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Combination vaccines improve parental and provider satisfaction and schedule compliance by decreasing the number of injections. In a Phase 2, randomized, double-blind, multicenter study, we compared four formulations of a liquid, hexavalent diphtheria-tetanus-acellular pertussis-inactivated poliovirus-Haemophilus influenzae b conjugate-hepatitis B virus (DTaP-IPV-Hib-HBV) vaccine in 708 infants immunized at 2, 3, 4, and 12-14 months of age. The formulations contained identical DTaP and IPV components, differing in the contents of Hib polyribosylribitol phosphate (PRP) conjugate component (tetanus-toxoid [PRP-T, 12microg] or Neisseria meningitidis outer-membrane-protein-complex [PRP-OMPC, 3microg or 6microg]), and in hepatitis B surface antigen (HBsAg, 10microg or 15microg). A minimum acceptable postdose 3 antibody response rate was defined by the lower limit of the 95% confidence interval exceeding a prespecified target. Rates of adverse events (AEs) were similar among groups, with a trend for increased solicited injection-site reactions (pain, redness, swelling) with increasing PRP-OMPC and HBsAg concentration. Serious AEs reported by eight subjects were not considered to be vaccine related. All PRP-OMPC formulations met prespecified acceptability criteria for postdose 3 immunogenicity for all antigens: PRP, HBsAg, pertussis, diphtheria, tetanus and polio. Apart from the Hib response, the postdose 3 responses obtained with the PRP-T formulation met the acceptability criterion for each antigen. Postdose 4 responses were acceptable for all antigens in all formulations. All vaccine formulations were well tolerated. The three PRP-OMPC formulations met prespecified immunogenicity criteria, and the one with the lowest PRP-OMPC concentration was selected for further optimization of immunogenicity.

Combination vaccines decrease the number of injections and improve parental satisfaction and vaccination schedule compliance. In a phase 1, randomized, partially-blinded, single-dose booster study, we evaluated two formulations of an investigational liquid hexavalent vaccine containing diphtheria, tetanus, acellular pertussis (5-component), inactivated poliovirus, Haemophilus influenzae b conjugate and hepatitis B surface antigen (DTaP-IPV-Hib-HBV) in 60 healthy toddlers, 15 to 18 months of age, who had been primed with three doses of a licensed pentavalent diphtheria, tetanus, acellular pertussis (5-component), inactivated poliovirus, Haemophilus influenzae b conjugate (DTaP-IPV//PRP-T) vaccine. The DTaP-IPV//PRP-T vaccine was used as a control in 30 subjects. The investigational formulations, which contained the same DTaP-IPV components, differed only in Hib (content and conjugate) and HBV (content) (PRP-T/HBV10 = 12 mug Hib tetanus toxoid conjugate with 10 microg HBsAg; PRP-OMPC/HBV15 = 6 microg Hib Neisseria meningitidis outer membrane protein complex with 15 microg HBsAg). Injection-site pain, redness and swelling were reported by 46.7%, 46.7%, and 20.0% of the licensed vaccine recipients, 43.3%, 43.3%, and 26.7% of PRP-T/HBV10 recipients and 70.0%, 46.7%, and 46.7% of PRP-OMPC/HBV15 recipients, respectively. Fever > or = 37.8 degrees C and irritability were reported by 0% and 16.7% of licensed vaccine recipients, 10.3% and 23.3% of PRP-T/HBV10 recipients and 30.0% and 16.7% of PRP-OMPC/HBV15 recipients, respectively. There were no apparent differences between the groups in the proportion of participants achieving predefined, threshold or seroprotective immune responses. Geometric mean antibody levels for all antigens were similar except for anti-PRP levels, which were 19.0 microg/mL in recipients of the licensed vaccine, 40.8 microg/mL in PRP-T/HBV10 recipients and 9.4 microg/mL in PRP-OMPC/HBV15 recipients. We conclude that the hexavalent formulations appear generally well tolerated and immunogenic as a booster dose in these toddlers.

Immunogenicity data obtained after primary series immunisations against Haemophilus influenzae type b (Hib), using a vaccine prepared by conjugating the capsular polysaccharide of Hib to tetanus toxoid (ActHIB), were compiled from 146 study groups comprising 85 clinical trials or vaccination programs conducted between 1987 and 1999. ActHIB was administered as a monovalent lyophilised vaccine, injected either in association with another paediatric vaccine (at separate administration sites) or in combination (where the different vaccines are mixed together in the same syringe before injection). Review of these data reveals two trends. First, PRP-T vaccine, given either alone or in combination with DTwcP, resulted in a stronger anti-PRP serum antibody response than when PRP-T was combined with DTacP vaccine. Second, an accelerated (i.e. one-month interval) immunisation schedule tended to induce a poorer anti-PRP antibody response than did the more widely spaced, standard inoculation schedules. Although an in-depth analysis of these over 11000 study subjects on an individual basis with multivariate analysis or multifactorial statistical methods might eventually provide working hypotheses to fully understand these phenomenon, the various licensed, PRP-T-containing paediatric combination vaccines have proved to be clinically effective.

Following a study in Senegal (1990-1995) in which the relative efficacy of a diphtheria-tetanus-acellular pertussis vaccine (DTaP) was compared with that of a diphtheria-tetanus-whole-cell pertussis vaccine in children given a simultaneous injection of Bacille Calmette-Guérin (BCG) vaccine, this subsequent study was conducted to evaluate the possible adjuvant effect of the BCG vaccine on acellular pertussis vaccine components. A second objective was to compare the immunogenicity of these components when administered in accordance with a 2-4-6-month (spaced) schedule or an accelerated 2-3-4-month schedule. In all, 390 healthy Senegalese infants were randomly divided into three groups of 130 infants. Antibodies to acellular pertussis components were measured in serum samples obtained within 2 days of the first DTaP dose and 1 month after the third dose. BCG vaccine, given simultaneously with the DTaP vaccine, did not influence the immunogenicity of the acellular pertussis vaccine components when compared with separate adminstration of the two vaccines. Infants immunised according to a 2-4-6-month schedule had a significantly higher immune response than those immunised according to a 2-3-4-month schedule with respect to the response to pertussis toxoid assessed by seroneutralisation on Chinese hamster ovary cells (P is less than 0.0001). These results suggest that BCG and DTaP vaccines can be given simultaneously without interference or enhancement and that more optimal immunogenicity is achieved with an extended than with an accelerated schedule. (Résumé d'auteur)

Methods. In an open randomized study we compared the safety and immunogenicity of two schedules for priming and booster vaccinations of infants. A pentavalent combination vaccine, including a lyophilized Haemophilus influenzae type b-tetanus toxoid conjugate vaccine reconstituted with a liquid diphtheria, tetanus, acellular pertussis (pertussis toxoid and filamentous hemagglutinin) and inactivated polio vaccine (DTaP-IPV/Act-HIB®; Pasteur Merieux Connaught, Lyon, France) was administered to 236 Swedish infants either at 2, 4 and 6 months or at 3 and 5 months, and a booster dose was administered 7 months after the last primary dose. Adverse events were monitored by diaries for 3 days after each vaccination and by questions at the ensuing visits. Antibodies against the different vaccine components were analyzed after the primary series of vaccinations, before and after the booster injections. Results. There were no serious adverse reactions, and the rates of febrile events and local reactions were low in both groups. The three dose primary schedule induced higher geometric mean concentrations for all antigens than did the two dose schedule, but there were no differences between the groups in proportions with protective antibody titers against diphtheria, tetanus, Hib and polio or in proportions with certain defined levels of pertussis antibodies. Prebooster results showed a similar pattern, with the exception that the group primed with three injections showed higher proportions of infants with detectable antibodies against polio-virus types 1 and 3. After booster vaccinations there were no differences between the two schedules in geometric mean or in proportions with antibodies above defined antibody concentrations, indicating effective priming from both primary series of vaccinations. Conclusion. The combined vaccine DTaP-IPV/ Act-HIB® vaccine was equally safe and immunogenic when administered according to both time schedules studied.

In recent years additional parenteral vaccines have been recommended for routine immunization of infants in the US and elsewhere. The ability to administer multiple vaccines as a single injection without unacceptably increasing reactogenicity or decreasing immunogenicity of any component would offer many practical advantages.A randomized, open, controlled trial was conducted to assess the tolerance profile and immunogenicity, as well as to identify potential antigenic interferences, resulting from administration of a parenteral combination vaccine for infants. The vaccine contains diphtheria and tetanus toxoids, acellular pertussis antigens (DTaP), enhanced inactivated poliovirus (eIPV) and Haemophilus influenzae type b-tetanus toxoid conjugate (PRP-T). Infants (n=711) were randomly assigned to receive 1 of 5 regimens as the primary series at 2, 4 and 6 months of age, by group: (1) DTaP plus oral polio vaccine (OPV); (2) DTaP plus eIPV (separate injections); (3) DTaP-eIPV combined as a single injection; (4) DTaP-eIPV combined, plus a separate injection of PRP-T; or (5) DTaP-eIPV combined and reconstituting PRP-T, as a single injection. At 3, 5 and 7 months Groups 1, 2 and 3 received PRP-T. At 12 months all infants received a booster dose of DTaP reconstituting PRP-T as a single injection, plus a separate injection of measles, mumps and rubella vaccine. Groups 2, 3, 4 and 5 received OPV at 7 months, and all infants received OPV at 13 months. Serum immune responses were measured to the primary series at 2 and 7 months and to the booster dose at 12 and 13 months.Reaction rates were similar among groups. In the primary series combining eIPV with DTaP decreased geometric mean titers (GMTs) to diphtheria, tetanus and pertussis. In addition concomitant PRP-T (either simultaneous or combined) with DTaP-eIPV lowered anti-PRP and further decreased tetanus GMTs. Nonetheless in 100% of infants protective titers were achieved against diphtheria and tetanus (0.01 IU/ml each) and against the poliovirus types 1, 2 and 3 after eIPV (Groups 2 to 5); 99% of infants (Groups 4 and 5) had protective titers against PRP (or = 0.15 microg/ml). After boosting with DTaP/PRP-T decreased GMTs to diphtheria and PRP antigens were observed in the groups that received DTaP and eIPV combined. Nonetheless protective titers to diphtheria, tetanus and PRP occurred consistently. In contrast concomitant PRP-T with DTaP-eIPV enhanced the pertussis GMTs.We conclude that combined DTaP, eIPV and PRP-T in a single injection is well-tolerated and elicits an acceptable immune response to each component.

Two groups of BALB/c mice were inoculated with either 10(7) or 10(5) MLM subcutaneously into the lefthind footpad. Mice receiving 10(7) MLM were followed throughout infection for granuloma size, and antibody production against sonicated M. lepraemurium (MLM), whole M. lepraemurium and whole M. triviale, using a radioimmunoassay. All mice were sacrificed at 37 weeks post infection and acid fast bacilli were enumerated in both footpads and in the spleen. Noticeable individual variations were observed in the pattern of progression of the granuloma, and in the resistance to the infection, as assessed by measurements of bacilli local growth and dissemination. Antibody formation against MLM sonicate was detected as early as at 6 weeks post inoculation, a time when granulomas started to develop. Antibody production increased further when the infection progressed, against MLM (sonicate or whole bacilli), as well as against whole M. triviale. No correlation could be found between antibody activity and local bacilli growth or bacilli dissemination. Mice receiving 10(5) MLM s.c. were followed for ganuloma size and antibody production against sonicated MLM or other sonicated mycobacteria (pool of 6 different species). Antibody production could be detected against MLM and other mycobacteria as soon as 4 and 8 weeks after infection respectively, i.e. several weeks prior to the appearance of granulomas, which occurred at 12 weeks of infection.

Mice of the C57BL/6 strain were injected either subcutaneously (s.c.) in the foot pad or intravenously (i.v.) with 10(5) or 10(8) Mycobacterium lepraemurium (MLM). Anti-MLM sonicate total immunoglobulin (Ig), IgM, and IgG antibody production was followed during the course of the infection. The kinetics of appearance and the magnitude of anti-MLM antibodies were found to be related to the size and route of inoculation. The i.v. route induced earlier and higher amounts of anti-MLM antibodies than did the s.c. route. In i.v.-infected mice, a relatively predominant IgM response to MLM was observed, while a relatively higher IgG response was seen in s.c.-infected mice. IgM antibody level was found to increase sharply with the bacterial load as assessed in the spleens of mice with i.v.-disseminated infection; whereas a slow progression of both IgM and IgG levels was noted with time in s.c.-infected mice.

Sera from 92 patients were tested by the ELISA method for the presence of IgM antibodies to phenolic glycolipid-1 (PGL-1) of Mycobacterium leprae, and of both IgM and IgG antibodies to the whole M. leprae bacillus. All untreated lepromatous patients exhibited high antibody levels in all three assays. A sharp decline of IgM antibodies to PGL-1 and whole M. leprae was observed during the first two years of therapy, while IgG antibodies to whole M. leprae showed a progressive decrease only over a number of years. Low titers of IgM antibodies to PGL-1 and IgG antibodies to whole M. leprae could be detected in about 50% and 75% of patients, respectively, after more than ten years of treatment, with only 15% showing persisting IgM antibodies to the whole bacillus. Antibody levels as measured by the three assays used were correlated with the bacterial index in patients treated for less than four years. In patients treated longer than four years, only IgM antibodies, whether directed to PGL-1 or to whole M. leprae, remained correlated to the bacillary load. Tuberculoid patients exhibited a different antibody pattern, showing a lower frequency (and lower levels) of antibodies of PGL-1 and of IgG antibodies to whole M. leprae than lepromatous patients, and no detectable IgM antibodies to the whole bacillus. IgG antibodies to whole M. leprae were more frequently noted than antibodies to PGL-1, the latter declining more rapidly during therapy.

C57BL/6, DBA/2, BALB/c and CBA mice were thymectomized as adults, or sham-thymectomized, and infected subcutaneously with 10(6) MLM. The number of MLM in the spleen and in the inoculated footpad was measured after 1 year of infection as well as the DTH reactions and the IgM and IgG antibody levels to MLM. Non-thymectomized mice exhibited a broad spectrum of resistance to MLM infection and of T cell mediated immunity grading from the highly resistant C57BL/6 strain to the highly susceptible CBA strain. In between, DBA/2 was found more resistant than BALB/c mice. Adult thymectomy reduced by 100 times the MLM number in the spleen of infected DBA/2 mice, without affecting that measured in the inoculated footpad, and significantly decreased DTH reaction in the same strain. No effect of adult thymectomy was observed in any other strain, except for an increase of anti MLM antibodies in BALB/c mice. These results may suggest that the medium-resistant DBA/2 strain develops after MLM infection suppressor T cells which favour MLM dissemination and are sensitive to adult.

Different mouse strains were infected Subcutaneously in the footpad with 10 7 Mycobacterium lepraemurium (MLM). At various stages of the infection, the number of acid-fast bacilli (AFB) in different organs, spleen cell interleukin 2 production, and specific IgM and IgG serum antibodies to MLM sonicate were assessed. Strains were separable into two distinct groups depending on the number of AFB recovered from the different organs, without any obvious influence of the Bcg gene. Thus C57BL/6, DBA/2, (C57BL/6 × DBA/2)F 1 and C3H/Pas mice belonged to the high resistance group and DBA/1, BALB/c, and CBA strains to the low resistance group. Interleukin 2 production was depressed only in C57BL/6 and C3H/Pas mice. Anti-MLM antibody response also markedly varied according to strains, in terms of antibody titers, Ig class distribution, and species specificity, but with a different genetic pattern from that observed for MLM growth Control.

Mice from strains showing either phenotypical expression of Bcg gene (C57BL/6, BALB/c, DBA/1, and (C57BL/6 X DBA/2)/F1, CBA, A/J, DBA/2) were infected intravenously with 10(7) Mycobacterium lepraemurium (MLM). The number of acid-fast bacilli (AFB) within the spleens, the ability of spleen cells to produce in vitro interleukin 1 and 2, and the serum levels of specific anti-MLM antibodies were assessed 3 months later. The number of AFB recovered from the spleens of various strains followed the strain distribution of genetically controlled innate resistance established for Mycobacterium bovis infection. A decrease of interleukin 2 production by spleen cells could be detected in C57BL/6, DBA/1, DBA/2 and (C57BL/6 X DBA/2)F1 mice only. The level of anti-MLM antibodies was found to be higher in C57BL/6, BALB/c and A/J mice than in the other strains tested. Thus no evidence appeared of a direct influence of the Bcg gene on lymphokine production and antibody secretion.