Journal of Adolescent Health 37 (2005) 517.e1 517.e5 Original article Immunogenicity and reactogenicity of a reduced-antigen-content diphtheria-tetanus-acellular pertussis vaccine in healthy Taiwanese children and adolescents Li-Min Huang, MD, PhD a, Luan-Yin Chang, MD, PhD a, Haiwen Tang, MD, PhD b, Hans L. Bock, MD b, Chun-Yi Lu, MD a, Fu-Yuan Huang, MD c, Tzou-Yien Lin, MD d, *, and Chin-Yun Lee, MD a a Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan b GlaxoSmithKline Biologicals, Rixensart, Belgium c Department of Pediatrics, Mackay Memorial Hospital, Taipei, Taiwan d Chang Gung Children s Hospital and Chang Gung University, College of Medicine, Taoyuan, Taiwan Manuscript received May 3, 2005; manuscript accepted August 10, 2005 Abstract Keywords: Purpose: Disease caused by Bordetella pertussis is increasingly being identified among older children and adults in immunized populations, indicating a waning of the vaccine-induced immunity. These findings suggest the need for booster immunization of older children and adults. Modern acellular reduced-antigen-content vaccines have been developed, which can be given as a booster in individuals more than 4 years of age. This study was to assess the immunogenicity and reactogenicity of Boostrix TM, GlaxoSmithKline Biologicals reduced-antigen-content diphtheria-tetanus acellular pertussis (dtpa) vaccine, when administered as a booster in healthy subjects previously primed with DTP vaccine. Methods: Healthy Taiwanese children and adolescents aged 6 8 years and 15 20 years, previously primed with DTP vaccine, were enrolled. All received one dose of Boostrix TM. Two blood samples were taken from each of them, one before vaccination and one at 1 month after vaccination. Serum antibodies to diphtheria and tetanus toxoids and immunoglobulin G (IgG) antibodies against the pertussis components PT, FHA and PRN were measured by enzyme-linked immunosorbent assay (ELISA) technique. Adverse reactions following vaccination were recorded. Results: A total of 180 subjects were recruited. The vaccine response rates to the pertussis antigens ranged between 89.0 100%. There were no serious adverse events reported during the study period. Conclusions: The results of this study suggest that Boostrix TM may be safely and effectively administered as a booster dose to children previously primed with DTP vaccine. 2005 Society for Adolescent Medicine. All rights reserved. Reduced-antigen-content dtpa vaccine; Bordetella pertussis; Taiwan; Booster vaccination; Adolescents Universal infant immunization against diphtheria, tetanus, and pertussis is one of the major goals of the World Health Organization (WHO) Expanded Program on Immunization (EPI). Diphtheria-tetanus-pertussis (DTP) primary vaccination *Address correspondence to: Dr. Tzou-Yien Lin, Chang Gung Children s Hospital, No. 5, Fu-shin St, Kweishang, Taipei, Taiwan. E-mail address: pidlin@adm.cgmn.org.tw of infants followed by a booster dose in the second year of life is almost a universal practice [1]. In the prevaccination era, pertussis infection commonly occurred in early life. The subsequent natural immunity was then maintained by periodic exposure to the organism (Bordetella pertussis), which acted as a natural booster [2]. Childhood immunization against pertussis has been effective in decreasing the incidence of pertussis but has not eliminated the circulation of Bor- 1054-139X/05/$ see front matter 2005 Society for Adolescent Medicine. All rights reserved. doi:10.1016/j.jadohealth.2005.08.009
517.e2 L.-M. Huang et al. / Journal of Adolescent Health 37 (2005) 517.e1 517.e5 detella pertussis [3]. Although the incidence of pertussis in young children has been markedly reduced since the successful implementation of infant immunization programs, there has been a subsequent increase in the incidence in older children, adolescents and adults in immunized populations [3 10]. Neither vaccination-acquired nor natural immunity from pertussis is life long. An increasing number of adults and adolescents with waning immunity, especially in wellvaccinated populations where natural boosting has been reduced, are now susceptible to pertussis reinfection [8,11 14]. The major cause for concern is the potential for older infected family members to serve as reservoir of infection to young infants, which has been shown in several household studies [11,12,14 18]. Furthermore, because the symptoms are generally atypical in adults [19], adult infection is often difficult to diagnose [20] and this situation creates the potential for further spread. Treatment with antibiotics is effective in clearing the organism and limiting spread of the disease only within the first three weeks after onset of symptoms [21]. These findings suggest the need for booster immunizations of older children and adults, with the goal of preventing transmission of B. pertussis from these age groups to infants. Pertussis vaccine boosters have not previously been recommended after seven years of age, mainly due to the high reactogenicity of traditional whole-cell pertussis vaccines [22] in older children and the belief that pertussis is both uncommon and mild in older children, adolescents and adults. Although combined diphtheria-tetanus-pertussis (DTPa) vaccines, which are less reactogenic than whole-cell vaccines [23,24], have become routine pediatric vaccines in many countries, their reactogenicity increases with successive doses, making the pediatric formulation less suitable for older individuals [25]. The recent development of a reduced-antigen-content diphtheria-tetanus acellular pertussis vaccine (dtpa) provides health practitioners with a new option. In many countries, immunity to diphtheria and tetanus is currently maintained by booster vaccination at 5- to 10-year intervals. A reduced-antigen-content diphtheria-tetanus (Td) vaccine is used to improve tolerability while eliciting an adequate immune response. Utilizing a reduced antigen dtpa vaccine would provide the added benefit of boosting waning pertussis antibodies in addition to maintaining immunity to diphtheria and tetanus. This article reports the immunogenicity and reactogenicity of Boostrix, GlaxoSmithKline Biologicals reduced-antigen-content diphtheria-tetanus-acellular pertussis (dtpa) vaccine, when administered as a booster vaccination to healthy Taiwanese children six to eight years of age and adolescents and young adults aged 15 to 20 years, all of whom were previously primed with DTP vaccine. Materials and Methods Subjects and ethics Sixty healthy children six to eight years of age and 120 healthy young adolescents and adults 15 to 20 years of age who were previously primed with four doses of DTP vaccine according to local schedule, were enrolled. This study was conducted at the National Taiwan University Hospital and Chang Gung Children s Hospital in Taiwan. The conduct of this study followed the Declaration of Helsinki and Good Clinical Practice guidelines, with approval of the respective ethical review committee and with witnessed written parental informed consent before the start of the study. Children and adolescents/young adults were excluded from the study if they had a history of allergic reaction to any of the vaccine components, had a history of diphtheria or tetanus disease or a history of confirmed pertussis disease within the previous five years, had any chronic or neurological illness, or had received any blood products. Vaccine Reduced-antigen-content diphtheria-tetanus-acellular pertussis (dtpa) vaccine, Boostrix (GlaxoSmithKline Biologicals, Rixensart, Belgium), was used in this study. One dose (0.5 ml) contained diphtheria toxoid ( 2 International Units, IU), tetanus toxoid ( 20 IU), Pertussis toxin (PT; 8 g), filamentous haemagglutinin (FHA; 8 g), and pertactin (PRN; 2.5 g). The same manufacturer s lot of the dtpa vaccine was used in both studies. Study design An open label design was used. All subjects received a single booster dose of dtpa vaccine intramuscularly in the deltoid region. Data collection Diary cards provided by the investigator were used by parents/guardians to record solicited local reactions at the injection site (pain, redness and swelling) and systemic (general) symptoms (axillary temperature, headache, fatigue and gastrointestinal symptoms) on the day of vaccination and for the 14 subsequent days (15-day follow-up period). Symptoms were graded from 1 to 3 in intensity with total (any symptom irrespective of intensity and relationship to vaccination) and Grade 3 (symptoms that prevented normal activities) incidence being reported here. Grade 3 pain was defined as spontaneously painful. For local swelling and redness, the largest diameter was measured and a diameter of 50 mm was defined as intensity Grade 3. Fever was defined as axillary temperature 37.5 C, and intensity
L.-M. Huang et al. / Journal of Adolescent Health 37 (2005) 517.e1 517.e5 517.e3 Grade 3 as a temperature 39.0 C. Unsolicited symptoms reported during the 30-day follow-up period after the vaccine dose and serious adverse events (SAEs) reported during the entire study period were also recorded. Immunological assays Blood samples were collected before the vaccine dose (pre) and one month after the vaccine dose (post). Serum antibodies to diphtheria and tetanus toxoids and immunoglobulin G (IgG) antibodies against the pertussis components PT, FHA and PRN were measured by enzyme-linked immunosorbent assay (ELISA) technique. For anti-diphtheria and anti-tetanus antibodies, titres above the assay cut-offs were considered to be seroprotective. For pertussis antigens, subjects with antibody titres above the assay cut-off were termed as seropositive. Furthermore, because there is no defined serological correlate of protection for B. pertussis, a vaccine response was defined as post-vaccination antibody titres above the assay cut-off value in initially seronegative subjects, and as at least a twofold increase in antibody titres from prevaccination to postvaccination in initially seropositive subjects. Statistical analysis All analyses performed to assess the antibody response and reactogenicity of a single dose of GSK Biologicals dtpa vaccine were descriptive. At each blood sampling time point (pre- and postbooster), seroprotection rates against diphtheria and tetanus toxoids, vaccine response rates to pertussis antigens, and geometric mean concentrations (GMCs) with 95% confidence intervals (CI) were tabulated for all antibodies. The incidences of local and general adverse events (solicited/unsolicited after the vaccine dose) were calculated with exact 95% CI, in addition to tabulating intensity and relationship. Serious adverse events and discontinuation due to adverse events were described. Results Demographics The mean age of the enrolled children was six years, with a standard deviation of.13 years in the group of six- to eight-year-olds. All 60 children completed the study. All were Asian and the male-to-female ratio was approximately 1:1. All 60 were included in the reactogenicity analysis and 59 were included in the immunogenicity analysis (one subject was outside of the accepted age range). The mean age in the group of 15- to 20-year-olds was 17 years (SD 1.64 years). All subjects were Asian and the male-to-female ratio was approximately.5: 1. Of the 120 subjects enrolled, 119 were vaccinated and included in the analyses. One subject did not return for the postvaccination blood sampling. Immunogenicity One month after the vaccine dose, all subjects in both age groups had seroprotective anti-diphtheria and anti-tetanus antibody titres and a vaccine response against the pertussis antigens was elicited in most subjects (90.9 100%) (Table 1). GMCs increased significantly from prebooster to postbooster vaccination in both groups (data not shown). In the group of six- to eight-year-olds, there was a 22-fold increase for anti-diphtheria and a 52-fold for anti-tetanus concentrations. Anti-PT and anti-fha concentrations increased 24-fold and anti-prn increased 25-fold. In the group of 15- to 20-year-olds, GMC of anti-diphtheria increased 19-fold, anti-tetanus increased 23-fold, anti-pt increased 10-fold, anti-fha 32-fold, and anti-prn 34-fold. Reactogenicity In both groups, local reactions were reported more frequently than were general symptoms (approximately three times more often in the six- to eight-year-olds and twice as Table 1 Immunogenicity results following reduced-antigen dtpa vaccine administered to children and adolescents Vaccine antigen Subjects n Age (years) Response 95% CI GMC 95% CI (%) a Diphtheria 59 6 8 100 93.9 100 4.7 3.6 6.2 119 15 20 100 96.9 100 11.7 10.1 13.7 Tetanus 59 6 8 100 93.9 100 20.3 16.5 25.1 119 15 20 100 96.9 100 2.4 2.0 3.0 PT 59 6 8 94.9 85.9 98.9 89.2 68.7 115.9 119 15 20 90.8 84.1 95.3 53.3 43.4 65.4 FHA 59 6 8 98.3 90.9 100 572.2 469.9 696.8 119 15 20 100 96.9 100 780.6 681.4 894.2 PRN 59 6 8 96.6 88.3 99.6 223.7 159.4 313.8 119 15 20 99.2 85.4 100 350.8 257.6 477.7 a Vaccine response definition: diphtheria and tetanus: post-vaccination antibody titer 0.1IU/mL by ELISA; pertussis antibodies: initially seronegative participants before vaccination with postvaccination antibody titer 5 EL.U/mL; initially seropositive participants with post-vaccination antibody titer at least twofold higher than prevaccination titer.
517.e4 L.-M. Huang et al. / Journal of Adolescent Health 37 (2005) 517.e1 517.e5 Table 2 Reactogenicity: incidence of solicited local and general symptoms reported within the 15-day follow-up period after vaccination Adverse event often in the 15- to 20-year-olds). For both groups, pain at injection site and fatigue were the most frequently reported solicited local and general symptoms, respectively (Table 2). No Grade 3-solicited local or general symptoms were reported by the six- to eight-year-old group; two cases were reported in the older age group, both of which resolved by Day 18 postvaccination without sequelae. No cases of fever were reported by the younger children. The six cases reported in the 15- to 20-year-olds were assessed by the investigator as being unrelated to vaccination. The majority of the solicited local and general symptoms had an onset within 48 hours after vaccination. No unsolicited symptoms were reported in the younger age group. Seven of the 15- to 20-year-olds reported an unsolicited symptom within 30 days after vaccination and were assessed as having a probable or suspected relationship to vaccination. These included injection site reaction, pain, diarrhea, upper respiratory tract infection, pharyngitis, rhinitis and lymphadenopathy. No serious adverse events were reported and no child or adolescent/young adult experienced an adverse event that led to discontinuation from the study. Discussion 6 to 8-year-olds (n 60) 15 to 20-year-olds (n 119) % 95% CI % 95% CI Local injection site reactions Pain Total 66.7 53.3 78.3 79.9 71.5 86.6 Grade 3 0 2.0.2 6.9 Redness Total 35 23.1 48.4 25.2 17.7 34.0 Swelling Total 40 27.6 53.5 21.8 14.8 30.4 Grade 3 0 2.9.6 8.4 General symptoms 6 to 8 year olds 15 to 20 year olds Fever Total 0 6.7 2.9 12.8 Fatigue Total 16.7 8.3 28.5 24.4 17.0 33.1 Gastrointestinal Total 6.7 1.8 16.2 11.8 6.6 19.0 Headache Total 10 3.8 20.5 12.6 7.2 19.9 n Overall number of subjects with diary cards completed and returned. Vaccination of older children, adolescents and adults against pertussis is now being proposed by some authorities to manage the recently observed epidemiological shift in the incidence of the disease to older age groups [8,26]. To achieve long-term protection, it is possible that subsequent doses of pertussis vaccine are required at regular intervals throughout life, irrespective of both past immunization history and exposure to the natural infection [27]. As is the case for most vaccine-preventable diseases, high vaccination coverage must be achieved before herd immunity can be acquired and control of infection is afforded the entire population [28]. Combination with an already routinely used booster vaccine such as the diphtheria-tetanus vaccine (Td) is generally accepted as not only the most efficient, but also the most cost-effective means of achieving high coverage [29,30]. However, it is important to ensure that neither the immunogenicity nor the reactogenicity profile of the combined vaccine is compromised. The assessment of immune response assumes greater significance in the case of dtpa vaccine, in which the diphtheria toxoid and pertussis antigen contents have been reduced to improve greater tolerability [31]. Earlier studies [26,32 38] have demonstrated safety, good tolerability, and immunogenicity of DTPa vaccines as compared with DTPw vaccines when administered as booster doses in infants, preschool children and adults. However, the reactogenicity of DTPa vaccines is higher when used as a booster dose as compared with primary immunization [37,39]. This can be circumvented by using a reduced-antigen-content dtpa vaccine. Historical data have shown that reduced-antigen-content dtpa vaccines elicit immunogenicity profiles comparable with DTPa vaccines when administered as a booster dose [40]. Findings from other historical data indicate that vigorous booster responses can be elicited by reduced quantities of vaccine antigens in previously primed subjects [41]. The reduction of diphtheria toxoid and pertussis antigen contents did not have a deleterious effect on the immunogenicity of the vaccine when administered as a booster dose. The results of these dtpa vaccine studies are consistent with these earlier results as demonstrated by seroprotection/ vaccine response to all antibodies in a majority of the subjects and absence of Grade 3-solicited symptoms, unsolicited symptoms or serious adverse events. In conclusion, these studies suggest that the reducedantigen-content dtpa vaccine may be safely and effectively administered as a booster dose to children aged six to eight years and adolescents/young adults aged 15 to 20 years who were previously primed with DTP vaccine. The dtpa combination vaccine offers the benefits of lower reactogenicity as compared with the DTPa vaccines, satisfactory immunogenicity profile, and increased compliance. Given the recent epidemiological data showing an increase in the susceptibility of older age groups to pertussis and the apparent lack of protection against diphtheria, there is a need for harmonized, universal primary vaccination followed by a booster policy [31]. A reduced-antigencontent dtpa vaccine, with its improved tolerability and the
L.-M. Huang et al. / Journal of Adolescent Health 37 (2005) 517.e1 517.e5 517.e5 ability to boost titres against all three diseases, meets the growing need for a booster vaccine by offering protection against pertussis infection and providing the opportunity for control of the disease in these age groups. Acknowledgment This study was funded by a grant from GlaxoSmithKline Biologicals, Rixensart, Belgium. References [1] Davey S. The vaccine challenge. In: State of the World s Vaccines and Immunisation. Geneva: World Health Organization and United Nations Children s Fund, 1996:1 25. [2] Giammanco A, Chiarini A, Stroffolini T, et al. Seroepidemiology of pertussis in Italy. Rev Infect Dis 1991;13:1216 20. [3] Black S. Epidemiology of pertussis. Pediatr Infect Dis J 1997; 16(suppl):85 89. [4] Baron S, Njamkepo E, Grimprel E, et al. Epidemiology of pertussis in French hospitals in 1993 and 1994: thirty years after a routine use of vaccination. Pediatr Infect Dis J 1998;17:412 8. [5] Centers for Disease Control and Prevention. Pertussis outbreaks Massachusetts and Maryland, 1992. MMWR 1993;147:522 5. [6] Cromer BA, Goydos J, Hackell J, et al. Unrecognized pertussis infection in adolescents. Am J Dis Child 1993;147:575 7. [7] He Q, Viljanen MK, Nikkari S, et al. Outcomes of Bordetella pertussis infection in different age groups of an immunised population. J Infect Dis 1994;17:873 7. [8] Keitel WA, Edwards KM. Pertussis in adolescents and adults: time to reimmunize? Semin Respir Infect 1995;10:51 7. [9] Nennig ME, Shinefield HR, Edwards KM, et al. Prevalence and incidence of adult pertussis in an urban population. JAMA 1996;275: 1672 4. [10] Robertson PW, Goldberg H, Jarvie BH, et al. Bordetella pertussis infection: a cause of persistent cough in adults. Med J Aust 1987;147:522 5. [11] Bass JW, Wittler RR. Return of epidemic pertussis in the United States. Pediatr Infect Dis J 1994;13:343 5. [12] Cherry JD, Baraff LJ, Hewlett E. The past, present and future of pertussis. The role of adults in epidemiology and future control. West J Med 1989;150:319 28. [13] Hoppe JE. Update on epidemiology, diagnosis, and treatment of pertussis. Eur J Clin Microbiol Infect Dis 1996;15:189 93. [14] Mortimer EA Jr. Pertussis and its prevention: a family affair. J Infect Dis 1990;161:473 9. [15] Nelson JD. The changing epidemiology of pertussis in young infants: the role of adults as reservoirs of infection. Am J Dis Child 1978; 132:371 3. [16] Mertsola J, Ruuskanen O, Eerola E, Viljanen MK. Intrafamilial spread of pertussis. J Pediatr 1983;103:359 63. [17] Long SS, Welkon CJ, Clark JL. Widespread silent transmission of pertussis in families: antibody correlates of infection and symptomatology. J Infect Dis 1990;161:480 6. [18] Izurieta HS, Kenyon TA, Strebel PM, et al. Risk factors for pertussis in young infants during an outbreak in Chicago in 1993. Clin Infect Dis 1996;22:503 7. [19] Fine PE. Adult pertussis: a salesman s dream and an epidemiologist s nightmare. Biologicals 1997;25:195 8. [20] Deville JG, Cherry JD, Christenson PD, et al. Frequency of unrecognized Bordetella pertussis infections in adults. Clin Infect Dis 1995;21:639 42. [21] National Advisory Committee on Immunisation, the Advisory Committee on Epidemiology, the Canadian Paediatric Society. Statement on management of persons exposed to pertussis and pertussis outbreak control. Can Med Assoc J 1995;152:712 6. [22] Immunization Practices Advisory Committee. Diphtheria, tetanus and pertussis: recommendations for vaccine use and other preventive measures. MMWR Recomm Rep 1991;40:1 28. [23] Decker MD, Edwards KM, Steinhoff MC, et al. Comparison of 13 acellular pertussis vaccines: adverse reactions. Pediatrics 1995;96:557 66. [24] Pichichero ME. Acellular pertussis vaccines. Towards an improved safety profile. Drug Saf 1996;15:311 24. [25] Kimura M, Kuno-Sakai H, Sato Y, et al. A comparative trial of the reactogenicity and immunogenicity of Takeda acellular pertussis vaccine combined with tetanus and diphtheria toxoids. Outcome in 3- to 8-month-old infants, 9- to 23-month-old infants and children, and 24- to 30-month-old children. Am J Dis Child 1991;145:734 41. [26] Edwards KM, Decker MD, Graham BS, et al. Adult immunization with acellular pertussis vaccine. JAMA 1993;269:53 6. [27] Liese JG, Stojanov S, Belohradsky BH. Pertussis vaccination with acellular vaccines. Tolerance effectiveness current vaccination recommendations. Fortschr Med 1997;115:22 7. [28] Anderson RM, May RM. Immunization and herd immunity. Lancet 1990;335:641 5. [29] Hadler SC. Cost benefit of combining antigens. Biologicals 1994;22: 415 8. [30] Begue P, Grimprel E. Future combined vaccines. J Infect Dis 1996; 174(suppl 3):S295 7. [31] Van der Wielen M, Van Damme P, Joossens E, et al. A randomized controlled trial with a diphtheria-tetanus-acellular pertussis (dtpa) vaccine in adults. Vaccine 2000;18(20):2075 82. [32] Ruuskanen O, Noel A, Putto-Laurila A, et al. Development of an acellular pertussis vaccine and its administration as a booster in healthy adults. Vaccine 1991;9:117 21. [33] Annunziato PW, Rothstein EP, Bernstein HH, et al. Comparison of a three-component acellular pertussis vaccine with a whole-cell pertussis vaccine in 4- through 6-year-old children. Arch Pediatr Adolescent Med 1994;148(5):503 7. [34] Bernstein HH, Rothstein EP, Reisinger KS, et al. Comparison of a three-component acellular pertussis vaccine with a whole-cell pertussis vaccine in 15- through 20-month-old infants. Pediatrics 1994;93: 656 9. [35] Kanra G, Ceyhan M, Vandevoorde D, Bogaerts H. Acellular pertussis diphtheria-tetanus-pertussis vaccine containing separately purified pertussis toxoid, filamentous hemagglutinin and 69 kda outer membrane protein as a booster in children. Eur J Pediatr 1993;152:478 83. [36] Englund JA, Decker MD, Edwards KM, et al. Acellular and wholecell pertussis vaccines as a booster dose: a multicentre study. Pediatrics 1994;93:37 43. [37] Pichichero ME, Deloria MA, Rennels MB, et al. A safety and immunogenicity comparison of 12 acellular pertussis vaccines and one whole-cell pertussis vaccine given as a fourth dose in 15- to 20- month-old children. Pediatrics 1997;100:772 88. [38] Schmitt H-J, Beutel K, Schuind A, et al. Reactogenicity and immunogenicity of a booster dose of a combined diphtheria, tetanus, and tricomponent acellular pertussis vaccine at fourteen to twenty-eight months of age. J Pediatr 1997;130:616 23. [39] Zepp F. Reactogenicity of booster doses: field experiences in Germany. Proceedings of the Acellular Pertussis Vaccine Conference. Bethesda, MD: 2000. [40] Dagan R, Igbaria K, Piglansky L, et al. Reactogenicity and immunogenicity of reduced antigen content diphtheria-tetanus-acellular pertussis vaccines as a booster in 4 7-year-old children primed with diphtheria-tetanus-whole cell pertussis vaccine before 2 years of age. Vaccine 1999;17(20 21):2620 7. [41] Minh NNT, He Q, Ramalho A, et al. Acellular vaccines containing reduced quantities of pertussis antigens as a booster in adolescents. Pediatrics 1999;104(6):1377 8.