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Efficacy and safety of a modified killed-whole-cell oral cholera vaccine in India: an interim analysis of a cluster-randomised, double-blind, placebo-controlled trial.

Journal article
Authors Dipika Sur
Anna Lena Lopez
Suman Kanungo
Allison Paisley
Byomkesh Manna
Mohammad Ali
Swapan K Niyogi
Jin Kyung Park
Banawarilal Sarkar
Mahesh K Puri
Deok Ryun Kim
Jacqueline L Deen
Jan Holmgren
Rodney Carbis
Raman Rao
Thu Van Nguyen
Allan Donner
Nirmal K Ganguly
G Balakrish Nair
Sujit K Bhattacharya
John D Clemens
Published in Lancet
Volume 374
Issue 9702
Pages 1694-702
ISSN 1474-547X
Publication year 2009
Published at Institute of Biomedicine, Department of Microbiology and Immunology
Pages 1694-702
Language en
Keywords Administration, Oral, Adolescent, Adult, Child, Child, Preschool, Cholera, epidemiology, microbiology, prevention & control, Cholera Vaccines, administration & dosage, adverse effects, immunology, supply & distribution, Cluster Analysis, Double-Blind Method, Endemic Diseases, prevention & control, statistics & numerical data, Female, Follow-Up Studies, Humans, Immunization Schedule, India, epidemiology, Infant, Kaplan-Meiers Estimate, Male, Proportional Hazards Models, Safety, Vaccines, Inactivated
Subject categories Microbiology in the medical area


BACKGROUND: Oral cholera vaccines consisting of killed whole cells have been available for many years, but they have not been used extensively in populations with endemic disease. An inexpensive, locally produced oral killed-whole-cell vaccine has been used in high-risk areas in Vietnam. To expand the use of this vaccine, it was modified to comply with WHO standards. We assessed the efficacy and safety of this modified vaccine in a population with endemic cholera. METHODS: In this double-blind trial, 107 774 non-pregnant residents of Kolkata, India, aged 1 year or older, were cluster-randomised by dwelling to receive two doses of either modified killed-whole-cell cholera vaccine (n=52 212; 1966 clusters) or heat-killed Escherichia coli K12 placebo (n=55 562; 1967 clusters), both delivered orally. Randomisation was done by computer-generated sequence in blocks of four. The primary endpoint was prevention of episodes of culture-confirmed Vibrio cholerae O1 diarrhoea severe enough for the patient to seek treatment in a health-care facility. We undertook an interim, per-protocol analysis at 2 years of follow-up that included individuals who received two completely ingested doses of vaccine or placebo. We assessed first episodes of cholera that occurred between 14 days and 730 days after receipt of the second dose. This study is registered with, number NCT00289224. FINDINGS: 31 932 participants assigned to vaccine (1721 clusters) and 34 968 assigned to placebo (1757 clusters) received two doses of study treatment. There were 20 episodes of cholera in the vaccine group and 68 episodes in the placebo group (protective efficacy 67%; one-tailed 99% CI, lower bound 35%, p<0.0001). The vaccine protected individuals in age-groups 1.0-4.9 years, 5.0-14.9 years, and 15 years and older, and protective efficacy did not differ significantly between age-groups (p=0.28). We recorded no vaccine-related serious adverse events. INTERPRETATION: This modified killed-whole-cell oral vaccine, compliant with WHO standards, is safe, provides protection against clinically significant cholera in an endemic setting, and can be used in children aged 1.0-4.9 years, who are at highest risk of developing cholera in endemic settings. FUNDING: Bill & Melinda Gates Foundation, Swedish International Development Cooperation Agency, Governments of South Korea, Sweden, and Kuwait.

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