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Efikasi Tetravalent Vaksin Dengue pada Anak di Amerika

Latin
Latar belakang
Menyoroti terjadinya peningkatan terhadap rasio infeksi dengue di dunia
meskipun telah dilakukan langkah kontrol terhadap vektor, beberapa vaksin dengue
sedang dikembangkan.
Metode
Pada tahap 3 penelitian vaksin dengue tetravalent di 5 negara di Amerika Latin
di mana dengue menjadi endemik, peneliti melibatkan secara acak anak-anak sehat
berumur antara 9 dan 16 tahun dalam perbandingan rasio 2:1 untuk menerima 3
injeksi dari vaksin dengue tetravalent (CYD-TDV) yang merupakan rekombinan, hidup
dan dilemahkan atau placebo pada bulan ke 0, 6 dan 12 di bawah kondisi yang
dibutakan. Anak-anak yang terlibat kemudian difollow up selama 25 bulan. Outcome
primer adalah efikasi dibanding dengan gejala simptomatik, terkonfirmasi tes virologi
dengue (VCD) tanpa memperhatikan dari keparahan penyakit atau serotype, terjadi
lebih dari 28 hari setelah injeksi yang ke tiga.
Hasil
Total dari 20,869 anak-anak yang sehat menerima salah satu dari vaksin dan
placebo. Pada dasar sebanyak 79,4% dari subgroup immunogenicity yaitu 1944 anak
memiliki status seropositive untuk satu atau lebih dengue sorotype. Pada setiap
protokol populasi di sana ada 176 kasus VCD (dengan 11,793 orang beresiko per
tahun), pada kelompok kontrol, untuk efikasi vaksin sebanyak 60,8% (95% confidence
interval [CI], 52.0 sampai 68.0). Pada populasi intention-to-treat analysis (populasi
yang menerima setidaknya 1 injeksi), efikasi vaksin ialah 64.7% (95% CI, 58.7 sampai
69.8). Efikasi vaksin spesifik serotype ialah 50.3% untuk serotype 1, 42.3% untuk
serotype 2, 74.0% untuk serotype 3, dan 77.7% untuk serotype 4. Untuk kasus VCD
yang berat, 1 dari 12 ialah ada dalam grup vaksin, untuk analisis intention-to-treat
efikasi dari vaksin ialah 95.5%. efikasi vaksin dibandingkan perawatan di rumah sakit
untuk dengue ialah 80.3%. Profile keamanan untuk vaksin CYD-TDV adalah serupa
dengan placebo tidak ada perbedaan bermakna pada efek samping.

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Kesimpulan
Vaksin dengue CYD-TDV itu berkhasiat terhadap VCD dan VCD yang parah dan
menyebabkan anak harus di rawat inap di lima negara Amerika Latin di mana demam
berdarah adalah endemik. (Didanai oleh Sanofi Pasteur, nomor ClinicalTrials.gov,
NCT01374516.).

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Critical Appraisal Worksheet

Judul : Efficacy of a Tetravalent Dengue Vaccine in Children in Latin America.

Penulis : Luis Villar, M.D., Gustavo Horacio Dayan, M.D., Jos Luis Arredondo-Garca,
M.D., Doris Maribel Rivera, M.D., Rivaldo Cunha, M.D., Carmen Deseda, M.D., Humberto
Reynales, M.D., Maria Selma Costa, M.D., Javier Osvaldo Morales-Ramrez, M.D., Gabriel
Carrasquilla, M.D., Luis Carlos Rey, M.D., Reynaldo Dietze, M.D., Kleber Luz, M.D.,
Enrique Rivas, M.D., Maria Consuelo Miranda Montoya, M.D., Margarita Corts Supelano,
M.D., Betzana Zambrano, M.D., Edith Langevin, M.Sc., Mark Boaz, Ph.D., Nadia
Tornieporth, M.D., Melanie Saville, M.B., B.S., and Fernando Noriega, M.D.

Nama jurnal :The New England and Journal of Medicine published on November 3, 2014.

Apakah hasil penelitian prevensi atau terapi ini valid?


Apakah semua pasien yang Ya, di halaman 1 dijelaskan pada bagian abstrak dan halaman 2
akan mendapat perlakuan pada bagian metode :
dipilih secara random? we randomly assigned healthy children between the ages of 9 and
Apakah randomisasi 16 years in a 2:1 ratio to receive three injections of recombinant,
dilakukan tersembunyi? live, attenuated, tetravalent dengue vaccine (CYD-TDV) or placebo
at months 0, 6, and 12 under blinded conditions
We assigned the children in a 2:1 ratio to receive three doses of
vaccine or placebo at 0, 6, and 12 months, using an interactive
voice-response or Web-response system. Randomization was
performed with the use of computer-generated permuted blocks of
six, stratified according to study site and age group (9 to 11 years
or 12 to 16 years). In each country, before the study-group
assignments were made, children who were enrolled during the first
2 to 4 months were randomly assigned in a 1:1 ratio to a subgroup
of children (representing 10% of the participants from that country)
who were followed for reactogenicity and immunogenicity .

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Apakah follow up cukup Ya, dijelaskan di halaman 3 pada bagian prosedur dijelaskan follow
panjang dan lengkap? up yang dilakukan cukup panjang :
All children were scheduled for visits at months 0, 6, and 12 for
vaccination and at month 13 for follow-up and blood sampling. In
addition, the children were contacted by telephone or had a home
visit at months 18 and 25 for follow-up
Apakah semua pasien yang Ya, dijelaskan di halaman 2
dianalisis ke dalam We assigned the children in a 2:1 ratio to receive three doses of
kelompok-kelompok yang vaccine or placebo at 0, 6, and 12 months, using an interactive
random? voice-response or Web-response system. Randomization was
performed with the use of computer-generated permuted blocks of
six, stratified according to study site and age group (9 to 11 years
or 12 to 16 years). In each country, before the study-group
assignments were made, children who were enrolled during the first
2 to 4 months were randomly assigned in a 1:1 ratio to a subgroup
of children (representing 10% of the participants from that country)
who were followed for reactogenicity and immunogenicity
Apakah pasien dan peneliti Ya, dijelaskan di halaman 2 bahwa metode penelitian ini ialah acak
"blind" terhadap dan blind :
pengobatan? Here we report the first results from the randomized, blinded,
placebo-controlled efficacy trial involving healthy children between
the ages of 9 and 16 years in five countries in Latin America where
dengue is endemic.
Apakah kelompok Ya, pada halaman 3 dijelaskan semua kelompok kontrol baik yang
diperlakukan sama, terlepas menerima vaksin ataupun placebo diperlakukan sama baik selama
dari pengobatan masa pemberian vaksin atau selama follow up:
eksperimental? All children were scheduled for visits at months 0, 6, and 12 for
vaccination and at month 13 for follow-up and blood sampling. In
addition, the children were contacted by telephone or had a home
visit at months 18 and 25 for follow-up. Children in the
reactogenicity and immunogenicity subgroup were scheduled for

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visits at months 1, 7, and 13 for assessment, and blood samples
from these children were obtained at months 0, 7, 13, and 25 and
tested for dengue serotypespecific antibodies. This assessment
was performed in a central laboratory by means of a plaque-
reduction neutralization test and a 50% reduction in the plaque
count as the neutralizing end point (PRNT50), with the use of
standard operating procedures.
Apakah semua kelompok Ya, di halaman 2 dijelaskan mengenai perekrutan partisipan yaitu
serupa di awal penelitian? semua anak-anak yang sehat yang berasal dari Amerika Latin baru
setelah itu dikelompokkan ke dalam kelompok untuk mendapat
vaksin dan placebo dalam perbandingan 2:1:
From June 2011 through March 2012, we enrolled healthy children
between the ages of 9 and 16 years in a total of 22 centers in
Colombia (9 centers), Brazil (5 centers), Mexico (5 centers), Puerto
Rico (2 centers), and Honduras (1 center). We selected the five
countries on the basis of the incidence of dengue.
We assigned the children in a 2:1 ratio to receive three doses of
vaccine or placebo at 0, 6, and 12 months, using an interactive
voice-response or Web-response system. Randomization was
performed with the use of computer-generated permuted blocks of
six, stratified according to study site and age group (9 to 11 years
or 12 to 16 years). In each country, before the study-group
assignments were made, children who were enrolled during the first
2 to 4 months were randomly assigned in a 1:1 ratio to a subgroup
of children (representing 10% of the participants from that country)
who were followed for reactogenicity and immunogenicity.
Apakah hasil penelitian?
Berapa besar efek terapi? Dijelaskan di halaman 5-6 mengenai efek vaksin terhadap dengue
virus :
In the per-protocol analysis, the vaccine efficacy was 60.8% (95%
confidence interval [CI], 52.0 to 68.0), on the basis of 176 cases of

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VCD in the vaccine group and 221 in the control group that were
diagnosed more than 28 days after the third dose (primary
outcome). In the intention-totreat analysis, which included all
children who received at least one injection from month 0 to month
25, the vaccine efficacy was 64.7% (95% CI, 58.7 to 69.8) (Table
2). In addition, efficacy was observed between the first dose and
the second dose and between the second dose and the third dose
and throughout the 25-month period.
Efficacy was highest for serotype 4 and lowest for serotype 2. For
all four serotypes, the lower boundary of the 95% confidence
interval for vaccine efficacy was more than 0 in both the perprotocol
and intention-to-treat analyses. Efficacy was similar in the two age
groups and was 83.7% (95% CI, 62.2 to 93.7) among children who
had antibodies against dengue at baseline, as compared with
43.2% (95% CI, 61.5 to 80.0) among those who did not. Vaccine
efficacy varied according to country.
There were 17 hospitalizations for VCD after at least one injection
in the vaccine group, as compared with 43 hospitalizations in the
control group, for a vaccine efficacy of 80.3% (95% CI, 64.7 to
89.5). Among the children who were hospitalized, all four serotypes
were detected, and fewer children in the vaccine group than in the
control group had any type of hemorrhage, visceral manifestations,
or plasma leakage with clinical signs. The median length of
hospitalization was 6 days in the vaccine group and 4 days in the
control group, a difference that was not significant.
There were 12 cases of severe dengue: 1 in the vaccine group
(serotype 1) and 11 in the control group (3 cases of serotype 1, 4
cases of serotype 2, 3 cases of serotype 3, and 1 case of serotype
4). Efficacy against severe dengue was 95.5% (95% CI, 68.8 to
99.9) after the first injection and 91.7% (95% CI, 31.4 to 99.8) after
the third injection. Eleven of the patients with severe VCD had

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dengue hemorrhagic fever (according to the WHO definition): 1
patient in the vaccine group (grade 2) and 10 patients in the control
group (2 patients with grade 1 and 8 patients with grade 2). Efficacy
against dengue hemorrhagic fever was 95.0% (95% CI, 64.9 to
99.9) after the first injection and 90.0% (95% CI, 10.7 to 99.8) after
the third injection. The single episode of dengue hemorrhagic fever
in the vaccine group was classified as severe on the basis of
laboratory results only; the child was not hospitalized.
Seberapa tepat estimasi Dijelaskan di halaman 4 :
efek terapi? We estimated that enrollment of 20,875 children, with a 2:1 ratio
of assignments to the vaccine group and the placebo group, would
result in the identification of 57 cases of VCD and provide a power
of 90% or more to show vaccine efficacy of more than 25%,
assuming a true vaccine efficacy of 70% after three injections, a
one-sided alpha level of 2.5%, and a lower boundary of the 95%
confidence interval of more than 25%. In these calculations, we
assumed a dropout rate of 20% and a disease incidence of 0.64%.
The assumed incidence was based on mean dengue incidence
rates in the 4 or 5 years before enrollment, according to passive
surveillance data provided by the municipalities in which the trial
was conducted.
Applicable
Apakah pasein yang ada Ya, karena pasien di Indonesia dengan populasi yang digunakan
berbeda dengan pasien dalam penelitian berbeda karakteristik. Walaupun secara klinis
dalam penelitian? ialah sama.
Apakah hasil yang baik dari Ya,namun efikasi vaksin dapat berbeda di setiap negara dijelaskan
penelitian dapat diterapkan di halaman 6:
dengan kondisi yang kita ..Vaccine efficacy varied according to country
miliki?

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Apakah semua outcome Ya, dijelaskan di halamn 6-7, semua diperhatikan termasuk efek
klinis yang penting samping yang timbul selama massa follow up :
dipertimbangkan? Serious adverse events within 28 days after an injection were
reported in 121 children: 81 of 13,915 children (0.6%) in the vaccine
group and 40 of 6939 (0.6%) in the control group (Table 4). No
deaths occurred during this period. During the entire study period,
the rates of serious adverse events were similar in the two groups,
with the most common events being infection and injury not
considered to be related to vaccination. Twelve deaths (six in each
group), which were all considered to be unrelated to the vaccine,
were reported. In the vaccine group, four deaths were due to
accidents, one was due to respiratory failure 9 months after the
third injection, and one was due to systemic vasculitis with renal
failure 10 months after the third injection.
Four serious adverse events were deemed to be vaccine-related
by investigators: three in the vaccine group (a moderate asthma
attack 16 hours after the first injection, allergic urticaria 4 hours
after the second injection, and acute peripheral polyneuropathy
associated with viral meningitis 3 days after the first injection,
without detectable vaccine virus in samples) and one in the control
group (transient visual disturbance 1 day after the first injection). A
fifth serious adverse event in the vaccine group (unspecified
seizures 18 hours after the first injection, without detectable
vaccine virus in samples) was judged to be vaccine-related by the
sponsor. All five children recovered fully without sequelae. There
were no cases of viscerotropic or neurotropic diseases (adverse
events of special interest, since this vaccine is based on the
backbone of the yellow fever vaccine virus) or of severe
anaphylactic reactions related to the vaccine. In the reactogenicity
and immunogenicity subgroup, the rate and profile of solicited

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reactions and unsolicited adverse events were similar in the
vaccine and placebo groups.
Apakah manfaat senilai Ya, penelitian ini sangat bermanfaat untuk mengendalikan infeksi
dengan kerugian dan biaya? dengue virus terutama untuk di daerah tropis seperti Indonesia
yang biasanya mewabah terutama di musim-musim tertentu.
Seperti dijelaskan di kesimpulan pada abstrak :
The CYD-TDV dengue vaccine was efficacious against VCD and
severe VCD and led to fewer hospitalizations for VCD in five Latin
American countries where dengue is endemic. (Funded by Sanofi
Pasteur; ClinicalTrials.gov number, NCT01374516.).