Shanchol group D was above the predefined non-inferiority margin of -10%. The trial was registered at ClinicalTrials.gov, NCT04760236. FINDINGS Between Oct 6, 2021, and Jan 19, 2022, 2529 healthy participants (1261 [49·9%] males; 1268 [50·1%] females), were randomly assigned to group A (n=330; Euvichol-S lot number ES-2002), group B (n=331; Euvichol-S ES-2003), group C (n=934; Euvichol-S ES-2004]), or group D (n=934; Shanchol). Non-inferiority of Euvichol-S versus Shanchol in seroconversion rate for both serotypes at 2 weeks after the second dose was confirmed in all ages (difference in seroconversion rate for V cholerae O1 Inaba -0·00 [95% CI -1·86 to 1·86]; for V cholerae O1 Ogawa -1·62 [-4·80 to 1·56]). Treatment-emergent adverse events were reported in 244 (9·7%) of 2529 participants in the safety analysis set, with a total of 403 events; 247 events were reported among 151 (9·5%) of 1595 Euvichol-S recipients and 156 events among 93 (10·0%) of 934 Shanchol recipients. Pyrexia was the most common adverse event in both groups (57 events among 56 [3·5%] of 1595 Euvichol-S recipients and 37 events among 35 [3·7%] of 934 Shanchol recipients). No serious adverse events were deemed to be vaccine-related. INTERPRETATION A two-dose regimen of Euvichol-S vaccine was non-inferior to the active control vaccine, Shanchol, in terms of seroconversion rates 2 weeks after the second dose. The simplified formulation and production requirements of the Euvichol-S vaccine have the potential to increase the supply of oral cholera vaccine and reduce the gap between the current oral cholera vaccine supply and demand. FUNDING The Bill & Melinda Gates Foundation. TRANSLATION For the Nepali translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Katerina Rok Song
- Clinical, Assessment, Regulatory, Evaluation Unit, International Vaccine Institute, Seoul, South Korea.
| | - Ram Hari Chapagain
- Department of Pediatric Medicine, Kanti Children's Hospital, Kathmandu, Nepal
| | - Dipesh Tamrakar
- Center for Clinical Trial Studies, Dhulikhel Hospital, Kathmandu University Hospital, Dhulikhel, Nepal
| | - Rajeev Shrestha
- Center for Clinical Trial Studies, Dhulikhel Hospital, Kathmandu University Hospital, Dhulikhel, Nepal
| | - Piush Kanodia
- Department of Pediatrics and Neonatology, Nepalgunj Medical College, Nepalgunj, Nepal
| | - Shipra Chaudhary
- Department of Pediatrics and Adolescent Medicine, BP Koirala Institute of Health Sciences, Dharan, Nepal
| | - T Anh Wartel
- International Vaccine Institute, Stockholm, Sweden
| | - Jae Seung Yang
- Science Unit, International Vaccine Institute, Seoul, South Korea
| | - Deok Ryun Kim
- Department of Biostatistics and Data Management, International Vaccine Institute, Seoul, South Korea
| | - Jinae Lee
- Department of Biostatistics and Data Management, International Vaccine Institute, Seoul, South Korea
| | - Eun Lyeong Park
- Department of Biostatistics and Data Management, International Vaccine Institute, Seoul, South Korea
| | - Haeun Cho
- Department of Biostatistics and Data Management, International Vaccine Institute, Seoul, South Korea
| | - Jiyoung Lee
- Department of Biostatistics and Data Management, International Vaccine Institute, Seoul, South Korea
| | | | - Sridhar Vemula
- Clinical, Assessment, Regulatory, Evaluation Unit, International Vaccine Institute, Seoul, South Korea
| | - Bo Mi Kim
- Clinical, Assessment, Regulatory, Evaluation Unit, International Vaccine Institute, Seoul, South Korea
| | - Birendra Gupta
- Clinical, Assessment, Regulatory, Evaluation Unit, International Vaccine Institute, Seoul, South Korea
| | - Tarun Saluja
- Clinical, Assessment, Regulatory, Evaluation Unit, International Vaccine Institute, Seoul, South Korea
| | - Ruchir Kumar Pansuriya
- Vaccine Process Development Unit, International Vaccine Institute, Seoul, South Korea; Graduate School of Public Health, Yonsei University, Seoul, South Korea
| | - Ravi Ganapathy
- Research and Development, Hilleman Laboratories, Singapore
| | - Yeong Ok Baik
- Research and Development Division, EuBiologics, Seoul, South Korea
| | - Young Jin Lee
- Research and Development Division, EuBiologics, Seoul, South Korea
| | - Suhi Jeon
- Production Division, EuBiologics, Seoul, South Korea
| | | | - Howard L Her
- Research and Development Division, EuBiologics, Seoul, South Korea
| | | | - Julia A Lynch
- Clinical, Assessment, Regulatory, Evaluation Unit, International Vaccine Institute, Seoul, South Korea
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Bwire G, Kisakye A, Amulen E, Bwanika JB, Badebye J, Aanyu C, Nakirya BD, Okello A, Okello SA, Bukenya JN, Orach CG. Cholera and COVID-19 pandemic prevention in multiple hotspot districts of Uganda: vaccine coverage, adverse events following immunization and WASH conditions survey. BMC Infect Dis 2023; 23:487. [PMID: 37479986 PMCID: PMC10362646 DOI: 10.1186/s12879-023-08462-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 07/13/2023] [Indexed: 07/23/2023] Open
Abstract
BACKGROUND Between March, 2020 and December, 2021 due to cholera and coronavirus disease 2019 (COVID-19) pandemics, there were 1,534 cholera cases with 14 deaths and 136,065 COVID-19 cases with 3,285 deaths reported respectively in Uganda. This study investigated mass vaccination campaigns for the prevention of the two pandemics namely: oral cholera vaccine (OCV) and COVID-19 vaccine coverage; adverse events following immunization (AEFI); barriers and enablers for the vaccine uptake and assessed water, sanitation and hygiene (WASH) conditions in the six cholera and COVID-19 hotspot districts of Uganda. METHODS A household survey was conducted between January and February, 2022 in the six cholera hotspot districts of Uganda which had recently conducted OCV mass vaccination campaigns and had ongoing COVID-19 mass vaccination campaigns. The survey randomly enrolled 900 households with 4,315 persons of whom 2,085 were above 18 years. Data were collected using a data entry application designed in KoBoToolbox and analysed using STATA version 14. Frequencies, percentages, odds ratios, means, confidence intervals and maps were generated and interpreted. RESULTS The OCV coverage for dose one and two were 85% (95% CI: 84.2-86.4) and 67% (95% CI: 65.6-68.4) respectively. Among the 4,315 OCV recipients, 2% reported mild AEFI, 0.16% reported moderate AEFI and none reported severe AEFI. The COVID-19 vaccination coverage for dose one and two were 69.8% (95% CI: 67.8-71.8) and 18.8% (95% CI: 17.1-20.5) respectively. Approximately, 23% (478/2,085) of COVID-19 vaccine recipient reported AEFI; most 94% were mild, 0.6% were moderate and 2 cases were severe. The commonest reason for missing COVID-19 vaccine was fear of the side effects. For most districts (5/6), sanitation (latrine/toilet) coverage were low at 7.4%-37.4%. CONCLUSION There is high OCV coverage but low COVID-19 vaccine and sanitation coverage with high number of moderate cases of AEFI recorded due to COVID-19 vaccines. The low COVID-19 vaccine coverage could indicate vaccine hesitancy for COVID-19 vaccines. Furthermore, incorporation of WASH conditions assessment in the OCV coverage surveys is recommended for similar settings to generate data for better planning. However, more studies are required on COVID-19 vaccine hesitancy.
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Affiliation(s)
- Godfrey Bwire
- School of Public Health, Makerere University, Kampala, Uganda.
- Division of Public Health Emergency Preparedness and Response, Ministry of Health, Kampala, Uganda.
| | | | - Esther Amulen
- School of Public Health, Makerere University, Kampala, Uganda
| | | | - Joan Badebye
- School of Forestry, Environmental and Geographical Sciences, Makerere University, Kampala, Uganda
| | - Christine Aanyu
- School of Public Health, Makerere University, Kampala, Uganda
| | | | - Alfred Okello
- Department of Public Health, St Mary's Hospital Lacor, Gulu, Uganda
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Raghava Mohan V, Raj S, Dhingra MS, Aloysia D’Cor N, Singh AP, Saluja T, Kim DR, Midde VJ, Kim Y, Vemula S, Narla SK, Sah B, Ali M. Safety and immunogenicity of a killed bivalent (O1 and O139) whole-cell oral cholera vaccine in adults and children in Vellore, South India. PLoS One 2019; 14:e0218033. [PMID: 31211792 PMCID: PMC6581248 DOI: 10.1371/journal.pone.0218033] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 05/24/2019] [Indexed: 11/18/2022] Open
Abstract
This open-label study assessed the safety and immunogenicity of two doses (14 days apart) of an indigenously manufactured, killed, bivalent (Vibrio cholerae O1 and O139), whole-cell oral cholera vaccine (SHANCHOL; Shantha Biotechnics) in healthy adults (n = 100) and children (n = 100) in a cholera endemic area (Vellore, South India) to fulfill post-licensure regulatory requirements and post-World Health Organization (WHO) prequalification commitments. Safety and reactogenicity were assessed, and seroconversion rates (i.e. proportion of participants with a ≥ 4-fold rise from baseline in serum vibriocidal antibody titers against V. cholerae O1 Inaba, O1 Ogawa and O139, respectively) were determined 14 days after each vaccine dose. No serious adverse events were reported during the study. Commonly reported solicited adverse events were headache and general ill feeling. Seroconversion rates after the first and second dose in adults were 67.7% and 55.2%, respectively, against O1 Inaba; 47.9% and 45.8% against O1 Ogawa; and 19.8% and 20.8% against O139. In children, seroconversion rates after the first and second dose were 80.2% and 68.8%, respectively, against O1 Inaba; 72.9% and 67.7% against O1 Ogawa; and 26.0% and 18.8% against O139. The geometric mean titers against O1 Inaba, O1 Ogawa, and O139 in both adults and children were significantly higher after each vaccine dose compared to baseline titers (P < 0.001; for both age groups after each dose versus baseline). The seroconversion rates for O1 Inaba, O1 Ogawa, and O139 in both age groups were similar to those in previous studies with the vaccine. In conclusion, the killed, bivalent, whole-cell oral cholera vaccine has a good safety and reactogenicity profile, and is immunogenic in healthy adults and children. Trial Registration: ClinicalTrials.gov NCT00760825; CTRI/2012/01/002354.
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Affiliation(s)
| | | | | | | | | | - Tarun Saluja
- International Vaccine Institute, Seoul, South Korea
| | | | | | - Yanghee Kim
- International Vaccine Institute, Seoul, South Korea
| | | | | | - Binod Sah
- International Vaccine Institute, Seoul, South Korea
| | - Mohammad Ali
- Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
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Khan AI, Ali M, Lynch J, Kabir A, Excler JL, Khan MA, Islam MT, Akter A, Chowdhury F, Saha A, Khan IA, Desai SN, Kim DR, Saha NC, Singh AP, Clemens JD, Qadri F. Safety of a bivalent, killed, whole-cell oral cholera vaccine in pregnant women in Bangladesh: evidence from a randomized placebo-controlled trial. BMC Infect Dis 2019; 19:422. [PMID: 31092224 PMCID: PMC6518748 DOI: 10.1186/s12879-019-4006-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 04/22/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Cholera increases the risk of harmful effects on foetuses. We prospectively followed pregnant women unaware of their pregnancy status who received a study agent in a clinical trial evaluating the association between exposure to an oral cholera vaccine (OCV) and foetal survival. METHODS Study participants were selected from a randomized placebo-controlled trial conducted in Dhaka, Bangladesh. The vaccination campaign was conducted between January 10 and February 4, 2014. We enrolled women who were exposed to an OCV or placebo during pregnancy (Cohort 1) and women who were pregnant after the vaccination was completed (Cohort 2). Our primary endpoint was pregnancy loss (spontaneous miscarriage or stillbirth), and the secondary endpoints were preterm delivery and low birth weight. We employed a log-binomial regression to calculate the relative risk of having adverse outcomes among OCV recipients compared to that among placebo recipients. RESULT There were 231 OCV and 234 placebo recipients in Cohort 1 and 277 OCV and 299 placebo recipients in Cohort 2. In Cohort 1, the incidence of pregnancy loss was 113/1000 and 115/1000 among OCV and placebo recipients, respectively. The adjusted relative risk for pregnancy loss was 0.97 (95% CI: 0.58-1.61; p = 0.91) in Cohort 1. We did not observe any variation in the risk of pregnancy loss between the two cohorts. The risks for preterm delivery and low birth weight were not significantly different between the groups in both cohorts. CONCLUSIONS Our study provides additional evidence that exposure to an OCV during pregnancy does not increase the risk of pregnancy loss, preterm delivery, or low birth weight, suggesting that pregnant women in cholera-affected regions should not be excluded in a mass vaccination campaign. TRIAL REGISTRATION The study is registered at ( http://clinicaltrials.gov ). Identifier: NCT02027207 .
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Affiliation(s)
- Ashraful Islam Khan
- International Centre for Diarrhoeal Disease Research Bangladesh (icddr,b), 68, Shaheed Tajuddin Ahmed Sarani, Mohakhali Dhaka, 1212 Bangladesh
| | - Mohammad Ali
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | - Julia Lynch
- International Vaccine Institute, Seoul, South Korea
| | - Alamgir Kabir
- International Centre for Diarrhoeal Disease Research Bangladesh (icddr,b), 68, Shaheed Tajuddin Ahmed Sarani, Mohakhali Dhaka, 1212 Bangladesh
| | | | - Md. Arifuzzaman Khan
- International Centre for Diarrhoeal Disease Research Bangladesh (icddr,b), 68, Shaheed Tajuddin Ahmed Sarani, Mohakhali Dhaka, 1212 Bangladesh
| | - Md. Taufiqul Islam
- International Centre for Diarrhoeal Disease Research Bangladesh (icddr,b), 68, Shaheed Tajuddin Ahmed Sarani, Mohakhali Dhaka, 1212 Bangladesh
| | - Afroza Akter
- International Centre for Diarrhoeal Disease Research Bangladesh (icddr,b), 68, Shaheed Tajuddin Ahmed Sarani, Mohakhali Dhaka, 1212 Bangladesh
| | - Fahima Chowdhury
- International Centre for Diarrhoeal Disease Research Bangladesh (icddr,b), 68, Shaheed Tajuddin Ahmed Sarani, Mohakhali Dhaka, 1212 Bangladesh
| | - Amit Saha
- International Centre for Diarrhoeal Disease Research Bangladesh (icddr,b), 68, Shaheed Tajuddin Ahmed Sarani, Mohakhali Dhaka, 1212 Bangladesh
| | - Iqbal Ansary Khan
- International Centre for Diarrhoeal Disease Research Bangladesh (icddr,b), 68, Shaheed Tajuddin Ahmed Sarani, Mohakhali Dhaka, 1212 Bangladesh
| | | | | | - Nirod Chandra Saha
- International Centre for Diarrhoeal Disease Research Bangladesh (icddr,b), 68, Shaheed Tajuddin Ahmed Sarani, Mohakhali Dhaka, 1212 Bangladesh
| | | | - John D. Clemens
- International Centre for Diarrhoeal Disease Research Bangladesh (icddr,b), 68, Shaheed Tajuddin Ahmed Sarani, Mohakhali Dhaka, 1212 Bangladesh
| | - Firdausi Qadri
- International Centre for Diarrhoeal Disease Research Bangladesh (icddr,b), 68, Shaheed Tajuddin Ahmed Sarani, Mohakhali Dhaka, 1212 Bangladesh
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Semá Baltazar C, Rafael F, Langa JPM, Chicumbe S, Cavailler P, Gessner BD, Pezzoli L, Barata A, Zaina D, Inguane DL, Mengel MA, Munier A. Oral cholera vaccine coverage during a preventive door-to-door mass vaccination campaign in Nampula, Mozambique. PLoS One 2018; 13:e0198592. [PMID: 30281604 PMCID: PMC6169854 DOI: 10.1371/journal.pone.0198592] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Accepted: 05/22/2018] [Indexed: 12/13/2022] Open
Abstract
Background In addition to improving water, sanitation and hygiene (WASH) measures and optimal case management, the introduction of Oral cholera vaccine (OCV) is a complementary strategy for cholera prevention and control for vulnerable population groups. In October 2016, the Mozambique Ministry of Health implemented a mass vaccination campaign using a two-dose regimen of the Shanchol™ OCV in six high-risk neighborhoods of Nampula city, in Northern Mozambique. Overall 193,403 people were targeted by the campaign, which used a door-to-door strategy. During campaign follow-up, a population survey was conducted to assess: (1) OCV coverage; (2) frequency of adverse events following immunization; (3) vaccine acceptability and (4) reasons for non-vaccination. Methodology/Principal findings In the absence of a household listing and clear administrative neighborhood delimitations, we used geospatial technology to select households from satellite images and used the support of community leaders. One person per household was randomly selected for interview. In total, 636 individuals were enrolled in the survey. The overall vaccination coverage with at least one dose (including card and oral reporting) was 69.5% (95%CI: 51.2–88.2) and the two-dose coverage was 51.2% (95%CI: 37.9–64.3). The campaign was well accepted. Among the 185 non-vaccinated individuals, 83 (44.6%) did not take the vaccine because they were absent when the vaccination team visited their houses. Among the 451 vaccinated individuals, 47 (10%) reported minor and non-specific complaints, and 78 (17.3%) mentioned they did not receive any information before the campaign. Conclusions/Significance In spite of overall coverage being slightly lower than expected, the use of a mobile door-to-door strategy remains a viable option even in densely-populated urban settings. Our results suggest that campaigns can be successfully implemented and well accepted in Mozambique in non-emergency contexts in order to prevent cholera outbreaks. These findings are encouraging and complement the previous Mozambican experience related to OCV.
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Affiliation(s)
| | | | | | - Sergio Chicumbe
- Instituto Nacional de Saúde, Ministry of Health, Maputo, Mozambique
| | | | | | | | - Américo Barata
- Direcção Provincial de Saúde, Ministry of Health, Nampula, Mozambique
| | - Dores Zaina
- Direcção de Saúde de Cidade, Ministry of Health, Nampula, Mozambique
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Affiliation(s)
- D F D'Costa
- Department of Neurology, Leicester Royal Infirmary
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Capeding MRZ, Gonzales MLAM, Dhingra MS, D'Cor NA, Midde VJ, Patnaik BN, Thollot Y, Desauziers E. Safety and immunogenicity of the killed bivalent (O1 and O139) whole-cell cholera vaccine in the Philippines. Hum Vaccin Immunother 2017; 13:2232-2239. [PMID: 28910563 PMCID: PMC5975480 DOI: 10.1080/21645515.2017.1342908] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2016] [Revised: 05/30/2017] [Accepted: 06/20/2017] [Indexed: 10/25/2022] Open
Abstract
The killed bivalent (O1 and O139) whole cell oral cholera vaccine (OCV) (Shanchol™) was first licensed in India in 2009 and World Health Organization pre-qualified in 2011. We assessed the safety and immunogenicity of this OCV in the Philippines. This was a phase IV, single-arm, descriptive, open-label study. We recruited 336 participants from 2 centers: 112 participants in each age group (1-4, 5-14 and ≥ 15 years). Participants received 2 OCV doses 14 d apart. Safety was monitored throughout the trial. Blood samples were collected at baseline (pre-vaccination) and 14 d after each dose. Serum vibriocidal antibody titers to V. cholerae O1 (El Tor Inaba and El Tor Ogawa) and O139 strains were assessed, with seroconversion defined as ≥ 4-fold increase from baseline in titers. No immediate unsolicited systemic adverse events/reactions were observed. Unsolicited systemic adverse events were mostly grade 1 intensity. One serious adverse event occurred after the first dose, but was unrelated to vaccination. High seroconversion rates (range 69-92%) were achieved against the O1 serotypes with a trend toward higher rates in the 1-4 y (86-92%) and 5-14 y (86-88%) age groups than the ≥ 15 y age group (69-83%). Lower seroconversion rates were achieved against the O139 serotype (35-70%), particularly in those aged ≥ 15 y (35-42%). The 2-dose regimen of the killed bivalent whole cell OCV was well-tolerated in this study conducted in the Philippines, a cholera-endemic country. Robust immune responses were observed even after a single-dose.
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Affiliation(s)
| | | | | | | | - Venkat Jayanth Midde
- Shantha Biotechnics Private Limited (A Sanofi Company), Hyderabad, Telangana, India
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Khan AI, Islam MT, Qadri F. Safety of oral cholera vaccines during pregnancy in developing countries. Hum Vaccin Immunother 2017; 13:2245-2246. [PMID: 28825876 PMCID: PMC5647996 DOI: 10.1080/21645515.2017.1356525] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 07/08/2017] [Indexed: 10/19/2022] Open
Affiliation(s)
- Ashraful Islam Khan
- International Centre for Diarrheal Disease Research Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Md Taufiqul Islam
- International Centre for Diarrheal Disease Research Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Firdausi Qadri
- International Centre for Diarrheal Disease Research Bangladesh (icddr,b), Dhaka, Bangladesh
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Cholera vaccines: WHO position paper – August 2017. Wkly Epidemiol Rec 2017; 92:477-98. [PMID: 28845659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
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Khan AI, Ali M, Chowdhury F, Saha A, Khan IA, Khan A, Akter A, Asaduzzaman M, Islam MT, Kabir A, You YA, Saha NC, Cravioto A, Clemens JD, Qadri F. Safety of the oral cholera vaccine in pregnancy: Retrospective findings from a subgroup following mass vaccination campaign in Dhaka, Bangladesh. Vaccine 2017; 35:1538-1543. [PMID: 28196715 PMCID: PMC5341737 DOI: 10.1016/j.vaccine.2017.01.080] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Revised: 01/23/2017] [Accepted: 01/24/2017] [Indexed: 11/30/2022]
Abstract
Few women received the OCV unknowingly while pregnant during a large vaccine trial. There is limited data on the safety of OCVs in pregnancy. We evaluated the effect of a killed OCV, Shanchol™, on pregnancy outcomes. Study showed no evidence of exposure to Shanchol™ on adverse pregnancy outcomes.
Background Pregnant women are vulnerable to complications of cholera. Killed oral cholera vaccines (OCV) are not recommended for pregnant women though there is no evidence of harmful effects during pregnancy. We evaluated the effect of a killed OCV, Shanchol™, on pregnancy outcomes during an effectiveness trial of the vaccine in urban Bangladesh. Methodology Individuals ⩾1 year were invited to participate in the trial, conducted in 2011 in Dhaka, Bangladesh. Pregnancy by history was an exclusion criterion and all women of reproductive age (15–49 years) were verbally questioned about pregnancy at enrollment and prior to vaccination. Out of 48,414 women of reproductive age 286 women received the OCV unknowingly while pregnant. Out of these, we could recruit 69 women defined as exposed to OCV. Accordingly, we selected 69 pregnant women randomly from those who did not take the OCV (non-exposed to OCV). We evaluated adverse pregnancy outcome (spontaneous miscarriages, still births, or congenital malformations) between those who were exposed to OCV and those who were not exposed to OCV. Results About 16% of pregnant women exposed to OCV had pregnancy loss, as compared to 12% of unvaccinated pregnant women (P = 0.38). One congenital anomaly was observed and occurred in women non-exposed to OCV group. Models that adjusted for baseline characteristics that were unbalanced between the exposed and non-exposed groups, revealed a no elevation of risk of adverse pregnancy outcomes in vaccinees versus non-vaccinees (Adj. OR (95% CI): 0.45 (0.11–1.88). Conclusions No excess of adverse fetal outcomes associated with receipt of OCV was observed in this study. Trial registration: Clinical Trials.gov number NCT01339845.
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Affiliation(s)
- Ashraful Islam Khan
- International Centre for Diarrheal Disease Research Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Mohammad Ali
- Johns Hopkins School of Public Health, Baltimore, MD, USA
| | - Fahima Chowdhury
- International Centre for Diarrheal Disease Research Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Amit Saha
- International Centre for Diarrheal Disease Research Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Iqbal Ansary Khan
- International Centre for Diarrheal Disease Research Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Arifuzzaman Khan
- International Centre for Diarrheal Disease Research Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Afroza Akter
- International Centre for Diarrheal Disease Research Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Muhammad Asaduzzaman
- International Centre for Diarrheal Disease Research Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Md Taufiqul Islam
- International Centre for Diarrheal Disease Research Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Alamgir Kabir
- International Centre for Diarrheal Disease Research Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Young Ae You
- International Vaccine Institute (IVI), Seoul, Republic of Korea
| | - Nirod Chandra Saha
- International Centre for Diarrheal Disease Research Bangladesh (icddr,b), Dhaka, Bangladesh
| | | | - John D Clemens
- International Centre for Diarrheal Disease Research Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Firdausi Qadri
- International Centre for Diarrheal Disease Research Bangladesh (icddr,b), Dhaka, Bangladesh.
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Uddin MI, Islam S, Nishat NS, Hossain M, Rafique TA, Rashu R, Hoq MR, Zhang Y, Saha A, Harris JB, Calderwood SB, Bhuiyan TR, Ryan ET, Leung DT, Qadri F. Biomarkers of Environmental Enteropathy are Positively Associated with Immune Responses to an Oral Cholera Vaccine in Bangladeshi Children. PLoS Negl Trop Dis 2016; 10:e0005039. [PMID: 27824883 PMCID: PMC5100882 DOI: 10.1371/journal.pntd.0005039] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2016] [Accepted: 09/13/2016] [Indexed: 12/14/2022] Open
Abstract
Environmental enteropathy (EE) is a poorly understood condition that refers to chronic alterations in intestinal permeability, absorption, and inflammation, which mainly affects young children in resource-limited settings. Recently, EE has been linked to suboptimal oral vaccine responses in children, although immunological mechanisms are poorly defined. The objective of this study was to determine host factors associated with immune responses to an oral cholera vaccine (OCV). We measured antibody and memory T cell immune responses to cholera antigens, micronutrient markers in blood, and EE markers in blood and stool from 40 Bangladeshi children aged 3-14 years who received two doses of OCV given 14 days apart. EE markers included stool myeloperoxidase (MPO) and alpha anti-trypsin (AAT), and plasma endotoxin core antibody (EndoCab), intestinal fatty acid binding protein (i-FABP), and soluble CD14 (sCD14). We used multiple linear regression analysis with LASSO regularization to identify host factors, including EE markers, micronutrient (nutritional) status, age, and HAZ score, predictive for each response of interest. We found stool MPO to be positively associated with IgG antibody responses to the B subunit of cholera toxin (P = 0.03) and IgA responses to LPS (P = 0.02); plasma sCD14 to be positively associated with LPS IgG responses (P = 0.07); plasma i-FABP to be positively associated with LPS IgG responses (P = 0.01) and with memory T cell responses specific to cholera toxin (P = 0.01); stool AAT to be negatively associated with IL-10 (regulatory) T cell responses specific to cholera toxin (P = 0.02), and plasma EndoCab to be negatively associated with cholera toxin-specific memory T cell responses (P = 0.02). In summary, in a cohort of children 3-14 years old, we demonstrated that the majority of biomarkers of environmental enteropathy were positively associated with immune responses after vaccination with an OCV.
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Affiliation(s)
- Muhammad Ikhtear Uddin
- Mucosal Immunology and Vaccinology Laboratory, Infectious Diseases Division, icddr,b, Dhaka, Bangladesh
| | - Shahidul Islam
- Mucosal Immunology and Vaccinology Laboratory, Infectious Diseases Division, icddr,b, Dhaka, Bangladesh
| | - Naoshin S. Nishat
- Mucosal Immunology and Vaccinology Laboratory, Infectious Diseases Division, icddr,b, Dhaka, Bangladesh
| | - Motaher Hossain
- Mucosal Immunology and Vaccinology Laboratory, Infectious Diseases Division, icddr,b, Dhaka, Bangladesh
| | - Tanzeem Ahmed Rafique
- Mucosal Immunology and Vaccinology Laboratory, Infectious Diseases Division, icddr,b, Dhaka, Bangladesh
| | - Rasheduzzaman Rashu
- Mucosal Immunology and Vaccinology Laboratory, Infectious Diseases Division, icddr,b, Dhaka, Bangladesh
| | - Mohammad Rubel Hoq
- Mucosal Immunology and Vaccinology Laboratory, Infectious Diseases Division, icddr,b, Dhaka, Bangladesh
| | - Yue Zhang
- Department of Internal Medicine, Division of Epidemiology, University of Utah, School of Medicine, Salt Lake City, Utah, United States of America
| | - Amit Saha
- Mucosal Immunology and Vaccinology Laboratory, Infectious Diseases Division, icddr,b, Dhaka, Bangladesh
| | - Jason B. Harris
- Department of Immunology and Infectious Diseases, Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Stephen B. Calderwood
- Department of Immunology and Infectious Diseases, Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Taufiqur Rahman Bhuiyan
- Mucosal Immunology and Vaccinology Laboratory, Infectious Diseases Division, icddr,b, Dhaka, Bangladesh
| | - Edward T. Ryan
- Department of Immunology and Infectious Diseases, Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Daniel T. Leung
- Mucosal Immunology and Vaccinology Laboratory, Infectious Diseases Division, icddr,b, Dhaka, Bangladesh
- Department of Internal Medicine, Division of Infectious Diseases, University of Utah, School of Medicine, Salt Lake City, Utah, United States of America
- Department of Pathology, Division of Microbiology and Immunology, University of Utah, School of Medicine, Salt Lake City, Utah, United States of America
| | - Firdausi Qadri
- Mucosal Immunology and Vaccinology Laboratory, Infectious Diseases Division, icddr,b, Dhaka, Bangladesh
- * E-mail:
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12
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An oral cholera vaccine for travelers (Vaxchora). Med Lett Drugs Ther 2016; 58:113-4. [PMID: 27552209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
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13
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Baik YO, Choi SK, Olveda RM, Espos RA, Ligsay AD, Montellano MB, Yeam JS, Yang JS, Park JY, Kim DR, Desai SN, Singh AP, Kim IY, Kim CW, Park SN. A randomized, non-inferiority trial comparing two bivalent killed, whole cell, oral cholera vaccines (Euvichol vs Shanchol) in the Philippines. Vaccine 2015; 33:6360-5. [PMID: 26348402 DOI: 10.1016/j.vaccine.2015.08.075] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 07/27/2015] [Accepted: 08/28/2015] [Indexed: 11/17/2022]
Abstract
BACKGROUND Currently, there are two oral cholera vaccines (OCV) that are prequalified by the World Health Organization. Both (Dukoral and Shanchol) have been proven to be safe, immunogenic, and effective. As the global supply of OCV remains limited, we assessed the safety and immunogenicity of a new low cost, killed, bivalent OCV (Euvichol) in the Philippines. METHODS The randomized controlled trial was carried out in healthy Filipino adults and children. Two doses of either the current WHO prequalified OCV (Shanchol) or the same composition OCV being considered for WHO prequalification (Euvichol) were administered to participants. RESULTS The pivotal study was conducted in total of 1263 healthy participants (777 adults and 486 children). No serious adverse reactions were elicited in either vaccine groups. Vibriocidal antibody responses to V. cholerae O1 Inaba following administration of two doses of Euvichol were non-inferior to those of Shanchol in adults (82% vs 76%) and children (87% vs 89%). Similar findings were observed for O1 Ogawa in adults (80% vs 74%) and children (91% vs 88%). CONCLUSION A two dose schedule with Euvichol induces a strong vibriocidal response comparable to those elicited by the currently WHO prequalified OCV, Shanchol. Euvichol will be an oral cholera vaccine suitable for use in lower income countries, where cholera still has a significant economic and public health impact.
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Affiliation(s)
- Yeong Ok Baik
- EuBiologics Co., Ltd., Seoul, Republic of Korea; Department of Biotechnology, Korea University, Seoul, Republic of Korea
| | - Seuk Keun Choi
- EuBiologics Co., Ltd., Seoul, Republic of Korea; Department of Biotechnology, Korea University, Seoul, Republic of Korea
| | - Remigio M Olveda
- Research Institute for Tropical Medicine, Muntinlupa City, Philippines
| | - Roberto A Espos
- De Lasalle University Medical Center, Dasmarinas, Philippines
| | | | | | | | - Jae Seung Yang
- Clinical Immunology, Laboratory Science Unit, International Vaccine Institute (IVI), Seoul, Republic of Korea
| | - Ju Yeon Park
- Development and Delivery, International Vaccine Institute (IVI), Seoul, Republic of Korea
| | - Deok Ryun Kim
- Development and Delivery, International Vaccine Institute (IVI), Seoul, Republic of Korea
| | - Sachin N Desai
- Development and Delivery, International Vaccine Institute (IVI), Seoul, Republic of Korea
| | - Ajit Pal Singh
- Development and Delivery, International Vaccine Institute (IVI), Seoul, Republic of Korea
| | - Ick Young Kim
- Department of Biotechnology, Korea University, Seoul, Republic of Korea
| | - Chan Wha Kim
- Department of Biotechnology, Korea University, Seoul, Republic of Korea
| | - Sue-nie Park
- EuBiologics Co., Ltd., Seoul, Republic of Korea.
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Desai SN, Akalu Z, Teshome S, Teferi M, Yamuah L, Kim DR, Yang JS, Hussein J, Park JY, Jang MS, Mesganaw C, Taye H, Beyene D, Bedru A, Singh AP, Wierzba TF, Aseffa A. A Randomized, Placebo-Controlled Trial Evaluating Safety and Immunogenicity of the Killed, Bivalent, Whole-Cell Oral Cholera Vaccine in Ethiopia. Am J Trop Med Hyg 2015; 93:527-533. [PMID: 26078323 PMCID: PMC4559691 DOI: 10.4269/ajtmh.14-0683] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Accepted: 03/22/2015] [Indexed: 11/07/2022] Open
Abstract
Killed whole-cell oral cholera vaccine (OCV) has been a key component of a comprehensive package including water and sanitation measures for recent cholera epidemics. The vaccine, given in a two-dose regimen, has been evaluated in a large number of human volunteers in India, Vietnam, and Bangladesh, where it has demonstrated safety, immunogenicity, and clinical efficacy. We conducted a double-blind randomized placebo-controlled trial in Ethiopia, where we evaluated the safety and immunogenicity of the vaccine in 216 healthy adults and children. OCV was found to be safe and elicited a robust immunological response against Vibrio cholerae O1, with 81% adults and 77% children demonstrating seroconversion 14 days after the second dose of vaccine. This is the first study to evaluate safety and immunogenicity of the vaccine in a population outside Asia using a placebo-controlled, double-blind, randomized study design.
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Affiliation(s)
- Sachin N. Desai
- *Address correspondence to Sachin N. Desai, International Vaccine Institute, SNU Research Park, San 4-8, Nakseongdae-dong, Gwanak-gu, Seoul, Korea 151-919. E-mail:
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15
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Tohme RA, François J, Wannemuehler K, Iyengar P, Dismer A, Adrien P, Hyde TB, Marston BJ, Date K, Mintz E, Katz MA. Oral Cholera Vaccine Coverage, Barriers to Vaccination, and Adverse Events following Vaccination, Haiti, 2013. Emerg Infect Dis 2015; 21:984-91. [PMID: 25988350 PMCID: PMC4451924 DOI: 10.3201/eid2106.141797] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
In 2013, the first government-led oral cholera vaccination (OCV) campaign in Haiti was implemented in Petite Anse and Cerca Carvajal. To evaluate vaccination coverage, barriers to vaccination, and adverse events following vaccination, we conducted a cluster survey. We enrolled 1,121 persons from Petite Anse and 809 persons from Cerca Carvajal, categorized by 3 age groups (1-4, 5-14, >15 years). Two-dose OCV coverage was 62.5% in Petite Anse and 76.8% in Cerca Carvajal. Two-dose coverage was lowest among persons >15 years of age. In Cerca Carvajal, coverage was significantly lower for male than female respondents (69% vs. 85%; p<0.001). No major adverse events were reported. The main reason for nonvaccination was absence during the campaign. Vaccination coverage after this campaign was acceptable and comparable to that resulting from campaigns implemented by nongovernmental organizations. Future campaigns should be tailored to reach adults who are not available during daytime hours.
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16
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Kanungo S, Desai SN, Nandy RK, Bhattacharya MK, Kim DR, Sinha A, Mahapatra T, Yang JS, Lopez AL, Manna B, Bannerjee B, Ali M, Dhingra MS, Chandra AM, Clemens JD, Sur D, Wierzba TF. Flexibility of oral cholera vaccine dosing-a randomized controlled trial measuring immune responses following alternative vaccination schedules in a cholera hyper-endemic zone. PLoS Negl Trop Dis 2015; 9:e0003574. [PMID: 25764513 PMCID: PMC4357440 DOI: 10.1371/journal.pntd.0003574] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Accepted: 01/28/2015] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND A bivalent killed whole cell oral cholera vaccine has been found to be safe and efficacious for five years in the cholera endemic setting of Kolkata, India, when given in a two dose schedule, two weeks apart. A randomized controlled trial revealed that the immune response was not significantly increased following the second dose compared to that after the first dose. We aimed to evaluate the impact of an extended four week dosing schedule on vibriocidal response. METHODOLOGY/PRINCIPAL FINDINGS In this double blind randomized controlled non-inferiority trial, 356 Indian, non-pregnant residents aged 1 year or older were randomized to receive two doses of oral cholera vaccine at 14 and 28 day intervals. We compared vibriocidal immune responses between these schedules. Among adults, no significant differences were noted when comparing the rates of seroconversion for V. cholerae O1 Inaba following two dose regimens administered at a 14 day interval (55%) vs the 28 day interval (58%). Similarly, no differences in seroconversion were demonstrated in children comparing the 14 (80%) and 28 day intervals (77%). Following 14 and 28 day dosing intervals, vibriocidal response rates against V. cholerae O1 Ogawa were 45% and 49% in adults and 73% and 72% in children respectively. Responses were lower for V. cholerae O139, but similar between dosing schedules for adults (20%, 20%) and children (28%, 20%). CONCLUSIONS/SIGNIFICANCE Comparable immune responses and safety profiles between the two dosing schedules support the option for increased flexibility of current OCV dosing. Further operational research using a longer dosing regimen will provide answers to improve implementation and delivery of cholera vaccination in endemic and epidemic outbreak scenarios.
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Affiliation(s)
- Suman Kanungo
- Division of Epidemiology, National Institute of Cholera and Enteric Diseases, Kolkata, India
| | - Sachin N. Desai
- Development and Delivery Unit, International Vaccine Institute, Seoul, Republic of Korea
| | - Ranjan Kumar Nandy
- Division of Bacteriology, National Institute of Cholera and Enteric Diseases, Kolkata, India
| | - Mihir Kumar Bhattacharya
- Division of Clinical Medicine, National Institute of Cholera and Enteric Diseases, Kolkata, India
| | - Deok Ryun Kim
- Development and Delivery Unit, International Vaccine Institute, Seoul, Republic of Korea
| | - Anuradha Sinha
- Division of Bacteriology, National Institute of Cholera and Enteric Diseases, Kolkata, India
| | - Tanmay Mahapatra
- Division of Epidemiology, National Institute of Cholera and Enteric Diseases, Kolkata, India
| | - Jae Seung Yang
- Laboratory Science Division, International Vaccine Institute, Seoul, Republic of Korea
| | - Anna Lena Lopez
- University of the Philippines Manila, National Institutes of Health, Manila, Philippines
| | - Byomkesh Manna
- Division of Data Management, National Institute of Cholera and Enteric Diseases, Kolkata, India
| | - Barnali Bannerjee
- Division of Data Management, National Institute of Cholera and Enteric Diseases, Kolkata, India
| | - Mohammad Ali
- Development and Delivery Unit, International Vaccine Institute, Seoul, Republic of Korea
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, United States of America
| | - Mandeep Singh Dhingra
- Clinical Research and Development, Shantha Biotechnics Private Limited, Hyderabad, India
| | | | - John D. Clemens
- Office of the Executive Director, International Centre for Diarrheal Disease Research, Bangladesh
- Department of Epidemiology, University of California Los Angeles Fielding School of Public Health, Los Angeles, United States of America
| | - Dipika Sur
- Division of Epidemiology, National Institute of Cholera and Enteric Diseases, Kolkata, India
- Office of the Scientific Director, PATH India Office, New Delhi, India
| | - Thomas F. Wierzba
- Development and Delivery Unit, International Vaccine Institute, Seoul, Republic of Korea
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17
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Kanungo S, Sen B, Ramamurthy T, Sur D, Manna B, Pazhani GP, Chowdhury G, Jhunjhunwala P, Nandy RK, Koley H, Bhattacharya MK, Gupta S, Goel G, Dey B, M T, Nair GB, Ghosh A, Mahalanabis D. Safety and immunogenicity of a live oral recombinant cholera vaccine VA1.4: a randomized, placebo controlled trial in healthy adults in a cholera endemic area in Kolkata, India. PLoS One 2014; 9:e99381. [PMID: 24983989 PMCID: PMC4077646 DOI: 10.1371/journal.pone.0099381] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 05/08/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND A live oral cholera vaccine VA 1.4 developed from a non-toxigenic Vibrio cholerae O1 El Tor strain using ctxB gene insertion was further developed into a clinical product following cGMP and was evaluated in a double-blind randomized placebo controlled parallel group two arm trial with allocation ratio of 1∶1 for safety and immunogenicity in men and women aged 18-60 years from Kolkata, India. METHOD A lyophilized dose of 1.9×109 CFU (n = 44) or a placebo (n = 43) reconstituted with a diluent was administered within 5 minutes of drinking 100 ml of a buffer solution made of sodium bicarbonate and ascorbic acid and a second dose on day 14. RESULT The vaccine did not elicit any diarrhea related adverse events. Other adverse events were rare, mild and similar in two groups. One subject in the vaccine group excreted the vaccine strain on the second day after first dose. The proportion of participants who seroconverted (i.e. had 4-folds or higher rise in reciprocal titre) in the vaccine group were 65.9% (95% CI: 50.1%-79.5%) at both 7 days (i.e. after 1st dose) and 21 days (i.e. after 2nd dose). None of the placebo recipients seroconverted. Anti-cholera toxin antibody was detected in very few recipients of the vaccine. CONCLUSION This study demonstrates that VA 1.4 at a single dose of 1.9×109 is safe and immunogenic in adults from a cholera endemic region. No additional benefit after two doses was seen. TRIAL REGISTRATION Clinical Trials Registry-India, National Institute of Medical Statistics (Indian Council of Medical Research) CTRI/2012/04/002582.
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Affiliation(s)
- Suman Kanungo
- Department of Epidemiology, National Institute of Cholera & Enteric Diseases, Kolkata, West Bengal, India
| | - Bandana Sen
- Society for Applied Studies, Kolkata, West Bengal, India
| | - Thandavarayan Ramamurthy
- Department of Microbiology, National Institute of Cholera & Enteric Diseases, Kolkata, West Bengal, India
| | - Dipika Sur
- Department of Epidemiology, National Institute of Cholera & Enteric Diseases, Kolkata, West Bengal, India
| | - Byomkesh Manna
- Department of Epidemiology, National Institute of Cholera & Enteric Diseases, Kolkata, West Bengal, India
| | - Gururaja P. Pazhani
- Department of Microbiology, National Institute of Cholera & Enteric Diseases, Kolkata, West Bengal, India
| | - Goutam Chowdhury
- Department of Microbiology, National Institute of Cholera & Enteric Diseases, Kolkata, West Bengal, India
| | - Puja Jhunjhunwala
- Department of Microbiology, National Institute of Cholera & Enteric Diseases, Kolkata, West Bengal, India
| | - Ranjan K. Nandy
- Department of Microbiology, National Institute of Cholera & Enteric Diseases, Kolkata, West Bengal, India
| | - Hemanta Koley
- Department of Microbiology, National Institute of Cholera & Enteric Diseases, Kolkata, West Bengal, India
| | - Mihir Kumar Bhattacharya
- Department of Epidemiology, National Institute of Cholera & Enteric Diseases, Kolkata, West Bengal, India
| | - Sanjay Gupta
- Catalyst Clinical Services Pvt. Ltd., Delhi, India
| | - Gaurav Goel
- Catalyst Clinical Services Pvt. Ltd., Delhi, India
| | - Bindu Dey
- Department of Biotechnology, Ministry of Science and Technology, New Delhi, India
| | - Thungapathra M
- Institute of Post Graduate Medicine and Research, Chandigarh, India
| | - G. Balakrish Nair
- Translational Health Science and Technology Institute, Gurgaon, Haryana, India
| | - Amit Ghosh
- Department of Microbiology, National Institute of Cholera & Enteric Diseases, Kolkata, West Bengal, India
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Oral cholera vaccine campaign among internally displaced persons in South Sudan. Wkly Epidemiol Rec 2014; 89:214-20. [PMID: 24864347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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19
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Baik YO, Choi SK, Kim JW, Yang JS, Kim IY, Kim CW, Hong JH. Safety and immunogenicity assessment of an oral cholera vaccine through phase I clinical trial in Korea. J Korean Med Sci 2014; 29:494-501. [PMID: 24753695 PMCID: PMC3991791 DOI: 10.3346/jkms.2014.29.4.494] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2013] [Accepted: 02/14/2014] [Indexed: 11/20/2022] Open
Abstract
The safety, tolerability and immunogenicity of an oral cholera vaccine (OCV) was assessed in adult Korean male through an open-label, non-comparative clinical study. Two doses of vaccine with an interval of 2 weeks were given to 20 healthy subjects. A total of 7 adverse events occurred in 6 subjects. However, no clinically significant change was observed in electrocardiograms, vital signs, physical examinations, and clinical laboratory tests. The immunogenicity of OCV was evaluated by serum vibriocidal assay where anti-Vibrio cholerae O1 and O139 antibodies were measured at day 0, 14, and 28 of vaccine administration. The antibody titers ranged from < 2.5-5,120 for V. cholerae O1 Inaba, < 2.5-10,240 for V. cholerae O1 Ogawa and < 2.5-480 for V. cholerae O139. In addition, the fold increase in antibody titers ranged from 1-4,096 for O1 Inaba, 1-8,192 for O1 Ogawa, and 1-384 for O139. The seroconversion rate was 95% and 45% for O1 and O139 antibodies, respectively. Our study clearly shows that administration of two doses of OCV at a 2 week-interval increases an appropriate level of antibody titer in the serum of healthy Korean adult males (Clinical Trial Number, NCT01707537).
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Affiliation(s)
- Young Ok Baik
- Department of Biotechnology, Korea University and EuBiologics Co., Ltd., Chuncheon, Korea
| | - Seuk Keun Choi
- Department of Biotechnology, Korea University and EuBiologics Co., Ltd., Chuncheon, Korea
| | - Jae Woo Kim
- Department of Pharmacology and Clinical Trials Center, Chungnam National University, College of Medicine and Hospital, Daejeon, Korea
| | - Jae Seung Yang
- Clinical Immunology Section, International Vaccine Institute (IVI), Seoul, Korea
| | - Ick Young Kim
- Department of Biotechnology, Korea University, Seoul, Korea
| | - Chan Wha Kim
- Department of Biotechnology, Korea University, Seoul, Korea
| | - Jang Hee Hong
- Department of Pharmacology and Clinical Trials Center, Chungnam National University, College of Medicine and Hospital, Daejeon, Korea
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Luquero FJ, Grout L, Ciglenecki I, Sakoba K, Traore B, Heile M, Dialo AA, Itama C, Serafini M, Legros D, Grais RF. First outbreak response using an oral cholera vaccine in Africa: vaccine coverage, acceptability and surveillance of adverse events, Guinea, 2012. PLoS Negl Trop Dis 2013; 7:e2465. [PMID: 24147164 PMCID: PMC3798604 DOI: 10.1371/journal.pntd.0002465] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Accepted: 08/21/2013] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Despite World Health Organization (WHO) prequalification of two safe and effective oral cholera vaccines (OCV), concerns about the acceptability, potential diversion of resources, cost and feasibility of implementing timely campaigns has discouraged their use. In 2012, the Ministry of Health of Guinea, with the support of Médecins Sans Frontières organized the first mass vaccination campaign using a two-dose OCV (Shanchol) as an additional control measure to respond to the on-going nationwide epidemic. Overall, 316,250 vaccines were delivered. Here, we present the results of vaccination coverage, acceptability and surveillance of adverse events. METHODOLOGY/PRINCIPAL FINDINGS We performed a cross-sectional cluster survey and implemented adverse event surveillance. The study population included individuals older than 12 months, eligible for vaccination, and residing in the areas targeted for vaccination (Forécariah and Boffa, Guinea). Data sources were household interviews with verification by vaccination card and notifications of adverse events from surveillance at vaccination posts and health centres. In total 5,248 people were included in the survey, 3,993 in Boffa and 1,255 in Forécariah. Overall, 89.4% [95%CI:86.4-91.8%] and 87.7% [95%CI:84.2-90.6%] were vaccinated during the first round and 79.8% [95%CI:75.6-83.4%] and 82.9% [95%CI:76.6-87.7%] during the second round in Boffa and Forécariah respectively. The two dose vaccine coverage (including card and oral reporting) was 75.8% [95%CI: 71.2-75.9%] in Boffa and 75.9% [95%CI: 69.8-80.9%] in Forécariah respectively. Vaccination coverage was higher in children. The main reason for non-vaccination was absence. No severe adverse events were notified. CONCLUSIONS/SIGNIFICANCE The well-accepted mass vaccination campaign reached high coverage in a remote area with a mobile population. Although OCV should not be foreseen as the long-term solution for global cholera control, they should be integrated as an additional tool into the response.
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Affiliation(s)
| | - Lise Grout
- Epicentre, Paris, France
- Médecins sans Frontières, Geneva, Switzerland
| | | | - Keita Sakoba
- Ministry of Health, Conakry, Guinea
- African Cholera Surveillance Network, Paris, France
| | - Bala Traore
- Direction Préfectorale de la Santé, Ministry of Health, Conakry, Guinea
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21
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Abstract
BACKGROUND Infection with enterotoxigenic Escherichia coli (ETEC) bacteria is a common cause of diarrhoea in adults and children in developing countries and is a major cause of 'travellers' diarrhoea' in people visiting or returning from endemic regions. A killed whole cell vaccine (Dukoral®), primarily designed and licensed to prevent cholera, has been recommended by some groups to prevent travellers' diarrhoea in people visiting endemic regions. This vaccine contains a recombinant B subunit of the cholera toxin that is antigenically similar to the heat labile toxin of ETEC. This review aims to evaluate the clinical efficacy of this vaccine and other vaccines designed specifically to protect people against diarrhoea caused by ETEC infection. OBJECTIVES To evaluate the efficacy, safety, and immunogenicity of vaccines for preventing ETEC diarrhoea. SEARCH METHODS We searched the Cochrane Infectious Disease Group Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, LILACS, and http://clinicaltrials.gov up to December 2012. SELECTION CRITERIA Randomized controlled trials (RCTs) and quasi-RCTs comparing use of vaccines to prevent ETEC with use of no intervention, a control vaccine (either an inert vaccine or a vaccine normally given to prevent an unrelated infection), an alternative ETEC vaccine, or a different dose or schedule of the same ETEC vaccine in healthy adults and children living in endemic regions, intending to travel to endemic regions, or volunteering to receive an artificial challenge of ETEC bacteria. DATA COLLECTION AND ANALYSIS Two authors independently assessed each trial for eligibility and risk of bias. Two independent reviewers extracted data from the included studies and analyzed the data using Review Manager (RevMan) software. We reported outcomes as risk ratios (RR) with 95% confidence intervals (CI). We assessed the quality of the evidence using the GRADE approach. MAIN RESULTS Twenty-four RCTs, including 53,247 participants, met the inclusion criteria. Four studies assessed the protective efficacy of oral cholera vaccines when used to prevent diarrhoea due to ETEC and seven studies assessed the protective efficacy of ETEC-specific vaccines. Of these 11 studies, seven studies presented efficacy data from field trials and four studies presented efficacy data from artificial challenge studies. An additional 13 trials contributed safety and immunological data only. Cholera vaccinesThe currently available, oral cholera killed whole cell vaccine (Dukoral®) was evaluated for protection of people against 'travellers' diarrhoea' in a single RCT in people arriving in Mexico from the USA. We did not identify any statistically significant effects on ETEC diarrhoea or all-cause diarrhoea (one trial, 502 participants, low quality evidence).Two earlier trials, one undertaken in an endemic population in Bangladesh and one undertaken in people travelling from Finland to Morocco, evaluated a precursor of this vaccine containing purified cholera toxin B subunit rather than the recombinant subunit in Dukoral®. Short term protective efficacy against ETEC diarrhoea was demonstrated, lasting for around three months (RR 0.43, 95% CI 0.26 to 0.71; two trials, 50,227 participants). This vaccine is no longer available. ETEC vaccinesAn ETEC-specific, killed whole cell vaccine, which also contains the recombinant cholera toxin B-subunit, was evaluated in people travelling from the USA to Mexico or Guatemala, and from Austria to Latin America, Africa, or Asia. We did not identify any statistically significant differences in ETEC-specific diarrhoea or all-cause diarrhoea (two trials, 799 participants), and the vaccine was associated with increased vomiting (RR 2.0, 95% CI 1.16 to 3.45; nine trials, 1528 participants). The other ETEC-specific vaccines in development have not yet demonstrated clinically important benefits. AUTHORS' CONCLUSIONS There is currently insufficient evidence from RCTs to support the use of the oral cholera vaccine Dukoral® for protecting travellers against ETEC diarrhoea. Further research is needed to develop safe and effective vaccines to provide both short and long-term protection against ETEC diarrhoea.
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Affiliation(s)
- Tanvir Ahmed
- Variation Biotechnologies Inc.1740 Woodroffe Ave, Building 400OttawaCanadaK2G 3R8
| | - Taufiqur R Bhuiyan
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b)Centre for Vaccine Sciences68 Shaheed Tajuddin Ahamed Sharani, MohakhaliDhakaBangladesh1212
| | - K Zaman
- International Centre for Diarrhoeal Disease Research, BangladeshChild Health Unit68 Shaheed Tajuddin AhmedSarani, MohakhaliDhakaBangladesh1212
| | - David Sinclair
- Liverpool School of Tropical MedicineDepartment of Clinical SciencesPembroke PlaceLiverpoolUKL3 5QA
| | - Firdausi Qadri
- International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b)Centre for Vaccine Sciences68 Shaheed Tajuddin Ahamed Sharani, MohakhaliDhakaBangladesh1212
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22
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Hashim R, Khatib AM, Enwere G, Park JK, Reyburn R, Ali M, Chang NY, Kim DR, Ley B, Thriemer K, Lopez AL, Clemens JD, Deen JL, Shin S, Schaetti C, Hutubessy R, Aguado MT, Kieny MP, Sack D, Obaro S, Shaame AJ, Ali SM, Saleh AA, von Seidlein L, Jiddawi MS. Safety of the recombinant cholera toxin B subunit, killed whole-cell (rBS-WC) oral cholera vaccine in pregnancy. PLoS Negl Trop Dis 2012; 6:e1743. [PMID: 22848772 PMCID: PMC3404114 DOI: 10.1371/journal.pntd.0001743] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2012] [Accepted: 06/10/2012] [Indexed: 11/19/2022] Open
Abstract
Introduction Mass vaccinations are a main strategy in the deployment of oral cholera vaccines. Campaigns avoid giving vaccine to pregnant women because of the absence of safety data of the killed whole-cell oral cholera (rBS-WC) vaccine. Balancing this concern is the known higher risk of cholera and of complications of pregnancy should cholera occur in these women, as well as the lack of expected adverse events from a killed oral bacterial vaccine. Methodology/Principal Findings From January to February 2009, a mass rBS-WC vaccination campaign of persons over two years of age was conducted in an urban and a rural area (population 51,151) in Zanzibar. Pregnant women were advised not to participate in the campaign. More than nine months after the last dose of the vaccine was administered, we visited all women between 15 and 50 years of age living in the study area. The outcome of pregnancies that were inadvertently exposed to at least one oral cholera vaccine dose and those that were not exposed was evaluated. 13,736 (94%) of the target women in the study site were interviewed. 1,151 (79%) of the 1,453 deliveries in 2009 occurred during the period when foetal exposure to the vaccine could have occurred. 955 (83%) out of these 1,151 mothers had not been vaccinated; the remaining 196 (17%) mothers had received at least one dose of the oral cholera vaccine. There were no statistically significant differences in the odds ratios for birth outcomes among the exposed and unexposed pregnancies. Conclusions/Significance We found no statistically significant evidence of a harmful effect of gestational exposure to the rBS-WC vaccine. These findings, along with the absence of a rational basis for expecting a risk from this killed oral bacterial vaccine, are reassuring but the study had insufficient power to detect infrequent events. Trial Registration ClinicalTrials.gov NCT00709410 Pregnant women are more vulnerable to complications of cholera than other people. It would be helpful to include pregnant women in vaccination campaigns against cholera but pregnant women and their unborn children are highly vulnerable to the potential adverse effects of biological products such as vaccines. The safety of oral cholera vaccines in pregnant women has up to now not been evaluated. During a large mass cholera vaccination campaign in Zanzibar in 2009, women were advised not to participate if they thought they may be pregnant. The large majority (955 or 83%) of women residing in the study area who were to be pregnant during the 9 months following the vaccinations did not participate in the campaign. The remaining 196 (17%) women received the vaccine. A comparison between vaccine exposed and unexposed pregnancies did not reveal any significant differences in outcome between the two groups. The small number of miscarriages, infant deaths and ill infants was similarly distributed between the two groups. These findings are reassuring but continued monitoring of this vaccine when given during pregnancy is recommended.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Benedikt Ley
- International Vaccine Institute, Seoul, Korea
- Biocenter, University of Vienna, Vienna, Austria
| | | | | | | | | | | | - Christian Schaetti
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | | | | | | | - David Sack
- Johns Hopkins School of Public Health, Baltimore, Maryland, United States of America
| | - Stephen Obaro
- Michigan State University, East Lansing, Michigan, United States of America
| | | | - Said M. Ali
- Public Health Laboratory Ivo de Carneri, Chake-Chake, Zanzibar
| | - Abdul A. Saleh
- Ministry of Health and Social Welfare, Stonetown, Zanzibar
| | - Lorenz von Seidlein
- Menzies School of Health Research, Casuarina, Northern Territory, Australia
- * E-mail:
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Saha A, Chowdhury MI, Khanam F, Bhuiyan MS, Chowdhury F, Khan AI, Khan IA, Clemens J, Ali M, Cravioto A, Qadri F. Safety and immunogenicity study of a killed bivalent (O1 and O139) whole-cell oral cholera vaccine Shanchol, in Bangladeshi adults and children as young as 1 year of age. Vaccine 2011; 29:8285-92. [PMID: 21907255 DOI: 10.1016/j.vaccine.2011.08.108] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2011] [Revised: 08/22/2011] [Accepted: 08/24/2011] [Indexed: 11/13/2022]
Abstract
BACKGROUND Safety and immunogenicity study of an oral, killed, bivalent whole-cell, cholera vaccine, Shanchol was carried out in Bangladeshi participants. This study was conducted prior to initiating a feasibility study in Bangladesh. STUDY PARTICIPANTS The double-blind, randomized placebo controlled study was carried out in adults (18-45 years), toddlers (2-5 years) and younger children (12-23 months). Two doses of the vaccine/placebo were given 14 days apart. RESULTS Shanchol did not elicit major adverse events in any age group. Vibriocidal antibody responses in adults were 60% against Vibrio cholerae O1 Inaba, 72% against V. cholerae O1 Ogawa and 21% against V. cholerae O139. In toddlers, responses were 84%, 75% and 64% and in younger children it was 74%, 78% and 54% against Inaba, Ogawa and O139 serotypes. The responses in all ages were higher in vaccinees compared to pre-immune titers or to responses in placebo recipients (P<0.001). Plasma IgA antibody response to O1 Inaba LPS was seen in 61%, 73% and 45% of adults, toddlers and younger children, respectively. CONCLUSIONS The safety and immunogenicity data for Shanchol is promising and warrants future use in large scale trial in cholera endemic areas, high risk Bangladeshi population and in other countries in the region.
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Affiliation(s)
- Amit Saha
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka, Bangladesh
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24
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Abstract
EDITORIAL NOTE This review is superseded by the published Cochrane Review, Saif‐Ur‐Rahman 2024 [https://doi.org/10.1002/14651858.CD014573], which considers only the oral killed vaccines because the live oral vaccines do not have World Health Organization (WHO) prequalification. Saif‐Ur‐Rahman 2024 also considered only currently available WHO pre‐qualified oral killed cholera vaccines (Dukoral, Shanchol, and Euvichol/Euvichol‐Plus). BACKGROUND Cholera is a cause of acute watery diarrhoea which can cause dehydration and death if not adequately treated. It usually occurs in epidemics, and is associated with poverty and poor sanitation. Effective, cheap, and easy to administer vaccines could help prevent epidemics. OBJECTIVES To assess the effectiveness and safety of oral cholera vaccines in preventing cases of cholera and deaths from cholera. SEARCH STRATEGY In October 2010, we searched the Cochrane Infectious Disease Group Specialized Register; Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; LILACS; the metaRegister of Controlled Trials (mRCT), and the WHO International Clinical Trials Registry Platform (ICTRP) for relevant published and ongoing trials. SELECTION CRITERIA Randomized or quasi-randomized controlled trials of oral cholera vaccines in healthy adults and children. DATA COLLECTION AND ANALYSIS Each trial was assessed for eligibility and risk of bias by two authors working independently. Data was extracted by two independent reviewers and analysed using the Review Manager 5 software. Outcomes are reported as vaccine protective efficacy (VE) with 95% confidence intervals (CIs). MAIN RESULTS Seven large efficacy trials, four small artificial challenge studies, and twenty-nine safety trials contributed data to this review.Five variations of a killed whole cell vaccine have been evaluated in large scale efficacy trials (four trials, 249935 participants). The overall vaccine efficacy during the first year was 52% (95% CI 35% to 65%), and during the second year was 62% (95% CI 51% to 62%). Protective efficacy was lower in children aged less than 5 years; 38% (95% CI 20% to 53%) compared to older children and adults; 66% (95% CI 57% to 73%).One trial of a killed whole cell vaccine amongst military recruits demonstrated 86% protective efficacy (95% CI 37% to 97%) in a small epidemic occurring within 4 weeks of the 2-dose schedule (one trial, 1426 participants). Efficacy data is not available beyond two years for the currently available vaccine formulations, but based on data from older trials is unlikely to last beyond three years.The safety data available on killed whole cell vaccines have not demonstrated any clinically significant increase in adverse events compared to placebo.Only one live attenuated vaccine has reached Phase III clinical evaluation and was not effective (one trial, 67508 participants). Two new candidate live attenuated vaccines have demonstrated clinical effectiveness in small artificial challenge studies, but are still in development. AUTHORS' CONCLUSIONS The currently available oral killed whole cell vaccines can prevent 50 to 60% of cholera episodes during the first two years after the primary vaccination schedule. The impact and cost-effectiveness of adopting oral cholera vaccines into the routine vaccination schedule of endemic countries will depend on the prevalence of cholera, the frequency of epidemics, and access to basic services providing rapid rehydration therapy.
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Affiliation(s)
- David Sinclair
- International Health Group, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, UK, L3 5QA
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25
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Abstract
BACKGROUND Injected cholera vaccines are rarely used today, although they may have some benefit. It is valuable to summarize the evidence for effectiveness of injected cholera vaccines for comparison with newer oral vaccines (subject of a separate Cochrane Review). OBJECTIVES To evaluate killed whole cell (KWC) cholera vaccines and other inactive subunit vaccines (administered by injection) for preventing cholera and death, and to evaluate the adverse effects. SEARCH STRATEGY In September 2008, we searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (The Cochrane Library 2008, Issue 3), EMBASE, and LILACS. We also searched reference lists and handsearched the journal Vaccine up to 1997. SELECTION CRITERIA Randomized and quasi-randomized controlled trials comparing injected cholera vaccines (KWC or other inactive subunit) with placebo, control vaccines, or no intervention in adults and children irrespective of immune status or special risk category. DATA COLLECTION AND ANALYSIS Two authors extracted data and assessed trial methodological quality independently. Dichotomous data were reported using the risk ratio (RR) with 95% confidence intervals (CI). Vaccine efficacies were also calculated (% vaccine efficacy = (1-RR) x 100%). MAIN RESULTS Sixteen trials, involving over one million adults, children and infants, fulfilled the inclusion criteria. Twenty-four comparisons reported on vaccine efficacy (cholera cases and/or deaths) and 11 comparisons considered adverse effects (nine reported on both). Compared to placebo, vaccinees had a reduced risk of death from cholera (RR 0.49, 95% CI 0.25 to 0.93; 837,442 participants) and a reduced risk of contracting cholera at 12 months (RR 0.52, 95% CI 0.42 to 0.65, random-effects model; 1,512,573 participants). This translates to an efficacy of 48%, 95% confidence interval 35% to 58%. Significant protection lasted for two years, even after only a single dose, and for three years with an annual booster. Children over five years and adults were protected for up to three years, while children under five years were protected for up to a year. Injected cholera vaccines were associated with more systemic and local adverse effects compared to placebo, but these were not severe or life-threatening. AUTHORS' CONCLUSIONS Injected cholera vaccines appear to be safe and relatively more effective than usually realized. Protection against cholera persists for up to two years following a single dose of vaccine, and for three years with an annual booster. However, they have been superseded by oral vaccines.
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Affiliation(s)
| | - Jonathan J Deeks
- University of BirminghamPublic Health, Epidemiology and BiostatisticsEdgbastonBirminghamUKB15 2TT
| | - Vittorio Demicheli
- Regione Piemonte ‐ Azienda Sanitaria Locale ASL ALHealth Councillorship ‐ Servizio Regionale di Riferimento per l'Epidemiologia, SSEpi‐SeREMI ‐ Cochrane Vaccines FieldC.so Regina Margherita 153 bisTorinoPiemonteItaly10122
| | - Tom Jefferson
- The Cochrane CollaborationVaccines FieldVia Adige 28aAnguillara SabaziaRomaItaly00061
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Cholera vaccines: WHO position paper. Wkly Epidemiol Rec 2010; 85:117-28. [PMID: 20349546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
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Shi NM, Luo FJ, Li SM, Bai YH, Qu Y, Song X. [Analysis of safety and effects on the oral whole cell/recombinant B subunit cholera vaccine in university students and workers]. Zhonghua Yi Xue Za Zhi 2010; 90:192-195. [PMID: 20356556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
OBJECTIVE To evaluate the safety, immunogenicity and protective efficiency of the oral whole cell/recombinant B subunit cholera vaccine in Beijing Olympic volunteers and workers. METHOD Analyzing the incidence rate of adverse reaction and Protective Rate (PR) after taking the vaccine in Olympic volunteers in 6 universities in Beijing; comparing the anti-cholera toxin (CT) detected with ELISA prior and after taking the vaccine in Olympic workers. RESULTS The total rate of adverse reaction of Olympic volunteers was 0.38%; the main side effects were gastrointestinal symptoms, such as bellyache and diarrhea which were mild and temple; the acute diarrhea incidence rate of Olympic volunteers after taking the vaccine was significantly lower than those not taking it, the PR was 76.27%; the positive rate of anti-CT of Olympic workers after taking the vaccine was significantly higher than those before taking it, the levels of anti-CT titers declined after 6 months since they had taken the vaccine. CONCLUSION The results from above two observed population indicate that the oral rBS-WC cholera vaccine is efficient and safe.
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Affiliation(s)
- Nian-min Shi
- Center of Disease Control and Prevention, Chaoyang District, Beijing 100021, China.
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Sur D, Lopez AL, Kanungo S, Paisley A, Manna B, Ali M, Niyogi SK, Park JK, Sarkar B, Puri MK, Kim DR, Deen JL, Holmgren J, Carbis R, Rao R, Nguyen TV, Donner A, Ganguly NK, Nair GB, Bhattacharya SK, Clemens JD. Efficacy and safety of a modified killed-whole-cell oral cholera vaccine in India: an interim analysis of a cluster-randomised, double-blind, placebo-controlled trial. Lancet 2009; 374:1694-702. [PMID: 19819004 DOI: 10.1016/s0140-6736(09)61297-6] [Citation(s) in RCA: 191] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Oral cholera vaccines consisting of killed whole cells have been available for many years, but they have not been used extensively in populations with endemic disease. An inexpensive, locally produced oral killed-whole-cell vaccine has been used in high-risk areas in Vietnam. To expand the use of this vaccine, it was modified to comply with WHO standards. We assessed the efficacy and safety of this modified vaccine in a population with endemic cholera. METHODS In this double-blind trial, 107 774 non-pregnant residents of Kolkata, India, aged 1 year or older, were cluster-randomised by dwelling to receive two doses of either modified killed-whole-cell cholera vaccine (n=52 212; 1966 clusters) or heat-killed Escherichia coli K12 placebo (n=55 562; 1967 clusters), both delivered orally. Randomisation was done by computer-generated sequence in blocks of four. The primary endpoint was prevention of episodes of culture-confirmed Vibrio cholerae O1 diarrhoea severe enough for the patient to seek treatment in a health-care facility. We undertook an interim, per-protocol analysis at 2 years of follow-up that included individuals who received two completely ingested doses of vaccine or placebo. We assessed first episodes of cholera that occurred between 14 days and 730 days after receipt of the second dose. This study is registered with ClinicalTrials.gov, number NCT00289224. FINDINGS 31 932 participants assigned to vaccine (1721 clusters) and 34 968 assigned to placebo (1757 clusters) received two doses of study treatment. There were 20 episodes of cholera in the vaccine group and 68 episodes in the placebo group (protective efficacy 67%; one-tailed 99% CI, lower bound 35%, p<0.0001). The vaccine protected individuals in age-groups 1.0-4.9 years, 5.0-14.9 years, and 15 years and older, and protective efficacy did not differ significantly between age-groups (p=0.28). We recorded no vaccine-related serious adverse events. INTERPRETATION This modified killed-whole-cell oral vaccine, compliant with WHO standards, is safe, provides protection against clinically significant cholera in an endemic setting, and can be used in children aged 1.0-4.9 years, who are at highest risk of developing cholera in endemic settings. FUNDING Bill & Melinda Gates Foundation, Swedish International Development Cooperation Agency, Governments of South Korea, Sweden, and Kuwait.
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Affiliation(s)
- Dipika Sur
- National Institute of Cholera and Enteric Diseases, Kolkata, India
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Zhang XP, Chen EF, Lv HK. [A safety assessment on adverse reaction of recombinant B-subunit/inactivated whole cell oral cholera vaccine among non-infected population]. Zhongguo Yi Miao He Mian Yi 2009; 15:255-258. [PMID: 20084896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
OBJECTIVE To observe the safety of recombinant B-subunit/inactivated whole cell (rBS/WC) oral cholera vaccine among non-infected population. METHOD A method of double-blind and case control was conducted randomly. 3041 non-infected persons who aged from 5- to 60-years-old were divided randomly into 3 groups, including 2 vaccine groups and 1 placebo group. The vaccine and placebo were taken respectively by vaccine groups and placebo group on the 1st, 7th and 28th day in every months of sequential 3 months. The adverse reaction was observed in sequential 3 days after intaking orally. The follow-up interviews were conducted in 1, 2, 3 months. RESULTS No severe adverse reaction was occurred. The rate of adverse reaction was 1.70% in vaccine groups, 1.74% in placebo group. There was no statistically significant difference between two groups (chi2=0.013, P=0.909). The adverse reaction were mainly abdominal pain, diarrhea, partly anaphylaxis, and the others of dizziness, fatigue, weakness. Most people recovered within short time without any medical treatment. The adverse reactions might be related to psychogenic reaction. CONCLUSION The safety of oral rBS/WC cholera vaccine among non-infected population was pretty good.
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Affiliation(s)
- Xin-pei Zhang
- Shangyu Municipal Center for Disease Control and Prevention, Shangyu 312300, Zhejiang, China
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Qadri F, Chowdhury MI, Faruque SM, Salam MA, Ahmed T, Begum YA, Saha A, Al Tarique A, Seidlein LV, Park E, Killeen KP, Mekalanos JJ, Clemens JD, Sack DA. Peru-15, a live attenuated oral cholera vaccine, is safe and immunogenic in Bangladeshi toddlers and infants. Vaccine 2007; 25:231-8. [PMID: 16996172 DOI: 10.1016/j.vaccine.2006.08.031] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2006] [Revised: 08/13/2006] [Accepted: 08/17/2006] [Indexed: 10/24/2022]
Abstract
A live oral Vibrio cholerae O1 El Tor vaccine, Peru-15 was tested in a double-blind, randomized placebo controlled study for safety and immunogenicity in Phase I and Phase II studies in 240 Bangladeshi children aged 9 months-5 years of age. Two different doses (2x10(7) and 2x10(8)cfu) were tested. Vaccination did not elicit adverse events and the strain was genetically stable. Vibriocidal antibody responses developed in 42/50 (84%) toddlers (2-5 years) and 35/50 (70%) of younger children (9-23 months) and overall 77/100 (77%) who received the high dose. LPS-IgA-antibody responses were seen in 60% of toddlers and 34% of infants; 40% responded with IgA antibodies to cholera toxin. The responses to the reduced dose was lower. These studies demonstrate that Peru-15 at a dose of 2x10(8)cfu is safe and immunogenic in children in Bangladesh.
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Affiliation(s)
- Firdausi Qadri
- ICDDR,B: Centre for Health and Population Research, Bangladesh.
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Anh DD, Canh DG, Lopez AL, Thiem VD, Long PT, Son NH, Deen J, von Seidlein L, Carbis R, Han SH, Shin SH, Attridge S, Holmgren J, Clemens J. Safety and immunogenicity of a reformulated Vietnamese bivalent killed, whole-cell, oral cholera vaccine in adults. Vaccine 2006; 25:1149-55. [PMID: 17055622 DOI: 10.1016/j.vaccine.2006.09.049] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2006] [Revised: 09/07/2006] [Accepted: 09/12/2006] [Indexed: 02/07/2023]
Abstract
Vietnam currently produces an orally administered, bivalent (O1 and O139) killed whole-cell vaccine and is the only country in the world with endemic cholera to use an oral cholera vaccine in public health practice. In order to allow international use, the vaccine had to be reformulated to meet World Health Organization (WHO) requirements. We performed a randomized, placebo controlled, safety and immunogenicity studies of this reformulated vaccine among Vietnamese adults. One hundred and forty-four subjects received the two-dose regimen and 143 had two blood samples obtained for analysis. We found that this reformulated oral killed whole-cell cholera vaccine was safe, well tolerated and highly immunogenic.
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Affiliation(s)
- Dang Duc Anh
- National Institute of Hygiene and Epidemiology, Hanoi, Vietnam
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Talavera A, Año G, García H, Moreira T, Delgado H, Riverón L, Gil S, Miranda A, Cedré B, Valmaseda T, Pino Y, Pérez JL, Infante JF, García L, Sierra G. Process development for a Cuban cholera vaccine based on the attenuated strain Vibrio cholerae 638. Vaccine 2006; 24:3746-9. [PMID: 16085342 DOI: 10.1016/j.vaccine.2005.07.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Genetically modified Vibrio cholerae strain 638 (biotype El Tor, serotype Ogawa) has previously been shown to be immunogenic in animal models and in human trials. Our objective in the work reported herein was to describe the process development methods for the production of the 638 attenuated cholera vaccine. Cell seed bank, culture of biomass, lyophilization and final formulation were processes were developed. The results show kinetics of culture that fulfils a logistical model. The microbiological properties, colonizing capability, immunogenicity and non-toxigenicity of the final product were indistinguishable from the properties of the working seed lot. We conclude that the non-reactogenic, immunogenic and protective strain 638 is robust and can withstand the fermentation processes required for large-scale production of a vaccine.
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Affiliation(s)
- A Talavera
- Finlay Institute, 27 Ave, # 19805 La Lisa, Ciudad de la Habana, A.P. 16017, Cod. 11600, Cuba.
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Abstract
Live bacterial vaccines represent a highly valid preventive strategy in the fight against infectious disease. However, the road from research to market is peppered with hurdles, one of which is the requirement for high biosafety characteristics, which the candidate vaccine has to display. In Europe, the European Agency for the evaluation of medicinal products (EMEA) is the relevant authority regulating the licensure of genetically engineered vaccines. For this purpose, the agency may rely on several directives and guidelines defined in the past 15 years. As for live vaccines containing genetically modified organisms (GMOs) susceptible to be released into the environment, Directive 2001/18/EC determines the framework and principles of an environmental risk assessment (ERA) process, the results of which constitute an important section of the vaccine registration package submitted to registration authorities. In this article, we address the implications of current European regulations for the approval of live oral bacterial vaccines with emphasis on the assessment of potential risks associated with environmental release. Biosafety aspects of already registered and some promising live bacterial vaccine strains will be briefly discussed.
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Affiliation(s)
- Didier Favre
- Berna Biotech Ltd., Research Rehhagstrasse 79, 3018 Berne, Switzerland
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Qadri F, Chowdhury MI, Faruque SM, Salam MA, Ahmed T, Begum YA, Saha A, Alam MS, Zaman K, Seidlein LV, Park E, Killeen KP, Mekalanos JJ, Clemens JD, Sack DA. Randomized, controlled study of the safety and immunogenicity of Peru-15, a live attenuated oral vaccine candidate for cholera, in adult volunteers in Bangladesh. J Infect Dis 2005; 192:573-9. [PMID: 16028125 DOI: 10.1086/432074] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2005] [Accepted: 03/23/2005] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND A live oral Vibrio cholerae O1 El Tor vaccine candidate, Peru-15, was studied for safety, immunogenicity, and excretion in phase 1 (inpatient) and phase 2 (outpatient) studies of Bangladeshi adults.METHODs. The study was conducted among adults, by use of a double-blind, randomized, placebo-controlled design. A single dose of Peru-15 (approximately 2 x 108 cfu) or placebo (buffer only) was given in standard bicarbonate and ascorbic acid buffer.RESULTS. Study treatment did not elicit any major adverse events in the volunteers, during either the inpatient or the outpatient phases, and there were no reports of diarrhea. V. cholerae was isolated from the stool of only 1 volunteer and was found to be genetically identical to the vaccine strain. Vibriocidal antibody responses were seen in 30 (75%) of 40 vaccine recipients and in 3 (10%) of 30 placebo recipients. Peripheral blood immunoglobulin (Ig) A and IgM antibody-secreting cell responses to lipopolysaccharide were seen in the majority of vaccine recipients (response rate, 78%--88%). Seroconversion for lipopolysaccharide-specific IgA antibodies was seen in 88% of vaccine recipients. The response in vaccine recipients was significantly higher than that in placebo recipients, in all of the immunological assays (P=.036 to <.001). A lower immunological response against cholera toxin B subunit was detected.CONCLUSIONS. The safety and immunogenicity of this Peru-15 vaccine candidate indicates the usefulness of future studies in Bangladesh, where cholera is endemic.
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Affiliation(s)
- Firdausi Qadri
- International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B): Centre for Health and Population Research, Dhaka, Bangladesh.
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36
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María García H, Año G, Cedré B, Valmaseda T, Maestre JL, Díaz M, Mirabal M, Talavera A, García L. [Selection of attenuated Vibrio cholerae strains to obtain oral attenuated candidate vaccines against cholera]. Rev Cubana Med Trop 2005; 57:92-104. [PMID: 17966578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
A methodology was developed for the selection of genetically modified strains of Vibrio cholerae 01 and 0139 aimed at obtaining oral attenuated candidate vaccines against cholera. The modified strains underwent microbiological characterization, bacterial susceptibility and different biological tests (mean lethal dose, colonizing capacity, adherence in mice, ligated intestine and intraduodenal inoculation in rabbits as virulence and potency tests. The strains 81, 638, 638T and 1333 were evaluated in clinical trials to determine their reactogenicity and immunogenicity. All the strains were sensitive to tetracycline and doxoclycine. They showed their attenuation and immunogenicity in animal models. The strains 638 and 1333 proved to be immunogenic and non reactogenic in volunteers.
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Stellfeld M. [Dukoral. Oral vaccine against cholera]. Ugeskr Laeger 2004; 166:4251-3. [PMID: 15587356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
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38
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Jones T. Peru-1 5 (AVANT). Curr Opin Investig Drugs 2004; 5:887-91. [PMID: 15600246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Abstract
Peru-15 is a single dose, recombinant cholera vaccine under development by AVANT Immunotherapeutics for the potential prevention of cholera. A phase II trial of Peru-15 was ongoing in June 2003, and as of September 2003 AVANT was planning a phase III trial in a developing country, and phase IIb and phase III challenge studies in travelers.
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Affiliation(s)
- Taff Jones
- ID Biomedical Corp of Quebec, 7150 Frederick Banting, Montreal H4S 2A1, Quebec, Canada
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Viret JF, Dietrich G, Favre D. Biosafety aspects of the recombinant live oral Vibrio cholerae vaccine strain CVD 103-HgR. Vaccine 2004; 22:2457-69. [PMID: 15193410 DOI: 10.1016/j.vaccine.2003.12.033] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2003] [Accepted: 12/03/2003] [Indexed: 11/26/2022]
Abstract
The development of live attenuated vaccines, allowing for the safe and effective immunisation at mucosal surfaces, is a strategy of great interest for vaccinologists. The main advantage of this approach over conventional parenteral vaccines is the induction of strong mucosal immune responses, allowing targeting of the pathogen at the initial point of contact with the host. Further advantages include the ease of administration, high acceptance by vaccines, and relatively low production costs. Finally, well-characterised, safe and immunogenic vaccine strains are well suited as vectors for the mucosal delivery of foreign vaccine antigens and of DNA vaccines. However, such vaccines, when based on or containing genetically modified organisms (GMOs), are facing new and specific regulatory hurdles, particularly regarding the potential risks for humans and the environment. In this contribution we address selected aspects of the risk assessment of live attenuated bacterial vaccines covered in the course of the registration of vaccine strain CVD 103-HgR as a recombinant live oral vaccine against cholera.
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Khiem HB, Huan LD, Phuong NTM, Dang DH, Hoang DH, Phuong LT, Sac PK, Chien TM, Tai LA, Dan NT, Deen JL, Seidlein LV, Clemens J, Trach DD. Mass psychogenic illness following oral cholera immunization in Ca Mau City, Vietnam. Vaccine 2003; 21:4527-31. [PMID: 14575763 DOI: 10.1016/s0264-410x(03)00498-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Targeted cholera immunization of high-risk populations in Vietnam is conducted based on routine surveillance data. Following mass immunization of schoolchildren in Ca Mau City using an oral bivalent killed cholera vaccine, adverse reactions were noted. METHODS Salient data were collected in a systematic fashion including the review of medical records; interview of the school principal, teachers, students, parents and doctors; and review of the storage and handling of the vaccine. FINDINGS On 18 December 2001, 234 children at a primary school in Ca Mau City received the cholera vaccine. Within 1h of immunization, three children in one of the classrooms complained of trembling, nausea and headache and were brought to the library and soon other children followed. Out of 234, 97 (42%) pupils were affected and brought to the Municipal Health Center or Ca Mau Provincial Hospital. Those who were affected were younger (mean age=9.6 years; 95% CI=9.4-9.7) compared to those who were not affected (mean age=10 years; 95% CI=9.7-10.3; t-test=-2.4; P-value=0.02). The proportion of affected females among those who had received the vaccine (49/114 or 43%) was similar to the proportion in males (48/120 or 40%; RR=1.07; 95% CI=0.79-1.46). The most frequent presenting complaint was cold extremities (60%) followed by headache (27%). All affected children recovered and were discharged in a few hours. None reported any sequelae or relapse. Once the situation was recognized, the cholera immunization campaign was continued. Laboratory tests of vaccine samples from the same batch detected no abnormality or contaminating agent. DISCUSSION The findings suggest that the children at primary school number 1 suffered from a mass psychogenic illness. This incident was unusual in that a similar number of boys and girls were affected, in contrast to the frequently reported preponderance of female cases. Furthermore the underlying cause was very quickly diagnosed, medical interventions were kept to a minimum, and no relapse was observed. Future vaccination campaigns have to assure that the families are informed in advance.
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Affiliation(s)
- Ha Ba Khiem
- Pasteur Institute, 167 Pasteur Street, District 3, Ho Chi Minh City, Viet Nam
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41
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Abstract
Vibrio cholerae induces either non-inflammatory diarrhea or inflammatory gastroenteritis, depending on the presence of cholera toxin, a fluid secretion inducer and a modulator of host immunity. In the absence of cholera toxin, other toxins induce inflammation, resulting in gastroenteritis. Thus, multiple toxins likely affect the safety of live attenuated vaccines.
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Affiliation(s)
- Karla J Fullner Satchell
- Department of Microbiology-Immunology, Northwestern University Feinberg School of Medicine, 303 East Chicago Avenue, Morton 6-626, Chicago, IL 60611,USA.
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42
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Qadri F, Ahmed T, Ahmed F, Bradley Sack R, Sack DA, Svennerholm AM. Safety and immunogenicity of an oral, inactivated enterotoxigenic Escherichia coli plus cholera toxin B subunit vaccine in Bangladeshi children 18-36 months of age. Vaccine 2003; 21:2394-403. [PMID: 12744870 DOI: 10.1016/s0264-410x(03)00077-x] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A phase II safety and immunogenicity study of an oral-formalin inactivated enterotoxigenic Escherichia coli (ETEC) vaccine containing six colonization factors (CFA/I, CS1, CS2, CS3, CS4, CS5) and 1mg of recombinant cholera toxin B subunit (the CF-BS-ETEC vaccine) was carried out in an urban slum of Dhaka city in Bangladesh. The study was carried out in a double blinded, placebo controlled design in 158 children, 18-36 months of age. Children were given two doses of the CF-BS-ETEC vaccine or the placebo which consisted of E. coli K12. The vaccine was well tolerated. The immune response was studied in 60 children (30 each in the placebo and vaccine group). Significant vaccine specific IgA antibody-secreting cell (ASC) responses were seen 7 days after ingestion of the first and second dose of the vaccine. The responses to CFA/I (P<or=0.001), CS2 (P=0.021), CS4 (P=0.009) and rCTB (P<or=0.001) were elevated in the vaccines in comparison to the pre-immune values and in comparison to those seen in the placebo recipients (P=0.018 to <0.001). Vaccines but not placebo recipients also showed significantly increased IgM ASC responses to all three CF antigens that were tested (P=0.012 to <0.001) and IgG-ASCs to rCTB (P<0.001). Peak ASC levels were reached after one dose of the vaccine with no further increase or decrease after the second dose. The vaccine recipients also responded with IgA plasma antibodies to CFA/I, CS1, CS2, CS4 and rCTB after one or two doses of the vaccine (P=0.01 to <0.001). Subjects in the placebo group failed to mount responses to any of the antigens. The vaccine also induced responses in mucosal IgA antibodies in feces to CFA/I, CS2 and rCTB (61, 88 and 69% responder frequency, respectively) and the magnitude of the response was elevated in comparison to the pre-immune levels (P=0.031 to <0.001) and to the levels of the control group (P=0.003 to <0.001). This study thus shows that the CF-BS-ETEC vaccine is well tolerated in children, 18-36 months of age and gives rise to significant systemic and mucosal IgA antibody responses.
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Affiliation(s)
- Firdausi Qadri
- Laboratory Sciences Division, International Centre for Diarrhoeal Disease Research, GPO Box 128, Dhaka 1000, Bangladesh.
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43
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Abstract
Prior to the evaluation of protective efficacy, experimental vaccines conventionally undergo phase II randomized controlled clinical trials to evaluate safety and immunogenicity. Typically, an experimental vaccine is compared to another vaccine or to a placebo with respect to adverse events or immune responses, or both. Various strategies and methods are available for design and analysis of such studies. A key aspect of design is the determination of sample size. Often a sample size is chosen that gives a high probability ("power") of finding a statistically significant difference in an outcome of interest, if a difference of a specified size exists. This approach is appropriate when the primary goal of the study is to demonstrate that a difference exists between two groups or treatments. It may not, however, give adequate assurance that a confidence interval around the observed difference will be narrow enough to exclude the possibility of an unacceptably low immune response or unacceptably high adverse event frequency in recipients of the experimental vaccine. In this paper, we apply the "non-inferiority" trial design to phase II vaccine studies; that is, we design the trial to rule out a difference between the vaccine and control in immunogenicity or reactogenicity that is considered unacceptable. We also consider a setting in which the desire is to show that the difference between immune response rates for vaccine and control is greater than a specified value.
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Affiliation(s)
- Malla R Rao
- National Institute of Child Health and Human Development, Bethesda, MD 20892, USA.
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44
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Cohen MB, Giannella RA, Bean J, Taylor DN, Parker S, Hoeper A, Wowk S, Hawkins J, Kochi SK, Schiff G, Killeen KP. Randomized, controlled human challenge study of the safety, immunogenicity, and protective efficacy of a single dose of Peru-15, a live attenuated oral cholera vaccine. Infect Immun 2002; 70:1965-70. [PMID: 11895960 PMCID: PMC127885 DOI: 10.1128/iai.70.4.1965-1970.2002] [Citation(s) in RCA: 79] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Peru-15 is a live attenuated oral vaccine derived from a Vibrio cholerae O1 El Tor Inaba strain by a series of deletions and modifications, including deletion of the entire CT genetic element. Peru-15 is also a stable, motility-defective strain and is unable to recombine with homologous DNA. We wished to determine whether a single oral dose of Peru-15 was safe and immunogenic and whether it would provide significant protection against moderate and severe diarrhea in a randomized, double-blind, placebo-controlled human volunteer cholera challenge model. A total of 59 volunteers were randomly allocated to groups to receive either 2 x 10(8) CFU of reconstituted, lyophilized Peru-15 vaccine diluted in CeraVacx buffer or placebo (CeraVacx buffer alone). Approximately 3 months after vaccination, 36 of these volunteers were challenged with approximately 10(5) CFU of virulent V. cholerae O1 El Tor Inaba strain N16961, prepared from a standardized frozen inoculum. Among vaccinees, 98% showed at least a fourfold increase in vibriocidal antibody titers. After challenge, 5 (42%) of the 12 placebo recipients and none (0%) of the 24 vaccinees had moderate or severe diarrhea (> or = 3,000 g of diarrheal stool) (P = 0.002; protective efficacy, 100%; lower one-sided 95% confidence limit, 75%). A total of 7 (58%) of the 12 placebo recipients and 1 (4%) of the 24 vaccinees had any diarrhea (P < 0.001; protective efficacy, 93%; lower one-sided 95% confidence limit, 62%). The total number of diarrheal stools, weight of diarrheal stools, incidence of fever, and peak stool V. cholerae excretion among vaccinees were all significantly lower than in placebo recipients. Peru-15 is a well-tolerated and immunogenic oral cholera vaccine that affords protective efficacy against life-threatening cholera diarrhea in a human volunteer challenge model. This vaccine may therefore be a safe and effective tool to prevent cholera in travelers and is a strong candidate for further evaluation to prevent cholera in an area where cholera is endemic.
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Affiliation(s)
- Mitchell B Cohen
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Children's Hospital Medical Center, Cincinnati, Ohio 45229, USA.
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45
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Trach DD, Cam PD, Ke NT, Rao MR, Dinh D, Hang PV, Hung NV, Canh DG, Thiem VD, Naficy A, Ivanoff B, Svennerholm AM, Holmgren J, Clemens JD. Investigations into the safety and immunogenicity of a killed oral cholera vaccine developed in Viet Nam. Bull World Health Organ 2002; 80:2-8. [PMID: 11884967 PMCID: PMC2567633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023] Open
Abstract
OBJECTIVE To evaluate a killed oral cholera vaccine produced in Viet Nam, and to compare the Vietnamese vaccine with one that is licensed internationally. METHOD Two-dose regimens of a locally produced, bivalent, anti-O1, anti-O139 killed oral whole-cell cholera vaccine (biv-WC) and of a commercially available, monovalent (anti-O1) oral recombinant B subunit-killed whole-cell cholera vaccine (rBS-WC) were compared in two trials in Viet Nam. In the first trial, 144 adults were randomized to biv-WC with or without buffer, rBS-WC with buffer, or placebo without buffer. In the second, 103 children aged 1-12 years were randomized to biv-WC without buffer, rBS-WC with buffer, or placebo without buffer. FINDINGS No regimen was associated with significant side-effects. In adults, ca 60% of recipients of either vaccine exhibited at least fourfold serum anti-O1 vibriocidal antibody responses and ca 40% of recipients of biv-WC demonstrated anti-O139 vibriocidal responses. Both anti-O1 (ca 90% in each vaccine groupand anti-O139 (68% in the biv-WC group) vibriocidal responses occurred more frequently in children. The responses to biv-WC were unaffected by the receipt of buffer. CONCLUSION It was concluded that biv-WC was safe and immunogenic, that it could be administered without buffer, and that it could elicit robust immune responses even in children, for whom the risk of endemic cholera is highest.
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Affiliation(s)
- D D Trach
- National Institute of Hygiene and Epidemiology, Hanoi, Viet Nam
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46
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Richie EE, Punjabi NH, Sidharta YY, Peetosutan KK, Sukandar MM, Wasserman SS, Lesmana MM, Wangsasaputra FF, Pandam SS, Levine MM, O'Hanley PP, Cryz SJ, Simanjuntak CH. Efficacy trial of single-dose live oral cholera vaccine CVD 103-HgR in North Jakarta, Indonesia, a cholera-endemic area. Vaccine 2000; 18:2399-410. [PMID: 10738097 DOI: 10.1016/s0264-410x(00)00006-2] [Citation(s) in RCA: 151] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A randomized, double-blind, placebo-controlled efficacy trial of one dose of CVD 103-HgR live oral cholera vaccine was performed in Indonesia from 1993 to 1997. 67,508 persons aged 2-41 years ingested vaccine or placebo and were followed for four years, detecting cholera cases using hospital-based surveillance. A nested reactogenicity study (538 vaccinees, 535 controls) revealed no vaccine-attributable side effects. A nested immunogenicity study (N=657) showed vibriocidal seroresponses in 64-70% of vaccinees vs 1-2% of controls. Cholera incidence was lower than expected. 103 cases of Vibrio cholerae O1 El Tor diarrhea were detected, 93 evaluable for vaccine efficacy (43 vaccine, 50 placebo; efficacy=14%). A suggestion of protection was observed among persons with blood group O [P=0.12]. Only seven cases occurred within six months of vaccination, precluding assessment of short-term efficacy. In Jakarta, single-dose CVD 103-HgR did not confer long-term protection. Short-term protection from a single-dose and long-term protection from two doses have yet to be studied.
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Affiliation(s)
- E E Richie
- US Naval Medical Research Unit No. 2, Jakarta, Indonesia
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47
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Abstract
BACKGROUND Oral cholera vaccines (either killed whole cell or live recombinant vaccines) are newer alternatives to the parenteral vaccines which have been thought to confer only moderate and short-term immunity. OBJECTIVES The objective of this review was to assess the effect of cholera vaccines in preventing cases of cholera and preventing deaths. SEARCH STRATEGY We searched the Cochrane Infectious Diseases Group trials register, Medline, Embase and reference lists of articles. We handsearched the journal Vaccine, contacted researchers in the field and manufacturers. SELECTION CRITERIA Randomised and quasi-randomised studies comparing cholera vaccines (killed or live) with placebo, control vaccines or no intervention, or comparing types, doses or schedules of cholera vaccine. We included adults and children irrespective of immune status or special risk category. DATA COLLECTION AND ANALYSIS Data extraction and assessment of trial quality was done independently by two reviewers. MAIN RESULTS Thirty-two trials were included. Seventeen efficacy trials of relatively good quality, testing parenteral and oral killed whole cell vaccines and involving over 2. 6 million adults, children and infants were included. Nineteen safety trials have been conducted for both types of killed whole cell vaccines and for live vaccines and have involved 11,459 people. For all types of vaccines compared to placebo, the relative risk of contracting cholera at 12 months was 0.49, 95% confidence interval 0. 41 to 0.59 (random effects model). This translates to an efficacy of 51%, 95% confidence interval 41% to 59%. Both parenteral and oral administration were relatively efficacious, but significant protection extended into the third year for oral killed whole cell vaccines. Children under 5 were only protected for up to a year, while older children or adults were protected for up to three years. Parenteral killed whole cell vaccines were associated with increased systemic and local adverse effects compared to placebo. Oral killed whole cell vaccines or oral live vaccines were not. REVIEWER'S CONCLUSIONS Cholera killed whole cell vaccines appear to be relatively effective and safe. Live oral recombinant vaccines appear to be safe, but efficacy data are not available. Protection against cholera appears to persist for up to two years following a single dose of vaccine, and for three to four years with an annual booster.
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Affiliation(s)
- P Graves
- SPC Pacific Regional Vector-Borne Diseases Project, PO Box R272, Honiara, Solomon Islands.
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48
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Wiedermann G, Kollaritsch H, Kundi M, Svennerholm AM, Bjare U. Double-blind, randomized, placebo controlled pilot study evaluating efficacy and reactogenicity of an oral ETEC B-subunit-inactivated whole cell vaccine against travelers' diarrhea (preliminary report). J Travel Med 2000; 7:27-9. [PMID: 10689236 DOI: 10.2310/7060.2000.00007] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Diarrhea caused by enterotoxigenic E.coli (ETEC) is an important health problem in developing countries and in travelers to these areas. In previous trials formulations of ETEC vaccines containing the B-subunit of cholera toxin, which is antigenically similar to the heat labile enterotoxin of ETEC, and the most prevalent colonization factor antigens of ETEC, were shown to stimulate relevant mucosal immune responses in volunteers from Sweden and Egypt.
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Affiliation(s)
- G Wiedermann
- Institute for Specific Prophylaxis and Tropical Medicine, University of Vienna, Austria
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49
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Taylor DN, Cárdenas V, Perez J, Puga R, Svennerholm AM. Safety, immunogenicity, and lot stability of the whole cell/recombinant B subunit (WC/rCTB) cholera vaccine in Peruvian adults and children. Am J Trop Med Hyg 1999; 61:869-73. [PMID: 10674661 DOI: 10.4269/ajtmh.1999.61.869] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
To assess the safety, immunogenicity, and lot stability of the whole cell/recombinant B subunit cholera vaccine, 2 lots manufactured in June 1991 and February 1992 were tested in January 1995. Two oral doses of vaccine or placebo given 2 weeks apart were given with buffer to 216 Peruvian adults and children. Symptoms were elicited for 3 days after each dose. Serum and plasma specimens obtained from each volunteer before vaccination and 10-14 days after the second dose were tested for vibriocidal and anti-cholera toxin antibodies. The vaccine was well-tolerated. Nearly half of the 100 vaccinees had pre-vaccination vibriocidal titers > or = 1:40. Elevated titers were observed in 22% of 37 children 2-5 years of age compared with 66% of 63 vaccinees 6-65 years (P < 0.001). A > or =2-fold serum vibriocidal response was observed in 55% of 100 vaccinees and 6% of 32 placebo recipients. An elevated pre-vaccination titer (< or =1:40) did not change the proportion of vaccinees who responded with a > or =2-fold increase in vibriocidal titer (51% versus 59%, difference not significant), but did change the proportion responding with a > or =4-fold increase (41% versus 22%; P < 0.05). The vibriocidal seroconversion rate was lowest in children 2-5 years old despite low pre-vaccination titers. Two-fold or greater serum antitoxic responses in IgA and IgG were observed in >90% of the vaccinees; > or =4-fold responses were seen in 65-70% of the vaccinees with a 6-8-fold increase over baseline. Plasma specimens were as good as sera for determining anti-toxic antibodies by ELISA, but were less satisfactory for determining vibriocidal antibody titers.
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Affiliation(s)
- D N Taylor
- Naval Medical Research Institute Detachment, Lima, Peru
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50
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Lagos R, San Martin O, Wasserman SS, Prado V, Losonsky GA, Bustamante C, Levine MM. Palatability, reactogenicity and immunogenicity of engineered live oral cholera vaccine CVD 103-HgR in Chilean infants and toddlers. Pediatr Infect Dis J 1999; 18:624-30. [PMID: 10440439 DOI: 10.1097/00006454-199907000-00011] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Live oral cholera vaccine CVD 103-HgR is well-tolerated and immunogenic when administered to adults, school age children and preschool children in a single 5 x 10(9) colony-forming unit dose. Because elicitation of immune responses after administration of a single dose is exceptional for any oral vaccine in any age group, CVD 103-HgR was used as a probe to investigate the clinical acceptability, practicality and immunogenicity of this vaccine in infants and toddlers 3 to 17 months of age. METHODS The study was undertaken successively in 12- to 17-month-olds (n = 104), 7- to 11-month-olds (n = 106) and 3- to 5-month-olds (n = 102). One-half of the subjects were randomly allocated to receive vaccine and the other one-half to receive placebo, in double blind fashion. After 2 weeks of double blind follow-up, all subjects received a dose of vaccine. Vibriocidal antibody titers were measured on coded sera collected at baseline and 2 weeks after each dosing. The buffered vaccine "cocktail" had a volume of 100 ml; subjects who ingested > or =70 ml were considered fully vaccinated. FINDINGS Only 37% of subjects overall (25% of 3- to 5-month-olds) ingested > or =70 ml of the cocktail. The vaccine was well-tolerated with no significant differences in the rate or severity of adverse reactions after ingestion of vaccine vs. placebo. Seroconversion after ingestion of a single dose of CVD 103-HgR was similar in fully vaccinated subjects (66%) and in those who ingested a smaller fraction of the vaccine cocktail (63%). Of subjects who ingested two doses, 5 of 118 excreted vaccine organisms on Day 7 after the first dose vs. 0 of 118 after the second dose. INTERPRETATION Single dose oral CVD 103-HgR is well-tolerated and immunogenic in infants even when a partial dose is ingested. The buffered vaccine cocktail that is readily imbibed by older children is not appealing to young infants, and improved vaccine formulations and delivery vehicles for immunizing infants must be sought.
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Affiliation(s)
- R Lagos
- Centro para Vacunas en Desarrollo-Chile, Santiago
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