1
|
Kotei L, Clarke E. Novel oral poliovirus vaccine type 2 is an important eradication tool, but reaching every last child remains vital. Lancet Infect Dis 2024; 24:337-339. [PMID: 38246192 DOI: 10.1016/s1473-3099(23)00781-8] [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] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Accepted: 12/11/2023] [Indexed: 01/23/2024]
Affiliation(s)
- Larry Kotei
- MRC Unit The Gambia at the London School of Hygiene & Tropical Medicine, Banjul, The Gambia
| | - Ed Clarke
- MRC Unit The Gambia at the London School of Hygiene & Tropical Medicine, Banjul, The Gambia.
| |
Collapse
|
2
|
Mardini A, Shaykhon N, Khan A, Mardini A, Saeed HN. Global Disparities in Access to Vaccine Clinical Trials: A Review of the Literature. Vaccines (Basel) 2024; 12:348. [PMID: 38675731 PMCID: PMC11054150 DOI: 10.3390/vaccines12040348] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 03/06/2024] [Accepted: 03/13/2024] [Indexed: 04/28/2024] Open
Abstract
Vaccines are an effective tool to reduce the disease burden from infectious diseases on a population, infrastructural, and individual level. Before vaccines can be administered to populations at large, they must go through rigorous testing in the form of clinical trials. While vaccine trials can be used to assess the efficacy of interventions on a local populace as well as target local endemic diseases, most clinical trials are sponsored and conducted by companies in high-income countries (HICs). This can lead to vaccines that are not optimized for low- and middle-income countries (LMICs) and that often neglect to address diseases specific to the local population. This narrative review aims to explore the factors leading to discrepancies in the execution of and access to vaccine trials between HICs and LMICs, thus guiding future efforts in confronting them. This review was written using the literature sourced from the PubMed database and supplemented with articles from Google Scholar along with grey literature. Several themes are highlighted including poorly defined regulatory and ethical guidelines, staff shortages, lack of research infrastructure, and logistical barriers. We discuss how these challenges have affected vaccine development in various capacities through case examples of SARS-CoV-2, poliovirus, and malaria. Many challenges remain in equitable vaccine clinical trial development and implementation. Facilitating the implementation of locally sponsored vaccine clinical trials in LMICs may be one avenue to address these challenges. In doing so, LMICs can become active stakeholders in the health of their citizens by addressing endemic diseases, tailoring vaccine specifications based on local needs, and implementing wide-scale vaccine access and delivery.
Collapse
Affiliation(s)
- Ali Mardini
- School of Medicine, Royal College of Surgeons in Ireland—Medical University of Bahrain, Busaiteen 228, Bahrain; (A.M.); (N.S.); (A.K.)
| | - Norhan Shaykhon
- School of Medicine, Royal College of Surgeons in Ireland—Medical University of Bahrain, Busaiteen 228, Bahrain; (A.M.); (N.S.); (A.K.)
| | - Asher Khan
- School of Medicine, Royal College of Surgeons in Ireland—Medical University of Bahrain, Busaiteen 228, Bahrain; (A.M.); (N.S.); (A.K.)
- York Hospital, York and Scarborough Teaching Hospital and Foundation Trust, National Health Service (NHS), London SM5 1AA, UK
| | - Ahmad Mardini
- Advocate Christ Medical Center, Chicago, IL 60453, USA;
| | - Hajirah N. Saeed
- Department of Ophthalmology, Illinois Eye and Ear Infirmary, University Illinois Chicago, Chicago, IL 60612, USA
- Department of Ophthalmology, Loyola University Medical Center, Maywood, IL 60153, USA
- Harvard Medical School, Boston, MA 02115, USA
| |
Collapse
|
3
|
Voorman A, Lyons H, Shuaib F, Adamu US, Korir C, Erbeto T, Bandyopadhyay AS, Okiror S. Impact of Supplementary Immunization Activities using Novel Oral Polio Vaccine Type 2 during a Large outbreak of Circulating Vaccine-Derived Poliovirus in Nigeria. J Infect Dis 2024; 229:805-812. [PMID: 37357964 PMCID: PMC10938209 DOI: 10.1093/infdis/jiad222] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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: 04/06/2023] [Revised: 06/13/2023] [Accepted: 06/15/2023] [Indexed: 06/27/2023] Open
Abstract
BACKGROUND Novel oral poliovirus vaccine (OPV) type 2 (nOPV2) has been made available for outbreak response under an emergency use listing authorization based on supportive clinical trial data. Since 2021 more than 350 million doses of nOPV2 were used for control of a large outbreak of circulating vaccine-derived poliovirus type 2 (cVDPV2) in Nigeria. METHODS Using a bayesian time-series susceptible-infectious-recovered model, we evaluate the field effectiveness of nOPV2 immunization campaigns in Nigeria compared with campaigns using monovalent OPV type 2 (mOPV2). RESULTS We found that both nOPV2 and mOPV2 campaigns were highly effective in reducing transmission of cVDPV2, on average reducing the susceptible population by 42% (95% confidence interval, 28-54%) and 38% (20-51%) per campaign, respectively, which were indistinguishable from each other in this analysis (relative effect, 1.1 [.7-1.9]). Impact was found to vary across areas and between immunization campaigns. CONCLUSIONS These results are consistent with the comparable individual immunogenicity of nOPV2 and mOPV2 found in clinical trials but also suggest that outbreak response campaigns may have small impacts in some areas requiring more campaigns than are suggested in current outbreak response procedures.
Collapse
Affiliation(s)
- Arend Voorman
- The Bill & Melinda Gates Foundation, Seattle, Washington, USA
| | - Hil Lyons
- The Bill & Melinda Gates Foundation, Seattle, Washington, USA
| | - Faisal Shuaib
- National Primary Health Care Development Agency, Abuja, Nigeria
| | - Usman S Adamu
- National Primary Health Care Development Agency, Abuja, Nigeria
| | - Charles Korir
- World Health Organization, Nigeria Country Office, Abuja, Nigeria
| | - Tesfaye Erbeto
- World Health Organization, Nigeria Country Office, Abuja, Nigeria
| | | | - Samuel Okiror
- The Bill & Melinda Gates Foundation, Seattle, Washington, USA
| |
Collapse
|
4
|
Saleem AF, Kazi ZU, Zehra SM, Parkar S, Macklin G, Sifontes G, Mainou BA, Alam M, Lopez Cavestany R, Mach O. Mucosal immunity to poliovirus in children 0-15 years of age: A community-based study in Karachi, Pakistan in 2019. J Infect Dis 2024:jiae006. [PMID: 38195177 DOI: 10.1093/infdis/jiae006] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 12/30/2023] [Accepted: 01/05/2024] [Indexed: 01/11/2024] Open
Abstract
This study assesses poliovirus type 1 (PV1) immunity in children to inform the contribution of mucosal immunity in and preventing poliovirus circulation. A community-based study was conducted in peri-urban Karachi, Pakistan. Randomly selected children (0-15 years) received oral poliovirus vaccine (OPV) challenge dose. Blood and stool samples were collected at several time points and evaluated for polio-neutralizing antibodies and serotype-specific poliovirus, respectively. 81/589 (14%) children excreted PV1 7 days post-OPV-challenge; 70/81 (86%) were seropositive at baseline. 12/610 (2%) were asymptomatic Wild Poliovirus Type 1 (WPV1) excretors. Most poliovirus excretors had humoral immunity, suggesting mucosal immunity in these children likely waned or never developed. Without mucosal immunity, they are susceptible to poliovirus infection, shedding, and transmission. Asymptomatic WPV1 excretion suggests undetected poliovirus circulation within the community.
Collapse
Affiliation(s)
| | | | | | | | - Grace Macklin
- Polio Eradication, World Health Organization, Geneva, Switzerland
| | | | | | - Masroor Alam
- National Institute of Health, Islamabad, Pakistan
| | | | - Ondrej Mach
- Polio Eradication, World Health Organization, Geneva, Switzerland
| |
Collapse
|
5
|
Habib MA, Soofi SB, Hussain I, Ahmed I, Hussain Z, Tahir R, Anwar S, Cousens S, Bhutta ZA. Does IPV Boost Intestinal Immunity among Children under Five Years of Age? An Experience from Pakistan. Vaccines (Basel) 2023; 11:1444. [PMID: 37766121 PMCID: PMC10534550 DOI: 10.3390/vaccines11091444] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 08/28/2023] [Accepted: 08/30/2023] [Indexed: 09/29/2023] Open
Abstract
The oral poliovirus vaccine (OPV) has been the mainstay of polio eradication, especially in low-income countries, and its use has eliminated wild poliovirus type 2. However, the inactivated poliovirus vaccine (IPV) is safer than OPV, as IPV protects against paralytic poliomyelitis without producing adverse reactions. The present study compared mucosal and humoral responses to poliovirus vaccines administered to previously OPV-immunized children to assess the immunity gap in children in areas of high poliovirus transmission. A cluster-randomized trial was implemented in three high-risk districts of Pakistan-Karachi, Kashmore, and Bajaur-from June 2013 to May 2014. This trial was community-oriented and included three arms, focusing on healthy children below five years of age. The study involved the randomization of 387 clusters, of which 360 were included in the final analysis. The control arm (A) received the routine polio program bivalent poliovirus vaccine (bOPV). The second arm (B) received additional interventions, including health camps providing routine vaccinations and preventive maternal and child health services. In addition to the interventions in arm B, the third arm (C) was also provided with IPV. Blood and stool samples were gathered from children to evaluate humoral and intestinal immunity. The highest levels of poliovirus type 1 serum antibodies were observed in Group C (IPV + OPV). The titers for poliovirus type 2 (P2) and poliovirus type 3 (P3) were noticeably higher in those who had received a routine OPV dose than in those who had not across all study groups and visits. Providing an IPV booster after at least two OPV doses could potentially fill immunity gaps in regions where OPV does not show high efficacy. However, IPV only marginally enhances humoral immunity and fails to offer intestinal immunity, which is critical to stop the infection and spread of live poliovirus in populations that have not been exposed before.
Collapse
Affiliation(s)
- Muhammad Atif Habib
- Centre of Excellence in Women and Child Health, Aga Khan University, Karachi 74800, Pakistan (S.B.S.)
| | - Sajid Bashir Soofi
- Centre of Excellence in Women and Child Health, Aga Khan University, Karachi 74800, Pakistan (S.B.S.)
- Department of Pediatrics & Child Health, Aga Khan University, Karachi 74800, Pakistan
| | - Imtiaz Hussain
- Centre of Excellence in Women and Child Health, Aga Khan University, Karachi 74800, Pakistan (S.B.S.)
| | - Imran Ahmed
- Centre of Excellence in Women and Child Health, Aga Khan University, Karachi 74800, Pakistan (S.B.S.)
| | - Zamir Hussain
- Trust for Vaccines and Immunization, Karachi 74400, Pakistan
| | - Rehman Tahir
- Trust for Vaccines and Immunization, Karachi 74400, Pakistan
| | - Saeed Anwar
- Prime Institute of Public Health, Peshawar 25160, Pakistan
| | - Simon Cousens
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Zulfiqar A. Bhutta
- Centre of Excellence in Women and Child Health, Aga Khan University, Karachi 74800, Pakistan (S.B.S.)
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, ON M5G 1X8, Canada
| |
Collapse
|
6
|
|
7
|
Crothers JW, Ross Colgate E, Cowan KJ, Dickson DM, Walsh M, Carmolli M, Wright PF, Norton EB, Kirkpatrick BD. Intradermal fractional-dose inactivated polio vaccine (fIPV) adjuvanted with double mutant Enterotoxigenic Escherichia coli heat labile toxin (dmLT) is well-tolerated and augments a systemic immune response to all three poliovirus serotypes in a randomized placebo-controlled trial. Vaccine 2022; 40:2705-2713. [PMID: 35367069 PMCID: PMC9024222 DOI: 10.1016/j.vaccine.2022.03.056] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 02/25/2022] [Accepted: 03/22/2022] [Indexed: 11/19/2022]
Abstract
Eradication of poliomyelitis globally is constrained by fecal shedding of live polioviruses, both wild-type and vaccine-derived strains, into the environment. Although inactivated polio vaccines (IPV) effectively protect the recipient from clinical poliomyelitis, fecal shedding of live virus still occurs following infection with either wildtype or vaccine-derived strains of poliovirus. In the drive to eliminate the last cases of polio globally, improvements in both oral polio vaccines (OPV) (to prevent reversion to virulence) and injectable polio vaccines (to improve mucosal immunity and prevent viral shedding) are underway. The E. coli labile toxin with two or "double" attenuating mutations (dmLT) may boost immunologic responses to IPV, including at mucosal sites. We performed a double-blinded phase I controlled clinical trial to evaluate safety, tolerability, as well as systemic and mucosal immunogenicity of IPV adjuvanted with dmLT, given as a fractional (1/5th) dose intradermally (fIPV-dmLT). Twenty-nine volunteers with no past exposure to OPV were randomized to a single dose of fIPV-dmLT or fIPV alone. fIPV-dmLT was well tolerated, although three subjects had mild but persistent induration and hyperpigmentation at the injection site. A ≥ 4-fold rise in serotype-specific neutralizing antibody (SNA) titers to all three serotypes was seen in 84% of subjects receiving fIPV-dmLT vs. 50% of volunteers receiving IPV alone. SNA titers were higher in the dmLT-adjuvanted group, but only differences in serotype 1 were significant. Mucosal immune responses, as measured by polio serotype specific fecal IgA were minimal in both groups and differences were not seen. fIPV-dmLT may offer a benefit over IPV alone. Beyond NAB responses protecting the individual, studies demonstrating the ability of fIPV-dmLT to prevent viral shedding are necessary. Studies employing controlled human infection models, using monovalent OPV post-vaccine are ongoing. Studies specifically in children may also be necessary and additional biomarkers of mucosal immune responses in this population are needed. Clinicaltrials.gov Identifer: NCT03922061.
Collapse
Affiliation(s)
- Jessica W Crothers
- Department of Pathology and Laboratory Medicine, Vaccine Testing Center, University of Vermont Larner College of Medicine, Burlington, VT, USA.
| | - Elizabeth Ross Colgate
- Microbiology and Molecular Genetics, Vaccine Testing Center, University of Vermont Larner College of Medicine, Burlington, VT, USA
| | - Kelly J Cowan
- Department of Pediatrics, Vaccine Testing Center, University of Vermont Larner College of Medicine, Burlington, VT, USA
| | - Dorothy M Dickson
- Microbiology and Molecular Genetics, Vaccine Testing Center, University of Vermont Larner College of Medicine, Burlington, VT, USA
| | - MaryClaire Walsh
- Microbiology and Molecular Genetics, Vaccine Testing Center, University of Vermont Larner College of Medicine, Burlington, VT, USA
| | - Marya Carmolli
- Microbiology and Molecular Genetics, Vaccine Testing Center, University of Vermont Larner College of Medicine, Burlington, VT, USA
| | - Peter F Wright
- Department of Pediatrics, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | - Elizabeth B Norton
- Department of Immunology and Microbiology, Tulane University, New Orleans, LA, USA
| | - Beth D Kirkpatrick
- Microbiology and Molecular Genetics, Vaccine Testing Center, University of Vermont Larner College of Medicine, Burlington, VT, USA
| |
Collapse
|
8
|
Connor RI, Brickley EB, Wieland-Alter WF, Ackerman ME, Weiner JA, Modlin JF, Bandyopadhyay AS, Wright PF. Mucosal immunity to poliovirus. Mucosal Immunol 2022; 15:1-9. [PMID: 34239028 PMCID: PMC8732262 DOI: 10.1038/s41385-021-00428-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [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: 01/30/2021] [Revised: 05/26/2021] [Accepted: 06/14/2021] [Indexed: 02/04/2023]
Abstract
A cornerstone of the global initiative to eradicate polio is the widespread use of live and inactivated poliovirus vaccines in extensive public health campaigns designed to prevent the development of paralytic disease and interrupt transmission of the virus. Central to these efforts is the goal of inducing mucosal immunity able to limit virus replication in the intestine. Recent clinical trials have evaluated new combined regimens of poliovirus vaccines, and demonstrated clear differences in their ability to restrict virus shedding in stool after oral challenge with live virus. Analyses of mucosal immunity accompanying these trials support a critical role for enteric neutralizing IgA in limiting the magnitude and duration of virus shedding. This review summarizes key findings in vaccine-induced intestinal immunity to poliovirus in infants, older children, and adults. The impact of immunization on development and maintenance of protective immunity to poliovirus and the implications for global eradication are discussed.
Collapse
Affiliation(s)
- Ruth I Connor
- Department of Pediatrics, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
- Department of Microbiology and Immunology, Geisel School of Medicine, Dartmouth College, Hanover, NH, USA
| | - Elizabeth B Brickley
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Margaret E Ackerman
- Department of Microbiology and Immunology, Geisel School of Medicine, Dartmouth College, Hanover, NH, USA
- Thayer School of Engineering, Dartmouth College, Hanover, NH, USA
| | - Joshua A Weiner
- Thayer School of Engineering, Dartmouth College, Hanover, NH, USA
| | | | | | - Peter F Wright
- Department of Pediatrics, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA.
| |
Collapse
|
9
|
Bashorun AO, Badjie Hydara M, Adigweme I, Umesi A, Danso B, Johnson N, Sambou NA, Fofana S, Kanu FJ, Jeyaseelan V, Verma H, Weldon WC, Oberste MS, Sutter RW, Jeffries D, Wathuo M, Mach O, Clarke E. Intradermal administration of fractional doses of the inactivated poliovirus vaccine in a campaign: a pragmatic, open-label, non-inferiority trial in The Gambia. Lancet Glob Health 2021; 10:e257-e268. [PMID: 34951974 PMCID: PMC8786671 DOI: 10.1016/s2214-109x(21)00497-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 09/19/2021] [Accepted: 10/11/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND A rapid increase in circulating vaccine-derived poliovirus type 2 outbreaks, and the need to reserve inactivated poliovirus vaccine (IPV) for routine immunisation, has increased the value of fractional dose IPV (fIPV) as a measure to prevent acute flaccid paralysis. However, the intradermal route of administration has been viewed as prohibitive to outbreak response campaigns. We aimed to establish the immunogenicity and safety of administering intradermal fIPV with a disposable syringe jet injector (DSJI) or an intradermal adaptor (IDA) compared with standard administration with a BCG needle and syringe (N&S). METHODS This pragmatic, non-inferiority trial was undertaken in a campaign setting in communities in The Gambia. Children aged 4-59 months without contraindication to vaccination were eligible. Children were not individually randomly assigned; instead, the vaccination teams were randomly assigned (1:1:1) to one of three administration methods. Parents and the field team were not masked, but laboratory personnel were masked. Baseline demographic and anthropometric data were collected from the participants. Public health officers experienced at intradermal immunisation, and nurses without experience, had 2 h of training on each of the administration methods before the campaign. Participants were vaccinated using the administration method in use by the vaccination team in their community. Poliovirus serum neutralising antibodies (SNA) were measured in children aged 24-59 months before and 4 weeks after vaccination. Adverse events and data on injection quality were collected from all participants. The primary outcome was the type 2 immune response rate (seroconversion in seronegative [SNA titre <8] children plus a 4-fold titre rise in seropositive children). Adjusted differences in the immune response between the DSJI or IDA group versus the N&S group were calculated with 97·5% CIs. A margin of -10% was used to define the non-inferiority of DSJI or IDA compared to N&S. Immunogenicity analysis was done per protocol. The trial is registered with ClinicalTrials.govNCT02967783 and has been completed. FINDINGS Between Oct 28 and Dec 29, 2016, 3189 children aged 4-59 months were recruited, of whom 3170 were eligible. Over 3 days, 2720 children were vaccinated (N&S, 917; IDA, 874; and DSJI, 929). Among 992 children aged 25-59 months with a baseline SNA available, 90·1% (95% CI 86·1-92·9; 281/312) of those vaccinated using the DSJI had an immune response to type 2 compared with 93·8% (90·6-95·8; 331/353) of those vaccinated with N&S and 96·6% (94·0-98·0; 316/327) of those vaccinated with IDA. All (53/53) type 2 seronegative children seroconverted. For polio type 2, non-inferiority was shown for both the IDA (adjusted difference 0·7% [97·5% CI -3·3 to 4·7], unadjusted difference 2·9% [-0·9 to 6·8]) and DSJI (adjusted difference -3·3% [-8·3 to 1·5], unadjusted difference -3·7% [-8·7 to 1·1]) compared with N&S. Non-inferiority was shown for type 1 and 3 for the IDA and DSJI. Neither injection quality nor the training and experience of the vaccinators had an effect on immune response. No safety concerns were reported. INTERPRETATION In a campaign, intradermal fIPV is safe and generates consistent immune responses that are not dependent on vaccinator experience or injection quality when administered using an N&S, DSJI, or IDA. Countries facing vaccine-derived poliovirus type 2 outbreaks should consider fIPV campaigns to boost population immunity and prevent cases of acute flaccid paralysis. FUNDING World Health Organization and the Medical Research Council.
Collapse
Affiliation(s)
- Adedapo O Bashorun
- Medical Research Council Unit, The Gambia at the London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Mariama Badjie Hydara
- Medical Research Council Unit, The Gambia at the London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Ikechukwu Adigweme
- Medical Research Council Unit, The Gambia at the London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Ama Umesi
- Medical Research Council Unit, The Gambia at the London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Baba Danso
- Medical Research Council Unit, The Gambia at the London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Njilan Johnson
- Medical Research Council Unit, The Gambia at the London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | | | - Sidat Fofana
- Ministry of Health, Government of The Gambia, Banjul, The Gambia
| | - Francis J Kanu
- Medical Research Council Unit, The Gambia at the London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | | | | | | | | | | | - David Jeffries
- Medical Research Council Unit, The Gambia at the London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | - Miriam Wathuo
- Medical Research Council Unit, The Gambia at the London School of Hygiene and Tropical Medicine, Banjul, The Gambia
| | | | - Ed Clarke
- Medical Research Council Unit, The Gambia at the London School of Hygiene and Tropical Medicine, Banjul, The Gambia,Correspondence to: Dr Ed Clarke, Medical Research Council Unit, The Gambia at London School of Hygiene and Tropical Medicine, Banjul, PO Box 273, The Gambia
| |
Collapse
|
10
|
Mashunye TR, Ndwandwe DE, Dube KR, Shey M, Shelton M, Wiysonge CS. Fractional dose compared with standard dose inactivated poliovirus vaccine in children: a systematic review and meta-analysis. Lancet Infect Dis 2021; 21:1161-1174. [PMID: 33939958 DOI: 10.1016/s1473-3099(20)30693-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 03/05/2020] [Accepted: 07/30/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Since WHO recommended introduction of at least a single dose of inactivated poliovirus vaccine (IPV) in routine immunisation schedules, there have been global IPV shortages. Fractional-dose IPV (fIPV) administration is one of the strategies to ensure IPV availability. We reviewed studies comparing the effects of fractional with full-dose IPV vaccination to determine when seroconversion proportions with each strategy become similar in children aged 5 years and younger. METHOD In this systematic review and meta-analysis, we searched 16 databases in July, 2019, for trials and observational studies, including ongoing studies that compare immunogenicity and adverse events of fractional-dose (0·1 mL) to full-dose (0·5 mL) IPV in healthy children aged 5 years or younger regardless of study design, number of doses, and route of administration. Screening, selection of articles, data extraction, and risk of bias assessment were done in duplicate, and conflicts were resolved by discussion or arbitration by a third author. We assessed immunogenicity, the main outcome, as proportion of seroconverted participants and changes in geometric mean titres of anti-poliovirus antibodies. Timepoints were eligible for analysis if measurements were done at least 4 weeks after vaccination. Summary estimates were pooled by use of random-effects meta-analysis. Analysis was stratified by study design, type of outcome measure, type of poliovirus, and number of doses given. We assessed heterogeneity using the χ2 test of homogeneity and quantified it using the I2 statistic. We assessed risk of bias using the Cochrane risk of bias tool, and the certainty of evidence using the Grading of Recommendations Assessment, Development and Evaluation approach. The study is registered with PROSPERO, CRD42018092647. FINDINGS 860 records were screened for eligibility, of which 36 potentially eligible full-text articles were assessed and 14 articles were included in the final analysis: two ongoing trials and 12 articles reporting on ten completed studies. For poliovirus type 2, there were no significant differences in the proportions of seroconversions between fractional and full doses of IPV for two or three doses: the risk ratio for serconversion at one dose was 0·61 (95% CI 0·51-0·72), at two doses was 0·90 (0·82-1·00), and at three doses was 0·95 (0·91-1·00). Geometric mean titres (GMTs) for poliovirus type 2 were lower for fIPV than for full-dose IPV: -0·51 (95% CI -0·87 to -0·14) at one dose, -0·49 (-0·70 to -0·28) at two doses, and -0·98 (-1·46 to -0·51) at three doses. The seroconversion meta-analysis for the three-dose comparison was homogeneous (p=0·45; I2=0%), whereas heterogeneity was observed in the two-dose (p<0·00001; I2=88%) and one-dose (p=0·0004; I2=74%) comparisons. Heterogeneity was observed in meta-analyses of GMTs for one-dose (p<0·00001; I2=92%), two-dose (p=0·002; I2=80%), and three-dose (p<0·00001; I2=93%) comparisons. Findings for types 1 and 3 were similar to those for type 2. The certainty of the evidence was high for the three-dose comparisons and moderate for the rest of the comparisons. INTERPRETATION There is no substantial difference in seroconversion between three doses of fIPV and three doses of full-dose IPV, although the full dose gives higher titres of antibodies for poliovirus type 1, 2, and 3. Use of fractional IPV instead of the full dose can stretch supplies and possibly lower the cost of vaccination. FUNDING South African Medical Research Council and the National Research Foundation of South Africa.
Collapse
Affiliation(s)
- Thandiwe R Mashunye
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.
| | - Duduzile E Ndwandwe
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
| | - Kopano R Dube
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
| | - Muki Shey
- Department of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa; Wellcome Centre for Infectious Disease Research in Africa (CIDRI-Africa), Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Mary Shelton
- Health Sciences Library, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Charles S Wiysonge
- Division of Epidemiology and Biostatistics, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa; Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
| |
Collapse
|
11
|
Bandyopadhyay AS, Orenstein WA. Evolution of Inactivated Poliovirus Vaccine Use for the Endgame and Beyond. J Infect Dis 2020; 221:861-863. [PMID: 31242297 DOI: 10.1093/infdis/jiz300] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Accepted: 06/13/2019] [Indexed: 12/19/2022] Open
|
12
|
Jaiswal N, Singh S, Agarwal A, Chauhan A, Thumburu KK, Kaur H, Singh M. Equivalent schedules of intradermal fractional dose versus intramuscular full dose of inactivated polio vaccine for prevention of poliomyelitis. Cochrane Database Syst Rev 2019; 12:CD011780. [PMID: 31858595 PMCID: PMC6923520 DOI: 10.1002/14651858.cd011780.pub2] [Citation(s) in RCA: 2] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Poliomyelitis is a debilitating and deadly infection. Despite exponential growth in medical science, there is still no cure for the disease, which is caused by three types of wild polioviruses: types 1, 2, and 3. According to the Global Polio Eradication Initiative (GPEI), wild poliovirus is still in circulation in three countries, and fresh cases have been reported even in the year 2018. Due to the administration of live vaccines, the risk for vaccine-derived poliovirus (VDPV) is high in areas that are free from wild polioviruses. This is evident based on the fact that VDPV caused 20 outbreaks between 2000 and 2011. Recent recommendations from the World Health Organization favoured the inclusion of inactivated poliovirus vaccine (IPV) in the global immunisation schedule. IPV can be delivered in two ways: intramuscularly and intradermally. IPV was previously administered intramuscularly, but shortages in vaccine supplies, coupled with the higher costs of the vaccines, led to the innovation of delivering a fractional dose (one-fifth) of IPV intradermally. However, there is uncertainty regarding the efficacy, immunogenicity, and safety of an intradermal, fractional dose of IPV compared to an intramuscular, full dose of IPV. OBJECTIVES To compare the immunogenicity and efficacy of an inactivated poliovirus vaccine (IPV) in equivalent immunisation schedules using fractional-dose IPV given via the intradermal route versus full-dose IPV given via the intramuscular route. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, 10 other databases, and two trial registers up to February 2019. We also searched the GPEI website and scanned the bibliographies of key studies and reviews in order to identify any additional published and unpublished trials in this area not captured by our electronic searches. SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-RCTs of healthy individuals of any age who are eligible for immunisation with IPV, comparing intradermal fractional-dose (one-fifth) IPV to intramuscular full-dose IPV. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS We included 13 RCTs involving a total of 7292 participants, both children (n = 6402) and adults (n = 890). Nine studies were conducted in middle-income countries, three studies in high-income countries, and only one study in a low-income country. Five studies did not report methods of randomisation, and one study failed to conceal the allocations. Eleven studies did not blind participants, and six studies did not blind outcome assessments. Two studies had high attrition rates, and one study selectively reported the results. Three studies were funded by pharmaceutical companies. Paralytic poliomyelitis. No study reported data on this outcome. Seroconversion rates. These were significantly higher for all three types of wild poliovirus for children given intramuscular full-dose IPV after a single primary dose and two primary doses, but only significantly higher for type two wild poliovirus given intramuscularly after three primary doses: • dose one (six studies): poliovirus type 1 (odds ratio (OR) 0.30, 95% confidence interval (CI) 0.22 to 0.41; 2570 children); poliovirus type 2 (OR 0.43, 95% CI 0.31 to 0.60; 2567 children); poliovirus type 3 (OR 0.19, 95% CI 0.12 to 0.30; 2571 children); • dose two (three studies): poliovirus type 1 (OR 0.23, 95% CI 0.16 to 0.33; 981 children); poliovirus type 2 (OR 0.41, 95% CI 0.28 to 0.60; 853 children); and poliovirus type 3 (OR 0.12, 95% CI 0.07 to 0.22; 855 children); and • dose three (three studies): poliovirus type 1 (OR 0.45, 95% CI 0.07 to 3.15; 973 children); poliovirus type 2 (OR 0.34, 95% CI 0.19 to 0.63; 973 children); and poliovirus type 3 (OR 0.18, 95% CI 0.01 to 2.58; 973 children). Using the GRADE approach, we rated the certainty of the evidence as low or very low for seroconversion rate (after a single, two, or three primary doses) for all three poliovirus types due to significant risk of bias, heterogeneity, and indirectness in applicability/generalisability. Geometric mean titres. No study reported mean antibody titres. Median antibody titres were higher for intramuscular full-dose IPV (7 studies with 4887 children); although these studies also reported a rise in antibody titres in the intradermal group, none reported the duration for which the titres remained high. Any vaccine-related adverse event. Five studies (2217 children) reported more adverse events, such as fever and redness, in the intradermal group, whilst two studies (1904 children) reported more adverse events in the intramuscular group. AUTHORS' CONCLUSIONS There is low- and very low-certainty evidence that intramuscular full-dose IPV may result in a slight increase in seroconversion rates for all three types of wild poliovirus, compared with intradermal fractional-dose IPV. We are uncertain whether intradermal fractional-dose (one-fifth) IPV has better protective effects and causes fewer adverse events in children than intramuscular full-dose IPV.
Collapse
Affiliation(s)
- Nishant Jaiswal
- Postgraduate Institute of Medical Education and ResearchICMR Advanced Centre for Evidence‐Based Child HealthSector 12ChandigarhIndia160012
| | - Shreya Singh
- Postgraduate Institute of Medical Education and ResearchDepartment of Medical MicrobiologyResearch Block A, Sector 12ChandigarhChandigarhIndia160012
| | - Amit Agarwal
- Postgraduate Institute of Medical Education and ResearchICMR Advanced Centre for Evidence‐Based Child HealthSector 12ChandigarhIndia160012
| | - Anil Chauhan
- Postgraduate Institute of Medical Education and ResearchICMR Advanced Centre for Evidence‐Based Child HealthSector 12ChandigarhIndia160012
| | - Kiran K Thumburu
- Postgraduate Institute of Medical Education and ResearchICMR Advanced Centre for Evidence‐Based Child HealthSector 12ChandigarhIndia160012
| | - Harpreet Kaur
- Panjab UniversityUniversity Business SchoolSector 14ChandigarhIndia160014
| | - Meenu Singh
- Postgraduate Institute of Medical Education and ResearchDepartment of PediatricsSector 12ChandigarhIndia160012
| | | |
Collapse
|
13
|
Affiliation(s)
- Roland W Sutter
- Polio Eradication Department, World Health Organization, Geneva CH-1211, Switzerland.
| | - Michel Zaffran
- Polio Eradication Department, World Health Organization, Geneva CH-1211, Switzerland
| |
Collapse
|
14
|
Yousafzai MT. Role of Fractional-Dose Intradermal Inactivated Poliovirus Vaccine in Halting Polio Transmission: Finding the Missing Piece for Global Polio Eradication. J Infect Dis 2018; 218:1855-1857. [DOI: 10.1093/infdis/jiy390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 06/25/2018] [Indexed: 11/12/2022] Open
|