Rational approaches to reduce adverse reactions in man to vaccines containing tetanus and diphtheria toxoids

Adverse reactions to routine vaccines are obstacles to the mass vaccination campaigns. Though the absolute safety of any injectable vaccine cannot be guaranteed, the adverse side effects to vaccines can be minimized by practicing existing scientific knowledge. Adverse side effects to tetanus and diphtheria toxoids have been known for many years and there have been ways to minimize these reactions. These procedures did not get wide acceptance, because the current partially purified tetanus and diphtheria vaccines meet the regulatory requirements and the manufacturers are reluctant to change the established procedures of production due to the amount of work involved in the regulatory issues under the current Good Manufacturing Practices (GMP). Due to the recent epidemic of diphtheria in the independent states of the former Soviet Union, and its potential for spread to other European Countries, vaccination campaigns with tetanus and diphtheria vaccines received a new boost with several international agencies. In this report, we review the causes for adverse reactions to tetanus and diphtheria vaccines and offer practical suggestions for minimizing these reactions. The major issues in minimizing adverse reactions to these vaccines include: (1) purifying the toxins before detoxification as the reactogenic accessory antigens get covalently bound to the toxins during detoxification; (2) either using well-tolerated adjuvants which do not elicit the production of antigenic specific IgE antibodies responsible for adverse reactions or by using non-adjuvanted highly immunogenic polymerized antigens; (3) checking the status of immunity by recently developed rapid serological methods or by the Schick skin-test for diphtheria to avoid allergic or Arthus-type reactions. These approaches are applicable to industrial scales and would result in a pure, less reactogenic and better characterized toxoids antigens which would be more suitable for combined vaccines comprising highly purified acellular pertussis components, polysaccharide-protein conjugates and other antigens.     

Potentials and limitations of protein vaccines in infants

Immunization of infants represents a difficult challenge since immune responses in infants differ qualitatively from those of adults (immature immune and bias towards Th2 rather than a Th1 immune responses). While protein vaccines are immunogenic in infants earlier than polysaccharides in the very first months of life, requiring repeated administration. Protein vaccines such as diphtheria and tetanus toxoids and hepatitis B antigens are safe and immunogenic in infants, able to induce long-lasting memory, and effective. HB vaccines are the first vaccines administered at birth against a sexually transmitted disease and that prevent cancer. These success stories must however be tempered by the existence of immunologic interferences that may occur when combining vaccines in a single injection. Moreover, very little is known whether inappropriate protein conformation and glycosylation play roles in the impairment of the functional immunogenicity of protein vaccines in infants. Although much is known about how to produce and purify proteins, we know much less about how protein characteristics are related to functional immunogenicity.     

Inadvertent administration of DTP and DT after age six as recorded in the Vaccine Adverse Event Reporting System

OBJECTIVE: Diphtheria and tetanus toxoids and whole-cell pertussis vaccine (DTP) and pediatric diphtheria and tetanus toxoids (DT) are not recommended for individuals > or = 7 years of age due to increased adverse reactions and the low pertussis case-fatality rate. Our objective was to determine if reactions to DTP and DT in individuals > or = 7 years of age were due to administration of pediatric DTP or DT instead of adult tetanus and diphtheria toxoids (Td), after adjusting for database inaccuracies. METHODS: We analyzed data from the Vaccine Adverse Event Reporting System (VAERS) reported from July 1, 1990 through March 31, 1992. Vaccine manufacturers were contacted to verify whether lot numbers indicated DTP or DT. RESULTS: According to VAERS's data, among individuals 7 years of age or older, 26 received DTP and 77 received DT. When lot numbers were compared with manufacturers' records, 8 of the 77 DT doses were confirmed; 11 had incorrect or missing lot numbers; one was a duplicate; 56 were Td; and one was neither DT nor Td. Alleged adverse reactions included fever, headache, and convulsions. CONCLUSION: Individuals > or = 7 years of age are inadvertently receiving DTP or DT and may be unnecessarily experiencing adverse reactions. The 1992 VAERS database offers opportunities to investigate hypotheses but should be interpreted with caution due to inaccuracies in reporting and duplicate entries.     

Comparison of the conformation, hydrophobicity, and model membrane interactions of diphtheria toxin to those of formaldehyde-treated toxin (diphtheria toxoid): formaldehyde stabilization of the native conformation inhibits changes that allow membrane insertion

Toxoids are inactivated protein toxins that are used in vaccines. The behavior of diphtheria toxin reacted with formaldehyde (diphtheria toxoid) was compared to that of diphtheria toxin in order to understand the nature of the changes that occur in toxoids upon protein reaction with formaldehyde. Despite the intramolecular cross-links in the toxoid, the conformations of the toxoid and the toxin were very similar in both the native and low pH-induced membrane-penetrating states as judged by fluorescence and hydrophobicity properties. However, the toxoid underwent thermal-, low-pH-, and guanidinium chloride-induced conformational changes only at more extreme conditions than needed to induce such changes in the toxin. This implies that formaldehyde modification stabilizes the native conformation relative to several conformations that involve different degrees of unfolding. The stabilization to conformational changes induced by low pH is particularly interesting because low pH induces partial unfolding of the toxin to a molten globule-like state. It was found that the toxoid only gained the ability to interact with model membrane vesicles at a lower pH than the toxin. Because low-pH-induced unfolding and membrane interaction are critical steps in the entry of diphtheria toxin into cells, the resistance of the toxoid to these changes may be linked to its lack of toxicity. The implications of these results for the construction of toxoids are discussed.     

Mapplet: a CORBA-based genome map viewer

BACKGROUND: Pertussis vaccination in infancy has been suggested to increase the risk for development of asthma and allergy. OBJECTIVE: To assess sensitization rates and development of atopic diseases in a prospective randomized controlled trial of pertussis vaccine. PATIENTS AND METHODS: A total of 669 children were randomized to 1 of 4 vaccine groups (2-component acellular pertussis, 5-component acellular pertussis, whole-cell pertussis vaccines, and placebo [diphtheria and tetanus toxoids]). Diphtheria and tetanus toxoids were also given to the children in the pertussis vaccine groups. The children were evaluated by means of questionnaires at age 2 months, 7 months, and 2 1/2 years; skin prick tests at age 7 months and 2 1/2 years; and blinded clinical investigation at age 2 1/2 years. The families were contacted at regular intervals to assess possible adverse effects after the vaccinations and symptoms of whooping cough. RESULTS: The cumulative incidence of atopic diseases was 30% and incidence rates were similar in the 4 groups after adjusting for family history. Exposure to environmental tobacco smoke and home dampness did not confound these results. The frequency of adverse effects did not differ appreciably between atopic and nonatopic children, with the exception that a nodule at the vaccination site was more frequent after whole-cell pertussis vaccination in the nonatopic children. Among 47 children with proven pertussis, atopic disease appeared in 19 (40%). Of these 47 children, 9 (19%) developed asthma, as compared with 58 (9%) noninfected children (P=.03). CONCLUSIONS: We found no support for a drastic increase in allergic manifestations after pertussis vaccination. There was a positive association between whooping cough and asthma by 2 1/2 years of age. There seems to be little reason to withhold pertussis vaccination from infants, irrespective of family history of allergy.     

Substance P- and calcitonin gene-related peptide-containing nerve fibers in the nasal mucosa of chronically hypoxic rats

Changes made in 1997 and 1998 in the U.S. childhood immunization schedule are discussed, with a focus on the use of poliovirus, pertussis, and combination vaccines. Oral poliovirus vaccine (OPV), the vaccine of choice for all four doses in the polio immunization series since 1962, can cause vaccine-associated paralytic poliomyelitis (VAPP). The inactivated poliovirus vaccine (IPV) has not been associated with VAPP but must be administered by injection and provides inferior intestinal immunity. With the reduced threat of poliovirus importation into the United States, the risk of VAPP, although low, has become less acceptable. The Centers for Disease Control and Prevention accordingly recommended a shift from OPV to IPV in the childhood immunization schedule for the United States, effective January 1997. A sequential OPV and IPV series is recommended, but the schedule includes an OPV-only option, which may be preferred in order to avoid the required injections, and an IPV-only option, which is recommended for immunocompromised persons and their contacts. Concern over local and systemic reactions associated with whole-cell pertussis vaccines, in addition to controversy over a possible relationship between the whole-cell vaccine and neurologic damage, has led to the development of new diphtheria and tetanus toxoids and acellular pertussis vaccine products for use in the diphtheria and tetanus toxoids and pertussis immunization series. Several combination products were licensed in 1997, and more are on the way. This will mean fewer inoculations for children. Increased use of IPV and acellular pertussis products could reduce the frequency of VAPP due to OPV and the local and systemic reactions associated with whole-cell pertussis vaccine.     

Cloning of two putative Giardia lamblia glucosamine 6-phosphate isomerase genes only one of which is transcriptionally activated during encystment

Acellular pertussis vaccines provide protection against whooping cough with few adverse effects. Their introduction to routine immunisation programmes would be facilitated by their incorporation with other routinely administered vaccines. 262 infants were immunised with an acellular pertussis vaccine containing pertussis toxin and filamentous haemagglutinin, combined with diphtheria and tetanus toxoids. This vaccine was mixed with Haemophilus influenzae type b tetanus toxoid vaccine (PRP-T) so that infants received a single injection at age 2, 3 and 4 months. One month after the third dose the geometric mean titre of Hib IgG antibody was 0.48 microgram ml-1. Eighty-two percent of infants achieved a titre of 0.15 microgram ml-1, with only 27% achieving 1.0 microgram ml-1. This combination vaccine induced low Hib antibody responses when compared to other studies in which PRP-T was mixed with acellular or whole-cell pertussis vaccines. The combined vaccine did, however, appear to prime a subset of 35 infants for response to a fourth dose of PRP-T at 13 months of age, with a rise in GMT from 0.21 microgram ml-1 to 36.6 micrograms ml-1. These data have important implications for the introduction of combination acellular pertussis vaccines.     

Physico-chemical and antigenic properties of tetanus and diphtheria toxoids and steps towards improved stability

Physico-chemical, antigenic and immunogenic properties may be altered during microencapsulation of antigens and their release from poly(lactic acid) and poly(lactic-co-glycolic acid) microspheres. Here, the physico-chemical, conformational and antigenic stability of tetanus and diphtheria toxoids was studied in aqueous solutions stressed by elevated temperature and the presence of lactic and glycolic acids. Further, the stabilising effect of albumin was investigated. The analytical tools used were fluorimetry, circular dichroism spectroscopy, turbidimetry, electrophoresis and ELISA. Elevated temperatures altered the physico-chemical and antigenic properties of the toxoids to a greater extent than the acids (50 mM) did. Substantial unfolding and chemical changes of tryptophan were observed upon 1-4 weeks of incubation at 60 degreesC. At 4 degreesC, only minor conformational changes were observed, even in the presence of the acids. Furthermore, 40% of the tetanus toxoid antigenicity was lost after 7 days at 37 degreesC. This loss increased in the presence of the acids. At 60 degreesC, the antigenicity had completely vanished. Very importantly, 0.5% albumin preserved the tetanus antigenicity over 6 weeks' incubation at 37 degreesC, regardless of the presence of glycolic acid. This qualifies albumin as potential stabilising additive for toxoid loaded poly(lactic acid) and poly(lactic-co-glycolic acid) microspheres.     

Efficacy of a two-component acellular pertussis vaccine in infants

OBJECTIVE: This case-control study investigated the protective efficacy against pertussis of three doses of a two-component acellular pertussis vaccine (manufactured by Biken in Japan) combined with diphtheria and tetanus toxoids (manufactured by Connaught Laboratories in the US) in infants. METHODS: A case-control study was performed in 63 pediatric practices in Germany. Prospective recruitment of 16,780 infants ages 6 to 17 weeks took place between February, 1993, and July, 1994. According to parental choice infants received either Biken acellular pertussis vaccine combined with diphtheria and tetanus toxoids (DTacP) (74.6%) at approximately 2, 4 and 6 months of age, or a licensed German diphtheria-tetanus toxoids-whole cell pertussis vaccine (10.9%), diphtheria-tetanus toxoids vaccine (12.5%) or no vaccine (2.0%). Prospective surveillance of pertussis cases between February, 1993, and May, 1995, was accomplished by culturing all infants < or =2 years of age presenting with cough > or = 7 days. A pertussis case was defined as any cough of 21 days or longer plus a positive Bordetella pertussis culture or household contact exposure. RESULTS: We identified 241 pertussis cases prospectively by 11,017 B. pertussis cultures and 949 controls matched for age were selected from the same pediatric practices. Medical history and demographic and vaccine status data were collected from each case and for four controls. Data were analyzed through conditional logistic regression taking into account individual matching and adjusting for potential confounding variables. DTacP combined with diphtheria and tetanus toxoids vaccine was 82% protective (95% confidence interval, 68 to 90), diphtheria-tetanus toxoids-whole cell pertussis vaccine was 96% protective (95% confidence interval, 78 to 99). Protection against typical B. pertussis infection characterized by paroxysmal cough lasting > or =21 days was 96% (95% confidence interval, 87 to 99) for DTacP and was 97% (95% confidence interval, 79 to 100) for diphtheria-tetanus toxoids-whole cell pertussis vaccine. Adjustment for potentially confounding variables did not change the results significantly. CONCLUSIONS: Three doses of the two-component acellular pertussis vaccine protected infants against pertussis disease during the period before the recommended booster vaccination. For typical pertussis disease as defined by the WHO efficacy was high and similar to that of a licensed German diphtheria-tetanus toxoids-whole cell pertussis vaccine.     

Screening of Australian medicinal plants for antiviral activity

The nanoencapsulation of a model protein drug, bovine serum albumin (BSA), using gelatin as the matrix material is reported. Nanoencapsulation was conducted using a modified water-in-oil (w/o) emulsion method, which is emulsifier-free and simple. The nanoencapsulation product, BSA-containing gelatin nanoparticles, is characterized in terms of nanoparticle morphology, size and size distribution, water content, and in vitro protein release. The BSA-containing gelatin nanoparticles obtained from this nanoencapsulation process are nearly spherical and have a log-normal size distribution. The average diameter of the BSA-containing gelatin nanoparticles is approximately 840 nm. They can absorb 51-72% of water. In vitro release experiments demonstrate that BSA has been successfully encapsulated in, and can be released from the gelatin nanoparticles. The release of BSA from the gelatin nanoparticulate matrix follows a diffusion-controlled release mechanism. It is found that temperature affects both the water content and the BSA release rate of the gelatin nanoparticles.     

A routine high-performance size-exclusion chromatography to determine molecular size distribution of Haemophilus influenzae type b conjugate vaccines

High-performance size exclusion chromatography has been used to determine the molecular size distribution of Haemophilus influenzae type b (Hib) conjugate vaccines. Both high molecular weight preparations of native Hib capsular polysaccharide coupled to tetanus toxoid and low molecular weight vaccines with Hib oligosaccharides linked to the CRM197 nontoxic mutant diphtheria protein were analysed. Columns with different fractionation ranges were used for the two kinds of vaccines. This method showed to be rapid, accurate and reproducible for different lots of Hib vaccine of different composition produced by various manufacturers. It could replace more time-consuming chromatographic methods enabling control authorities to employ a single methodological approach for different Hib vaccines.     

Poly(vinyl alcohol) nanoparticles prepared by freezing-thawing process for protein/peptide drug delivery

Poly(vinyl alcohol) (PVA) hydrogel nanoparticles have been prepared by using a water-in-oil emulsion technology plus cyclic freezing-thawing process. The PVA hydrogel nanoparticles prepared by this method are suitable for protein/peptide drug delivery since formation of the hydrogel does not require crosslinking agents or other adjuvants and does not involve any residual monomer. Particularly, there is no emulsifier involved in this new method. Bovine serum albumin (BSA), as a model protein drug, is incorporated into the PVA hydrogel nanoparticles. The PVA hydrogel nanoparticles possess a skewed or log-normal size distribution. The average diameter of the PVA hydrogel nanoparticles is 675.5+/-42.7 nm. Protein drug loading efficiency in the PVA hydrogel nanoparticles is 96.2+/-3.8%. The PVA hydrogel nanoparticles swell in an aqueous solution and the swelling degree increases with the increase of temperature. In vitro release studies show that the BSA release from the nanoparticles can be prolonged to 30 h. The BSA release follows a diffusion-controlled mechanism. The number of freezing-thawing cycle and release temperature both influence BSA release rate considerably. Less freezing-thawing cycle or higher release temperature leads to faster drug release. The BSA is stable during preparation of the PVA hydrogel nanoparticles.     

The science and politics of dental amalgam

OBJECTIVE: To evaluate the effectiveness of pediatric practice consultation in reducing missed-opportunity rates at eight pediatric sites in Baltimore, Maryland. The overarching goal was to decrease the occurrence of missed opportunities from 33% to 15% for the first, second, and third diphtheria and tetanus toxoids and pertussis vaccines during visits at which children were eligible for the vaccines. DESIGN: The effect of an in-office educational program alone at four sites is compared with the educational program and a consultation on office vaccination practices at four matched sites. All eight sites received a small grant ($2,000) to fund practice changes. The medical records of children making visits before and after the interventions were audited to determine missed-opportunity rates. The policies and operations and the knowledge, attitudes, and practices of physicians and nurse practitioners at each site were also assessed. RESULTS: The four education-consultation sites experienced a statistically significant 14% net reduction in the missed-opportunity rate relative to the education-only sites. This positive effect, however, was largely due to an increase in missed opportunities at one education-only site. There was a 10% increase in the missed-opportunity rate among the education-only sites and a 4% decrease among the education-consultation sites; neither change was statistically significant. Two of the three sites that reduced missed opportunities were matched health maintenance organizations (HMOs). Shortly after the interventions, both HMOs implemented tracking and follow-up information systems, which were planned before the interventions. CONCLUSIONS: There is no evidence that either the educational program alone or the educational program and consultation combination reduced missed opportunities. The findings suggest that improved tracking and follow-up data systems and vaccination of children at sick visits may reduce missed opportunities.     

Safety and immunogenicity of a recombinant hepatitis B vaccine administered to infants at 2, 4 and 6 months of age. The Kaiser-UCLA Vaccine Study Group

A recombinant hepatitis B vaccine was administered to over 5000 infants in a prospective, randomized and blinded study. Infants were given either recombinant hepatitis B vaccine (Engerix-B, SmithKline Beecham Pharmaceuticals, 10 micrograms dose-1) or a Haemophilus influenzae type b (Hib) conjugate vaccine at 2, 4 and 6 months of age simultaneously with diphtheria-tetanus-pertussis and oral polio vaccines. Adverse reactions were ascertained by parental reports and interviews, and review of medical records. Blood specimens collected from 269 infants given hepatitis B vaccine were assayed for antibody to hepatitis B surface antigen (anti-HBs) by enzyme immunoassay. Infants given hepatitis B vaccine experienced low rates of adverse reactions that were similar or lower than the rates in infants given Hib conjugate vaccine. The geometric mean anti-HBs concentrations were 9.6 mIU ml-1 after one dose, 333 mIU ml-1 after two doses and 1812 mIU ml-1 after three doses (99% had levels > or = 10 mIU ml-1). Antibody responses to diphtheria and tetanus toxoids were unaffected by simultaneous administration of hepatitis B or Hib conjugate vaccine. Engerix-B vaccine was safe and immunogenic when given with other routine childhood immunizations at 2, 4 and 6 months of age, and should provide long-term protection against hepatitis B virus infection.     

Survey of disease of cultural shrimp in Taiwan

A water-in-oil-in-water (w/o/w) technique, sometimes known as in-water drying method, was used to prepare microcapsules consisting of polylactic acid and poly(lactide-co-glycolide). The influence of shear force to produce an initial water-in-oil (w/o) emulsion on the characteristics of microcapsules and protein release was investigated. Bovine serum albumin (BSA) was used as the model protein drug for encapsulation. The initial w/o emulsion was prepared by a Polytron homogenizer. The shear rate was varied from 11 to 23 krpm to produce w/o emulsions with different shear forces. This study revealed pronounced effects of shear force on the characteristics of microcapsules and release profiles of BSA. Depending on the degree of the shear applied, the inner structure of microcapsules showed very different morphology, which was responsible for different release patterns. A low shear produced microcapsules with a high initial burst release of BSA, whereas microcapsules using a high shear exhibited a controlled release of protein without any initial burst release. Also, at a given shear force, a variation in polymer composition of microcapsules was found to be effective in controlling the release characteristics of protein. Thus, the homogenization technique should be carefully considered in designing microcapsules with desirable release profiles of proteins and an adequate period of protein delivery.     

Reversal and prevention of cerebral vasospasm by intracarotid infusions of nitric oxide donors in a primate model of subarachnoid hemorrhage

OBJECTIVE: To determine the frequency of adverse reactions, particularly the occurrence of apnea, among preterm infants after immunization with diphtheria and tetanus toxoids and whole cell pertussis vaccine adsorbed (DTP) and Haemophilus influenzae type b conjugate (HibC) vaccine in the neonatal intensive care unit. STUDY DESIGN: After the occurrence of apnea in two preterm infants following immunization with DTP and HibC, a prospective surveillance of 97 preterm infants younger than 37 weeks of gestation who were immunized with DTP (94 also received HibC at the same time) in the neonatal intensive care unit was performed to assess the frequency of adverse reactions and in particular, the occurrence of apnea. For each infant, data were recorded for a 3-day period before and after receipt of the immunization. RESULTS: The majority of preterm infants tolerated immunizations with DTP and HibC without ill effects. However, 12 (12%) infants experienced a recurrence of apnea, and 11 (11%) had at least a 50% increase in the number of apneic and bradycardic episodes in the 72 hours after immunization. This occurred primarily among smaller preterm infants who were immunized at a lower weight (p = 0.01), had experienced more severe apnea of prematurity (p = 0.01), and had chronic lung disease (p = 0.03). CONCLUSION: The temporal association observed between immunization of preterm infants and a transient increase or recurrence of apnea after vaccination merits further study. Cardiorespiratory monitoring of these infants after immunization may be advisable.     

Thermodynamic characterization of interactions of native bovine serum albumin with highly excluded (glycine betaine) and moderately accumulated (urea) solutes by a novel application of vapor pressure osmometry

The thermodynamic consequences of interactions of native bovine serum albumin (BSA) with two smaller solutes (glycine betaine or urea) in aqueous solution are characterized by a novel application of vapor pressure osmometry (VPO), which demonstrates the utility of this method of investigating preferential interactions involving solutes that are either accumulated or excluded near the surface of a protein. From VPO measurements of osmolality (water activity) as a function of the solute concentration in the presence and absence of BSA, we determine the dependence of the solute molarity (C3) on that of BSA (C2) at fixed temperature (37 degrees C), pressure (approximately 1 atm), and osmolality (over the range 0-1.6 molal). After some thermodynamic transformations, these results yield values of [formula: see text] which characterizes the interdependence of solute molalities when temperature, pressure, and the chemical potential of solute 3 are fixed. This form of the preferential interaction coefficient can be interpreted directly in terms of the molecular exclusion or accumulation of the solute (relative to water) near the protein surface. Within experimental uncertainty, [formula: see text] is proportional to m3 both for glycine betaine (0-0.9 m) and for urea (0-1.6 m). For glycine betaine [formula: see text] = -49 +/- 4, a value consistent with the interpretation that this solute is completely excluded from the hydrated surface of BSA, whereas for urea [formula: see text] = 6 +/- 1, which indicates a moderate extent of accumulation at the surface of native BSA. The preferential accumulation of solutes (e.g., urea) that have some binding affinity for a protein can be quantified and interpreted using the two-domain model if the extent of hydration of the protein has been determined using a completely excluded solute (e.g., glycine betaine). Complete exclusion from the local hydration domain surrounding proteins, if general, justifies the use of glycine betaine as a thermodynamic probe of the changes in hydration that accompany protein folding, protein association, and protein-ligand binding interactions.     

Immunization for the internist

The emphasis of immunization programs and schedules has traditionally been directed to infants and children, since most of the vaccine-preventable diseases are seen predominantly in these age groups. Immunization procedures in adults are less well defined but still of importance. Diseases for which immunizations are given before disease exposure include tetanus, diphtheria, influenza, rubella, and mumps; travelers to foreign countries may need immunizations against typhoid, cholera, yellow fever, typhus, poliomyelitis, plague, and viral hepatitis; other vaccines are available before disease exposure in unusual epidemiologic situations. After exposure to disease but before onset of symptoms, immunizations are available for rabies, viral hepatitis, and measles. After the onset of clinical illness, passive immunization should be given for tetanus, diphtheria, and botulism. This paper summarizes current practices for active and passive immunization against these diseases in adults.     

Adverse events after school leavers received combined tetanus and low dose diphtheria vaccine

Since October 1994, children in the United Kingdom have been offered tetanus vaccine combined with a low dose of diphtheria vaccine (Td) at the age of 15 to 18 years. It is recommended that schoolchildren who have already received a booster of tetanus vaccine at the time of an injury should be given low dose diphtheria vaccine alone. When this vaccine is not available, however, it is recommended that Td vaccine should be given to all children. This study was performed to compare the frequency of adverse events after Td vaccine in 15 year old children with and without a history of an additional tetanus booster in the preceding 10 years. Two hundred and sixty-five children were followed up-52 pupils (20%) with a history of an additional tetanus booster, 157 (59%) with no such history, and 56 (21%) whose history was unclear. Mild local reactions were common and occurred more commonly in children with a history of an additional tetanus booster. Twenty-three pupils (44%) who had received an additional tetanus booster had swelling over 2 cm diameter at the injection site, compared with only 39 (25%) of those with no such history (p < 0.013). Systemic symptoms were equally unusual in both groups. Only three children experienced symptoms attributed to vaccine that were severe enough for them to miss school or attend a doctor; and none of these had received an additional tetanus booster. We conclude that, in the absence of a supply of low dose diphtheria vaccine, offering Td vaccine to children with a history of additional tetanus booster is an acceptable policy.     

Antigenicity and immunogenicity of multiple antigen peptides (MAP) containing P. vivax CS epitopes in Aotus monkeys

Using linear synthetic peptides corresponding to the Plasmodium vivax circumsporozoite (CS) protein of the common type, we have identified several T and B-cell epitopes recognized by human individuals. Three T-cell epitopes studied (p6) from the amino, (p11) from the central and (p25) from the carboxyl regions, were widely recognized by lymphocytes of immune donors. A series of six peptides, in addition to p11, representing the central repeat domain of the CS(p11-p17) protein were used in ELISA assays to map the B-cell epitopes of this region. P11 was the peptide most frequently recognized by sera containing antibodies to the homologous CS protein as determined by IFAT. The sequences corresponding to peptides p6, p11 and P25 as well as that representing a universal T-cell epitope derived from the tetanus toxin were used to assemble eight different Multiple Antigen Peptides (MAP). The immunogenicity of these MAP was analysed in Aotus monkeys. Groups of two animals were immunized with each MAP and both antibody response, T-lymphocyte proliferation and in vitro gamma-IFN production were evaluated. Two MAPs containing the same B-cell epitope and either a promiscuous CS-protein derived T-cell epitope (p25) or the tetanus toxin epitope (p-tt30) proved to be the most immunogenic and induced high levels of anti-peptide antibodies that recognized the native protein. Except for animals immunized with MAP VII, there was no correlation between antibody levels, lymphocyte proliferation or gamma-IFN production in vitro. The broad recognition of these epitopes by individuals which had been exposed to malaria, the capacity of these MAPs to induce antibodies, recognize the cognate protein, and in vitro gamma-IFN production encourages further analyses of the potential of these proteins as malaria vaccine candidates for human use.