Statistics from Altmetric.com
It has become increasingly clear that interaction between vaccines is an important consideration for immunogenicity studies. Only full information on all vaccines used in a particular population will allow correct interpretation of immunogenicity data.1 This is particularly important where comparison is made to historical controls in a rapidly changing schedule such as that used in the UK, or where immunogenicity data obtained using vaccines that differ significantly from those currently in use are subsequently used to guide practice.
It also apparent that the “best” combination of specific vaccines, the effects of interactions of conjugate proteins, the optimal timing of the primary course, and the necessity for boosters within the UK schedule are all currently unclear. Certain groups of infants may require separate consideration, for example those born preterm or from specific ethnic backgrounds.
We therefore read with interest the data presented by Booy et al of responses to primary series immunisation in Asian infants born in the UK to a population of parents of whom “most” (88%) were born abroad.2
Based on the achievement of an anti-PRP GMT of 15 μg/ml, Booy et al are reassured that vaccination with PRP-T should protect this population from Hib meningitis. We are uncertain as to whether this confidence is justified. There is no clear description of the exact vaccines administered to their population, or of when the study took place. PRP-T and DTP were administered in separate limbs, but the nature of the pertussis component of the DTP (whole cell [DTPw] or acellular [DTPa]) is unspecified. Since DoH advice from 1996 was for combined single limb injection of PRP-T and DTP, we assume that the study predates 1996.3 Given that DTPa was introduced in 1999,4 we therefore also assume that the study DTP was DTPw. Separate limb administration of DTP, or using DTPw may result in a higher anti-PRP GMT in comparison to that achieved by infants receiving either combined vaccines5) or an acellular DTP6 (or a combination of this, as with the UK’s new vaccine, Pediacel).
While Booy et al comment on their study as “descriptive and uncontrolled”, they do include a historical cohort of controls. Neither the original publication of the control data,7 nor this present publication clearly describe to the reader the actual (as opposed to planned) timing of important study interventions (vaccine administration, vaccine intervals, blood sampling in relation to vaccines), with the exception of acknowledging that the median time of primary course completion differed between the two groups. Clear descriptions of study timings would allow the reader to consider whether the populations are crudely comparable; alternatively a statistical analysis could have been performed that would take account of these differences. Without this the difference in GMTs is without context. Placing the data in context may help explain the otherwise very surprising finding that Asian infants appear to respond three times as well to PRP-T as Caucasians.
It would also be interesting to know the limits of detection for the anti-PRP assay, and how results above or below these limits were handled—the 28 (or 34) infants having surprisingly tight 95% confidence intervals around their GMT for such small numbers of infants.
Given the recurrence of Hib disease in the UK, the question of how well UK infants respond to PRP-T is clearly very important, as well as whether or not UK infants (like most others) should receive a fourth (booster) dose. Careful studies that help to address these questions are crucial. We would welcome the additional information from Booy and colleagues that would allow this current information to be more readily interpreted.