Effects of prophylactic ibuprofen and paracetamol administration on the immunogenicity and reactogenicity of the 10-valent pneumococcal non-typeable Haemophilus influenzae protein D conjugated vaccine (PHiD-CV) co-administered with DTPa-combined vaccines in children: An open-label, randomized, controlled, non-inferiority trial

Figures & data

Figure 1. Participant flow chart. Footnote: Primary vaccination: PHiD-CV and DTPa-(HBV)-IPV/Hib at 3, 4, and 5 months of age, with the following prophylactic antipyretic regimen: IIBU, immediate ibuprofen; DIBU, delayed ibuprofen; NIBU, no ibuprofen; IPARA, immediate paracetamol; DPARA, delayed paracetamol; NPARA, no paracetamol. Booster vaccination: PHiD-CV and DTPa-HBV-IPV/Hib at 12–15 months of age, with the following prophylactic antipyretic regimen: at primary vaccination: immediate ibuprofen, and at booster: immediate (IIBU-IIBU), delayed (IIBU-DIBU) or no ibuprofen (IIBU-NIBU); at primary vaccination: delayed ibuprofen, and at booster: immediate (DIBU-IIBU), delayed (DIBU-DIBU) or no ibuprofen (DIBU-NIBU); at primary vaccination: no ibuprofen, and at booster: immediate (NIBU-IIBU), delayed (NIBU-DIBU) or no ibuprofen (NIBU-NIBU); immediate paracetamol at primary vaccination and no paracetamol at booster (IPARA-NPARA); delayed paracetamol at primary vaccination and immediate paracetamol at booster (DPARA-IPARA); no paracetamol at primary vaccination, and immediate paracetamol at booster (NPARA-IPARA). ATP, according-to-protocol; N, number of participants.

Table 1. Serotype-specific pneumococcal and protein D antibody responses with pairwise group comparisons for the ibuprofen groups, at one month post-dose three (ATP cohort for immunogenicity).

Proportion of children with antibody concentrations ≥ 0.2 µg/mL
	% ≥ 0.2 µg/mL (95% CI)			Difference in % ≥ 0.2 µg/mL
Serotype	IIBU N = 154	DIBU N = 158	NIBU N = 164	NIBU minus IIBU 98.25% CI (LL; UL)	NIBU minus DIBU 98.25% CI (LL; UL)
Vaccine serotypes
1	100 (97.5; 100)	100 (97.6; 100)	99.4 (96.6; 100)	−0.62 (−4.52; 3.17)	−0.62 (−4.52; 2.91)
4	99.3 (96.2; 100)	100 (97.6; 100)	99.4 (96.5; 100)	0.06 (−3.94; 4.38)	−0.63 (−4.57; 2.91)
5	100 (97.5; 100)	100 (97.6; 100)	99.4 (96.5; 100)	−0.64 (−4.63; 3.19)	−0.64 (−4.63; 2.92)
6B	84.0 (77.0; 89.6)	87.1 (80.8; 91.9)	84.7 (78.1; 90.0)	0.69 (−9.40; 10.99)	−2.38 (−12.02; 7.22)
7F	99.4 (96.4; 100)	100 (97.7; 100)	100 (97.8; 100)	0.65 (−2.70; 4.71)	0.00 (−3.34; 3.48)
9V	99.3 (96.2; 100)	100 (97.6; 100)	98.7 (95.5; 99.8)	−0.58 (−5.05; 3.82)	−1.27 (−5.66; 2.32)
14	100 (97.5; 100)	99.4 (96.4; 100)	99.4 (96.5; 100)	−0.65 (−4.68; 3.15)	0.00 (−4.08; 4.12)
18C	99.3 (96.2; 100)	99.4 (96.4; 100)	98.7 (95.5; 99.8)	−0.58 (−5.04; 3.85)	−0.62 (−5.08; 3.54)
19F	100 (97.5; 100)	98.7 (95.4; 99.8)	99.4 (96.5; 100)	−0.63 (−4.60; 3.14)	0.67 (−3.40; 5.20)
23F	91.9 (86.3; 95.7)	89.2 (83.3; 93.6)	92.0 (86.7; 95.7)	0.08 (−7.66; 8.10)	2.73 (−5.30; 11.04)
Vaccine-related serotypes
6A	44.2 (36.0; 52.6)	47.4 (39.2; 55.6)	43.3 (35.4; 51.4)	NA	NA
19A	53.1 (44.6; 61.4)	52.0 (43.7; 60.1)	40.1 (32.4; 48.2)	NA	NA
Antibody GMCs
	Antibody GMC (95% CI)			Antibody GMC ratio
Serotype	IIBU N = 154	DIBU N = 158	NIBU N = 164	IIBU / NIBU 99.8% CI (LL; UL)	DIBU / NIBU 99.8% CI (LL; UL)
Vaccine serotypes (µg/mL)
1	1.82 (1.59; 2.09)	1.71 (1.49; 1.95)	1.90 (1.67; 2.17)	0.96 (0.71; 1.29)	0.90 (0.67; 1.21)
4	2.25 (1.97; 2.57)	2.21 (1.95; 2.51)	2.21 (1.96; 2.50)	1.02 (0.77; 1.35)	1.00 (0.76; 1.32)
5	2.93 (2.58; 3.33)	2.39 (2.13; 2.69)	2.77 (2.44; 3.15)	1.06 (0.80; 1.41)	0.86 (0.66; 1.14)
6B	0.67 (0.55; 0.81)	0.76 (0.63; 0.92)	0.60 (0.49; 0.72)	1.12 (0.72; 1.74)	1.28 (0.83; 1.97)
7F	2.87 (2.52; 3.27)	2.83 (2.52; 3.17)	2.77 (2.49; 3.09)	1.04 (0.79; 1.35)	1.02 (0.80; 1.31)
9V	2.10 (1.81; 2.42)	2.01 (1.79; 2.27)	2.18 (1.91; 2.50)	0.96 (0.70; 1.31)	0.92 (0.69; 1.22)
14	4.76 (4.10; 5.51)	4.52 (3.91; 5.21)	4.77 (4.08; 5.58)	1.00 (0.71; 1.40)	0.95 (0.68; 1.32)
18C	3.85 (3.23; 4.60)	3.80 (3.24; 4.46)	4.34 (3.65; 5.15)	0.89 (0.60; 1.31)	0.88 (0.60; 1.27)
19F	6.11 (5.26; 7.10)	5.04 (4.35; 5.86)	4.96 (4.22; 5.83)	1.23 (0.87; 1.75)	1.02 (0.72; 1.44)
23F	1.04 (0.86; 1.26)	0.92 (0.76; 1.11)	1.07 (0.91; 1.26)	0.97 (0.66; 1.44)	0.86 (0.58; 1.27)
Vaccine-related serotypes (µg/mL)
6A	0.17 (0.14; 0.21)	0.18 (0.15; 0.23)	0.15 (0.12; 0.19)	NA	NA
19A	0.23 (0.18; 0.28)	0.20 (0.16; 0.25)	0.16 (0.13; 0.19)	NA	NA
Protein D (EL.U/mL)
	1461.28 (1267.4; 1684.8)	1353.13 (1191.3; 1537.0)	1557.75 (1355.4; 1790.3)	0.94 (0.69; 1.28)	0.87 (0.64; 1.17)

Footnote: PHiD-CV and DTPa-(HBV)-IPV/Hib at 3, 4, and 5 months of age, with the following prophylactic antipyretic regimen: IIBU, immediate ibuprofen; DIBU, delayed ibuprofen; NIBU, no ibuprofen; N = maximum number of children with available results; LL, lower limit; UL, upper limit; CI, confidence interval; 98.25% CI, standardized asymptotic confidence interval; GMC, geometric mean antibody concentration; %, percentage of participants with anti-pneumococcal serotype-specific antibody concentrations ≥ 0.2 µg/mL; NA, not available; ATP, according-to-protocol. A statistically significant difference was defined as an UL ≥10% for the 98.25% CI of the difference between groups, or an UL <1 for the 99.8% CI of the GMC ratios (bold).

Table 2. Exploratory analysis: serotype-specific pneumococcal and protein D antibody responses with pairwise group comparisons for the paracetamol groups, one month post-dose three (ATP cohort for immunogenicity).

Proportion of children with antibody concentrations ≥ 0.2 µg/mL
	% ≥ 0.2 µg/mL (95% CI)			Difference in % ≥ 0.2 µg/mL
Serotype	IPARA N = 55	DPARA N = 55	NPARA N = 56	NPARA minus IPARA 95% CI (LL; UL)	NPARA minus DPARA 95% CI (LL; UL)
Vaccine serotypes
1	96.3 (87.3; 99.5)	98.0 (89.6; 100)	100 (93.5; 100)	3.70 (−3.01; 12.59)	1.96 (−4.69; 10.37)
4	96.4 (87.5; 99.6)	100 (93.0; 100)	100 (93.6; 100)	3.64 (−2.96; 12.38)	0.00 (−6.48; 7.07)
5	100 (93.3; 100)	100 (92.9; 100)	100 (93.4; 100)	0.00 (−6.70; 6.82)	0.00 (−6.70; 7.20)
6B	79.2 (65.9; 89.2)	72.5 (58.3; 84.1)	87.3 (75.5; 94.7)	8.03 (−6.35; 22.68)	14.72 (−0.55; 30.18)
7F	100 (93.5; 100)	100 (93.5; 100)	100 (93.6; 100)	0.00 (−6.47; 6.58)	0.00 (−6.47; 6.58)
9V	100 (93.3; 100)	100 (92.9; 100)	98.1 (90.1; 100)	−1.85 (−9.83; 5.03)	−1.85 (−9.83; 5.41)
14	100 (93.3; 100)	100 (92.9; 100)	100 (93.3; 100)	0.00 (−6.82; 6.82)	0.00 (−6.82; 7.20)
18C	98.1 (89.9; 100)	100 (92.9; 100)	100 (93.4; 100)	1.89 (−4.88; 10.00)	0.00 (−6.70; 7.20)
19F	100 (93.3; 100)	100 (92.9; 100)	100 (93.4; 100)	0.00 (−6.70; 6.82)	0.00 (−6.70; 7.20)
23F	87.0 (75.1; 94.6)	81.1 (68.0; 90.6)	90.9 (80.0; 97.0)	3.87 (−8.61; 16.76)	9.78 (−3.55; 23.71)
Vaccine-related serotypes
6A	35.8 (23.1; 50.2)	30.0 (17.9; 44.6)	49.1 (35.1; 63.2)	NA	NA
19A	41.5 (28.1; 55.9)	50.0 (35.5; 64.5)	56.6 (42.3; 70.2)	NA	NA
Antibody GMCs
	Antibody GMC (95% CI)			Antibody GMC ratio
Serotype	IPARA N = 55	DPARA N = 55	NPARA N = 56	IPARA / NPARA 95% CI (LL ; UL)	DPARA / NPARA 95% CI (LL ; UL)
Vaccine serotypes (µg/mL)
1	1.32 (1.04; 1.67)	1.38 (1.09; 1.74)	1.95 (1.64; 2.32)	0.68 (0.51; 0.90)	0.71 (0.53; 0.94)
4	1.57 (1.21; 2.04)	1.95 (1.63; 2.32)	2.59 (2.07; 3.24)	0.61 (0.43; 0.85)	0.75 (0.56; 1.00)
5	1.95 (1.53; 2.48)	2.36 (1.89; 2.94)	3.05 (2.53; 3.68)	0.64 (0.47; 0.86)	0.77 (0.58; 1.03)
6B	0.49 (0.34; 0.69)	0.42 (0.28; 0.62)	0.72 (0.51; 1.02)	0.67 (0.41; 1.09)	0.58 (0.35; 0.97)
7F	2.18 (1.75; 2.70)	2.45 (2.01; 2.99)	2.95 (2.37; 3.69)	0.74 (0.54; 1.00)	0.83 (0.62; 1.11)
9V	1.67 (1.30; 2.13)	1.82 (1.48; 2.23)	2.40 (1.87; 3.10)	0.69 (0.49; 0.98)	0.76 (0.55; 1.05)
14	3.44 (2.55; 4.62)	4.12 (3.21; 5.29)	5.17 (4.20; 6.36)	0.66 (0.46; 0.95)	0.80 (0.58; 1.10)
18C	3.08 (2.29; 4.15)	4.08 (3.15; 5.29)	4.96 (3.75; 6.55)	0.62 (0.42; 0.93)	0.82 (0.57; 1.20)
19F	4.95 (3.74; 6.54)	5.20 (3.94; 6.85)	6.98 (5.48; 8.88)	0.71 (0.49; 1.02)	0.75 (0.52; 1.07)
23F	0.77 (0.54; 1.09)	0.74 (0.51; 1.08)	1.00 (0.73; 1.36)	0.77 (0.48; 1.22)	0.74 (0.46; 1.20)
Vaccine-related serotypes (µg/mL)
6A	0.11 (0.08; 0.16)	0.12 (0.08; 0.17)	0.19 (0.13; 0.27)	NA	NA
19A	0.15 (0.11; 0.22)	0.17 (0.12; 0.25)	0.25 (0.17; 0.36)	NA	NA
Protein D (EL.U/mL)
	1109.64 (876.9; 1404.1)	1348.55 (1048.2; 1734.9)	1667.91 (1401.9; 1984.4)	0.67 (0.50; 0.89)	0.81 (0.60; 1.09)

Footnote: PHiD-CV and DTPa-(HBV)-IPV/Hib at 3, 4, and 5 months of age, with the following prophylactic antipyretic regimen: IPARA, immediate paracetamol; DPARA, delayed paracetamol; NPARA, no paracetamol; N = maximum number of children with available results; LL, lower limit; UL, upper limit; 95% CI, standardized asymptotic confidence interval; GMC, geometric mean antibody concentration; %, percentage of participants with anti-pneumococcal serotype-specific antibody concentrations ≥ 0.2 µg/mL; NA, not available; ATP, according-to-protocol. The exclusion of 0 from the 95% CI of difference between groups, and the exclusion of 1 from the 95% CI of antibody GMC ratios were used to highlight potential group differences (bold).

Table 3. Exploratory analysis: antibody responses to DTPa-HBV-IPV/Hib antigens with pairwise group comparisons, one month post-dose three (ATP cohort for immunogenicity).

	Seroprotection/seropositivity rates (95% CI)			GMC (95% CI)			GMC ratio
Antibody (cut-off /threshold)	IIBU N = 138	DIBU N = 150	NIBU N = 155	IIBU N = 138	DIBU N = 150	NIBU N = 155	IIBU / NIBU 95% CI (LL; UL)	DIBU / NIBU 95% CI (LL; UL)
DIPHT (≥0.1 IU/mL)	100 (97.3; 100)	100 (97.6; 100)	100 (97.6; 100)	3.33 (2.97; 3.73)	2.94 (2.65; 3.26)	3.13 (2.80; 3.50)	1.06 (0.91; 1.24)	0.94 (0.81; 1.09)
TET (≥0.1 IU/mL)	100 (97.3; 100)	100 (97.6; 100)	100 (97.6; 100)	3.75 (3.31; 4.25)	3.37 (3.04; 3.74)	3.96 (3.52; 4.46)	0.95 (0.80; 1.12)	0.85 (0.73; 1.00)
PT (≥5 EL.U/mL)	100 (97.3; 100)	100 (97.5; 100)	100 (97.5; 100)	59.1 (53.7; 65.1)	64.2 (58.7; 70.2)	65.0 (59.6; 71.0)	0.91 (0.80; 1.03)	0.99 (0.87; 1.12)
FHA (≥5 EL.U/mL)	100 (97.2; 100)	100 (97.5; 100)	100 (97.4; 100)	163.1 (147.8; 180.1)	171.6 (154.7; 190.4)	191.1 (171.1; 213.5)	0.85 (0.74; 0.99)	0.90 (0.77; 1.04)
PRN (5 EL.U/mL)	99.3 (96.0; 100)	100 (97.6; 100)	100 (97.6; 100)	103.9 (91.5; 118.0)	114.3 (101.0; 129.3)	118.1 (103.9; 134.3)	0.88 (0.73; 1.05)	0.97 (0.81; 1.16)
PRP (≥0.15 µg/mL)	100 (97.3; 100)	99.3 (96.3; 100)	100 (97.6; 100)	3.99 (3.27; 4.88)	3.66 (3.07; 4.36)	4.51 (3.75; 5.42)	0.89 (0.68; 1.16)	0.81 (0.63; 1.04)
HBs (≥10 mIU/mL)	100 (96.7; 100)	99.2 (95.4; 100)	100 (97.0; 100)	911.85 (719.55; 1155.56)	1139.10 (902.93; 1437.04)	1245.07 (998.97; 1551.80)	0.73 (0.53; 1.01)	0.91 (0.67; 1.26)
	IPARA N = 50	DPARA N = 49	NPARA N = 53	IPARA N = 52	DPARA N = 49	NPARA N = 53	IPARA / NPARA 95% CI (LL; UL)	DPARA / NPARA 95% CI (LL; UL)
DIPHT (≥0.1 IU/mL)	100 (92.9; 100)	100 (92.7; 100)	100 (93.3; 100)	3.06 (2.57; 3.66)	2.89 (2.32; 3.60)	3.46 (2.91; 4.11)	0.89 (0.69; 1.13)	0.84 (0.64; 1.10)
TET (≥0.1 IU/mL)	100 (92.7; 100)	100 (92.7; 100)	100 (92.7; 100)	2.94 (2.43; 3.56)	3.06 (2.55; 3.68)	3.76 (3.11; 4.56)	0.78 (0.60; 1.02)	0.81 (0.62; 1.06)
PT (≥5 EL.U/mL)	100 (92.5; 100)	100 (92.1; 100)	100 (93.3; 100)	60.4 (51.4; 71.0)	63.1 (52.0; 76.6)	61.52 (53.1; 71.2)	0.98 (0.79; 1.22)	1.03 (0.81; 1.30)
FHA (≥5 EL.U/mL)	100 (92.5; 100)	100 (92.1; 100)	100 (93.2; 100)	171.1 (139.8; 209.2)	196.5 (163.1; 236.8)	168.9 (141.9; 201.0)	1.01 (0.78; 1.32)	1.16 (0.90; 1.50)
PRN (≥5 EL.U/mL)	100 (92.5; 100)	100 (92.6; 100)	100 (93.3; 100)	97.1 (76.7; 123.1)	106.2 (83.1; 135.7)	114.0 (95.6; 136.0)	0.85 (0.64; 1.14)	0.93 (0.69; 1.25)
PRP (≥0.15 µg/mL)	100 (93.2; 100)	100 (92.5; 100)	100 (93.3; 100)	3.29 (2.36; 4.58)	4.23 (3.03; 5.91)	5.01 (3.69; 6.79)	0.66 (0.42; 1.03)	0.84 (0.54; 1.32)
HBs (≥10 mIU/mL)	97.5 (86.8; 99.9)	97.2 (85.5; 99.9)	100 (92.0; 100)	934.65 (580.70; 1504.32)	674.25 (373.26; 1217.95)	1027.79 (719.24; 1468.70)	0.91 (0.51; 1.62)	0.66 (0.34; 1.26)

Footnote: DIPHT, Diphtheria; TET, Tetanus; PT, Pertussis Toxoid; FHA, Filamentous Haemagglutinin; PRN, Pertactin; PRP, Polyribosyl-ribitol Phosphate; HBs, Hepatitis B Surface; EL.U/mL, ELISA units/milliliter; mIU/mL, milli-international units/milliliter; PHiD-CV and DTPa-(HBV)-IPV/Hib at 3, 4, and 5 months of age, with the following prophylactic antipyretic regimen: IIBU, immediate ibuprofen; DIBU, delayed ibuprofen; NIBU, no ibuprofen; IPARA, immediate paracetamol; DPARA, delayed paracetamol; NPARA, no paracetamol; N, maximum number of children with available results; LL, lower limit; UL, upper limit; 95% CI, confidence interval for the GMC ratio (Anova model – pooled variance); GMC, geometric mean concentration. The exclusion of 1 from the 95% CI of antibody GMC ratios was used to highlight potential group differences (bold).

Figure 2. Incidence of fever post-primary (A) and post-booster (B) vaccination (TVC). Footnote: Primary vaccination: PHiD-CV and DTPa-(HBV)-IPV/Hib at 3, 4, and 5 months of age, with the following prophylactic antipyretic regimen: IIBU, immediate ibuprofen; DIBU, delayed ibuprofen; NIBU, no ibuprofen; IPARA, immediate paracetamol; DPARA, delayed paracetamol; NPARA, no paracetamol. Booster vaccination: PHiD-CV and DTPa-HBV-IPV/Hib at 12–15 months of age, with the following prophylactic antipyretic regimen: at primary vaccination: immediate ibuprofen, and at booster: immediate (IIBU-IIBU), delayed (IIBU-DIBU) or no ibuprofen (IIBU-NIBU); at primary vaccination: delayed ibuprofen, and at booster: immediate (DIBU-IIBU), delayed (DIBU-DIBU) or no ibuprofen (DIBU-NIBU); at primary vaccination: no ibuprofen, and at booster: immediate (NIBU-IIBU), delayed (NIBU-DIBU) or no ibuprofen (NIBU-NIBU); immediate paracetamol at primary vaccination and no paracetamol at booster (IPARA-NPARA); delayed paracetamol at primary vaccination and immediate paracetamol at booster (DPARA-IPARA); no paracetamol at primary vaccination, and immediate paracetamol at booster (NPARA-IPARA). Fever: rectal temperature ≥38.0°C; Grade 3 fever: rectal temperature >40°C or axillary/oral/tympanic temperature >39.5°C; TVC, total vaccinated cohort. Error bars indicate 95% confidence intervals.

Figure 3. Study design. Footnote: Primary vaccination: PHiD-CV and DTPa-(HBV)-IPV/Hib at 3, 4, and 5 months of age, with the following prophylactic antipyretic regimen: IIBU, immediate ibuprofen; DIBU, delayed ibuprofen; NIBU, no ibuprofen; IPARA, immediate paracetamol; DPARA, delayed paracetamol; NPARA, no paracetamol. Booster vaccination: PHiD-CV and DTPa-HBV-IPV/Hib at 12–15 months of age, with the following prophylactic antipyretic regimen: at primary vaccination: immediate ibuprofen, and at booster: immediate (IIBU-IIBU), delayed (IIBU-DIBU) or no ibuprofen (IIBU-NIBU); at primary vaccination: delayed ibuprofen, and at booster: immediate (DIBU-IIBU), delayed (DIBU-DIBU) or no ibuprofen (DIBU-NIBU); at primary vaccination: no ibuprofen, and at booster: immediate (NIBU-IIBU), delayed (NIBU-DIBU) or no ibuprofen (NIBU-NIBU); immediate paracetamol at primary vaccination and no paracetamol at booster (IPARA-NPARA); delayed paracetamol at primary vaccination and immediate paracetamol at booster (DPARA-IPARA); no paracetamol at primary vaccination, and immediate paracetamol at booster (NPARA-IPARA). N, number of children per group; m, months; * DTPa-IPV/Hib instead of DTPa-HBV-IPV/Hib.