Analyses of adverse reactions to diphtheria and tetanus toxoids and pertussis vaccine by vaccine lot, endotoxin content, pertussis vaccine potency and percentage of mouse weight gain

Pertussis vaccines

PURPOSE OF REVIEW

Pertussis is a vaccine preventable cough illness. It can be controlled by universal pertussis vaccination.

RECENT FINDINGS

Pertussis cases and deaths in children are at a record low number. More complete use of adolescent/adult vaccine can further reduce morbidity and mortality.

SUMMARY

Considerable progress in the control of pertussis has occurred over the last 75 years. The universal use of Tdap vaccines in all pregnant women will prevent virtually all pertussis deaths.

Immunogenicity and Safety of a Newly Developed Tetanus-Diphtheria Toxoid (Td) in Healthy Korean Adolescents: a Multi-center, Randomized, Double-blind, Active-Controlled Phase 3 Trial

BACKGROUND

Although the combination tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) is recommended at adolescence in developed countries, the tetanus and diphtheria toxoid vaccine (Td), which is less costly, is recommended instead in some parts of the world. A new Td, BR-TD-1001, was developed by a Korean manufacturer for distribution to endemic regions and for use in the initial step of novel Tdap development.

METHODS

This phase 3, randomized, double-blind, multi-center trial, conducted in Korea, aimed to evaluate the immunogenicity and safety of BR-TD-1001. Healthy children aged 10 to 12 years were randomized 1:1 to receive either BR-TD-1001 or the control Td (Td-pur, GlaxoSmithKline). Antibodies were measured using enzyme-linked immunosorbent assay.

RESULTS

A total of 218 subjects (BR-TD-1001, n = 108; control, n = 110) were enrolled and included in the safety analysis. Vaccine-mediated antibody responses were similar in both groups. We confirmed the non-inferiority of BR-TD-1001 against the control, Td; 100% of both groups achieved seroprotection against diphtheria and tetanus. Furthermore, there was no significant difference between groups in the proportion of participants who demonstrated boost responses against diphtheria and tetanus toxoids. The incidence of solicited local and systemic adverse events (AEs), unsolicited AEs, and serious AEs did not differ significantly between groups.

CONCLUSION

The BR-TD-1001 satisfied the immunological non-inferiority criterion against diphtheria and tetanus, with a clinically acceptable safety profile.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04618939.

The 112-Year Odyssey of Pertussis and Pertussis Vaccines-Mistakes Made and Implications for the Future

Effective diphtheria, tetanus toxoids, whole-cell pertussis (DTwP) vaccines became available in the 1930s, and they were put into routine use in the United States in the 1940s. Their use reduced the average rate of reported pertussis cases from 157 in 100 000 in the prevaccine era to <1 in 100 000 in the 1970s. Because of alleged reactions (encephalopathy and death), several countries discontinued (Sweden) or markedly decreased (United Kingdom, Germany, Japan) use of the vaccine. During the 20th century, Bordetella pertussis was studied extensively in animal model systems, and many "toxins" and protective antigens were described. A leader in B pertussis research was Margaret Pittman of the National Institutes of Health/US Food and Drug Administration. She published 2 articles suggesting that pertussis was a pertussis toxin (PT)-mediated disease. Dr Pittman's views led to the idea that less-reactogenic acellular vaccines could be produced. The first diphtheria, tetanus, pertussis (DTaP) vaccines were developed in Japan and put into routine use there. Afterward, DTaP vaccines were developed in the Western world, and definitive efficacy trials were carried out in the 1990s. These vaccines were all less reactogenic than DTwP vaccines, and despite the fact that their efficacy was less than that of DTwP vaccines, they were approved in the United States and many other countries. DTaP vaccines replaced DTwP vaccines in the United States in 1997. In the last 13 years, major pertussis epidemics have occurred in the United States, and numerous studies have shown the deficiencies of DTaP vaccines, including the small number of antigens that the vaccines contain and the type of cellular immune response that they elicit. The type of cellular response a predominantly, T2 response results in less efficacy and shorter duration of protection. Because of the small number of antigens (3-5 in DTaP vaccines vs >3000 in DTwP vaccines), linked-epitope suppression occurs. Because of linked-epitope suppression, all children who were primed by DTaP vaccines will be more susceptible to pertussis throughout their lifetimes, and there is no easy way to decrease this increased lifetime susceptibility.

Pertussis: Microbiology, Disease, Treatment, and Prevention

Pertussis is a severe respiratory infection caused by Bordetella pertussis, and in 2008, pertussis was associated with an estimated 16 million cases and 195,000 deaths globally. Sizeable outbreaks of pertussis have been reported over the past 5 years, and disease reemergence has been the focus of international attention to develop a deeper understanding of pathogen virulence and genetic evolution of B. pertussis strains. During the past 20 years, the scientific community has recognized pertussis among adults as well as infants and children. Increased recognition that older children and adolescents are at risk for disease and may transmit B. pertussis to younger siblings has underscored the need to better understand the role of innate, humoral, and cell-mediated immunity, including the role of waning immunity. Although recognition of adult pertussis has increased in tandem with a better understanding of B. pertussis pathogenesis, pertussis in neonates and adults can manifest with atypical clinical presentations. Such disease patterns make pertussis recognition difficult and lead to delays in treatment. Ongoing research using newer tools for molecular analysis holds promise for improved understanding of pertussis epidemiology, bacterial pathogenesis, bioinformatics, and immunology. Together, these advances provide a foundation for the development of new-generation diagnostics, therapeutics, and vaccines.

Filamentous hemagglutinin of Bordetella pertussis: a key adhesin with immunomodulatory properties?

The filamentous hemagglutinin of pathogenic Bordetellae is a prototype of a large two-partner-system-secreted and β-structure-rich bacterial adhesin. It exhibits several binding activities that may facilitate bacterial adherence to airway mucosa and host phagocytes in the initial phases of infection. Despite three decades of research on filamentous hemagglutinin, there remain many questions on its structure-function relationships, integrin interactions and possible immunomodulatory signaling capacity. Here we review the state of knowledge on this important virulence factor and acellular pertussis vaccine component. Specific emphasis is placed on outstanding questions that are yet to be answered.

Fever following immunization

Fever is a frequent systemic adverse event following immunization, especially in infants and young children. Any fever after immunization may be caused by immunization or may coincide temporally as an indication of underlying disease, usually an infectious one. The time pattern of fever attributable to immunization has characteristic features depending on the vaccine used. Comparability of fever rates associated with different vaccines, or the same vaccines in different studies, is frequently hampered by the use of different definitions and/or assessment techniques for fever. A recent analysis by the Brighton Collaboration has provided a standardized case definition for fever, the use of which should be strongly encouraged.

Substitution of the Bordetella pertussis lipid A phosphate groups with glucosamine is required for robust NF-kappaB activation and release of proinflammatory cytokines in cells expressing human but not murine Toll-like receptor 4-MD-2-CD14

Bordetella pertussis endotoxin is a key modulator of the host immune response, mainly due to the role of its lipid A moiety in Toll-like receptor 4 (TLR4)-mediated signaling. We have previously demonstrated that the lipid A phosphate groups of B. pertussis BP338 can be substituted with glucosamine in a BvgAS-regulated manner. Here we examined the effect of this lipid A modification on the biological activity of B. pertussis endotoxin. We compared purified endotoxin and heat-killed B. pertussis BP338 whole cells that have modified lipid A phosphate groups to an isogenic mutant lacking this modification with respect to their capacities to induce the release of inflammatory cytokines by human and murine macrophages and to participate in the TLR4-mediated activation of NF-kappaB in transfected HEK-293 cells. We found inactivated B. pertussis cells to be stronger inducers of proinflammatory cytokines in THP-1-derived macrophages when lipid A was modified. Most notably, lack of lipid A modification abolished the ability of purified B. pertussis endotoxin to induce the release of inflammatory cytokines by human THP-1-derived macrophages but led to only slightly reduced inflammatory cytokine levels when stimulating murine (RAW 264.7) macrophages. Accordingly, upon stimulation of HEK-293 cells with inactivated bacteria and purified endotoxin, lack of lipid A modification led to impaired NF-kappaB activation only when human, and not when murine, TLR4-MD-2-CD14 was expressed. We speculate that in B. pertussis, lipid A modification has evolved to benefit the bacteria during human infection by modulating immune defenses rather than to evade innate immune recognition.

Eventos adversos pós-vacina contra a difteria, coqueluche e tétano e fatores associados à sua gravidade

OBJETIVO: Avaliar os eventos adversos pós-vacina contra a difteria, coqueluche e tétano (EAPV-DPT) e os fatores associados à sua gravidade. MÉTODOS: Estudo transversal com componente descritivo e analítico, abrangendo os eventos adversos pós-vacina DPT notificados no Estado de São Paulo, de 1984 a 2001, entre crianças menores de sete anos de idade. A definição de caso foi a adotada pela vigilância de EAPV-DPT; os dados obtidos foram originados da vigilância passiva desses eventos. No cálculo das taxas, o numerador foram os EAPV e o denominador o número de doses aplicadas. A associação entre a gravidade dos EAPV-DPT e as exposições de interesse foi investigada pelas estimativas não ajustadas e ajustadas da odds ratio, com os respectivos intervalos de 95% de confiança, usando regressão logística não condicional. RESULTADOS: Identificaram-se 10.059 EAPV-DPT relativos a 6.266 crianças, apresentando um ou mais EAPV, 29,5% foram internadas e em 68,2% houve contra-indicação das doses subseqüentes de DPT. Cerca de 75% dos eventos ocorreram nas primeiras seis horas após a aplicação da vacina. Os eventos mais freqüentes foram: febre<39,5°C, reação local, evento hipotônico hiporresponsivo e convulsão. Mostraram-se independentemente associadas à gravidade: intervalo inferior a uma hora entre a aplicação da vacina e o evento (OR=2,1), primeira dose aplicada (OR=5,8), antecedentes neurológicos pessoais (OR=2,2) e familiares (OR=5,3). CONCLUSÕES: A vigilância passiva de EAPV mostrou-se útil no monitoramento da segurança da vacina DPT, descrevendo as características e a magnitude desses eventos, assim como permitiu identificar possíveis fatores associados às formas graves.

Effect of injection site on reactogenicity and immunogenicity of acellular and whole-cell pertussis component diphtheria-tetanus-pertussis vaccines in infants

The effect of injection site on reactogenicity and specific immunogenicity was assessed in participants in a pertussis vaccine efficacy trial. The percent of DTwP and DTaP recipients with any reaction was slightly lower in subjects injected in the buttock compared with those injected in the thigh. This finding was most common in DTwP recipients. Geometric mean antibody values to pertactin, filamentous hemagglutinin and fimbriae (Bordetella pertussis antigens) were lower in DTaP vaccinees when buttock was utilized as the injection site. Our findings present evidence against the use of the buttock as the site of immunization for DTaP vaccines since the benefit with regards to reactogenicity is minimal and the immunologic response to an important antigen of B. pertussis, pertactin, is decreased.

Cutaneous adverse reactions following anti-infective vaccinations

Although widely administered, anti-infective vaccinations are rarely responsible for cutaneous adverse effects. In this context, hepatitis B and bacillus Calmette-Guerin vaccines are the most frequently incriminated products. Cutaneous adverse effects are less frequently encountered following administration of vaccines against varicella, diphtheria/tetanus/pertussis (primary and booster doses), measles, poliomyelitis, rubella, pneumococcus, tick-borne encephalitis, smallpox, Meningococcus and influenza. The adverse effects can occur at the site of or at a distance from the injection. The patho-mechanisms of local adverse cutaneous reactions include predominantly nonspecific lymphoid or granulomatous reactions. Allergic reactions to the vaccine strain, adjuvants, conservatives or other components are less frequently involved in local vaccine adverse effects. Systemic reactions are mainly mediated by immediate type or immune complex-related allergic reactions to toxoid-, ovalbumin-, gelatin- or pneumococcal-containing vaccines. Systemic reactions are sometimes related to a specific vaccine strain. Other cutaneous reactions may also occur through unknown patho-mechanisms. No vaccine type or strain is specifically associated with a particular type of cutaneous adverse effect. This article presents seven case reports of cutaneous adverse effects following anti-infective vaccination then reviews the relevant literature on this subject.

When Should Vaccination Be Contraindicated in Children?

No child should be denied immunisation without serious consideration given to the consequences. In the past, many contraindications to vaccination were based on theoretical concerns. These concerns often assumed an immunoallergic mechanism for adverse reactions, whereas many such events are often due to other causes. Other contraindications were based on evidence of excess risk, but this risk was not always balanced against the higher risk of disease. Therefore, contraindications often varied between countries and over time. In recent years, the widespread availability of less reactogenic vaccines and the common use of combined preparations have prompted a review of contraindications in many countries. Accumulated experience worldwide has allowed the list of conditions that contraindicate vaccination to be reduced. The international consensus now is that there are very few situations in which a child should not be immunised and the only true contraindication applicable to all vaccines is a history of anaphylaxis to a vaccine component or following a previous dose of the vaccine. Health professionals should feel confident in accepting national recommendations and, if in doubt, should refer children for an expert opinion, rather than deny a child protection against a serious infection.

Immediate allergy to tetanus toxoid vaccine: determination of immunoglobulin E and immunoglobulin G antibodies to allergenic proteins

BACKGROUND

Adverse reactions to tetanus toxoid (TT) vaccine are mostly mild and limited to the injection site. However, immunoglobulin (Ig)E-mediated reactions may occur, and the incidence of anaphylactic responses to TT immunization is 0.001%. When TT induces an allergic reaction, the potential causative agents can be TT antigens, thimerosal or aluminum phosphate.

OBJECTIVE

We studied four children who developed immediate urticaria after TT vaccine, soon after the reaction and 5 years later.

METHODS

Skin tests were performed separately with TT vaccine and two vaccine components, thimerosal and aluminum phosphate, and the diagnosis was confirmed by provocation test. IgE and IgG antibodies to TT and their specificities were determined. Sodium dodecyl sulfate-polyacrylamide gel electrophoresis and immunoblotting were performed to characterize the antigenic proteins.

RESULTS

All four children were immediate skin test-positive to TT, but negative to thimerosal and aluminum phosphate; 3 developed a reaction after intramuscular provocation using increasing doses of TT vaccine; and 1 refused to be tested. All these tests were negative in five controls, all of whom received TT vaccine and developed only local swelling at the site of application 24 hours after vaccine administration. After 5 years the IgG antibodies were still high in all cases and the IgE antibody values fell by 50%. Patients allergic to TT vaccine produced IgE and IgG antibodies, which decreased at different rates but remained for at least 5 years. The pattern of antibody decrease was confirmed by radioallergosorbent test, enzyme-linked immunoadsorbent assay, or immunoblotting assay. IgE and IgG antibodies recognized two proteins derived from TT, of 150 and 50 kDa, corresponding to the intracellular form and to a chain of the extracellular form of the tetanus neurotoxin.

CONCLUSIONS

In children with immediate allergic reactions to TT vaccine, antibodies may persist for at least 5 years, requiring evaluation by skin and/or in vitro tests before subsequent treatment.

Which strategy for pertussis vaccination today?

Pertussis (whooping cough) remains an epidemic disease responsible for infant and child morbidity and mortality, and is perceived as a serious public health problem. Since the widespread use of whole-cell pertussis vaccines in the 1940s, vaccination programs have varied greatly between countries. National specificity is a function of several factors. The most important are: vaccine efficacy and tolerability;vaccine coverage and distribution; and vaccine acceptance by parents and professionals. During the 1970s, Sweden, England, Wales and Japan provided contrasting examples of the attitude of health authorities to the use of whole-cell vaccines. The increase in pertussis incidence was noted as a consequence of active opposition to this vaccine. The re-emergence of pertussis in the 1990s, in countries with high vaccination coverage and increased incidence of disease in individuals >15 years and <6 months of age, has drawn attention to the role of booster doses of pertussis vaccines and their introduction into regular vaccination programs. The use of acellular vaccines for booster doses for adolescents and adults would seem unambiguous because of their decreased reactogenicity, although the exact schedule has yet to be established. The choice between the two kinds of vaccines is more difficult for primary courses, where safety and efficacy profiles are similar, and the attitude towards acellular vaccines varies from country to country. In this case, the strategy adopted results from the national history of pertussis infection and from the quality of the available whole-cell vaccine. Two contrasting examples are the US, where acellular vaccines were licensed for the primary series in the 1990s, and the UK, where whole-cell vaccines are exclusively used for primary immunization. The changing epidemiology of pertussis, and its local diversification, would suggest that at present it is difficult to define a single worldwide strategy with only one kind of vaccine and one schedule. In order to control pertussis incidence, each country should continue to determine the best national vaccination program established in very close relation to the past and present epidemiological situation and available healthcare resources.

Hypotonic-hyporesponsive episodes following pertussis vaccination: a cause for concern?

Vaccine safety has become a major community concern and of particular importance for parents, vaccine recipients and vaccine providers. A hypotonic-hyporesponsive episode (HHE) is a sudden and unexpected episode of loss of tone, unresponsiveness and colour change which uncommonly affects infants and children after vaccination. Although any vaccine may be associated with this adverse event, HHE usually follows administration of a pertussis containing vaccine. There has been renewed interest in this adverse event in the light of community concerns regarding vaccine safety. The focus of this interest has been to formulate an acceptable case definition, to document possible risk factors and to better define the outcome of HHE. In addition, studies have documented the outcome of revaccination of children who have had an HHE. Although much remains to be learnt about HHE it would appear that there are no long-term sequelae and that children who have had an HHE can be revaccinated. Parents should be provided with the available information such that they can make an assessment of the risks and benefits of pertussis vaccination. The benefits of pertussis vaccination still outweigh the risk and universal childhood pertussis vaccination should continue to be advocated.

Seroprevalence of antibodies specific for gram-negative core antigens in chickens on the basis of an Escherichia coli J5 enzyme-linked immunosorbent assay

Antibodies directed toward gram-negative core antigens (GNCAs) have been demonstrated in many mammalian species but to date are unexamined in any avian species. An enzyme-linked immunosorbent assay with phenol-killed whole cell Escherichia coli J5 was used to assess the presence of serum antibodies directed toward GNCAs in chickens. The first experiment consisted of collecting blood samples from randomly selected hens at egg laying ranches in northern California. The ages ranged from several days of age to 77 wk of age. Birds were classified into age groups (hatchling [1 day-4 wk], pullet [4-18 wk], pullet cycle [18-60 wk], and postmolt [>60 wk]) and husbandry style for titer comparison. The geometric mean titer (GMT) for all adult hens regardless of age was 2147. The geometric mean titers were 220, 5691, 2304, and 1776 for hatchlings, pullets, pullet cycle hens, and postmolt hens, respectively. The age group titer trends were similar to those of humans rather than those of farm animals in that the highest titers occurred during "adolescence" (pullets) and titers decreased slightly with maturity. The GMTs were 2870 for hens housed intensively and 1872 for those housed extensively. The second experiment looked at the progression of GNCA titers within individual birds over a 1-yr period. Individual titers increased slightly throughout the study time of the second experiment.

Monokine production following in vitro stimulation of the THP-1 human monocytic cell line with pertussis vaccine components

Whole-cell pertussis found in diphtheria-tetanus-pertussis (DTP) vaccine can produce symptoms reminiscent of biological responses to circulating proinflammatory monokines such as IL-6, IL-1beta, and TNFalpha. Therefore the ability of pertussis-containing vaccines and several heat-killed Bordetella pertussis preparations to stimulate cytokine production in a human monocytic cell line, THP-1, were examined. The whole-cell pertussis vaccine induced significantly more IL-6, IL-1beta, and TNFalpha production than did the acellular pertussis or diphtheria-tetanus-only vaccine. Polymyxin B was able to inhibit most of the IL-6 induced by pertussis endotoxin and a heat-killed preparation of B. pertussis containing a null mutation in bvgAS, a regulatory locus required for expression of all known protein virulence factors synthesized by this organism. However, it only partially inhibited IL-6 production induced by other pertussis-containing preparations, including DTP vaccine. These results indicate that in vitro whole-cell vaccine is a potent stimulator of IL-6, IL-1beta, and TNFalpha. They also suggest that although endotoxin is a major inducer of IL-6, other components of B. pertussis also contribute to IL-6 production by monocytes.

Combined diphtheria, tetanus, pertussis, and Haemophilus influenzae type b vaccines for primary immunisation

A total of 146 infants were immunised at ages 2, 3, and 4 months with a combined diphtheria, tetanus, pertussis (DTP)--Haemophilus influenzae type b (Hib) tetanus toxoid conjugate (PRP-T) vaccine (Pasteur Merieux) to assess the antibody response and adverse events associated with immunisation. Adverse events, including fever, were recorded by parents in a diary for three days following each injection. Blood was taken before the first immunisation and four weeks after the third immunisation to assess antibody response. Data were compared with those from historical controls who had received DTP and PRP-T vaccines by separate injection. The combined vaccine was well tolerated. Rates of local and general reactions were similar to those reported for infants immunised by separate injection. All infants achieved protective antibody titres (> 0.01 IU/ml) for diphtheria and tetanus; 98% acquired Hib (PRP) antibody > 0.15 microgram/ml and 82.5% > 1.0 microgram/ml. Pertussis antibody titres (pertussis toxin, filamentous haemagglutinin, total agglutinins, and agglutinins 2 and 3) showed appreciable rise following immunisation. DTP and PRP-T vaccines provide similar antibody responses and adverse effects whether mixed in the same syringe or administered by separate injection. The vaccines could be combined for use in the United Kingdom primary immunisation schedule.

Interaction of Haemophilus influenzae type b conjugate vaccines with diphtheria-tetanus-pertussis vaccine in control tests

The effects of combining three Haemophilus influenzae type b (Hib) capsular polysaccharide vaccines, conjugated to different proteins, with DTP vaccine on the subsequent control testing were examined. The addition of the Hib vaccines had little effect on the reactogenicity or the potency of the whole-cell pertussis component. The potency of, and antibody responses to, the diphtheria component were also unaffected in all three combinations. However, combination with the Hib vaccine comprising polysaccharide conjugated to tetanus toxoid resulted in a fivefold potentiation of the tetanus potency and large increases in the antibody responses to tetanus toxin and toxoid and Hib polysaccharide. These results have implications for the control testing of combined vaccines containing a whole-cell pertussis component and Hib polysaccharide-tetanus protein conjugate vaccine.

Comparison of acellular and whole-cell pertussis-component diphtheria-tetanus-pertussis vaccines in infants. The APDT Vaccine Study Group

In a multicenter, double-blind, randomized, longitudinal study, 252 children received licensed Lederle diphtheria-tetanus toxoids and pertussis vaccine adsorbed (DTP) at 2, 4, and 6 months of age, and 245 children received a DTP vaccine with the Lederle/Takeda acellular pertussis component (APDT) at the same ages. Both groups of children received APDT vaccine at 18 months of age. After each of the first three immunizations, APDT vaccine recipients had fewer local and systemic reactions than did DTP vaccinees. Reactions after the 18-month APDT vaccination were minimal in severity regardless of the vaccine previously received. Antibody responses to lymphocytosis-promoting factor and agglutinogens were more pronounced in DTP recipients; however, APDT recipients had a better serologic response to filamentous hemagglutinin, and responses to the 69K protein were equivalent. This APDT vaccine produces fewer reactions than the standard whole-cell DTP vaccine. The protective significance of the serologic responses to the APDT vaccine is unknown, but the greater response to filamentous hemagglutinin and equivalent response to the 69K protein compared with those to DTP vaccine seem promising.