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Mao Q, Xu M, He Q, Li C, Meng S, Wang Y, Cui B, Liang Z, Wang J. COVID-19 vaccines: progress and understanding on quality control and evaluation. Signal Transduct Target Ther 2021; 6:199. [PMID: 34006829 PMCID: PMC8129697 DOI: 10.1038/s41392-021-00621-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 04/19/2021] [Accepted: 04/26/2021] [Indexed: 11/09/2022] Open
Abstract
The outbreak of COVID-19 has posed a huge threat to global health and economy. Countermeasures have revolutionized norms for working, socializing, learning, and travel. Importantly, vaccines have been considered as most effective tools to combat with COVID-19. As of the beginning of 2021, >200 COVID-19 vaccine candidates, covering nearly all existing technologies and platforms, are being research and development (R&D) by multiple manufacturers worldwide. This has posed a huge obstacle to the quality control and evaluation of those candidate vaccines, especially in China, where five vaccine platforms are deployed in parallel. To accelerate the R&D progress of COVID-19 vaccines, the guidances on R&D of COVID-19 vaccine have been issued by National Regulatory Authorities or organizations worldwide. The Center for Drug Evaluation and national quality control laboratory in China have played a leading role in launching the research on quality control and evaluation in collaboration with relevant laboratories involved in the vaccine R&D, which greatly supported the progression of vaccines R&D, and accelerated the approval for emergency use and conditional marketing of currently vaccine candidates. In this paper, the progress and experience gained in quality control and evaluation of COVID-19 vaccines developed in China are summarized, which might provide references for the R&D of current and next generation of COVID-19 vaccines worldwide.
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Affiliation(s)
- Qunying Mao
- National Institutes for Food and Drug Control, Beijing, China
| | - Miao Xu
- National Institutes for Food and Drug Control, Beijing, China
| | - Qian He
- National Institutes for Food and Drug Control, Beijing, China
| | - Changgui Li
- National Institutes for Food and Drug Control, Beijing, China
| | - Shufang Meng
- National Institutes for Food and Drug Control, Beijing, China
| | - Yiping Wang
- National Institutes for Food and Drug Control, Beijing, China
| | - Bopei Cui
- National Institutes for Food and Drug Control, Beijing, China
| | - Zhenglun Liang
- National Institutes for Food and Drug Control, Beijing, China.
| | - Junzhi Wang
- National Institutes for Food and Drug Control, Beijing, China.
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Zhang L, Yu C, Ge Z, Tao H, Meng F, Xu X, Tian T, Song C, Hu Z, Li J, Zhu F. Whole exome sequencing reveals the different responsiveness to Enterovirus 71 vaccination in Chinese children. Int J Infect Dis 2020; 97:47-53. [DOI: 10.1016/j.ijid.2020.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 06/04/2020] [Accepted: 06/04/2020] [Indexed: 10/24/2022] Open
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Wei M, Meng F, Wang S, Li J, Zhang Y, Mao Q, Hu Y, Liu P, Shi N, Tao H, Chu K, Wang Y, Liang Z, Li X, Zhu F. 2-Year Efficacy, Immunogenicity, and Safety of Vigoo Enterovirus 71 Vaccine in Healthy Chinese Children: A Randomized Open-Label Study. J Infect Dis 2016; 215:56-63. [DOI: 10.1093/infdis/jiw502] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 10/13/2016] [Indexed: 11/13/2022] Open
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Zhou Y, Li JX, Jin PF, Wang YX, Zhu FC. Enterovirus 71: a whole virion inactivated enterovirus 71 vaccine. Expert Rev Vaccines 2016; 15:803-13. [PMID: 27206811 DOI: 10.1080/14760584.2016.1191357] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Enterovirus A71 (EV71) is the predominant causative agent of hand, foot, and mouth disease (HFMD), which is often associated with severe cases and even deaths. EV71-associated epidemics have emerged as a serious threat to public health, particularly in the Asia-Pacific region. AREAS COVERED We searched PubMed using the terms 'enterovirus 71', 'hand, foot, and mouth disease', and 'vaccine', with no date or language restrictions for all publications before April 27, 2016. Among various vaccine candidates, the alum-adjuvant inactivated EV71 vaccines are most promising. Three alum-adjuvant inactivated EV71 vaccines developed by mainland China showed high efficacy, good immunogenicity persistence and acceptable safety profiles in clinical trials. Recently, two of these EV71 vaccines have been approved for marketing in China and the other one is undergoing the review process of licensure. In this manuscript, we summarized previous study results as well as discussed the regulatory affairs and post-market surveillances issues. Expert commentary: The marketing of EV71 vaccines is a milestone in the controlling of HFMD. International clinical trials are needed to further assess the efficacy and cross-immunogenicity. Establishing a sensitive pathogen monitoring system would be essential to monitor the variation of genotypes and control HFMD epidemics.
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Affiliation(s)
- Yang Zhou
- a School of Public Health , Southeast University , Nanjing , PR China
| | - Jing-Xin Li
- b Department of Vaccine Clinical Evaluation , Jiangsu Provincial Center for Disease Control and Prevention , Nanjing , PR China.,c College of Pharmacy , Third Military Medical University & National Engineering Research Center for Immunological Products , Chongqing , PR China
| | - Peng-Fei Jin
- d School of Public Health , Nanjing Medical University , Nanjing , PR China
| | - Yu-Xiao Wang
- a School of Public Health , Southeast University , Nanjing , PR China
| | - Feng-Cai Zhu
- b Department of Vaccine Clinical Evaluation , Jiangsu Provincial Center for Disease Control and Prevention , Nanjing , PR China
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Seroprevalence of Enterovirus 71 Antibody Among Children in China: A Systematic Review and Meta-analysis. Pediatr Infect Dis J 2015; 34:1399-406. [PMID: 26368058 PMCID: PMC4718881 DOI: 10.1097/inf.0000000000000900] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Hand, foot and mouth disease mostly affects children and carries a substantial disease burden in the Western Pacific region. Enterovirus 71 (EV71) is the most virulent causative agent, and a monovalent vaccine against EV71 will soon become commercially available in China. An improved understanding of EV71 epidemiology would aid policy decisions regarding childhood immunization in China. We aimed to assess and summarize information to date from individual seroepidemiologic studies of EV71 in mainland China to determine patterns of the age-specific risk of infection. METHODS A systematic review and meta-analysis of studies of children aged 0-15 years, published in English or Chinese, was conducted. Estimates of seroprevalence were summarized by age group. A mixed-effects regression model was used to explore factors covarying with EV71 seroprevalence. RESULTS We identified 42 published studies, 15 in English. We found that an average of 78% of neonates was seropositive to EV71 infection, but such maternally conferred immunity almost completely waned by 5 months. The seroprevalence of EV71 antibody increased directly with age among preschool children, from 26% (95% confidence interval: 18%-33%) at 1 year to 70% (95% confidence interval: 62%-78%) at 5 years. Age of subjects, sample size, sampling year, sampling method, geographic latitude and publication language were associated with variations of individual seroprevalence estimates. CONCLUSIONS Seroprevalence of EV71 antibody gradually declined during the first 5 months in infants. Infection of EV71 was most likely to occur between 2 and 4 years. Our findings may be useful in informing population-based EV71 vaccination strategies.
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Mao Q, Wang Y, Shao J, Ying Z, Gao F, Yao X, Li C, Ye Q, Xu M, Li R, Zhu F, Liang Z. The compatibility of inactivated-Enterovirus 71 vaccination with Coxsackievirus A16 and Poliovirus immunizations in humans and animals. Hum Vaccin Immunother 2015; 11:2723-33. [PMID: 25715318 DOI: 10.1080/21645515.2015.1011975] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Enterovirus 71 (EV71) is the key pathogen for Hand, Foot, and Mouth Disease (HFMD) and can result in severe neurological complications and death among young children. Three inactivated-EV71 vaccines have gone through phase III clinical trials and have demonstrated good safety and efficacy. These vaccines will benefit young children under the threat of severe HFMD. However, the potential immunization-related compatibility for different enterovirus vaccines remains unclear, making it hard to include the EV71 vaccine in Expanded Program on Immunization (EPI). Here, we measured the neutralizing antibodies (NTAbs) against EV71, Coxsackievirus A16 (CA16) and Poliovirus from infants enrolled in those EV71 vaccine clinical trials. The results indicated that the levels of NTAb GMTs for EV71 increased significantly in all 3 vaccine groups (high, middle and low dosages, respectively) post-vaccination. Seroconversion ratios and Geometric mean fold increase were significantly higher in the vaccine groups (≥ 7/9 and 8.9 ~ 228.1) than in the placebo group (≤ 1/10 and 0.8 ~ 1.7, P < 0.05). But no similar NTAb response trends were found in CA16 and 3 types of Poliovirus. The decrease of 3 types of Poliovirus NTAb GMTs and an increase of CA16 GMTs post-EV71-vaccination were found in vaccine and placebo groups. Further animal study on CA16 and poliovirus vaccine co-immunization or pre-immunization with EV71 vaccine in mice indicated that there was no NTAb cross-activity between EV71 and CA16/Poliovirus. Our research showed that inactivated-EV71 vaccine has good specific-neutralizing capacity and can be included in EPI.
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Affiliation(s)
- Qunying Mao
- a National Institutes for Food and Drug Control ; Beijing , China
| | - Yiping Wang
- a National Institutes for Food and Drug Control ; Beijing , China
| | - Jie Shao
- a National Institutes for Food and Drug Control ; Beijing , China
| | - Zhifang Ying
- a National Institutes for Food and Drug Control ; Beijing , China
| | - Fan Gao
- a National Institutes for Food and Drug Control ; Beijing , China
| | - Xin Yao
- a National Institutes for Food and Drug Control ; Beijing , China
| | - Changgui Li
- a National Institutes for Food and Drug Control ; Beijing , China
| | - Qiang Ye
- a National Institutes for Food and Drug Control ; Beijing , China
| | - Miao Xu
- a National Institutes for Food and Drug Control ; Beijing , China
| | - Rongcheng Li
- b The Center for Disease Control and Prevention of the Guangxi Zhuang Autonomous Region ; Nanning , China
| | - Fengcai Zhu
- c Jiangsu Provincial Center for Disease Control and Prevention ; Nanjing , China
| | - Zhenglun Liang
- a National Institutes for Food and Drug Control ; Beijing , China
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Li L, Yin H, An Z, Feng Z. Considerations for developing an immunization strategy with enterovirus 71 vaccine. Vaccine 2014; 33:1107-12. [PMID: 25444807 DOI: 10.1016/j.vaccine.2014.10.081] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Revised: 10/21/2014] [Accepted: 10/30/2014] [Indexed: 12/16/2022]
Abstract
Enterovirus 71 (EV71) is a common pathogen for hand, foot, and mouth disease (HFMD), which has significant morbidity and mortality, and for which children aged 6-59 months age are at highest risk. Due to lack of effective treatment options, control of EV71 epidemics has mainly focused on development of EV71 vaccines. Clinical trials have been completed on 3 EV71 vaccines, with trial results demonstrating good vaccine efficacy and safety. When EV71 vaccine is approved by China's national regulatory authority, an evidence-based strategy should be developed to optimize impact and safety. An immunization strategy for EV71 vaccine should consider several factors, including the target population age group, the number of doses for primary immunization, the need for a booster dose, concomitant administration of other vaccines, economic value, program capacity and logistics, and public acceptance. Once EV71 vaccines are in use, vaccine effectiveness and safety must be monitored in large populations, and the epidemiology of HFMD must be evaluated to assure a match between vaccination strategy and epidemiology. Evaluation in China is especially important because there are no other EV71 vaccines globally.
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Affiliation(s)
- Li Li
- Chinese Center for Disease Control and Prevention, Beijing 100050, China
| | - Hongzhang Yin
- The Center for Drug Evaluation, China Food and Drug Administration, Beijing 100050, China
| | - Zhijie An
- Chinese Center for Disease Control and Prevention, Beijing 100050, China
| | - Zijian Feng
- Chinese Center for Disease Control and Prevention, Beijing 100050, China.
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Cheng J, Wu J, Xu Z, Zhu R, Wang X, Li K, Wen L, Yang H, Su H. Associations between extreme precipitation and childhood hand, foot and mouth disease in urban and rural areas in Hefei, China. THE SCIENCE OF THE TOTAL ENVIRONMENT 2014; 497-498:484-490. [PMID: 25150743 DOI: 10.1016/j.scitotenv.2014.08.006] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Revised: 08/01/2014] [Accepted: 08/04/2014] [Indexed: 06/03/2023]
Abstract
BACKGROUND Understanding the relationship between extreme weather events and childhood hand, foot and mouth disease (HFMD) is important in the context of climate change. This study aimed to quantify the relationship between extreme precipitation and childhood HFMD in Hefei, China, and further, to explore whether the association varied across urban and rural areas. METHODS Daily data on HFMD counts among children aged 0-14 years from 2010 January 1st to 2012 December 31st were retrieved from Hefei Center for Disease Control and Prevention. Daily data on mean temperature, relative humidity and precipitation during the same period were supplied by Hefei Bureau of Meteorology. We used a Poisson linear regression model combined with a distributed lag non-linear model to assess the association between extreme precipitation (≥90th precipitation) and childhood HFMD, controlling for mean temperature, humidity, day of week, and long-term trend. RESULTS There was a statistically significant association between extreme precipitation and childhood HFMD. The effect of extreme precipitation on childhood HFMD was the greatest at six days lag, with a 5.12% (95% confident interval: 2.7-7.57%) increase of childhood HFMD for an extreme precipitation event versus no precipitation. Notably, urban children and children aged 0-4 years were particularly vulnerable to the effects of extreme precipitation. CONCLUSIONS Our findings indicate that extreme precipitation may increase the incidence of childhood HFMD in Hefei, highlighting the importance of protecting children from forthcoming extreme precipitation, particularly for those who are young and from urban areas.
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Affiliation(s)
- Jian Cheng
- Department of Epidemiology and Health Statistics, School of Public Health, Anhui Medical University, Hefei, Anhui 230032, China
| | - Jinju Wu
- Hefei Center for Disease Control and Prevention of Anhui Province, Hefei, Anhui 230061, China
| | - Zhiwei Xu
- School of Public Health and Social Work & Institute of Health and Biomedical Innovation, Queensland University of Technology, Kelvin Grove, Brisbane, Qld 4509, Australia
| | - Rui Zhu
- Department of Child and Maternal Health Care, School of Public Health, Anhui Medical University, Hefei, Anhui 230032, China
| | - Xu Wang
- Department of Epidemiology and Health Statistics, School of Public Health, Anhui Medical University, Hefei, Anhui 230032, China
| | - Kesheng Li
- Department of Epidemiology and Health Statistics, School of Public Health, Anhui Medical University, Hefei, Anhui 230032, China
| | - Liying Wen
- Department of Epidemiology and Health Statistics, School of Public Health, Anhui Medical University, Hefei, Anhui 230032, China
| | - Huihui Yang
- Department of Epidemiology and Health Statistics, School of Public Health, Anhui Medical University, Hefei, Anhui 230032, China
| | - Hong Su
- Department of Epidemiology and Health Statistics, School of Public Health, Anhui Medical University, Hefei, Anhui 230032, China.
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Benschop KSM, Wolthers KC. The need for concerted action against the cousins of poliovirus. Future Virol 2014. [DOI: 10.2217/fvl.14.38] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Kimberley SM Benschop
- Centre for Infectious Diseases Research, Diagnostics, & Screening, National Institute for Public Health & the Environment, PO Box 1, 3720BA, Bilthoven, The Netherlands
| | - Katja C Wolthers
- Laboratory of Clinical Virology, Department of Medical Microbiology, Academic Medical Center, Amsterdam, The Netherlands
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A neonatal gnotobiotic pig model of human enterovirus 71 infection and associated immune responses. Emerg Microbes Infect 2014; 3:e35. [PMID: 26038741 PMCID: PMC4051366 DOI: 10.1038/emi.2014.35] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Revised: 02/10/2014] [Accepted: 03/25/2014] [Indexed: 12/13/2022]
Abstract
Vaccine development and pathogenesis studies for human enterovirus 71 are limited by a
lack of suitable animal models. Here, we report the development of a novel neonatal
gnotobiotic pig model using the non-pig-adapted neurovirulent human enterovirus 71 strain
BJ110, which has a C4 genotype. Porcine small intestinal epithelial cells, peripheral
blood mononuclear cells and neural cells were infected in vitro. Oral and
combined oral–nasal infection of 5-day-old neonatal gnotobiotic pigs with
5×108 fluorescence forming units (FFU) resulted in shedding up to 18
days post-infection, with viral titers in rectal swab samples peaking at
2.22×108 viral RNA copies/mL. Viral capsid proteins were detected in
enterocytes within the small intestines on post-infection days (PIDs) 7 and 14.
Additionally, viral RNA was detected in intestinal and extra-intestinal tissues, including
the central nervous system, the lung and cardiac muscle. The infected neonatal gnotobiotic
pigs developed fever, forelimb weakness, rapid breathing and some hand, foot and mouth
disease symptoms. Flow cytometry analysis revealed increased frequencies of both
CD4+ and CD8+ IFN-γ-producing T cells in the brain
and the blood on PID 14, but reduced frequencies were observed in the lung. Furthermore,
high titers of serum virus-neutralizing antibodies were generated in both orally and
combined oral–nasally infected pigs on PIDs 7, 14, 21 and 28. Together, these
results demonstrate that neonatal gnotobiotic pigs represent a novel animal model for
evaluating vaccines for human enterovirus 71 and for understanding the pathogenesis of
this virus and the associated immune responses.
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Abstract
BACKGROUND An effective enterovirus 71 (EV71) vaccine is needed to control the annual outbreaks of hand, foot and mouth disease (HFMD) in China. Adequate epidemiologic data relating to HFMD are needed to make decisions about appropriate public health interventions and implementation of the new EV71 vaccine. METHODS We analyzed the population-based epidemiologic characteristics, clinical outcome and laboratory investigation of the 2011 HFMD outbreak in children based on the citywide surveillance system in Shanghai. RESULTS The incidence rate of HFMD was 25.8 per 1000 in children <10 years of age in Shanghai in 2011, ranging from 2.5 per 1000 in the age group 7 to 9.9 years to 48.4 per 1000 in the age group 3 to 3.9 years. Children 1 to 1.9 years were at the highest risk of developing severe complications and most susceptible to HFMD. Boys and migrant children had significantly increased risks of contracting HFMD and developing severe disease. More institutional clusters/outbreaks occurred in the winter peak months than in the summer peak months. Migrant young children played a central role in the spread of HFMD in the community. EV71 was identified in 39.7% of mild HFMD outpatients, 47.4% of hospitalized patients, 92.1% of severe inpatients with complications, 50% of outbreaks and 38.8% of clusters in institutions. CONCLUSION HFMD and EV71 infections have a significant health effect on Shanghai children.
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Cryo-electron microscopy study of insect cell-expressed enterovirus 71 and coxsackievirus a16 virus-like particles provides a structural basis for vaccine development. J Virol 2014; 88:6444-52. [PMID: 24672036 DOI: 10.1128/jvi.00200-14] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
UNLABELLED Enterovirus 71 (EV71) and coxsackievirus A16 (CA16) are the two most common etiological agents responsible for the epidemics of hand, foot, and mouth disease (HFMD), a childhood illness with occasional severe neurological complications. A number of vaccine candidates against EV71 or CA16 have been reported; however, no vaccine is currently available for clinical use. Here, we generated a secreted version of EV71 and CA16 virus-like particles (VLPs) using a baculovirus-insect cell expression system and reconstructed the three-dimensional (3D) structures of both VLPs by cryo-electron microscopy (cryo-EM) single-particle analysis at 5.2-Å and 5.5-Å resolutions, respectively. The reconstruction results showed that the cryo-EM structures of EV71 and CA16 VLPs highly resemble the recently published crystal structures for EV71 natural empty particles and CA16 135S-like expanded particles, respectively. Our cryo-EM analysis also revealed that the majority of previously identified linear neutralizing epitopes are well preserved on the surface of EV71 and CA16 VLPs. In addition, both VLPs were able to induce efficiently neutralizing antibodies against various strains of EV71 and CA16 viruses in mouse immunization. These studies provide a structural basis for the development of insect cell-expressed VLP vaccines and for a potential bivalent VLP vaccine against both EV71- and CA16-associated HFMD. IMPORTANCE The recent outbreaks of hand, foot, and mouth disease (HFMD) in the Asia Pacific region spurred the search for effective vaccines against EV71 and CA16 viruses, the two most common etiological agents responsible for HFMD. In this paper, we show that secreted versions of EV71 and CA16 VLPs generated in the baculovirus-insect cell expression system highly resemble the crystal structures of their viral conterparts and that the majority of previously identified linear neutralizing epitopes are well preserved on the VLP surfaces. In addition, the generated VLPs can efficiently induce neutralizing antibodies against various strains of EV71 and CA16 viruses in mouse immunization. These studies provide a structural basis for the development of insect cell-expressed VLP vaccines and for a potential bivalent VLP vaccine against both EV71- and CA16-associated HFMD.
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Li JX, Mao QY, Liang ZL, Ji H, Zhu FC. Development of enterovirus 71 vaccines: from the lab bench to Phase III clinical trials. Expert Rev Vaccines 2014; 13:609-18. [PMID: 24621093 DOI: 10.1586/14760584.2014.897617] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The widespread epidemics of enterovirus 71 (EV71) seriously affected the Western Pacific Region. Young children, especially those younger than 3 years are the most susceptible population to the EV71-associated diseases. Several Asian countries have begun to focus on the research and development of EV71 vaccines. Five inactivated whole-virus EV71 candidate vaccines (three were manufactured in mainland China based on a C4 genotype strain, one in Taiwan based on a B4 genotype strain and one in Singapore based on a B2 genotype strain) have been assessed in clinical trials. Three candidate vaccines developed in mainland China have already completed Phase III clinical trials recently. The tested EV71 vaccine could provide good efficacy, satisfactory safety, and high immunogenicity. Thus, inactivated EV71 vaccines are expected to become the first available vaccines against EV71 in the near future.
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Affiliation(s)
- Jing-Xin Li
- College of Pharmacy, Third Military Medical University and National Engineering Research Center for Immunological Products, Chongqing, PR China
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Wang SM, Liu CC. Update of enterovirus 71 infection: epidemiology, pathogenesis and vaccine. Expert Rev Anti Infect Ther 2014; 12:447-56. [PMID: 24579906 DOI: 10.1586/14787210.2014.895666] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Enterovirus 71 (EV71) is a neurotropic human pathogen that is the causative agent of hand foot and mouth disease (HFMD), herpangina and brain stem encephalitis. Recurrent EV71 epidemics of various scales have occurred in the Asia-Pacific region. Several specific cell surface molecules serve as the receptors for EV71. Identification of the receptors is an important step to understand EV71 disease. Cytokines, lymphocytes and monocytes contribute significantly to EV71 pathogenesis. The interaction of EV71 and receptors may be associated with the cytokines immunopathogenesis. Some animal models have been established and aim to explore the pathogenesis of EV71 infections. EV71 antibodies can neutralize or enhance infection at subneutralizing levels. These results are important for EV71 vaccine and therapeutics design. Several clinical trials of human inactivated EV71 vaccine have recently been completed. The purpose of this review is to summarize recent discoveries about the epidemiology and pathogenesis of EV71 and provide insights into human vaccine development.
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Affiliation(s)
- Shih-Min Wang
- Department of Emergency Medicine, College of Medicine, National Cheng Kung University and Hospital, Tainan, Taiwan
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Zhu F, Xu W, Xia J, Liang Z, Liu Y, Zhang X, Tan X, Wang L, Mao Q, Wu J, Hu Y, Ji T, Song L, Liang Q, Zhang B, Gao Q, Li J, Wang S, Hu Y, Gu S, Zhang J, Yao G, Gu J, Wang X, Zhou Y, Chen C, Zhang M, Cao M, Wang J, Wang H, Wang N. Efficacy, safety, and immunogenicity of an enterovirus 71 vaccine in China. N Engl J Med 2014; 370:818-28. [PMID: 24571754 DOI: 10.1056/nejmoa1304923] [Citation(s) in RCA: 357] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Enterovirus 71 (EV71) is one of the major causative agents of outbreaks of hand, foot, and mouth disease or herpangina worldwide. This phase 3 trial was designed to evaluate the efficacy, safety, and immunogenicity of an EV71 vaccine. METHODS We conducted a randomized, double-blind, placebo-controlled, multicenter trial in which 10,007 healthy infants and young children (6 to 35 months of age) were randomly assigned in a 1:1 ratio to receive two intramuscular doses of either EV71 vaccine or placebo, 28 days apart. The surveillance period was 12 months. The primary end point was the occurrence of EV71-associated hand, foot, and mouth disease or herpangina. RESULTS During the 12-month surveillance period, EV71-associated disease was identified in 0.3% of vaccine recipients (13 of 5041 children) and 2.1% of placebo recipients (106 of 5028 children) in the intention-to-treat cohort. The vaccine efficacy against EV71-associated hand, foot, and mouth disease or herpangina was 94.8% (95% confidence interval [CI], 87.2 to 97.9; P<0.001) in this cohort. Vaccine efficacies against EV71-associated hospitalization (0 cases vs. 24 cases) and hand, foot, and mouth disease with neurologic complications (0 cases vs. 8 cases) were both 100% (95% CI, 83.7 to 100 and 42.6 to 100, respectively). Serious adverse events occurred in 111 of 5044 children in the vaccine group (2.2%) and 131 of 5033 children in the placebo group (2.6%). In the immunogenicity subgroup (1291 children), an anti-EV71 immune response was elicited by the two-dose vaccine series in 98.8% of participants at day 56. An anti-EV71 neutralizing antibody titer of 1:16 was associated with protection against EV71-associated hand, foot, and mouth disease or herpangina. CONCLUSIONS The EV71 vaccine provided protection against EV71-associated hand, foot, and mouth disease or herpangina in infants and young children. (Funded by Sinovac Biotech; ClinicalTrials.gov number, NCT01507857.).
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Affiliation(s)
- Fengcai Zhu
- From the Jiangsu Provincial Center for Disease Control and Prevention, Nanjing (F.Z., X.Z., Yuemei Hu, Q.L., J.L., S.W., H.W.); National Institutes for Viral Disease Control and Prevention, Chinese Center for Disease Control and Prevention (W.X., X.T., T.J., B.Z.), National Institutes for Food and Drug Control (Z.L., Q.M., J. Wang), and Sinovac Biotech (Y.L., J. Wu, L.S., Q.G., Yuansheng Hu, N.W.), Beijing; the Fourth Military Medical University, Xi'an (J.X., L.W.); Sheyang County Center for Disease Control and Prevention, Yancheng City (S.G., J.G., C.C.); Ganyu County Center for Disease Control and Prevention, No. 98, Lianyungang City (J.Z., X.W., M.Z.); and Taixing County Center for Disease Control and Prevention, No. 224, Taizhou City (G.Y., Y.Z., M.C.) - all in China
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Abzug MJ. The enteroviruses: Problems in need of treatments. J Infect 2014; 68 Suppl 1:S108-14. [DOI: 10.1016/j.jinf.2013.09.020] [Citation(s) in RCA: 83] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2013] [Indexed: 01/26/2023]
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Mao Q, Cheng T, Zhu F, Li J, Wang Y, Li Y, Gao F, Yang L, Yao X, Shao J, Xia N, Liang Z, Wang J. The cross-neutralizing activity of enterovirus 71 subgenotype c4 vaccines in healthy chinese infants and children. PLoS One 2013; 8:e79599. [PMID: 24260259 PMCID: PMC3834186 DOI: 10.1371/journal.pone.0079599] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2013] [Accepted: 09/24/2013] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND EV71 is one of major etiologic causes of hand-foot-mouth disease (HFMD) and leads to severe neurological complications in young children and infants. Recently inactivated EV71 vaccines have been developed by five manufactures and clinically show good safety and immunogenicity. However, the cross-neutralizing activity of these vaccines remains unclear, and is of particular interest because RNA recombination is seen more frequently in EV71 epidemics. METHODOLOGY/PRINCIPAL FINDINGS In this post-hoc study, sera from a subset of 119 infants and children in two clinical trials of EV71 subgenotype C4 vaccines (ClinicalTrials.gov Identifier: NCT01313715 and NCT01273246), were detected for neutralizing antibody (NTAb) titres with sera from infected patients as controls. Cytopathogenic effect method was employed to test NTAb against EV71 subgenotype B4, B5, C2, C4 and C5, which were prominent epidemic strains worldwide over the past decade. To validate the accuracy of the results, ELISpot assay was employed in parallel to detect NTAb in all the post-vaccine sera. After two-dose vaccination, 49 out of 53 participants in initially seronegative group and 52 out of 53 participants in initially seropositive group showed less than 4-fold differences in NTAb titers against five EV71 strains, whereas corresponding values among sera from pediatric patients recovering from EV71-induced HFMD and subclinically infected participants were 8/8 and 41/43, respectively. The geometric mean titers of participants against five subgenotypes EV71 all grew significantly after vaccinations, irrespective of the baseline NTAb titer. The relative fold increase in antibody titers (NTAb-FI) against B4, B5, C2, and C5 displayed a positive correlation to the NTAb-FI against C4. CONCLUSIONS/SIGNIFICANCE The results demonstrated broad cross-neutralizing activity induced by two C4 EV71 vaccines in healthy Chinese infants and children. However, the degree of induced cross-protective immunity, and the potential escape evolution for EV71 still need to be monitored and researched in future for these new vaccines.
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Affiliation(s)
- Qunying Mao
- National Institutes for Food and Drug Control, Beijing, China
| | - Tong Cheng
- National Institute of Diagnostics and Vaccine Development in Infectious Disease, School of Life Science, Xiamen University, Xiamen, China
| | - Fengcai Zhu
- Jiangsu Provincial Center for Disease Control and Prevention, Nanjing, China
| | - Jingxin Li
- Jiangsu Provincial Center for Disease Control and Prevention, Nanjing, China
| | - Yiping Wang
- National Institutes for Food and Drug Control, Beijing, China
| | - Yanping Li
- The Center for Disease Control and Prevention of the Guangxi Zhuang Autonomous Region, Nanning, China
| | - Fan Gao
- National Institutes for Food and Drug Control, Beijing, China
| | - Lisheng Yang
- National Institute of Diagnostics and Vaccine Development in Infectious Disease, School of Life Science, Xiamen University, Xiamen, China
| | - Xin Yao
- National Institutes for Food and Drug Control, Beijing, China
| | - Jie Shao
- National Institutes for Food and Drug Control, Beijing, China
| | - Ningshao Xia
- National Institute of Diagnostics and Vaccine Development in Infectious Disease, School of Life Science, Xiamen University, Xiamen, China
| | - Zhenglun Liang
- National Institutes for Food and Drug Control, Beijing, China
- * E-mail: (ZL); (JW)
| | - Junzhi Wang
- National Institutes for Food and Drug Control, Beijing, China
- * E-mail: (ZL); (JW)
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Immunogenicity, safety, and lot consistency of a novel inactivated enterovirus 71 vaccine in Chinese children aged 6 to 59 months. CLINICAL AND VACCINE IMMUNOLOGY : CVI 2013; 20:1805-11. [PMID: 24108780 DOI: 10.1128/cvi.00491-13] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The determination of lot-to-lot consistency in the manufacturing process is a mandatory step in the clinical development of the novel enterovirus 71 (EV71) vaccine. A phase III, randomized, placebo-controlled, double-blind trial assessed the lot consistency, immunogenicity, and safety of the EV71 vaccine in children aged 6 to 59 months. Healthy children (n = 1,400) received one of three lots of the EV71 vaccine containing 400 U of EV71 antigen or a placebo at days 0 and 28. Blood samples were collected before dose 1 and at 28 days after dose 2 (day 56) for an anti-EV71 neutralizing antibody (NTAb) assay. The geometric mean titer (GMT) and the seropositivity rates (with titers of ≥1:8) were compared at day 56. After each dose, the solicited injection site and general adverse events (AEs) were recorded for 7 days, and unsolicited AEs were recorded for 28 days. At day 56, the seropositivity rates ranged from 99.7% to 100% for the vaccine groups. The NTAb GMTs for the vaccine were 140.3 (95% confidence interval [CI], 117.8 to 167.1), 141.5 (95% CI, 118.0 to 169.6), and 146.6 (95% CI, 122.5 to 175.3). The two-sided 95% CI of the log difference in GMTs between the pairs of lots were between -0.176 and 0.176, therefore meeting the predefined equivalence criteria. The percentages of subjects reporting any injection site AEs, general AEs, or serious AEs were similar across the four vaccination groups. In conclusion, the demonstration of consistency between the manufacturing lots confirms for the purposes of clinical development the reliability of the EV71 vaccine production process. (This study has been registered at ClinicalTrials.gov under registration no. NCT01636245.).
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Kiener TK, Premanand B, Kwang J. Immune responses to baculovirus-displayed enterovirus 71 VP1 antigen. Expert Rev Vaccines 2013; 12:357-64. [PMID: 23560917 DOI: 10.1586/erv.13.18] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The increased distribution and neurovirulence of enterovirus 71 is an important health threat for young children in Asia Pacific. Vaccine design has concentrated on inactivated virus with the most advanced undergoing Phase III clinical trials. By using a subunit vaccine approach, production costs could be reduced by lowering the need for biocontainment. In addition, novel mutations could be rapidly incorporated to reflect the emergence of new enterovirus 71 subgenogroups. To circumvent the problems associated with conventional subunit vaccines, the antigen can be displayed on a viral vector that conveys stability and facilitates purification. Additional advantages of viral-vectored subunit vaccines are their ability to stimulate the innate immune system by transducing cells and the possibility of oral or nasal delivery, which dispenses with the need for syringes and medical personnel. Baculovirus-displayed VP1 combines all these benefits with protection that is as efficient as inactivated virus.
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Affiliation(s)
- Tanja K Kiener
- Animal Health Biotechnology, Temasek Life Sciences Laboratory, Singapore
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Li YP, Liang ZL, Xia JL, Wu JY, Wang L, Song LF, Mao QY, Wen SQ, Huang RG, Hu YS, Yao X, Miao X, Wu X, Li RC, Wang JZ, Yin WD. Immunogenicity, Safety, and Immune Persistence of a Novel Inactivated Human Enterovirus 71 Vaccine: A Phase II, Randomized, Double-Blind, Placebo-Controlled Trial. J Infect Dis 2013; 209:46-55. [DOI: 10.1093/infdis/jit429] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Liang ZL, Mao QY, Wang YP, Zhu FC, Li JX, Yao X, Gao F, Wu X, Xu M, Wang JZ. Progress on the research and development of inactivated EV71 whole-virus vaccines. Hum Vaccin Immunother 2013; 9:1701-5. [PMID: 23744508 PMCID: PMC3906269 DOI: 10.4161/hv.24949] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2013] [Accepted: 05/06/2013] [Indexed: 12/12/2022] Open
Abstract
The prevalence of diseases caused by EV71 infection has become a serious public health problem in the Western Pacific region. Due to a lack of effective treatment options, controlling EV71 epidemics has mainly focused on the research and development (R&D) of EV71 vaccines. Thus far, five organizations have completed pre-clinical studies focused on the development of inactivated EV71 whole-virus vaccines, including vaccine strain screening, process optimization, safety and immunogenicity evaluation, and are in different stages of clinical trials. Among these organizations, three companies in Mainland China [Beijing Vigoo Biological Co., Ltd. (Vigoo), Sinovac Biotech Ltd. (Sinovac) and Institute of Medical Biology, Chinese Academy of Medical Science (CAMS)] have recently completed Phase III trials for the vaccines they developed. In addition, the other two vaccines, developed by National Health Research Institutes (NHRI) of Taiwan and Inviragen Pte., Ltd (Inviragen), of Singapore, have also completed Phase I clinical trials. Published clinical trial results indicate that the inactivated EV71 vaccines have good safety and immunogenicity in the target population (infants) and confer a relatively high rate of protection against EV71 infection-related diseases. The results of clinical trials suggest a promising future for the clinical use of EV71 vaccines. Here, we review and highlight the recent progress on the R&D of inactivated EV71 whole-virus vaccines.
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Affiliation(s)
- Zheng-Lun Liang
- National Institutes for Food and Drug Control; Beijing, P.R. China
| | - Qun-Ying Mao
- National Institutes for Food and Drug Control; Beijing, P.R. China
| | - Yi-Ping Wang
- National Institutes for Food and Drug Control; Beijing, P.R. China
| | - Feng-Cai Zhu
- Jiangsu Provincial Center for Disease Control and Prevention; Nanjing, P.R. China
| | - Jing-Xin Li
- Jiangsu Provincial Center for Disease Control and Prevention; Nanjing, P.R. China
| | - Xin Yao
- National Institutes for Food and Drug Control; Beijing, P.R. China
| | - Fan Gao
- National Institutes for Food and Drug Control; Beijing, P.R. China
| | - Xing Wu
- National Institutes for Food and Drug Control; Beijing, P.R. China
| | - Miao Xu
- National Institutes for Food and Drug Control; Beijing, P.R. China
| | - Jun-Zhi Wang
- National Institutes for Food and Drug Control; Beijing, P.R. China
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Zhu FC, Meng FY, Li JX, Li XL, Mao QY, Tao H, Zhang YT, Yao X, Chu K, Chen QH, Hu YM, Wu X, Liu P, Zhu LY, Gao F, Jin H, Chen YJ, Dong YY, Liang YC, Shi NM, Ge HM, Liu L, Chen SG, Ai X, Zhang ZY, Ji YG, Luo FJ, Chen XQ, Zhang Y, Zhu LW, Liang ZL, Shen XL. Efficacy, safety, and immunology of an inactivated alum-adjuvant enterovirus 71 vaccine in children in China: a multicentre, randomised, double-blind, placebo-controlled, phase 3 trial. Lancet 2013; 381:2024-32. [PMID: 23726161 DOI: 10.1016/s0140-6736(13)61049-1] [Citation(s) in RCA: 323] [Impact Index Per Article: 26.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND A vaccine for enterovirus 71 (EV71) is needed to address the high burden of disease associated with infection. We assessed the efficacy, safety, immunogenicity, antibody persistence, and immunological correlates of an inactivated alum-adjuvant EV71 vaccine. METHODS We did a randomised, double-blind, placebo-controlled, phase 3 trial. Healthy children aged 6-35 months from four centres in China were randomly assigned (1:1) to receive vaccine or alum-adjuvant placebo at day 0 and 28, according to a randomisation list (block size 30) generated by an independent statistician. Investigators and participants and their guardians were masked to the assignment. Primary endpoints were EV71-associated hand, foot, and mouth disease (HFMD) and EV71-associated disease during the surveillance period from day 56 to month 14, analysed in the per-protocol population. This study is registered with ClinicalTrials.gov, number NCT01508247. FINDINGS 10,245 participants were enrolled and assigned: 5120 to vaccine versus 5125 to placebo. 4907 (with three cases of EV71-associated HFMD and eight cases of EV71-associated disease) versus 4939 (with 30 cases of EV71-associated HFMD and 41 cases of EV71-associated disease) were included in the primary efficacy analysis. Vaccine efficacy was 90·0% (95% CI 67·1-96·9) against EV71-associated HFMD (p=0·0001) and 80·4% (95% CI 58·2-90·8) against EV71-associated disease (p<0·0001). Serious adverse events were reported by 62 of 5117 (1·2%) participants in the vaccine group versus 75 of 5123 (1·5%) in the placebo group (p=0·27). Adverse events occurred in 3644 (71·2%) versus 3603 (70·3%; p=0·33). INTERPRETATION EV71 vaccine provides high efficacy, satisfactory safety, and sustained immunogenicity. FUNDING China's 12-5 National Major Infectious Disease Program, Beijing Vigoo Biological.
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Affiliation(s)
- Feng-Cai Zhu
- Jiangsu Provincial Center for Disease Control and Prevention, Nanjing, Jiangsu, China.
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Cheng A, Fung CP, Liu CC, Lin YT, Tsai HY, Chang SC, Chou AH, Chang JY, Jiang RH, Hsieh YC, Su IJ, Chong PCS, Hsieh SM. A Phase I, randomized, open-label study to evaluate the safety and immunogenicity of an enterovirus 71 vaccine. Vaccine 2013; 31:2471-6. [DOI: 10.1016/j.vaccine.2013.03.015] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2012] [Revised: 01/26/2013] [Accepted: 03/11/2013] [Indexed: 10/27/2022]
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Zhu FC, Liang ZL, Li XL, Ge HM, Meng FY, Mao QY, Zhang YT, Hu YM, Zhang ZY, Li JX, Gao F, Chen QH, Zhu QY, Chu K, Wu X, Yao X, Guo HJ, Chen XQ, Liu P, Dong YY, Li FX, Shen XL, Wang JZ. Immunogenicity and safety of an enterovirus 71 vaccine in healthy Chinese children and infants: a randomised, double-blind, placebo-controlled phase 2 clinical trial. Lancet 2013; 381:1037-45. [PMID: 23352749 DOI: 10.1016/s0140-6736(12)61764-4] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Enterovirus 71 (EV71) outbreaks are a socioeconomic burden, especially in the western Pacific region. Results of phase 1 clinical trials suggest an EV71 vaccine has a clinically acceptable safety profile and immunogenicity. We aimed to assess the best possible dose and formulation, immunogenicity, and safety profile of this EV71 vaccine in healthy Chinese children. METHODS This randomised, double-blind, placebo-controlled, phase 2 trial was undertaken at one site in Donghai County, Jiangsu Province, China. Eligible participants were healthy boys or girls aged 6–36 months. Participants were randomly assigned (1:1:1:1:1) to receive either 160 U, 320 U, or 640 U alum-adjuvant EV71 vaccine, 640 U adjuvant-free EV71 vaccine, or a placebo (containing alum adjuvant only), according to a blocked randomisation list generated by SAS 9.1. Participants and investigators were masked to the assignment. The primary endpoint was anti-EV71 neutralising antibody geometric mean titres (GMTs) at day 56, analysed according to protocol. The study is registered with ClinicalTrials.gov, number NCT01399853. FINDINGS We randomly assigned 1200 participants, 240 (120 aged 6–11 months [infants] and 120 aged 12–36 months [children]) of whom were assigned to each dose. 1106 participants completed the study and were included in the according-to-protocol analysis. The main reasons for dropout were withdrawal of consent and refusal to donate a blood sample. Infants who received the 640 U adjuvant vaccine had the highest GMTs on day 56 (742·2 [95% CI 577·3–954·3]), followed by those who received the 320 U formulation (497·9 [383·1–647·0]). For children, those who received the 320 U formulation had the highest GMTs on day 56 (1383·2 [1037·3–1844·5]). Participants who received the vaccine had significantly higher GMTs than did who received placebo (p<0·0001). For the subgroup of participants who were seronegative at baseline, both infants and children who received the 640 U adjuvant vaccine had the highest GMTs on day 56 (522·8 [403·9–676·6] in infants and 708·4 [524·1–957·6] in children), followed by those who received the 320 U adjuvant vaccine (358·2 [280·5–457·5] in infants and 498·0 [383·4–646·9] in children). 549 (45·8%) of 1200 participants (95 CI 42·9–48·6%) reported at least one injection-site or systemic adverse reaction, but the incidence of adverse reactions did not differ significantly between groups (p=0·36). The 640 U alum-adjuvant vaccine group had a significantly higher incidence of induration than did the 640 U adjuvant-free group (p=0·001). INTERPRETATION Taking immunogenicity, safety, and production capacity into account, the 320 U alum-adjuvant formulation of the EV71 vaccine is probably the best possible formulation for phase 3 trials. FUNDING The National Science and Technology Major Project (2011ZX10004-902) of the Chinese Ministry of Science and Technology, China's 12–5 National Major Infectious Disease Program (2012ZX10002-001), and Beijing Vigoo Biological.
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Affiliation(s)
- Feng-Cai Zhu
- Jiangsu Provincial Center for Disease Control and Prevention, Nanjing, Jiangsu Province, China
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