Hexavalent vaccines containing diphtheria (D), tetanus (T), acellular pertussis (aP), inactivated poliovirus (IPV), hepatitis B (HB), Haemophilus influenzae type b [Hib polyribosylribitol phosphate (PRP)-T] antigens are routinely the standard of care in Europe.1 After an extensive clinical development program in 4 continents, using a wide range of primary vaccination series schedules, and with a booster in the second year of life, Sanofi Pasteur’s fully liquid D, T, 2-component aP [pertussis toxin (PT) and filamentous hemagglutinin (FHA)], IPV, HB, PRP-T vaccine (Hexaxim, Hexyon or Hexacima, depending on the country) was first licensed in 2012. Since that time, several postlicensure studies have been conducted globally, and at the request of the European Medicines Agency, a program of studies in a predominantly Caucasian population was implemented to support the use of this DTaP-IPV-HB-PRP-T vaccine in Europe according to immunization schedules in use in the European Union (EU).
The fully liquid DTaP-IPV-HB-PRP-T vaccine is based on a preexisting reconstituted DTaP-IPV//PRP-T pentavalent vaccine (Pentaxim/Pentavac) [Sanofi Pasteur]2 with the addition of a Hansenula polymorpha–derived HB antigen with proven immunogenicity and safety.3 Strong immunogenicity for each antigen, including persisting antibody levels in the second year of life and a good safety profile have been established for both primary series and booster administration of the hexavalent vaccine including after coadministration with other common childhood vaccines.4–19
However, despite the extensive program of clinical studies to evaluate the hexavalent vaccine, there has not been any prior evaluation of mixed/sequential-vaccine primary series schedules, that is, a 3-dose infant primary series combining the hexavalent vaccine, followed by a pentavalent vaccine (without an HB antigen) and then another dose of the hexavalent vaccine in individuals having received HB vaccination at birth. A demonstration of immunogenicity and safety for a mixed primary series would support its use in routine pediatric vaccination, thereby allowing greater flexibility without compromising protection against these childhood diseases. This study was, therefore, conducted to assess the immunogenicity and safety of such a mixed primary series schedule at 2, 4, 6 months of age, coadministered with pneumococcal vaccine (PCV13), rotavirus (RV), and meningococcal conjugate vaccine, as well as to assess a pentavalent booster vaccination coadministered with PCV13 in the second year of life.
MATERIALS AND METHODS
Study Design and Participants
Two consecutive open-label studies were carried out at a total of 12 study sites in Spain: an infant primary vaccination series study followed by a booster vaccination study in toddlers (World Health Organization Universal Trial Numbers U1111-1122–2329 and U1111-1122–2362, respectively). The study protocols and 1 amendment were approved by local independent ethics committees, and the studies were performed according to local regulations, Good Clinical Practices, applicable International Conference on Harmonization guidelines and the ethical principles of the Declaration of Helsinki (Edinburgh revision, October 2000). An informed consent form was signed by each subject’s parents or legally acceptable representatives before enrollment into each study. Primary vaccinations occurred between January to November 2014 and booster vaccinations between November 2014 and November 2015.
Healthy infants 55–75 days of age, born at full term (≥ 37 weeks), with birth weight ≥ 2.5 kg and who had previously received 1 dose of HB vaccine, usually at birth, were eligible for the primary series study. The main exclusion criteria were recent (in the 4 weeks before the first vaccination) or planned participation in another clinical trial or nonstudy vaccination during or in the 4 weeks before the study period (except for routine vaccines administered per the national immunization calendars, including influenza vaccination); previous vaccination against, or history of, DTP, poliomyelitis, Hib, pneumococcal, meningococcal, and RV infection; receipt of blood products since birth; personal/maternal history of human immunodeficiency virus, HB or hepatitis C infection or receipt of any immunosuppressive therapy; known hypersensitivity to any vaccine component; bleeding disorder in the 3 weeks before inclusion contraindicating intramuscular injection; history of seizures; any chronic illness that could interfere with study conduct or completion; acute illness or febrile illness. Subjects were excluded from the booster study if they had received any nonstudy vaccine in the 2 weeks before booster vaccine or had any nonstudy vaccination planned in the 4 weeks after the booster. Additionally, at the time of the booster study, contraindications to pertussis vaccination were assessed based on the temporal association of encephalopathy, temperature ≥ 40°C, hypotonic-hyporesponsive episode, persistent inconsolable crying and nonfebrile convulsions. There was no specific exclusion criterion for participants with genetic disorders.
In the primary series study, all participants had received a dose of HB vaccine before study entry in accordance with the national immunization calendar recommended in Spain by the Spanish Pediatric Association,20 and all were to receive the fully liquid, hexavalent vaccine (DTaP-IPV-HB-PRP-T) at 2 and 6 months of age and the reconstituted pentavalent vaccine (DTaP-IPV//PRP-T) at 4 months of age, coadministered with PCV13 (2 and 4 months of age, with a third dose at 6 months of age at the discretion of the Investigator), reassortant pentavalent RV vaccine (2, 4, 6 months of age) and T-toxoid-conjugated meningococcal serogroup C vaccine (2 months of age).
A booster vaccination of the reconstituted pentavalent vaccine (DTaP-IPV//PRP-T) coadministered with a PCV13 booster was administered at 18 months of age to participants who completed the primary series and were eligible and available for the booster study (Fig. 1). If a PCV booster had been administered between the primary and booster studies, no additional PCV13 booster was administered. Also, if a subject experienced a low anti-HB response prebooster (based on the Investigator’s assessment), an additional dose of standalone HB vaccine could be administered 1 month after the administration of the pentavalent vaccine booster.
Study vaccines were administered into the right thigh, left thigh (PCV13 and meningococcal vaccine) and orally (RV).
The hexavalent vaccine was manufactured by Sanofi Pasteur and supplied as a fully liquid, sterile suspension for injection in a prefilled syringe. Each 0.5 mL dose contained ≥20 IU (30 limit of flocculation) D-toxoid, ≥40 IU (10 limit of flocculation) T-toxoid, 25 µg PT, 25 µg FHA, 40, 8, and 32 D antigen units of poliovirus type 1, 2, and 3, respectively, 10 µg hepatitis B surface antigen, 12 µg Hib polysaccharide conjugated to 22–36 µg T protein (PRP-T), and 0.6 mg aluminum hydroxide.
The pentavalent vaccine was manufactured by Sanofi Pasteur and supplied as a freeze-dried PRP-T pellet to be rehydrated by an injectable DTaP-IPV suspension just before injection. Each 0.5 mL dose of reconstituted vaccine contained ≥30 IU D-toxoid, ≥40 IU T toxoid, 25 µg PT, 25 µg FHA, 40, 8, and 32 antigen units of IPV type 1, 2, and 3, respectively, 10 µg Hib polysaccharide (PRP) conjugated to 18–24 µg T protein (PRP-T) and 0.4 mg aluminum.
The PCV13 vaccine (Prevenar 13) was manufactured by Pfizer Incorporated and supplied in prefilled 0.5 mL syringes. Each 0.5 mL dose contained 2.2 µg of pneumococcal polysaccharide serotypes 1, 3, 4, 5, 6A, 7F, 9V, 14, 18C, 19A, 19F, and 23F and 4.4 µg pneumococcal polysaccharide serotype 6B. Each serotype was conjugated to a cross-reacting material (CRM) carrier protein.
The RV vaccine (RotaTeq) was manufactured by Merck Sharp & Dohme Corporation and supplied as a prefilled solution in a squeezable tube for oral administration. Each 2 mL dose contained RV type G1 (≥2.2 × 106 IU), G2 (≥2.8 × 106 IU), G3 (≥2.2 × 106 IU), G4 (≥2.0 × 106 IU) and P1A (≥2.3 × 106 IU).
The meningococcal vaccine (NeisVac-C) was manufactured by Baxter AG and supplied as a suspension for injection in a prefilled syringe. Each 0.5 mL dose contained 10 µg Neisseria meningitidis group C (strain C11) polysaccharide (de-O-acetylated) conjugated to 10–20 µg detoxified T toxin and 0.5 mg aluminum hydroxide.
All vaccines were commercial lots.
In the primary series study, 5 mL blood samples were collected prefirst vaccination (2 months of age) and 1-month after the third vaccination (7 months of age) for determination of antibodies to all antigens in the hexavalent, pentavalent and RV vaccines.
In the booster study, 5 mL blood samples were collected prebooster to assess antibody persistence for all antigens in the hexavalent and pentavalent vaccines and 1-month postbooster to assess the booster response to all antigens in the pentavalent vaccine. No postbooster assessment of anti-HB was performed (in the event that a subject had a low anti-HB response prebooster and received an additional dose of standalone HB vaccine 1 month after the pentavalent booster).
All assays were performed at either the Sponsor’s Global Clinical Immunology laboratory (Swiftwater, PA) or at qualified contract laboratories approved by Global Clinical Immunology. Anti-D antibody concentrations (IU/mL) and anti-polio 1, 2, 3 antibody titers (1/dil) were measured by neutralization assays. Anti-T (IU/mL), anti-PT (EU/mL), and anti-FHA (EU/mL) concentrations were evaluated by enzyme-linked immunosorbent assays, anti-HB concentrations (mIU/mL) by a commercially available chemiluminescence assay (VITROS ECi/ECiQ, Ortho Clinical Diagnostics, NJ), and anti-PRP-T (µg/mL) concentrations by a radioimmunoassay. Anti-RV IgA was assessed using enzyme-linked immunosorbent assays.
Reactogenicity and Safety
Participants were observed for 30 minutes after each vaccination to assess immediate unsolicited adverse events (AEs). For 7 days after each vaccination, parent(s)/legal representative(s) used diary cards to record the duration and intensity of solicited injection site reactions [tenderness, erythema, swelling (recorded separately for the DTaP-IPV-HB-PRP-T or control vaccine and PCV13 vaccination sites), and extensive swelling of the vaccinated limb (extensive swelling of the vaccinated limb was only assessed after the booster DTaP vaccinations [not PCV13])] and solicited systemic reactions (fever, vomiting, crying abnormal, drowsiness, appetite loss, irritability) reactions. All solicited reactions were automatically considered to be related to the vaccination. For temperature measurement, the rectal route was preferred.
Unsolicited AEs were recorded using diary cards for 30 days after each vaccination. Unsolicited injection-site AEs were considered to be related to the vaccination, and the investigator assessed unsolicited systemic AEs for causality. Serious AEs (SAEs) were collected throughout the study until 1 month after the last primary series vaccination or booster vaccination, and the investigator assessed their causality.
A total of 265 participants were planned to be enrolled. No formal sample size calculation was made since no hypotheses were tested and all evaluations were descriptive. The antibody-level thresholds and criteria used to define seroprotection (SP) and vaccine response rates are presented in Table 1. For RV, the definitions for SP and seroconversion rate are presented in Table 2. Additionally, geometric mean titers (for polio) and geometric mean concentrations (GMCs: anti-HB, anti-PRP, anti-D, anti-T, anti-PT, anti-FHA and anti-RV IgG) are presented. All data are presented with their 95% confidence intervals, calculated using the exact binomial distribution (Clopper-Pearson)21 for proportions and the normal approximation method for GMCs and geometric mean titers.
The primary series and booster analysis of immunogenicity used the per protocol population (participants with no protocol violation that could have interfered with the evaluation criteria, and analyzed according to the vaccine received). The safety evaluation used the safety analysis set population (participants who received at least 1 primary vaccination and all who received the booster).
The statistical analyses were done under the responsibility of Sanofi Pasteur’s statistical group using SAS software, version 9.2 or later (SAS Institute, Cary, NC).
A total of 265 participants entered the study and received at least 1 primary series vaccination, of whom 263 participants completed the primary series, 198 participants received the booster vaccination and 196 participants completed the booster study (Fig. 1). In both the primary series and booster studies, there was a similar number of males (52.8% and 48.5%) and females (47.2% and 51.5%) in the study, and most participants were Caucasian (95.8% and 94.9%).
Table 1 presents the immunogenicity data for the hexavalent-pentavalent-hexavalent primary series and the pentavalent booster vaccination. The observed immune responses (1-month postdose 3) were high in terms of SP and vaccine response rates for primary series (generally > 99%) and booster vaccination (generally > 95% at 1-month postbooster) and in the expected range for each antigen. Antibody persistence was good for all antigens, in particular, for HB 92.4% of participants had prebooster antibody ≥ 10 mIU/mL at 18 months of age, 1 year after the third primary series dose.
The response to RV was strong after the primary series (Table 2) with 90.8% of participants having anti-RV IgG ≥20 U/mL ad 88.4% having seroconverted. These data were in the expected range.
Safety and Tolerability
There were no immediate adverse reactions (ie, within 30 minutes postvaccination). The overall incidence of solicited injection site and systemic reactions was slightly higher for the 3-dose primary series vaccination (76.6% and 97.4%, respectively) than for the single booster dose (56.9% and 73.1%); the incidence of solicited reactions rated as grade 3 in severity was low for both the primary series and booster vaccinations (3.0%–17.4%) (Table 3). For both the primary and booster vaccinations, pain was the most common solicited injection site reaction (62.6% and 50.3%, respectively) and irritability was the most common solicited systemic reaction (83.8% and 56.9%, respectively). There were no episodes of extensive swelling of the vaccinated limb (assessed only for the booster vaccination). The incidence of solicited injection site reactions after administration of PCV13 was similar to that reported for the hexavalent and pentavalent vaccines for both the primary series and booster vaccinations.
For the primary series, 70.2% of participants reported an unsolicited AE within 30 days after vaccination, but only 1.9% of participants reported an unsolicited AE within 30 days that was considered to be related to the vaccination. The incidence was slightly less for the booster vaccination, with 44.9% of participants reporting an unsolicited AE within 30 days postbooster and 1.5% of participants reporting an unsolicited AE that was considered to be related to the booster vaccination. For both the primary series and booster, the most commonly reported AEs were infections and infestations (43.4% and 30.3%, respectively).
No AEs resulted in participant discontinuation in either the primary series or booster studies; there were no SAEs that were considered by the investigator to be related to the vaccine and no deaths.
This study is the first to evaluate the immunogenicity of a mixed hexavalent-pentavalent-hexavalent vaccine infant primary series schedule using DTaP-IPV-HB-PRP-T and DTaP-IPV//PRP-T, followed by a subsequent booster with the pentavalent vaccine at 18 months of age. The role of hexavalent vaccines, including a thorough evaluation of their coadministration with other vaccines as well as practical considerations regarding their use, has recently been reviewed.1
In this study, infant primary series (anti-D, anti-T, anti-PT, anti-FHA, anti-IPV 1, 2, 3, anti-HB and anti-PRP) and booster (anti-D, anti-T, anti-PT, anti-FHA, anti-IPV 1, 2, 3 and anti-PRP) immune responses were strong and consistent with those described in previous studies using 3 doses of the hexavalent vaccine followed by a pentavalent or hexavalent booster.8,9,13–15 Additionally, good persistence of the immune response to each antigen was demonstrated at 18 months of age, before the booster vaccination as has been shown in previous studies after 3 doses of the hexavalent vaccine.8,11,16 Similarly, the primary series anti-RV IgG response was strong and as expected based on previous data.8
Each participant received a total of 3 doses of HB vaccine (2 of them during the course of the study), that is, at birth, 2 and 6 months of age (the pentavalent vaccine administered at 4 and 18 months of age contained no HB antigen). These data confirm that 2 doses of HB vaccine at 2 and 6 months of age administered as part of a hexavalent vaccine, after a birth dose of HB vaccine, result in high postprimary series anti-HB antibody titers that persist for at least 1 year and that are comparable with those elicited historically after a 3-dose hexavalent vaccination schedule (2, 4, 6 months, 2, 3, 4 months, 6, 10, 14 weeks) with or without a birth dose of HB,5,8–10,12,13,15,17 supporting the integration of hexavalent formulations into existing vaccination schedules. Both the primary series and booster vaccination showed a good safety profile with the incidence and type of solicited and unsolicited AEs being consistent with previous studies using the hexavalent and pentavalent vaccines. There were no clinically important safety findings and no vaccine-related SAEs, and no deaths. Previous studies have supported the interchangeability of the hexavalent and pentavalent vaccines when administered as a booster vaccination after a primary series using the other vaccine.4,8,16 Such flexibility is important from a public health perspective to maintain vaccine coverage during ruptures of supply that can occur frequently because of the inherent difficulties in the manufacture of such complex multivalent vaccines.8,22
In conclusion, this study provides data that allow recommending authorities to consider the use of a sequential hexavalent-pentavalent-hexavalent primary vaccination series followed by a pentavalent booster as an alternative regimen in children who have received an HB vaccination at birth. Additionally, coadministration with PCV13, RV and meningococcal vaccines did not adversely affect the immune response to the antigens contained in the hexavalent and pentavalent vaccines.
The authors thank the participants and their families for their generous contribution to advancing the knowledge of vaccination. Additionally, the authors acknowledge the investigational staff in Spain at: Burriana (Dr. Suarez-Vicent), Castellon de la Plana (Dr. Cabanero-Pisa), L’Eliana (Dr. Ubeda-Sansano), Paiporta (Dr. Planelles-Cantarino), Pontevedra (Dr. Couceiro Gianzo, Dr. Javiera Francisca Hurtado Díaz, Dr. Mª Mercedes Busto Cuiñas), Quart de Poblet (Dr. Baldo-Torrenti), Santiago de Compostela (Dr. Lorenzo Redondo Collazo, Dr. Carmen Rodriguez Tenreiro, Dr Irene Rivero, Dr. Nazareth Martinón, Dr. Antonio Justicia Grande), Valencia (Dr. Gil-Mary, Dr. Peidro-Boronat, Dr. Cerdan-Vera, Dr. Martinez-Pons, Dr. Garces-Sanchez, Dr. Pérez-Breva). The authors also acknowledge Severine Paulhac, Estelle Chataigner, Gaelle Soupart, Manon Croix, Nicolas Corde, Catherine Moreau, Jesus Garrido, Christine Manson, Nathalie Chateau-Rivoire, Corinne Terle, Pascale Davaux, Alexandra Jouve, Catherine Forrat, Neil Scheff, Marie Bufferne, Roxane Couty, and Vincent Dallery (employed by Sanofi Pasteur) as well as Susana Ramos and Carmen Lizaso Romero (employed by Sanofi). Dr. Andrew Lane (Lane Medical Writing) provided medical writing assistance, funded by Sanofi Pasteur, in the preparation and development of the article in accordance with the European Medical Writers Association guidelines and Good Publication Practice and was funded by Sanofi Pasteur.
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Keywords:Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
hexavalent; pentavalent; vaccine; primary; booster