title: Efficacy of an 11-valent pneumococcal conjugate vaccine against radiologically confirmed pneumonia among children less than 2 years of age in the Philippines: a randomized, double-blind, placebo-controlled trial.
abstract: BACKGROUND
  Pneumococcus is a leading cause of childhood pneumonia worldwide. Pneumococcal conjugate vaccines (PCV) have demonstrated efficacy against childhood invasive pneumococcal disease (IPD) and pneumonia in the United States and Africa. No information is available from Asia on the impact of PCV on childhood pneumonia.
  
  
  METHODS
  We conducted a randomized, placebo-controlled, double-blind trial in Bohol, the Philippines (ISRCTN 62323832). Children 6 weeks to <6 months of age were randomly allocated to receive 3 doses of either an 11-valent PCV (11PCV, sanofi pasteur, Lyon, France) or a saline placebo, with a minimum interval of 4 weeks between doses to determine vaccine efficacy (VE) against the primary outcome of a child experiencing first episode of community-acquired radiologically defined pneumonia in the first 2 years of life. Secondary end points were clinical pneumonia, IPD, safety, and immunogenicity.
  
  
  RESULTS
  Twelve thousand one hundred ninety-one children were enrolled. By per protocol (PP) analysis, 93 of 6013 fully vaccinated 11PCV recipient children had a first episode of radiologic pneumonia compared with 120 of 6018 placebo recipients. VE against radiologically defined pneumonia for the PP cohort of children 3 to 23 months old was 22.9% (95% CI: -1.1, 41.2; P = 0.06), for the prespecified subgroups of children 3 to 11 months of age, 34.0% (95% CI: 4.8, 54.3; P = 0.02), and of those 12 to 23 months old, 2.7% (95% CI: -43.5, 34.0; P = 0.88). By intent-to-treat (ITT) analysis, 119 of 6097 11PCV recipient children had an episode of radiologic pneumonia compared with 141 of 6094 placebo recipients. VE against radiologic pneumonia for the ITT cohort of children <2 years old was 16.0% (95% CI -7.3, 34.2; P = 0.16), for a subgroup of children <12 months of age, 19.8% (95% CI: -8.8, 40.8; P = 0.15). VE against clinical pneumonia by PP was not significant (VE 0.1%; 95% CI -9.4, 8.7; P = 0.99). IPD was rare: only 3 cases of IPD due to vaccine serotypes were observed during the study. 11PCV was immunogenic and well tolerated. Among 11PCV recipients, a small excess of serious adverse respiratory events was observed in the first 28 days after the first and second dose of vaccine, and of nonrespiratory events after the first dose. An excess of pneumonia episodes in 11PCV recipients in the month following the second dose of vaccination was the principal reason for lower VE by ITT analysis than by PP analysis.
  
  
  CONCLUSIONS
  In PP analysis, a 22.9% reduction of community-acquired radiologically confirmed pneumonia in children younger than 2 years of age in the 11-valent tetanus-diphtheria toxoid-conjugated PCV vaccinated group was observed; a reduction similar as observed in other PCV trials. We could not demonstrate any VE against clinical pneumonia. Our finding confirms for the first time that in a low-income, low-mortality developing country in Asia, at least one-fifth of radiologically confirmed pneumonia is caused by pneumococcus, and thus preventable by PCV. Whether PCV should be included in national program in such settings, however, depends on careful country specific disease burden measurement and cost-effectiveness calculation.
authors.affiliation: Research Institute for Tropical Medicine, Manila, the Philippines.
authors.forename: Marilla G
authors.initials: MG
authors.lastname: Lucero
authors.forename: Hanna
authors.initials: H
authors.lastname: Nohynek
authors.forename: Gail
authors.initials: G
authors.lastname: Williams
authors.forename: Veronica
authors.initials: V
authors.lastname: Tallo
authors.forename: Eric A F
authors.initials: EA
authors.lastname: Simões
authors.forename: Socorro
authors.initials: S
authors.lastname: Lupisan
authors.forename: Diozele
authors.initials: D
authors.lastname: Sanvictores
authors.forename: Simon
authors.initials: S
authors.lastname: Forsyth
authors.forename: Taneli
authors.initials: T
authors.lastname: Puumalainen
authors.forename: Juanita
authors.initials: J
authors.lastname: Ugpo
authors.forename: Marites
authors.initials: M
authors.lastname: Lechago
authors.forename: Margaret
authors.initials: M
authors.lastname: de Campo
authors.forename: Erma
authors.initials: E
authors.lastname: Abucejo-Ladesma
authors.forename: Lydia
authors.initials: L
authors.lastname: Sombrero
authors.forename: Antti
authors.initials: A
authors.lastname: Nissinen
authors.forename: Anu
authors.initials: A
authors.lastname: Soininen
authors.forename: Petri
authors.initials: P
authors.lastname: Ruutu
authors.forename: Ian
authors.initials: I
authors.lastname: Riley
authors.forename: Helen P
authors.initials: HP
authors.lastname: Mäkelä
mesh_terms: D000907:Antibodies, Bacterial / Q000097:blood; D004311:Double-Blind Method; D006801:Humans; D007117:Immunization, Secondary; D007074:Immunoglobulin G / Q000097:blood; D007223:Infant; D010679:Philippines / Q000453:epidemiology; D022242:Pneumococcal Vaccines / Q000009:adverse effects / Q000276:immunology; D011018:Pneumonia, Pneumococcal / Q000000981:diagnostic imaging / Q000453:epidemiology / Q000517:prevention & control*; D016016:Proportional Hazards Models; D011859:Radiography; D018074:Vaccines, Conjugate / Q000009:adverse effects / Q000276:immunology
chemical_list: D000907:Antibodies, Bacterial; D007074:Immunoglobulin G; D022242:Pneumococcal Vaccines; D018074:Vaccines, Conjugate