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Gruhn S, Batram M, Wick M, Langevin E, Scholz S, Greiner W, Damm O. Modelling the Public Health Impact of MenACWY and MenC Adolescent Vaccination Strategies in Germany. Infect Dis Ther 2024; 13:907-920. [PMID: 38570446 PMCID: PMC11058744 DOI: 10.1007/s40121-024-00958-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 03/05/2024] [Indexed: 04/05/2024] Open
Abstract
INTRODUCTION Invasive meningococcal disease (IMD) causes significant mortality and long-term sequelae. This study assesses the potential public health impact of adolescent vaccination strategies employing MenACWY and MenC vaccines in Germany, where the existing meningococcal immunisation programme predominantly involves MenC administration in toddlers. METHODS A dynamic transmission model was developed to simulate the carriage of five meningococcal serogroup compartments (AY/B/C/W/Other) from 2019 until 2060 within 1-year age groups from 0 to 99 years of age. IMD cases were estimated based on case-carrier ratios. The model considered vaccine effectiveness against carriage acquisition and IMD. RESULTS The model predicts that introducing MenACWY adolescent vaccination could lead to a considerable reduction in IMD incidence, with the potential to prevent up to 65 cases per year and a cumulative total of 1467 cases by 2060. This decrease, mainly driven by herd effects, would result in a reduction of IMD incidence across all age groups, regardless of vaccination age. Furthermore, implementing MenACWY vaccination in adolescents is projected to decrease annual MenACWY-related IMD mortality by up to 64%, equating to an overall prevention of 156 IMD deaths by 2060. These protective outcomes are expected to culminate in approximately 2250 life years gained (LYG) throughout the model's projected time horizon. In contrast, the adoption of MenC vaccination in adolescents is predicted to have minimal influence on both IMD incidence and mortality, as well as on LYG. CONCLUSION The results of this study demonstrate that implementing MenACWY vaccination for adolescents in Germany is likely to notably reduce IMD incidence and mortality across age groups. However, the introduction of MenC adolescent vaccination shows only limited impact. Considering the extensive healthcare resources typically required for IMD management, these findings suggest the potential for economic benefits associated with the adoption of MenACWY adolescent vaccination, warranting further cost-effectiveness analysis.
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Affiliation(s)
- Sebastian Gruhn
- Department for Health Economics and Health Care Management, School of Public Health, Bielefeld University, Universitätsstraße 25, 33615, Bielefeld, Germany.
| | - Manuel Batram
- Vandage GmbH, Detmolder Straße 30, 33604, Bielefeld, Germany
| | - Moritz Wick
- Sanofi-Aventis Deutschland GmbH, Lützowstraße 107, 10785, Berlin, Germany
| | - Edith Langevin
- Sanofi Vaccines, 14 Espace Henry Vallee, 69007, Lyon, France
| | - Stefan Scholz
- Martin-Luther-University Halle-Wittenberg, Magdeburgerstr. 20, 06112, Halle (Saale)., Germany
| | - Wolfgang Greiner
- Department for Health Economics and Health Care Management, School of Public Health, Bielefeld University, Universitätsstraße 25, 33615, Bielefeld, Germany
| | - Oliver Damm
- Sanofi-Aventis Deutschland GmbH, Lützowstraße 107, 10785, Berlin, Germany
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Safety of Multiple Vaccinations and Durability of Vaccine-Induced Antibodies in an Italian Military Cohort 5 Years after Immunization. Biomedicines 2021; 10:biomedicines10010006. [PMID: 35052686 PMCID: PMC8773007 DOI: 10.3390/biomedicines10010006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 11/17/2021] [Accepted: 12/16/2021] [Indexed: 01/24/2023] Open
Abstract
We previously examined the safety and immunogenicity of multiple vaccines administered to a military cohort, divided into two groups, the first composed of students at military schools, thus operating inside the national borders for at least 3 years, and the other formed of soldiers periodically engaged in a 9-month-long mission abroad (Lebanon). In the current study, we analyzed 112 individuals of this cohort, 50 pertaining to the first group and 62 to the second group, in order to examine the possible late appearance of side effects and to calculate the half-life of the induced antibodies. Moreover, the possible involvement of B-cell polyclonal activation as a pathogenetic mechanism for long term antibody persistence has even been explored. No late side effects, as far as autoimmunity and/or lymphoproliferation appearance, have been noticed. The long duration of the vaccine induced anti-HAV antibodies has been confirmed, whereas the antibodies induced by tetravalent meningococcal polysaccharide vaccine have been found to persist above the threshold for putative protection for a longer time, and anti-tetanus, diphtheria, and polio 1 and 3 for a shorter time than previously estimated. No signs of polyclonal B-cell activation have been found, as a possible mechanism to understand the long antibody persistence.
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Tran TMP, Abrams S, Aerts M, Maertens K, Hens N. Measuring association among censored antibody titer data. Stat Med 2021; 40:3740-3761. [PMID: 33942345 PMCID: PMC8251995 DOI: 10.1002/sim.8995] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 12/26/2020] [Accepted: 04/03/2021] [Indexed: 12/21/2022]
Abstract
Censoring due to a limit of detection or limit of quantification happens quite often in many medical studies. Conventional approaches to deal with censoring when analyzing these data include, for example, the substitution method and the complete case (CC) analysis. More recently, maximum likelihood estimation (MLE) has been increasingly used. While the CC analysis and the substitution method usually lead to biased estimates, the MLE approach appears to perform well in many situations. This article proposes an MLE approach to estimate the association between two measurements in the presence of censoring in one or both quantities. The central idea is to use a copula function to join the marginal distributions of the two measurements. In various simulation studies, we show that our approach outperforms existing conventional methods (CC and substitution analyses). In addition, rank‐based measures of global association such as Kendall's tau or Spearman's rho can be studied, hence, attention is not only confined to Pearson's product‐moment correlation coefficient capturing solely linear association. We have shown in our simulations that our approach is robust to misspecification of the copula function or marginal distributions given a small association. Furthermore, we propose a straightforward MLE method to fit a (multiple) linear regression model in the presence of censoring in a covariate or both the covariate and the response. Given the marginal distribution of the censored covariate, our method outperforms conventional approaches. We also compare and discuss the performance of our method with multiple imputation and missing indicator model approaches.
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Affiliation(s)
- Thao M P Tran
- I-BioStat, Data Science Institute, Hasselt University, Hasselt, Belgium
| | - Steven Abrams
- I-BioStat, Data Science Institute, Hasselt University, Hasselt, Belgium.,Global Health Institute, Family Medicine and Population Health, University of Antwerp, Antwerp, Belgium
| | - Marc Aerts
- I-BioStat, Data Science Institute, Hasselt University, Hasselt, Belgium
| | - Kirsten Maertens
- Centre for Evaluation of Vaccination, Vaccine and Infectious Disease Institute, Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Niel Hens
- I-BioStat, Data Science Institute, Hasselt University, Hasselt, Belgium.,Global Health Institute, Family Medicine and Population Health, University of Antwerp, Antwerp, Belgium.,Centre for Health Economics Research and Modeling Infectious Diseases, Vaccine and Infectious Disease Institute, University of Antwerp, Antwerp, Belgium
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4
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Different Long-Term Duration of Seroprotection against Neisseria meningitidis in Adolescents and Middle-Aged Adults after a Single Meningococcal ACWY Conjugate Vaccination in The Netherlands. Vaccines (Basel) 2020; 8:vaccines8040624. [PMID: 33113834 PMCID: PMC7712102 DOI: 10.3390/vaccines8040624] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 10/14/2020] [Accepted: 10/15/2020] [Indexed: 01/29/2023] Open
Abstract
Neisseria meningitidis is often asymptomatically carried in the nasopharynx but may cause invasive meningococcal disease, leading to morbidity and mortality. Meningococcal conjugate vaccinations induce functional protective antibodies against capsular antigens, but seroprotection wanes over time. We measured functional antibody titers five years after administration of a single dose of the meningococcal ACWY-polysaccharide-specific tetanus toxoid-conjugated (MenACWY-TT) vaccine in adolescents and middle-aged adults in the Netherlands, using the serum bactericidal antibody with baby rabbit complement (rSBA) assay. Protection was defined as rSBA titer ≥8. The meningococcal ACWY-specific serum IgG concentrations were measured with a multiplex immunoassay. Duration of protection was estimated by a bi-exponential decay model. Sufficient protection for MenC, MenW, and MenY was achieved in 94–96% of the adolescents five years postvaccination, but, in middle-aged adults, only in 32% for MenC, 65% for MenW and 71% for MenY. Median duration of protection for MenCWY was 4, 14, and 21 years, respectively, in middle-aged adults, while, in adolescents, it was 32, 98, and 33 years. Our findings suggest that adolescents, primed in early childhood with MenC conjugate vaccination, remain sufficiently protected after a single dose of MenACWY-TT vaccine. Middle-aged adults without priming vaccination show fast waning of antibodies, particularly MenC, for which protection is lost after four years.
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Serologic response to meningococcal vaccination in patients with cold agglutinin disease (CAD) in the novel era of complement inhibition. Vaccine 2019; 37:6682-6687. [PMID: 31562002 DOI: 10.1016/j.vaccine.2019.09.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 09/02/2019] [Accepted: 09/09/2019] [Indexed: 11/22/2022]
Abstract
Cold agglutinin disease (CAD) is a rare, potentially life-threatening acquired autoimmune hemolytic anemia characterized by hemagglutination and hemolysis due to immunoglobulin-mediated (usually IgMκ) classic complement pathway activation. Complement inhibition (CI) represents a novel treatment option to control hemolysis. Due to CI patients (pts) are susceptible to encapsulated bacteria e.g. N. meningitidis. Therefore, meningococcal vaccination on CI is mandatory. In this study serologic response to the tetravalent conjugate vaccine Menveo® was analyzed in CAD pts on eculizumab treatment (DECADE trial) using rabbit serum as complement source (rSBA). Protective rSBA titers varied for meningococcal serogroups and over time reflecting an early decline to even non-protective rSBA titers. These data highlight the importance of serologic analyses under chronic CI. Currently, re-vaccination with a tetravalent meningococcal conjugate vaccine every 3 years is recommended on chronic CI. However, re-vaccination on CI might further rely on serologic analyses, implying even early booster vaccinations similar to adults with (functional) asplenia.
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Ferlito C, Biselli R, Cattaruzza MS, Teloni R, Mariotti S, Tomao E, Salerno G, Peragallo MS, Lulli P, Caporuscio S, Autore A, Bizzarro G, Germano V, Biondo MI, Picchianti Diamanti A, Salemi S, Nisini R, D'Amelio R. Immunogenicity of meningococcal polysaccharide ACWY vaccine in primary immunized or revaccinated adults. Clin Exp Immunol 2018; 194:361-370. [PMID: 30099753 DOI: 10.1111/cei.13202] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/06/2018] [Indexed: 12/19/2022] Open
Abstract
Meningococcal polysaccharide (Men-Ps) vaccine immunogenicity following either primary immunization or revaccination in adults was evaluated. The study population consisted of subjects who have received tetravalent Men-Ps vaccine once (group 1) or at least twice, with a 2-6 dose range (group 2). Human leucocyte antigen (HLA)-typing was performed by polymerase chain reaction and specific immunoglobulin (Ig)G was measured by enzyme-linked immunosorbent assay. Nine months post-immunization, the percentages of individuals with levels of anti-Men-Ps IgG ≥ 2 µg/ml were comparable in both groups, with the exception of anti-Men-PsW135 IgG, which were significantly higher in group 2. The percentage of subjects doubling IgG levels at 9 months was significantly higher in group 1. The high baseline anti-Men-Ps antibody levels negatively influenced the response to revaccination, suggesting a feedback control of specific IgG. The calculated durability of anti-Men-Ps IgG was 2·5-4·5 years, depending on the Men-Ps, following a single vaccine dose. No interference by other vaccinations nor HLA alleles association with immune response were observed. This study confirms that Men-Ps vaccine in adults is immunogenic, even when administered repeatedly, and underlines the vaccine suitability for large-scale adult immunization programmes that the higher costs of conjugate vaccines may limit in developing countries.
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Affiliation(s)
- C Ferlito
- Sapienza Università di Roma, Dipartimento di Medicina Clinica e Molecolare, Azienda Ospedaliera Universitaria S. Andrea, Rome, Italy
| | - R Biselli
- Aeronautica Militare Italiana, Comando Logistico, Servizio Sanitario, Rome, Italy
| | - M S Cattaruzza
- Sapienza Università di Roma, Dipartimento di Sanità Pubblica e Malattie Infettive, Rome, Italy
| | - R Teloni
- Istituto Superiore di Sanità, Dipartimento Malattie Infettive, Rome, Italy
| | - S Mariotti
- Istituto Superiore di Sanità, Dipartimento Malattie Infettive, Rome, Italy
| | - E Tomao
- Aeronautica Militare Italiana, Corpo Sanitario, Rome, Italy
| | - G Salerno
- Sapienza Università di Roma, Dipartimento di Medicina Clinica e Molecolare, Azienda Ospedaliera Universitaria S. Andrea, Rome, Italy
| | - M S Peragallo
- Esercito Italiano, Centro Studi e Ricerche di Sanità e Veterinaria, Rome, Italy
| | - P Lulli
- Sapienza Università di Roma, Dipartimento di Medicina Clinica e Molecolare, Azienda Ospedaliera Universitaria S. Andrea, Rome, Italy
| | - S Caporuscio
- Sapienza Università di Roma, Dipartimento di Medicina Clinica e Molecolare, Azienda Ospedaliera Universitaria S. Andrea, Rome, Italy
| | - A Autore
- Aeronautica Militare, Comando Logistico, Centro Sperimentale di Volo, Aeroporto Pratica di Mare, Rome, Italy
| | - G Bizzarro
- Aeronautica Militare, Comando Logistico, Centro Sperimentale di Volo, Aeroporto Pratica di Mare, Rome, Italy
| | - V Germano
- Sapienza Università di Roma, Dipartimento di Medicina Clinica e Molecolare, Azienda Ospedaliera Universitaria S. Andrea, Rome, Italy
| | - M I Biondo
- Sapienza Università di Roma, Dipartimento di Medicina Clinica e Molecolare, Azienda Ospedaliera Universitaria S. Andrea, Rome, Italy
| | - A Picchianti Diamanti
- Sapienza Università di Roma, Dipartimento di Medicina Clinica e Molecolare, Azienda Ospedaliera Universitaria S. Andrea, Rome, Italy
| | - S Salemi
- Sapienza Università di Roma, Dipartimento di Medicina Clinica e Molecolare, Azienda Ospedaliera Universitaria S. Andrea, Rome, Italy
| | - R Nisini
- Istituto Superiore di Sanità, Dipartimento Malattie Infettive, Rome, Italy
| | - R D'Amelio
- Sapienza Università di Roma, Dipartimento di Medicina Clinica e Molecolare, Azienda Ospedaliera Universitaria S. Andrea, Rome, Italy
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Caporuscio S, Ieraci R, Valesini G, Teloni R, Mariotti S, Spinelli FR, Ferlito C, Salemi S, Picchianti Diamanti A, Meneguzzi G, Markovic M, Sgrulletti M, von Hunolstein C, Ralli L, Pinto A, Salerno G, Canzoni M, Sorgi ML, Laganà B, Di Rosa R, Nisini R, D'Amelio R. Anti-polysaccharide and anti-diphtheria protective antibodies after 13-valent pneumococcal conjugate vaccination in rheumatoid arthritis patients under immunosuppressive therapy. Clin Immunol 2018; 195:18-27. [PMID: 30036638 DOI: 10.1016/j.clim.2018.07.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 06/20/2018] [Accepted: 07/19/2018] [Indexed: 01/22/2023]
Abstract
Immunogenicity of 13-valent pneumococcal polysaccharide (PnPS) conjugate vaccine (PCV13) was evaluated in 38 rheumatoid arthritis patients under immunosuppressive treatment and 20 healthy controls (HC). Antibodies to all PnPS and diphtheria-toxin analogue conjugate protein were measured pre- (T0), 1 (T1), 6 (T2), 12 (T3) months post-immunization. Patients and HC had similar response to individual PnPS. Mean antibody levels to all PnPS but one doubled at T1 compared with T0, with T3 persistence for only 8-7/13 PnPS. Baseline antibody levels was inversely associated with the rate of responders at T1 (T1/T0≥2) to 11/13 PnPS. Few subjects reached protective IgG levels against some serotypes frequently isolated in Italian patients with invasive pneumococcal disease. Antibody response was not influenced by therapy, except the one to PS7F, which was reduced by tumor necrosis factor-α-inhibitors. Vaccination increased also anti-diphtheria IgG. Despite this study substantially confirmed the PCV13 immunogenicity in immunocompromised patients, it also revealed some limitations.
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Affiliation(s)
- Sara Caporuscio
- Sapienza Università di Roma, Azienda Ospedaliera Universitaria Sant'Andrea, Roma, Italy
| | | | - Guido Valesini
- Dipartimento di Medicina Interna e Specialità Mediche, Reumatologia, Università La Sapienza, Roma, Italy
| | - Raffaela Teloni
- Dipartimento Malattie Infettive, Istituto Superiore di Sanità, Roma, Italy
| | - Sabrina Mariotti
- Dipartimento Malattie Infettive, Istituto Superiore di Sanità, Roma, Italy
| | - Francesca Romana Spinelli
- Dipartimento di Medicina Interna e Specialità Mediche, Reumatologia, Università La Sapienza, Roma, Italy
| | - Claudia Ferlito
- Sapienza Università di Roma, Azienda Ospedaliera Universitaria Sant'Andrea, Roma, Italy
| | - Simonetta Salemi
- Sapienza Università di Roma, Azienda Ospedaliera Universitaria Sant'Andrea, Roma, Italy
| | | | - Giorgia Meneguzzi
- Sapienza Università di Roma, Azienda Ospedaliera Universitaria Sant'Andrea, Roma, Italy
| | - Milica Markovic
- Sapienza Università di Roma, Azienda Ospedaliera Universitaria Sant'Andrea, Roma, Italy
| | - Mayla Sgrulletti
- Sapienza Università di Roma, Azienda Ospedaliera Universitaria Sant'Andrea, Roma, Italy
| | - Christina von Hunolstein
- Centro Nazionale per il Controllo e la Valutazione dei Farmaci, Istituto Superiore di Sanità, Roma, Italy
| | - Luisa Ralli
- Centro Nazionale per il Controllo e la Valutazione dei Farmaci, Istituto Superiore di Sanità, Roma, Italy
| | - Antonietta Pinto
- Centro Nazionale per il Controllo e la Valutazione dei Farmaci, Istituto Superiore di Sanità, Roma, Italy
| | - Gerardo Salerno
- Sapienza Università di Roma, Azienda Ospedaliera Universitaria Sant'Andrea, Roma, Italy
| | | | - Maria Laura Sorgi
- Sapienza Università di Roma, Azienda Ospedaliera Universitaria Sant'Andrea, Roma, Italy
| | - Bruno Laganà
- Sapienza Università di Roma, Azienda Ospedaliera Universitaria Sant'Andrea, Roma, Italy
| | - Roberta Di Rosa
- Sapienza Università di Roma, Azienda Ospedaliera Universitaria Sant'Andrea, Roma, Italy
| | - Roberto Nisini
- Dipartimento Malattie Infettive, Istituto Superiore di Sanità, Roma, Italy.
| | - Raffaele D'Amelio
- Sapienza Università di Roma, Azienda Ospedaliera Universitaria Sant'Andrea, Roma, Italy
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Induction of long-term immunity against respiratory syncytial virus glycoprotein by an osmotic polymeric nanocarrier. Acta Biomater 2014; 10:4606-4617. [PMID: 25110285 DOI: 10.1016/j.actbio.2014.07.034] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Revised: 07/26/2014] [Accepted: 07/31/2014] [Indexed: 11/22/2022]
Abstract
Respiratory syncytial virus (RSV) is one of the most common causes of viral deaths in infants worldwide, yet no effective vaccines are available. Here, we report an osmotically active polysaccharide-based polysorbitol transporter (PST) prepared from sorbitol diacrylate and low-molecular-weight polyethylenimine (PEI) showing a potent, yet safe, adjuvant activity and acting as an effective delivery tool for RSV glycoprotein (RGp) antigen. PST showed no toxicity in vitro or in vivo, unlike PEI and the well-known experimental mucosal adjuvant cholera toxin (CT). PST formed nano-sized complexes with RGp by simple mixing, without affecting antigenic stability. The complexes exhibited negative surface charges that made them highly efficient in the selective activation of phagocytic cells and enhancement of phagocytic uptake. This resulted in an improved cytokine production and in the significant augmentation of RGp-specific antibody production, which persisted for over 200 days. Interestingly, PST/RGp enhanced phagocytic uptake owing to the osmotic property of PST and its negative zeta potential, suggesting that PST could selectively stimulate phagocytic cells, thereby facilitating a long-lived antigen-specific immune response, which was presumably further enhanced by the polysaccharide properties of PST.
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Zahlanie YC, Hammadi MM, Ghanem ST, Dbaibo GS. Review of meningococcal vaccines with updates on immunization in adults. Hum Vaccin Immunother 2014; 10:995-1007. [PMID: 24500529 PMCID: PMC4896590 DOI: 10.4161/hv.27739] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2013] [Revised: 12/31/2013] [Accepted: 01/06/2014] [Indexed: 11/19/2022] Open
Abstract
Meningococcal disease is a serious and global life-threatening disease. Six serogroups (A, B, C, W-135, X, and Y) account for the majority of meningococcal disease worldwide. Meningococcal polysaccharide vaccines were introduced several decades ago and have led to the decline in the burden of disease. However, polysaccharide vaccines have several limitations, including poor immunogenicity in infants and toddlers, short-lived protection, lack of immunologic memory, negligible impact on nasopharyngeal carriage, and presence of hyporesponsiveness after repeated doses. The chemical conjugation of plain polysaccharide vaccines has the potential to overcome these drawbacks. Meningococcal conjugate vaccines include the quadrivalent vaccines (MenACWY-DT, MenACWY-CRM, and MenACWY-TT) as well as the monovalent A and C vaccines. These conjugate vaccines were shown to elicit strong immune response in adults. This review addresses the various aspects of meningococcal disease, the limitations posed by polysaccharide vaccines, the different conjugate vaccines with their immunogenicity and reactogenicity in adults, and the current recommendations in adults.
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Affiliation(s)
- Yorgo C Zahlanie
- Center for Infectious Diseases Research; Division of Pediatric Infectious Diseases; Department of Pediatrics and Adolescent Medicine; American University of Beirut Medical Center; Beirut, Lebanon
| | - Moza M Hammadi
- Center for Infectious Diseases Research; Division of Pediatric Infectious Diseases; Department of Pediatrics and Adolescent Medicine; American University of Beirut Medical Center; Beirut, Lebanon
| | - Soha T Ghanem
- Department of Pediatrics; Makassed General Hospital; Beirut, Lebanon
| | - Ghassan S Dbaibo
- Center for Infectious Diseases Research; Division of Pediatric Infectious Diseases; Department of Pediatrics and Adolescent Medicine; American University of Beirut Medical Center; Beirut, Lebanon
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