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The n e w e ng l a n d j o u r na l of m e dic i n e

Original Article

A Randomized, Controlled Trial


of an Aerosolized Vaccine against Measles
N. Low, A. Bavdekar, L. Jeyaseelan, S. Hirve, K. Ramanathan, N.J. Andrews,
N. Shaikh, R.S. Jadi, A. Rajagopal, K.E. Brown, D. Brown, J.B. Fink, O. John,
P. Scott, A.X. RiverosBalta, M. Greco, R. Dhere, P.S. Kulkarni,
and A.M. HenaoRestrepo

A BS T R AC T

BACKGROUND
Aerosolized vaccine can be used as a needle-free method of immunization against The authors full names, academic de-
measles, a disease that remains a major cause of illness and death. Data on the im- grees, and affiliations are listed in the Ap-
pendix. Address reprint requests to Dr.
munogenicity of aerosolized vaccine against measles in children are inconsistent. Henao Restrepo at Implementation Re-
search and Economic Evaluation, De-
METHODS partment of Immunization, Vaccines and
Biologicals, World Health Organization,
We conducted an open-label noninferiority trial involving children 9.0 to 11.9 months 20 Ave. Appia, CH-1211, Geneva 27, Swit-
of age in India who were eligible to receive a first dose of measles vaccine. Chil- zerland, or at henaorestrepoa@who.int.
dren were randomly assigned to receive a single dose of vaccine by means of either N Engl J Med 2015;372:1519-29.
aerosol inhalation or a subcutaneous injection. The primary end points were sero- DOI: 10.1056/NEJMoa1407417
positivity for antibodies against measles and adverse events 91 days after vaccina- Copyright 2015 Massachusetts Medical Society.

tion. The noninferiority margin was 5 percentage points.

RESULTS
A total of 1001 children were assigned to receive aerosolized vaccine, and 1003
children were assigned to receive subcutaneous vaccine; 1956 of all the children
(97.6%) were followed to day 91, but outcome data were missing for 331 children
because of thawed specimens. In the per-protocol population, data on 1560 of
2004 children (77.8%) could be evaluated. At day 91, a total of 662 of 775 children
(85.4%; 95% confidence interval [CI], 82.5 to 88.0) in the aerosol group, as com-
pared with 743 of 785 children (94.6%; 95% CI, 92.7 to 96.1) in the subcutaneous
group, were seropositive, a difference of 9.2 percentage points (95% CI, 12.2 to
6.3). Findings were similar in the full-analysis set (673 of 788 children in the
aerosol group [85.4%] and 754 of 796 children in the subcutaneous group [94.7%]
were seropositive at day 91, a difference of 9.3 percentage points [95% CI, 12.3
to 6.4]) and after multiple imputation of missing results. No serious adverse
events were attributable to measles vaccination. Adverse-event profiles were simi-
lar in the two groups.

CONCLUSIONS
Aerosolized vaccine against measles was immunogenic, but, at the prespecified
margin, the aerosolized vaccine was inferior to the subcutaneous vaccine with
respect to the rate of seropositivity. (Funded by the Bill and Melinda Gates Founda-
tion; Measles Aerosol Vaccine Project Clinical Trials RegistryIndia number, CTRI/
2009/091/000673.)

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T
he Global Vaccine Action Plan aims showed evidence of safety, immunogenicity, and
to eliminate measles from at least five feasibility in children older than 4 years of age
World Health Organization (WHO) regions and in adults.14 In this individually randomized,
by 2020.1 A safe and effective injectable measles open-label noninferiority trial involving children
vaccine has been widely available since 1963,2 in India, we aimed to compare the immunoge-
and intensified efforts between 2000 and 2010 nicity and safety of a primary dose of aerosol-
reduced measles-related deaths by 74%.3 Never- ized vaccine against measles with that of a pri-
theless, major outbreaks continue, particularly mary dose of vaccine delivered subcutaneously.
in resource-poor countries that lack investment
in health care systems and the health service Me thods
infrastructure. In these countries, immunization
coverage through routine services and mass cam- Study Design and Oversight
paigns remains low.4 The WHO Initiative for Vaccine Research coordi-
New approaches to measles vaccination could nated the Measles Aerosol Vaccine Project, and
contribute to reaching elimination goals, particu- the Centers for Disease Control and Prevention
larly if they increase coverage, can be adminis- and the American Red Cross were partners in
tered by people without clinical training, and do the project. An independent data and safety
not cause injection-associated infections.5-7 Aero- monitoring board had access to unblinded data
solized vaccine against measles was developed in to assess serious adverse events. A product devel-
Mexico and has been used in more than 4 mil- opment group (see the Supplementary Appendix,
lion children there since 1980.8 Nebulization available with the full text of this article at
delivers vaccine to the site of natural infection NEJM.org) reviewed progress. Ethics committees
and induces measles-specific antibodies and cell- of the WHO, Christian Medical College (in Vel-
mediated immunity.9,10 lore, India), the National Institute of Virology,
Data about the efficacy of this aerosolized and King Edward Memorial Hospital Research
vaccine against measles in children are inconsis- Centre (in Pune, India) approved the protocol.
tent, however. Two comprehensive reviews con- The trial was designed and conducted in accor-
cluded that it was as good as or better than vac- dance with Good Clinical Practice15 and Good
cine delivered subcutaneously in children 9 months Laboratory Practice16 guidelines.
of age or older.11,12 However, the two random- The Serum Institute of India provided all vac-
ized, controlled trials comparing these routes of cines free of charge, and Aerogen provided the
administration in children 8 to 13 months of delivery devices free of charge. Additional de-
age were small, associated with a risk of bias, tails about the trial design, conduct, and analy-
and inconsistent.9,10 A subsequent systematic re- sis are provided in the Supplementary Appendix
view pooled data about each route of adminis- and in the full protocol, including the statistical
tration from randomized, controlled trials and analysis plan, available at NEJM.org.
observational studies. Among children 10 to 35
months of age, the pooled seroconversion rate in Study Participants and Clinical Setting
five studies among those who received aerosol- The trial was conducted in villages served by
ized vaccine against measles was 93.5% (95% eight primary health centers in Pune. One study
confidence interval [CI], 89.4 to 97.7), and the has shown that more than 90% of infants in Pune
pooled seroconversion rate in two studies among are breast-fed from birth, for a median of 4.7
those who received the vaccine subcutaneously months.17 Children between 9.0 and 11.9 months
was 97.1% (95% CI, 92.4 to 100).13 After subcu- of age were eligible to participate in the study if
taneous vaccination, approximately 92% (inter- they were due to receive primary measles vacci-
quartile range, 84 to 96) of children 9 to 10 nation. Children were excluded from participa-
months of age and 99% (interquartile range, 93 tion if they were ineligible to receive measles
to 100) of children 11 to 12 months of age un- vaccine according to WHO criteria.18
derwent seroconversion.7
Given the established record of injectable Randomization and Vaccination
measles vaccine, alternative delivery methods From December 20, 2009, through April 5, 2010,
should show noninferiority. A phase 1 trial in we randomly assigned children, in a 1:1 ratio, to
India of aerosolized vaccine against measles receive measles vaccine by means of aerosol in-

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Trial of an Aerosolized Vaccine against Measles

halation or by means of a subcutaneous injec- a study that showed a positive predictive value
tion. A detailed description of the randomiza- of 99.4% for ELISA (cutoff value, 0.1 optical-
tion process is provided in the Supplementary density units) as compared with PRNT (cutoff
Appendix. After obtaining written informed value, 120 mIU per milliliter).20
consent from the parents or guardians of the All samples at baseline and day 91 were
children, the study nurses telephoned a central- tested by means of ELISA. Specimens with less
ized Web-based service and recorded the study than 0.1 optical-density units and all samples
assignments. At the Vadu site, which is part of a from the Vadu site were tested by means of
demographic surveillance system,19 two random PRNT. Paired prevaccination and post-vaccination
subgroups of 100 children were selected to have samples were tested in the same run. All speci-
blood drawn at either day 28 or day 364 for the mens were tested at the Virus Reference Depart-
monitoring of serologic responses. ment, Public Health England (formerly the United
We used a measles vaccine (Serum Institute of Kingdom Health Protection Agency), United King-
India), licensed by the WHO, that contained at dom, in March 2012. The specimens had been
least 1000 viral infective units of the live attenu- tested in Pune, but the results of a random 10%
ated EdmonstonZagreb strain of measles virus sample of ELISA and PRNT analyses did not meet
in each dose. The vaccine was delivered in 10- the prespecified quality-assurance criteria, so all
dose vials. samples were shipped to the United Kingdom.
The study nurses reconstituted the 10-dose Prespecified secondary end points were sero-
vials of measles vaccine and stored them until conversion and geometric mean concentrations
use at 2 to 8C. They reconstituted the vaccine of antibodies. Seroconversion was defined as a
for aerosol delivery in 2-ml diluent and adminis- change from seronegative at day 0 to seroposi-
tered a single 0.2-ml dose, nebulized for 30 sec- tive at day 91. Secondary outcomes were the
onds through a single-use nonvented face mask, difference in rates of seroconversion (among
using a battery-operated Aeroneb vibrating mesh participants who were seronegative at baseline),
nebulizer (Aerogen). The nebulizer generated the ratio of geometric mean concentrations, and
aerosol with a volume median diameter of 5.1 m geometric mean concentrations at days 0, 28, 91,
(geometric standard deviation, 2.1 m) as deter- and 364 in children in Vadu.
mined by means of laser diffraction (Spraytec)
(details are provided in the Supplementary Ap- Safety
pendix).14 The study nurses reconstituted the The prespecified primary safety outcome was
vaccine for subcutaneous delivery in 5-ml diluent the frequency of all solicited and unsolicited re-
and administered a single 0.5-ml dose into the ports of adverse events up to 91 days after vac-
left upper arm. The rooms for delivery of aero- cination on day 0.21 Study nurses observed all
solized vaccine and subcutaneous vaccine were children during and for 30 minutes after vacci-
separate so that children receiving subcutaneous nation. Adverse events were then assessed ac-
vaccine were not exposed unintentionally to cording to the report of parents and guardians
aerosolized vaccine. Reconstituted vaccine was during home visits on days 3, 7, 10, 17, 21, 28,
discarded after 6 hours. and 56 and by clinical examination on days 14
and 91 (Fig. S1 in the Supplementary Appendix).
End Points All children who were enrolled in Vadu were
Immunogenicity evaluated at day 364.
The prespecified primary end point was sero- We collected information with the use of
positivity for serum antibodies against measles questionnaires that solicited information on 16
91 days after vaccination. We defined seroposi- events (Table S1 in the Supplementary Appendix),
tivity as 0.1 or more optical-density units on an by means of active surveillance both for events
enzyme-linked immunosorbent assay (ELISA) requiring treatment or hospitalization and for
(Enzygnost Anti-Measles Virus/IgG, Siemens) or, deaths, and through unsolicited reports of events
in samples containing less than 0.1 optical- from parents or guardians. We sent reports of
density units, a measles antibody concentration all adverse events to the data and safety moni-
of 120 mIU per milliliter or more as measured toring board, which had the authority to stop
with the use of a plaque-reduction neutralization the trial if a single serious adverse event was
test (PRNT). The testing algorithm was based on judged to be attributable to the vaccine.

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Follow-up and Blinding proportion of children who were seropositive


We followed all participants until day 91 (from after receiving the aerosolized vaccine and the
March through August 2010, depending on the proportion who were seropositive after receiving
date the patient underwent randomization). the subcutaneous vaccine in the per-protocol
Case-based active surveillance with serologic con- population (which consisted of children who
firmation of cases of fever and rash (Enzygnost received the assigned vaccine, did not have any
Anti-Measles Virus IgM ELISA, Siemens) was in major protocol deviations, and had specimen
place in the entire trial area.22 Parents or guard- results at day 91) and the full-analysis popula-
ians, children, and study staff were aware of the tion (which consisted of all children who under-
route of vaccine administration. went randomization, excluding children for whom
To reduce bias, all outcome assessments were outcome data were missing). The full-analysis
blinded. Field workers used follow-up case-report population was equivalent to a modified intention-
forms that did not record the vaccination assign- to-treat population. We used the Wilson score
ment, laboratory staff conducted analyses of coded method to estimate 95% confidence intervals.23
specimens, and statisticians conducted data Multiple imputation was used to predict sero-
checks and preliminary analyses of blinded data. positivity when outcome data were missing, and
we repeated the analysis with inclusion of all
Statistical Analysis participants (see the Supplementary Appendix).24
We aimed to show that seropositivity after re- For the secondary end points, we used logis-
ceipt of aerosolized vaccine against measles was tic regression to investigate the association of
no more than 5 percentage points lower than prespecified factors with lack of seroconversion
seropositivity after subcutaneous vaccination. after receipt of aerosolized vaccine. For safety
This estimate was based on the 4 percentage- outcomes, we calculated the percentages of chil-
point difference in a previous systematic review dren (with 95% confidence intervals) who had
of studies involving children 10 to 35 months of any solicited or unsolicited reports of an adverse
age13; in addition, with a bigger margin, aerosol- event or serious adverse event up to day 91.
ized vaccine would not provide levels of protec-
tion required for herd immunity.18 R e sult s
We assumed that exactly 90% of the children
in each group would be seropositive at day 91, Study Participants
and we allowed for lower immunogenicity in In total, 2004 children underwent randomiza-
children younger than 10 months of age.7 For tion and 1996 received their assigned vaccine
noninferiority to be shown with the use of the (Fig.1). The baseline characteristics of the two
confidence-interval approach, the lower limit of groups were balanced (Table1, and Table S3 in
the two-sided 95% confidence interval for the the Supplementary Appendix). We followed 1956
difference (aerosol group minus subcutaneous of 2004 children (98%) until day 91. Specimens
group) in the proportion of seropositive children obtained from 331 participants (17%) thawed for
at day 91 had to be above 5 percentage points a period during transport and were, therefore,
in the per-protocol population. If the upper con- excluded from the primary-outcome analyses;
fidence interval was below 5 percentage points, these specimens were distributed equally be-
we would conclude inferiority, and if the lower tween the aerosol and subcutaneous groups (Fig.
interval was above zero, we would conclude su- S3 and Tables S4 and S5 in the Supplementary
periority (Fig. S2 in the Supplementary Appen- Appendix).
dix). We estimated that with a sample of 800 The per-protocol population for the primary
children per group, the study would have 90% outcome included 77% of the children (775 of
power to detect these differences. We planned to 1001 children) who were randomly assigned to
enroll 1000 children per group to allow for 20% aerosolized vaccine and 78% (785 of 1003 chil-
who would not have results that could be evalu- dren) who were randomly assigned to subcutane-
ated at follow-up. ous vaccine (Fig.1). The full-analysis set included
We calculated the difference between the 79% (788 of 1001) of the children who were

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Trial of an Aerosolized Vaccine against Measles

2384 Children were assessed for eligibility

380 Were excluded


4 Did not meet inclusion criteria
282 Had parents or guardians who declined
to participate
94 Had other reasons

2004 Underwent randomization

1001 Were assigned to receive measles 1003 Were assigned to receive subcutaneous
aerosolized vaccine measles vaccine

2 Were excluded 6 Were excluded


1 Received subcutaneous 3 Received aerosolized
vaccine vaccine
1 Had parent or guardian 3 Had parent or guardian
who withdrew consent who withdrew consent

999 Received aerosolized vaccine 997 Received subcutaneous vaccine

42 Were excluded 31 Were excluded


1 Had measles during 1 Had measles during
follow-up follow-up
24 Were lost to follow-up 20 Were lost to follow-up
before day 91 before day 91
17 Had other protocol 10 Had other protocol
deviations deviations

957 Were followed to day 91 966 Were followed to day 91

182 Were excluded 181 Were excluded


159 Had specimens that were 163 Had specimens that were
damaged in transit damaged in transit
23 Had specimens that 18 Had specimens that
were missing or could were missing or could
not be analyzed not be analyzed

775 Were evaluated for primary outcome 785 Were evaluated for primary outcome

ELISA on day 0, 764 children; day 91, 775 children ELISA on day 0, 767 children; day 91, 785 children
PRNT on day 0, 275 children; day 91, 278 children PRNT on day 0, 205 children; day 91, 209 children

Figure 1. Eligibility, Randomization, and Follow-up of Children in the Per-Protocol Population.


Data on children in the full-analysis set (788 children in the aerosol group and 796 children in the subcutaneous
group) are provided in Figure S3 in the Supplementary Appendix; in that analysis, 48 children were lost to follow-up
before day 91, and data on 331 children with missing laboratory results because of damage to specimens during
transport were excluded from the analysis of the primary end point. ELISA denotes enzyme-linked immunosorbent
assay, and PRNT plaque-reduction neutralization test.

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Table 1. Baseline Characteristics of the Participants.*

Aerosolized- Subcutaneous-
Vaccine Group Vaccine Group
Characteristic (N=1001) (N=1003)
Age no. (%)
9.0 to <10.0 mo 730 (72.9) 749 (74.7)
10.0 to <11.0 mo 198 (19.8) 165 (16.5)
11.0 to 11.9 mo 73 (7.3) 89 (8.9)
Female sex no. (%) 488 (48.8) 489 (48.8)
Usual health care provider no. (%)
Government 184 (18.4) 191 (19.0)
Private 812 (81.1) 802 (80.0)
Other 5 (0.5) 10 (1.0)
Health history no. (%)
Preexisting medical condition 2 (0.2) 7 (0.7)
Clinically significant illness in past 3 mo 29 (2.9) 24 (2.4)
Measurements outside normal range for age no./total no. (%)
Height 474/997 (47.5) 480/996 (48.2)
Weight 187/1000 (18.7) 185/1001 (18.5)
Location of primary health care center no. (%)
Alandi 64 (6.4) 64 (6.4)
Chakan 134 (13.4) 135 (13.5)
Nhavara 155 (15.5) 155 (15.5)
Pabal 130 (13.0) 122 (12.2)
Shel Pimpalgaon 83 (8.3) 84 (8.4)
Talegaon Dhamdhere 63 (6.3) 76 (7.6)
Vadu 191 (19.1) 181 (18.0)
Wagholi 181 (18.1) 186 (18.5)
Measles antibodies at baseline no. (%)
Yes 23 (2.3) 16 (1.6)
No 762 (76.1) 768 (76.6)
Could not be evaluated 216 (21.6) 219 (21.8)

* There were no significant differences in characteristics between the study groups.


Preexisting conditions were reported by the parents or guardians of the children and recorded on the case-report form
(see Table S3 in the Supplementary Appendix).
Recorded values that were greater than 6 SD from the mean were considered by the software package used to calculate
anthropometric measurements (WHO Anthro, version 3.1.0) to be outliers and were excluded from the analysis.
Seropositivity for serum antibodies against measles was defined as 0.1 or more optical-density units on ELISA or, in
samples containing less than 0.1 optical-density unit, a measles antibody concentration of 120 mIU per milliliter or
more as measured on the PRNT.

randomly assigned to aerosolized vaccine and Laboratory Assays


79% (796 of 1003) of the children who were ran- On the basis of both ELISA and PRNT results
domly assigned to subcutaneous vaccine (Fig. S3 from day 28 samples obtained from children in
in the Supplementary Appendix). The case-based Vadu, the positive predictive value of the ELISA
surveillance system in the trial villages identi- cutoff value of 0.1 optical-density units, as com-
fied 772 confirmed cases of measles from No- pared with PRNT, was 96% (241 of 250 samples).
vember 1, 2009, through December 31, 2011. The negative predictive value was 69% (34 of 49

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Trial of an Aerosolized Vaccine against Measles

No. of
Outcome and Analysis Patients Difference between Aerosol and Subcutaneous Groups (95% CI)
percentage points
Seropositivity (%)
Per-protocol population 1560 9.2 (12.2 to 6.3)
Full-analysis population 1584 9.3 (12.3 to 6.4)
Multiple-imputation population 2004 9.4 (12.0 to 6.8)
Population with data missing on children 1956 7.4 (11.2 to 3.5)
assumed to be seronegative
Population with data missing on children 1956 7.5 (9.9 to 5.2)
assumed to be seropositive
Seroconversion (%)
Per-protocol population 1531 9.4 (13.1 to 6.7)
Full-analysis population 1555 10.1 (13.1 to 6.7)
15 10 5 0 5

Subcutaneous Better Aerosol Better

Figure 2. Immunogenicity Outcomes at Day 91 in the Aerosolized and Subcutaneous Vaccine Groups.
Rates of seropositivity measured in the per-protocol, full-analysis, and multiple-imputation sets and in the two other
sensitivity analyses are shown. Seroconversion was measured in children who were seronegative for measles anti-
body at day 0 and had a valid result from a serum sample at day 91. The dashed line indicates the noninferiority mar-
gin of 5 percentage points, the squares indicate point estimates, and the I bars indicate 95% confidence intervals.

samples); this confirmed the need to test sam- geometric mean concentrations were similar in
ples that were negative on ELISA with the use of the two groups (ratio of the concentration in the
PRNT. All samples that were seronegative accord- aerosol group to that in the subcutaneous group,
ing to PRNT at baseline were also seronegative 1.05; 95% CI, 0.99 to 1.11) (Table S6 in the
on ELISA. Supplementary Appendix). None of the mea-
sured factors were very strongly associated with
Immunogenicity a lack of seroconversion after the receipt of aero-
At day 91, a total of 662 of the 775 children in solized vaccine (Table S7 in the Supplementary
the per-protocol population who received aero- Appendix).
solized vaccine (85.4%; 95% CI, 82.5 to 88.0) and Among children in Vadu, geometric mean
743 of the 785 who received subcutaneous vac- concentrations increased at each time point up
cine (94.6%; 95% CI, 92.7 to 96.1) were sero- to 364 days after vaccination in both the aerosol
positive, a difference of 9.2 percentage points and subcutaneous groups (Fig.3). Between-group
(95% CI, 12.2 to 6.3). The results, based on differences in the proportion of children in Vadu
the confidence intervals, did not show noninfe- who were seropositive (the percentage of chil-
riority of aerosolized vaccine to subcutaneous dren who were seropositive in the aerosol group
vaccine at the 5 percentage-point margin. Aero- minus the percentage of children who were sero-
solized vaccine, as compared with subcutaneous positive in the subcutaneous group) were as fol-
vaccine, resulted in statistically inferior rates of lows: 0.5 percentage points (95% CI, 5.9 to 4.5)
seropositivity (Fig.2). After multiple imputation on day 0, 24.4 percentage points (95% CI, 36.3
and with seroconversion as the outcome, results to 11.8) on day 28, 11.2 percentage points
in the per-protocol and full-analysis data sets (95% CI, 18.3 to 3.9) on day 91, and 1.5 per-
were similar (Table S6 in the Supplementary Ap- centage points (95% CI, 8.7 to 11.2) on day 364.
pendix). In a sensitivity analysis in which the
results of damaged specimens were classified as Safety
being either all seronegative or all seropositive, Serious Adverse Events
the differences between aerosolized and subcu- None of the children died during the trial or the
taneous vaccine were smaller but still did not follow-up period. By day 91, a total of 38 chil-
show noninferiority of the aerosolized vaccine. dren who had received aerosolized vaccine and
Among children who were seropositive at day 91, 31 who had received subcutaneous vaccine had

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The n e w e ng l a n d j o u r na l of m e dic i n e

had a serious adverse advent (Table2, and Tables The proportion of children who were sero-
S8 and S9 in the Supplementary Appendix). The positive 91 days after they received aerosolized
data and safety monitoring board did not judge vaccine against measles was 85% (95% CI, 83 to
any of the serious adverse events to be probably 88); this proportion was also lower than ex-
or most probably associated with vaccination pected. Inhibitory maternal antibodies and im-
(Table S8 in the Supplementary Appendix). mature immune systems could have reduced re-
sponses to the measles vaccine,7 but only 2% of
Adverse Events the children had measles antibodies at enroll-
In total, 3776 adverse events from any cause ment, and seropositivity was similar in older and
(1952 in the aerosol group and 1824 in the sub- younger children. Furthermore, seropositivity in
cutaneous group) were recorded up to 91 days children after receipt of the subcutaneous vac-
after vaccination, mostly during three home visits cine was in line with published data.7
in the first 14 days (Table2, and Tables S9 and The proportion of children who were protected
S10 in the Supplementary Appendix). Adverse- against measles by aerosolized vaccine could be
event profiles in the two groups were similar, higher than observed because cell-mediated im-
but coryza was more common among children munity is not captured by measurement of neu-
who received aerosolized vaccine (Table2) tralizing antibodies. There is no consistent evi-
(P=
0.02). Five adverse effects (rash, coryza, dence, however, that cell-mediated immunity is
cough, diarrhea, and fever) that were reported in relatively more important after aerosol vaccina-
4 episodes in 2 children in the aerosol group and tion than after subcutaneous vaccination.10,25
13 episodes in 3 children in the subcutaneous Prolonging the duration of nebulization to in-
group were judged as being probably or most crease the retained dose of aerosolized vaccine
probably related to the vaccination. could increase levels of both neutralizing anti-
bodies and cellular immune responses.25 In the
subgroup of children tested in Vadu, the geo-
Discussion
metric mean concentrations increased between
Aerosolized vaccine against measles, as com-
pared with subcutaneously administered vaccine,
Aerosol Subcutaneous
resulted in statistically inferior levels of sero-
700
positivity at 91 days in children who were 9.0 to
11.9 months of age. Profiles of adverse events 600
Geometric Mean Antibody
Concentration (mIU/ml)

were similar in the two groups, and adverse 500


events associated with vaccination were rare.
400
The difference of 9 to 10 percentage points in
seropositivity between the aerosolized and sub- 300
cutaneous vaccine was greater than the pre- 200
specified noninferiority margin of 5 percentage
100
points. The narrow noninferiority margin reflect-
ed the need to elicit a high level of seropositivity 0
0 28 91 364
for antibodies against measles, given the estab-
Day
lished record of the licensed subcutaneous vac-
cine.7 The main limitation of our trial was that
Figure 3. Geometric Mean Concentrations of Antibod-
we did not have measles antibody results for ies against Measles, According to Vaccine Group.
nearly 20% of the samples; although we followed Shown are the geometric mean concentrations of anti-
almost all participants to day 91, a batch of bodies to measles virus as measured on the PRNT in
specimens was damaged during transport. We children in Vadu who were randomly assigned to aero-
do not believe that this biased our results, how- solized or subcutaneous vaccine against measles.
ever, because these data were missing at ran- Specimens were available at days 0, 28, 91, and 364.
Observations from day 0 and day 91 include all chil-
dom, sensitivity analysis with the use of multiple dren who were enrolled in the trial; observations from
imputation showed that our findings were ro- day 28 and 364 are from randomly selected children.
bust, and the sample size was adequate because Circles and squares indicate point estimates, and
the enrollment target allowed for 20% loss to I bars indicate 95% confidence intervals.
follow-up.

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Trial of an Aerosolized Vaccine against Measles

Table 2. Adverse Events up to Day 91.*

Event Aerosolized-Vaccine Group (N=1002) Subcutaneous-Vaccine Group (N=998)

No. of No. of No. of No. of


Adverse Children with Adverse Children with
Events Event % (95% CI) Events Event % (95% CI)
Type of event
Any
Total 1952 644 64.3 (61.267.2) 1824 609 61.0 (57.964.1)
Probably or most probably related 4 2 0.2 (0.020.7) 13 3 0.3 (0.10.9)
to vaccination
Serious
Total 38 38 3.8 (2.75.2) 32 31 3.1 (2.14.4)
Probably or most probably related 0 0 0 (0.00.4) 0 0 0 (0.00.4)
to vaccination
Events of any severity
Anorexia 21 19 1.9 (1.23.0) 22 20 2.0 (1.23.1)
Conjunctivitis 8 8 0.8 (0.41.6) 4 4 0.4 (0.11.0)
Coryza 594 441 44.0 (40.947.1) 510 386 38.7 (35.641.8)
Cough 331 264 26.3 (23.629.2) 331 269 27.0 (24.229.8)
Crying 39 34 3.4 (2.44.7) 30 29 2.9 (2.04.2)
Diarrhea 366 282 28.1 (25.431.0) 368 286 28.7 (25.931.6)
Difficulty breathing 5 4 0.4 (0.11.0) 2 2 0.2 (0.020.7)
Fever 363 287 28.6 (25.931.6) 362 274 27.5 (24.730.3)
Irritability 33 29 2.9 (2.04.1) 28 24 2.4 (1.63.6)
Local reaction 2 2 0.2 (0.020.7) 0 0 0 (0.00.4)
Malaise 12 11 1.1 (0.62.0) 16 14 1.4 (0.82.3)
Rash 34 33 3.3 (2.34.6) 29 27 2.7 (1.83.9)
Seizure 1 1 0.1 (0.00.6) 0 0 0 (0.00.4)
Shivering 0 0 0.0 (0.00.4) 0 0 0 (0.00.4)
Vomiting 114 96 9.6 (7.811.6) 100 91 9.1 (7.411.1)
Wheeze 2 2 0.2 (0.020.7) 1 1 0.1 (0.00.6)
Others 27 18 1.8 (1.12.8) 21 11 1.1 (0.62.0)

* CI denotes confidence interval.


Each child could have more than one adverse event
P=0.02 for the between-group difference.

day 91 and day 364 in children in both trial ways in which aerosolized vaccine against mea-
groups. Vaccine-induced antibody levels tend to sles could still contribute to further policies and
decrease over time, but natural boosting from goals for measles immunization worldwide.1,18
circulating measles virus can result in sustained First, aerosolized vaccine against measles might
or increasing antibody levels.26 The case-based be effective in older children. In countries that
surveillance system showed that measles virus have high levels of measles vaccine coverage or
was circulating throughout the trial area,22 so that are in the elimination phase, primary vac-
natural boosting of antibody levels in children in cination at 12 months of age is recommended.
both trial groups might have attenuated the dif- Second, a second dose of a measles-containing
ference in seropositivity by day 364. vaccine is now recommended to protect children
The results of this trial are relevant for the who did not have a response to the first dose
planning of future research to determine the and to maintain the 95% level of population im-

n engl j med 372;16nejm.org April 16, 2015 1527


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The n e w e ng l a n d j o u r na l of m e dic i n e

munity required to eliminate measles.27 By 2014, this randomized, controlled trial, a primary dose
a total of 145 WHO member states had intro- of aerosolized vaccine against measles in children
duced a two-dose measles vaccination strategy.4 9 months of age or older was immunogenic, but
Aerosolized vaccine against measles induced at the prespecified margin, the aerosolized vac-
higher and more sustained levels of serologic cine was inferior to the subcutaneous vaccine with
protection than subcutaneous vaccine when ad- respect to the rate of seropositivity.
ministered as a second dose in school-age chil- The views expressed in this article are those of the authors
dren in South Africa.28,29 Third, if aerosolized and do not necessarily represent the decisions, policies, or views
vaccine increases the coverage of primary vacci- of the WHO.
Supported by a grant (21537) from the Bill and Melinda Gates
nation, this strategy could be more cost-effective Foundation.
than two-dose vaccination at lower levels of Disclosure forms provided by the authors are available with
coverage.30 the full text of this article at NEJM.org.
We thank the health center staff, field staff, parents or guard-
Data are lacking to evaluate the effectiveness ians, and children at the trial sites in Pune for their contribu-
and cost-effectiveness of aerosolized vaccine tions; Dr. Thomas Gsponer from the Institute of Social and Pre-
against measles as a primary dose in children ventive Medicine, University of Bern, who oversaw the initial
statistical analyses and performed additional statistical analy-
older than 12 months of age and as a second ses; Dr. Bernard Cohen from Public Health England, who pro-
dose in children younger than 5 years of age. vided support to set the laboratory standards for the trial and
Data are also lacking to evaluate the effective- oversaw the laboratory in India; Drs. Teresa Aguado and Marie-
Paule Kieny from the WHO for their expert advice; and the data
ness and cost-effectiveness of aerosolized vaccine and safety monitoring board and the product development group
containing both measles and rubella virus. In (members listed in the Supplementary Appendix).

Appendix
The authors full names and academic degrees are as follows: Nicola Low, M.D., Ashish Bavdekar, D.N.B., Lakshmanan Jeyaseelan,
Ph.D., Siddhivinayak Hirve, Ph.D., Kavitha Ramanathan, M.Sc., NicholasJ. Andrews, Ph.D., Naseem Shaikh, Ph.D., RameshS. Jadi,
Ph.D., Arunachalam Rajagopal, M.C.A., KevinE. Brown, M.D., David Brown, F.R.C.Path., JamesB. Fink, Ph.D., Oommen John, M.D.,
Pippa Scott, Ph.D., A.Ximena RiverosBalta, B.Sc., Michel Greco, M.B.A., Rajeev Dhere, Ph.D., PrasadS. Kulkarni, M.D., and AnaMaria
HenaoRestrepo, M.D.
The authors affiliations are as follows: the Institute of Social and Preventive Medicine, University of Bern, Bern (N.L., P.S.), and the
World Health Organization (WHO), Geneva (A.X.R.-B., A.M.H.R.) both in Switzerland; the Department of Pediatrics, King Edward
Memorial Hospital Research Centre (A.B.), the National Institute of Virology (N.S., R.S.J.), the Serum Institute of India (R.D., P.S.K.),
and Shirdi Sai Baba Hospital (S.H.), Pune, the Department of Biostatistics, Christian Medical College, Vellore (L.J., K.R., A.R.), and the
WHO Regional Office for South-East Asia, New Delhi (O.J.) all in India; the Statistics Unit (N.J.A.) and Virus Reference Department
(K.E.B., D.B.), Public Health England, London; Aerogen, Galway, Ireland (J.B.F.); and Sainte-Foy-ls-Lyon, France (M.G.).

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Trial of an Aerosolized Vaccine against Measles

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