Vaccine 35 (2017) 1926–1935

Contents lists available at ScienceDirect

Vaccine
journal homepage: www.elsevier.com/locate/vaccine

A randomized study of fever prophylaxis and the immunogenicity of

routine pediatric vaccinations
Jacek Wysocki a,⇑, Kimberly J. Center b, Jerzy Brzostek c, Ewa Majda-Stanislawska d, Henryk Szymanski e,
Leszek Szenborn f, Hanna Czajka g, Barbara Hasiec h, Jerzy Dziduch i, Teresa Jackowska j, Anita Witor k,
_
Elzbieta Kopińska l, Ryszard Konior m, Peter C. Giardina n, Vani Sundaraiyer o, Scott Patterson b,
William C. Gruber n, Daniel A. Scott b, Alejandra Gurtman n
a
Department of Preventive Medicine, Poznań University of Medical Sciences, ul. Smoluchowskiego 11, 60-179 Poznań, Poland
b
Pfizer Vaccine Research, 500 Arcola Rd, Collegeville, PA 19426, USA
c
Zespol Opieki Zdrowotnej w Debicy, Krakowska 91, 39-200 Debica, Poland
d
Department of Pediatric Infectious Diseases, Medical University of Lodz, Al. Kościuszki 4, 90-419 Lodz, Poland
e
NZOZ Praktyka Lekarza Rodzinnego Alina Grocka-Wlazlak, Trzebnicka 37, 55-120 Oborniki Slaskie, Poland
f
Department of Pediatric Infectious Diseases, Wroclaw Medical University, ul. Chałubińskiego 2-2a, 50-368 Wroclaw, Poland
g
Indywidualna Specjalistyczna Praktyka Lekarska, Braci Kiemliczow 14, 30-389 Krakow, Poland
h
NZOZ Praktyka Lekarza Rodzinnego, ul. Weteranów 46, 20-044 Lublin, Poland
i
SPZOZ Lubartow Oddzial Pediatryczny, ul. Cicha 14, 21-100 Lubartow, Poland
j
Department of Pediatrics, Medical Center of Postgraduate Education, ul. Marymoncka 99/103, 01-813 Warsaw, Poland
k
NZLA Michalkowice Jaroszy i Partnerzy, Kościelna 32, 41-103 Siemianowice, Slaskie, Poland
l
Physicians Practice Group Family Specialist Outpatient Clinic, Szosa Chelminska 54B/4, 87-100 Torun, Poland
m
NZOZ ‘‘Praktimed” sp. z o.o., Strzelców 15, 31-422 Krakow, Poland
n
Pfizer Vaccine Research, 401 N. Middletown Rd, Pearl River, NY 10965, USA
o
inVentiv Health Clinical, LLC, 504 Carnegie Center, Princeton, NJ 08540, USA

a r t i c l e i n f o a b s t r a c t

Article history: Objective: Prophylactic antipyretic use during pediatric vaccination is common. This study assessed
Received 16 September 2016 whether paracetamol or ibuprofen prophylaxis interfere with immune responses to the 13-valent pneu-
Received in revised form 3 February 2017 mococcal conjugate vaccine (PCV13) given concomitantly with the combined DTaP/HBV/IPV/Hib vaccine.
Accepted 14 February 2017
Methods: Subjects received prophylactic paracetamol or ibuprofen at 0, 6–8, and 12–16 h after vaccina-
Available online 3 March 2017
tion, or 6–8 and 12–16 h after vaccination at 2, 3, 4, and 12 months of age. At 5 and 13 months, immune
responses were evaluated versus responses in controls who received no prophylaxis.
Keywords:
Results: After the infant series, paracetamol recipients had lower levels of circulating serotype-specific
Pneumococcal conjugate vaccine
Immune response
pneumococcal anticapsular immunoglobulin G than controls, reaching significance (P < 0.0125) for 5 ser-
Antipyretic otypes (serotypes 3, 4, 5, 6B, and 23F) when paracetamol was started at vaccination. Opsonophagocytic
Ibuprofen activity assay (OPA) results were similar between groups. Ibuprofen did not affect pneumococcal
Paracetamol responses, but significantly (P < 0.0125) reduced antibody responses to pertussis filamentous hemagglu-
Infant tinin and tetanus antigens after the infant series when started at vaccination. No differences were
observed for any group after the toddler dose.
Conclusions: Prophylactic antipyretics affect immune responses to vaccines; these effects vary depending
on the vaccine, antipyretic agent, and time of administration. In infants, paracetamol may interfere with

Ò
Abbreviations: AE, adverse event; DTaP/HBV/IPV/Hib, diphtheria-tetanus-acellular pertussis, hepatitis B, inactivated poliovirus, and H influenzae type b (INFANRIX hexa);
FHA, filamentous hemagglutinin; GMC, geometric mean concentration; GMR, geometric mean ratio; GMT, geometric mean titer; IgG, immunoglobulin G; LLOQ, lower limit of
quantitation; mITT, modified intent to treat; OPA, opsonophagocytic activity; PCV, pneumococcal conjugate vaccine; PCV13, 13-valent pneumococcal conjugate vaccine; SAE,
serious adverse event.
⇑ Corresponding author.
E-mail addresses: jawysocki@pro.onet.pl (J. Wysocki), kimberly.center@pfizer.com (K.J. Center), jerzy_br@poczta.onet.pl (J. Brzostek), emajda@lodz.home.pl (E. Majda-
Stanislawska), henryktomasz@poczta.onet.pl (H. Szymanski), leszek.szenborn@am.wroc.pl (L. Szenborn), hanna.czajka@onet.pl (H. Czajka), bhasiec@wp.pl (B. Hasiec),
jurekad@tlen.pl (J. Dziduch), tjackowska@cmkp.edu.pl (T. Jackowska), adamanita@interia.pl (A. Witor), ela.kopinska@gmail.com (E. Kopińska), rkonior@szpitaljp2.krakow.pl
(R. Konior), peter.giardina@pfizer.com (P.C. Giardina), Vani.Sundaraiyer@inventivhealth.com (V. Sundaraiyer), Scott.Patterson@pfizer.com (S. Patterson), Bill.Gruber@pfizer.
com (W.C. Gruber), dan.scott@pfizer.com (D.A. Scott), Alejandra.Gurtman@pfizer.com (A. Gurtman).

http://dx.doi.org/10.1016/j.vaccine.2017.02.035
0264-410X/Ó 2017 Elsevier Ltd.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
 J. Wysocki et al. / Vaccine 35 (2017) 1926–1935 1927

immune responses to pneumococcal antigens, and ibuprofen may reduce responses to pertussis and
tetanus antigens. The use of antipyretics for fever prophylaxis during infant vaccination merits careful
consideration.
Conclusions: ClinicalTrials.gov identifier: NCT01392378 https://clinicaltrials.gov/ct2/show/NCT01392378?
term=NCT01392378&rank=1
Ó 2017 Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.
org/licenses/by-nc-nd/4.0/).

Ò
1. Introduction HBV/IPV/Hib; INFANRIX hexa, GlaxoSmithKline, Rixensart, Bel-
gium) antigens measured by GMCs and GMTs after the infant series
Immunization against Streptococcus pneumoniae with a pneu- and toddler dose. The PCV13 safety profile was evaluated by mea-
mococcal conjugate vaccine (PCV) is routinely recommended for suring fever incidence and adverse events (AEs).
children in many countries. Fever is frequently associated with
pediatric vaccination, and over-the-counter antipyretics are often 2.2. Study design
administered prophylactically at vaccination or shortly thereafter.
While paracetamol may reduce fever [1,2] and other common In this study conducted from August 2011–January 2013, sub-
adverse effects [3,4] after vaccination, limited data suggest that it jects from 14 sites in Poland were enrolled and randomized by
may also have deleterious effects on immune response. A 2009 an interactive voice response system into 5 groups
study [5] reported decreased antibody production against all 10 (10:10:10:10:12) to receive prophylactic antipyretics with PCV13
pneumococcal serotypes in infants given paracetamol concomi- and DTaP/HBV/IPV/Hib at approximately 2, 3, 4 (infant series),
tantly with 10-valent PCV vaccination. Moreover, immune and 12 months (toddler dose) of age. At each vaccine visit, Groups
responses to a coadministered multicomponent vaccine were also 1 and 2 received paracetamol (15 mg/kg/dose) or ibuprofen
reduced; some of these effects persisted 1 month after a booster (10 mg/kg/dose), respectively, starting 6–8 h after vaccination
dose for both vaccines [5]. Limitations of that study included eval- and again 6–8 h after the initial antipyretic dose. Groups 3 and 4
uation of only one antipyretic agent (paracetamol) given in a single received the same respective doses as Groups 1 and 2, but began
dosing regimen; other agents and the impact of dose timing on paracetamol (Group 3) or ibuprofen (Group 4) with vaccination.
vaccine immune responses were not explored. Ibuprofen is also Controls (Group 5) did not receive prophylactic antipyretics. For
available over-the-counter and is widely used in this setting [6– all groups, antipyretics were permitted for treatment of fever or
9], but no information exists regarding its effect, if any, on the other symptoms at the treating investigator’s discretion. All anti-
immunogenicity of routinely administered vaccines. pyretic doses, including missed or additional doses, were recorded
This paper reports results of a large, randomized, controlled, in an electronic diary (e-diary).
open-label trial examining effects of coadministration or delayed At approximately 5 and 13 months of age, blood samples
administration (ie, dose timing) of paracetamol or ibuprofen on (5 mL) were collected for assessing serum concentrations of ant-
immune responses to PCV13 and coadministered antigens after icapsular IgG for all 13 pneumococcal serotypes in the vaccine by
an infant vaccination series and a toddler dose. standardized ELISA, which used a C polysaccharide-containing cell
wall extract and serotype 22F capsular polysaccharide [10–12]. The
2. Methods same blood samples were used to assess DTaP/HBV/IPV/Hib anti-
body responses for all subjects and serum OPA for the 13 serotypes
This research protocol (ClinicalTrials.gov identifier: (described in [13]) in a randomly selected subset of 75 subjects per
NCT01392378) sponsored by Pfizer Inc was reviewed and group. Antibody responses to DTaP/HBV/IPV/Hib were measured as
approved by institutional review boards and/or independent ethics previously described [14–16].
committees for each participating center. This study was con- Rectal temperature, recorded in the e-diary, was measured 6–
ducted according to principles derived from the Declaration of Hel- 8 h postvaccination, 6–8 h later, and during the next 3 days at bed-
sinki and the International Conference on Harmonisation time and when fever was suspected. Fever was defined as a rectal
Guidelines for Good Clinical Practice. Both parents of all partici- temperature of 38.0–39.0 °C (mild), 39.1–40.0 °C (moderate), and
pants gave written, informed consent before enrollment and before >40.0 °C (severe). AEs and serious AEs (SAEs) were collected
performance of study-related procedures. Data analysis was per- throughout the study in a case report form, and were analyzed as
formed by the sponsor. percentages of each group reporting a specific MedDRA preferred
term.
2.1. Objectives
2.3. Vaccines administered
The primary objective was to assess the effect of prophylactic
paracetamol or ibuprofen on the immunogenicity of PCV13 (Pre- PCV13 (lot number 10-088269) and DTaP/HBV/IPV/Hib (lot
Ò
vnar 13/Prevenar 13 , Pfizer Inc, Sandwich, United Kingdom) rela- numbers 11-001342, 11-002167, 11-008164, or 11-008296) were
tive to controls, as measured by serotype-specific immunoglobulin given intramuscularly in the anterolateral thigh muscle in oppos-
G (IgG) geometric mean concentrations (GMCs) after completion of ing legs. PCV13 contains saccharides from pneumococcal serotypes
an infant vaccination series. Secondary objectives included assess- 1, 3, 4, 5, 6A, 6B, 7F, 9V, 14, 18C, 19A, 19F, and 23F individually con-
ment of prophylactic antipyretic effects on PCV13 serotype-specific jugated to CRM197. Each 0.5-mL dose contains 4.4 mg of serotype
IgG GMCs after a toddler dose, PCV13 immunogenicity measured 6B, 2.2 mg each of the remaining 12 saccharides, 5 mM succinate
by serotype-specific opsonophagocytic activity (OPA) geometric buffer, 0.02% polysorbate 80, and 0.125 mg aluminium phosphate.
mean titers (GMTs) in a subset of subjects after the infant series, Each 0.5-mL dose of DTaP/HBV/IPV/Hib contains 25 Lf diphtheria
and immunogenicity of diphtheria-tetanus-acellular pertussis, toxoid, 10 Lf tetanus toxoid, 25 mg pertussis toxin, 25 mg
hepatitis B, inactivated poliovirus, and H influenzae type b (DTaP/ filamentous haemagglutinin (FHA), 8 mg pertactin, 10 mg hepatitis
1928 J. Wysocki et al. / Vaccine 35 (2017) 1926–1935

B surface antigen, 40 D-antigen units (DU) of type 1 poliovirus, 8 0.15 mg/mL and 1.0 mg/mL); diphtheria (0.1 IU/mL); pertussis
DU type 2 poliovirus, 32 DU type 3 poliovirus, 10 mg Hib capsular (PT, FHA, PRN; 5 EL. U/mL, 5th percentile in Group 5); tetanus
polysaccharide covalently bound to 25 mg tetanus toxoid, 12.6 mg (0.1 IU/mL); HBV (10 mIU/mL); poliovirus (1:8 titer) [17].
lactose, 4.5 mg sodium chloride, 0.7 mg aluminium adjuvants (as Safety endpoints were fever, antipyretic use, AEs, and SAEs.
salts), and 0.12 mg aluminium phosphate [17].

2.6. Statistical analyses

2.4. Inclusion and exclusion criteria
The modified intent-to-treat (mITT) population was the primary
Eligible subjects were 2 months of age (56 to 98 days) and population for statistical analyses and comprised subjects who had
had not previously received pneumococcal vaccine or DTaP/HBV/ no major protocol violations, received the randomized antipyretic
IPV/Hib. Other routine vaccinations were permitted throughout regimen after all vaccinations, may have received additional doses
the study. Exclusion criteria included: contraindication to vaccina- of antipyretics (for fever), and had blood drawn within study-
tion with either study vaccine; history of anaphylactic reaction to specified periods. The per-protocol population comprised subjects
any vaccine or vaccine-related component; allergy or contraindica- included in the mITT population but had received no antipyretics
tion to paracetamol or ibuprofen; and chronic use of medications beyond those specified by the protocol. GMCs and GMRs were esti-
with known interactions with either antipyretic. mated by serotype using a general linear model with a fixed effect
of assigned antipyretic regimen group and natural log-transformed
2.5. Immunogenicity and safety endpoints IgG data as the response; a similar approach was taken for each of
the vaccine antigens contained in DTaP/HBV/IPV/Hib and for GMTs.
The immunogenicity endpoints of this study were: serotype- All subjects who received  1 dose of study vaccine were included
specific IgG GMCs and geometric mean ratios (GMRs) relative to in safety analyses, which were performed separately for each dose.
controls for 13 pneumococcal serotypes measured 1 month after As 4 between-group comparisons were of interest (each of
the infant series and toddler dose; the proportion of subjects Groups 1–4 relative to Group 5), it was necessary to control the
achieving a serotype-specific IgG antibody concentration type 1 error (false-positive) rate for multi-group comparisons. Sta-
0.35 mg/mL for the 13 pneumococcal serotypes 1 month after tistical significance for each of the between-group comparisons
the infant series and toddler dose; serotype-specific OPA GMTs therefore required a P value of <0.0125 (i.e., Bonferroni adjust-
and GMRs relative to controls for the 13 pneumococcal serotypes ment) to maintain the overall experiment-wise error rate at 5%.
1 month after the infant series in a subset of subjects; the propor- To also account for the 13 multiple comparisons across serotypes
tion of study participants achieving a serotype-specific OPA  the within each between-group comparison, the Benjamini-Hochberg
lower limit of quantitation (LLOQ) for the 13 pneumococcal sero- false discovery rate testing procedure [19] was applied to adjust
types 1 month after the infant series; DTaP/HBV/IPV/Hib GMCs for multiplicity within each between-group comparison across ser-
and GMRs relative to controls after the infant series and toddler otypes. Using the false discovery rate procedure, 150 evaluable
dose; and the proportion of subjects achieving prespecified anti- subjects per arm were estimated to provide 90% power to detect
body levels to DTaP/HBV/IPV/Hib antigens 1 month after the infant 50% decreases in GMRs using these statistical adjustments. Similar
series and toddler dose. Seroprotective IgG GMC thresholds were comparisons were constructed for concomitant antigens; however,
defined as 0.35 mg/mL for the 13 pneumococcal serotypes [18], as these comparisons were secondary/exploratory, no type 1 error
and as follows for the DTaP/HBV/IPV/Hib antigens: Hib (PRP; adjustment was applied.

Fig. 1. Subject Disposition. aCompletion of this dose includes blood draw.

 J. Wysocki et al. / Vaccine 35 (2017) 1926–1935 1929

Table 1
IgG GMCs 1 month after the infant series and toddler dose, including ratios relative to controls (mITT immunogenicity population).

Serotype After infant series After toddler dose

a b c d d e
Group N GMC (95% CI) Ratio (95% CI) P-value Nb GMCc (95% CI)d Ratio (95% CI)d P-valuee
PCV7 Serotypes
4
Group 1 137 1.64 (1.44–1.87) 0.81 (0.69–0.96) 0.0856 130 3.07 (2.66–3.54) 0.99 (0.82–1.19) 0.9350
Group 3 148 1.48 (1.31–1.68) 0.73 (0.62–0.86)** 0.0012 143 2.97 (2.60–3.41) 0.96 (0.80–1.14) 0.6922
Group 2 155 1.99 (1.76–2.25) 0.99 (0.84–1.16) 0.8546 143 3.43 (3.00–3.93) 1.11 (0.93–1.32) 0.7918
Group 4 146 2.07 (1.82–2.34) 1.02 (0.87–1.20) 0.8414 139 3.43 (2.99–3.94) 1.11 (0.93–1.32) 0.9765
Group 5 210 2.02 (1.82–2.25) 206 3.10 (2.77–3.48)
6B
Group 1 136 0.68 (0.55–0.83) 0.83 (0.64–1.08) 0.2412 130 6.70 (5.76–7.78) 0.95 (0.78–1.15) 0.6915
Group 3 148 0.56 (0.46–0.68) 0.69 (0.53–0.88)** 0.0093 143 6.38 (5.53–7.36) 0.90 (0.75–1.09) 0.4389
Group 2 155 0.91 (0.76–1.10) 1.13 (0.88–1.44) 0.4548 144 8.01 (6.94–9.24) 1.13 (0.94–1.36) 0.7918
Group 4 146 0.90 (0.74–1.09) 1.10 (0.86–1.42) 0.8414 139 7.30 (6.31–8.44) 1.03 (0.85–1.24) 0.9765
Group 5 210 0.81 (0.69–0.96) 206 7.08 (6.28–7.98)
9V
Group 1 138 1.13 (1.01–1.27) 0.87 (0.75–1.00) 0.1749 130 2.15 (1.93–2.40) 0.99 (0.87–1.14) 0.9350
Group 3 148 1.17 (1.05–1.30) 0.89 (0.78–1.03) 0.1351 143 2.17 (1.96–2.41) 1.00 (0.88–1.15) 0.9430
Group 2 155 1.45 (1.30–1.61) 1.11 (0.96–1.27) 0.3121 144 2.23 (2.01–2.47) 1.03 (0.90–1.18) 0.7918
Group 4 147 1.40 (1.26–1.56) 1.07 (0.93–1.24) 0.8414 139 2.12 (1.91–2.35) 0.98 (0.85–1.12) 0.9765
Group 5 210 1.31 (1.19–1.43) 206 2.16 (1.99–2.36)
14
Group 1 138 4.45 (3.76–5.26) 0.83 (0.67–1.03) 0.2158 130 8.10 (7.04–9.31) 0.89 (0.74–1.06) 0.5167
Group 3 148 4.75 (4.04–5.58) 0.88 (0.72–1.09) 0.2472 143 7.95 (6.96–9.08) 0.87 (0.73–1.04) 0.2514
Group 2 155 4.73 (4.04–5.54) 0.88 (0.71–1.08) 0.3279 144 8.40 (7.36–9.59) 0.92 (0.78–1.10) 0.7918
Group 4 147 5.26 (4.48–6.19) 0.98 (0.79–1.21) 0.8414 139 9.12 (7.96–10.43) 1.00 (0.84–1.19) 0.9872
Group 5 210 5.38 (4.70–6.16) 206 9.10 (8.15–10.17)
18C
Group 1 138 1.47 (1.29–1.66) 0.95 (0.81–1.12) 0.6193 130 1.35 (1.20–1.53) 0.85 (0.73–1.00) 0.2582
Group 3 148 1.25 (1.11–1.42) 0.82 (0.70–0.96) 0.0191 143 1.36 (1.21–1.53) 0.86 (0.74–1.00) 0.2514
Group 2 155 1.73 (1.54–1.95) 1.13 (0.96–1.32) 0.3121 144 1.68 (1.49–1.88) 1.06 (0.91–1.23) 0.7918
Group 4 147 1.75 (1.55–1.97) 1.14 (0.97–1.33) 0.8414 139 1.63 (1.45–1.84) 1.03 (0.88–1.20) 0.9765
Group 5 210 1.54 (1.39–1.70) 206 1.59 (1.44–1.75)
19F
Group 1 138 1.78 (1.57–2.02) 0.90 (0.76–1.05) 0.2412 130 8.41 (7.17–9.87) 1.06 (0.86–1.30) 0.6915
Group 3 148 1.59 (1.41–1.80) 0.80 (0.68–0.94) 0.0135 143 7.53 (6.47–8.76) 0.95 (0.78–1.15) 0.6922
Group 2 155 2.30 (2.04–2.59) 1.15 (0.99–1.35) 0.3121 144 8.99 (7.72–10.46) 1.13 (0.93–1.38) 0.7918
Group 4 147 2.04 (1.81–2.31) 1.03 (0.87–1.21) 0.8414 139 8.02 (6.88–9.36) 1.01 (0.83–1.23) 0.9872
Group 5 210 1.99 (1.80–2.20) 206 7.95 (7.00–9.02)
23F
Group 1 137 0.85 (0.72–1.00) 0.81 (0.66–1.00) 0.1749 130 2.34 (2.01–2.73) 0.85 (0.70–1.04) 0.3609
Group 3 148 0.73 (0.62–0.86) 0.70 (0.57–0.86)** 0.0038 142 2.37 (2.05–2.75) 0.86 (0.71–1.05) 0.2514
Group 2 155 1.19 (1.02–1.40) 1.15 (0.93–1.41) 0.3121 144 2.96 (2.56–3.43) 1.08 (0.89–1.30) 0.7918
Group 4 146 1.07 (0.91–1.26) 1.03 (0.84–1.27) 0.8414 139 2.86 (2.47–3.32) 1.04 (0.86–1.26) 0.9765
Group 5 210 1.04 (0.91–1.19) 206 2.75 (2.43–3.10)

Additional Serotypes
1
Group 1 138 1.12 (0.98–1.27) 0.90 (0.76–1.06) 0.2412 130 2.80 (2.47–3.17) 0.92 (0.79–1.08) 0.6304
Group 3 148 1.02 (0.90–1.16) 0.82 (0.70–0.96) 0.0241 143 2.66 (2.36–3.00) 0.88 (0.75–1.03) 0.2514
Group 2 155 1.50 (1.33–1.69) 1.20 (1.02–1.41) 0.2053 144 3.22 (2.85–3.62) 1.06 (0.91–1.24) 0.7918
Group 4 147 1.29 (1.14–1.47) 1.04 (0.88–1.22) 0.8414 139 3.12 (2.76–3.52) 1.03 (0.88–1.20) 0.9765
Group 5 210 1.25 (1.12–1.38) 206 3.04 (2.75–3.35)
3
Group 1 138 0.71 (0.63–0.79) 0.81 (0.69–0.94) 0.0732 129 0.46 (0.40–0.52) 0.84 (0.71–1.01) 0.2582
Group 3 148 0.57 (0.51–0.64) 0.65 (0.56–0.76)*** <0.0001 143 0.46 (0.40–0.52) 0.85 (0.72–1.01) 0.2514
Group 2 155 0.83 (0.75–0.93) 0.95 (0.82–1.10) 0.6090 144 0.54 (0.47–0.61) 0.99 (0.84–1.18) 0.9279
Group 4 147 0.84 (0.75–0.94) 0.96 (0.82–1.11) 0.8414 138 0.49 (0.42–0.55) 0.90 (0.76–1.07) 0.9765
Group 5 210 0.88 (0.79–0.96) 203 0.54 (0.48–0.60)
5
Group 1 137 0.79 (0.69–0.91) 0.98 (0.82–1.16) 0.7828 130 2.33 (2.07–2.63) 0.82 (0.71–0.96) 0.1424
Group 3 148 0.63 (0.55–0.72) 0.77 (0.65–0.92)** 0.0093 143 2.40 (2.15–2.69) 0.85 (0.73–0.98) 0.2514
Group 2 155 0.98 (0.86–1.11) 1.12 (1.02–1.43) 0.2053 144 2.75 (2.46–3.07) 0.97 (0.84–1.12) 0.7918
Group 4 146 0.90 (0.78–1.02) 1.11 (0.93–1.31) 0.8414 139 2.62 (2.33–2.93) 0.92 (0.79–1.07) 0.9765
Group 5 210 0.81 (0.73–0.91) 206 2.84 (2.59–3.12)
6A
Group 1 138 0.97 (0.84–1.13) 0.88 (0.73–1.07) 0.2412 130 5.12 (4.48–5.86) 0.93 (0.78–1.10) 0.6304
Group 3 148 0.85 (0.74–0.98) 0.77 (0.64–0.93) 0.0135 143 5.27 (4.64–5.99) 0.95 (0.81–1.13) 0.6922
Group 2 155 1.25 (1.09–1.44) 1.14 (0.95–1.37) 0.3121 144 5.73 (5.04–6.50) 1.04 (0.88–1.22) 0.7918
Group 4 146 1.22 (1.06–1.41) 1.11 (0.92–1.34) 0.8414 139 5.36 (4.70–6.10) 0.97 (0.82–1.15) 0.9765
Group 5 210 1.10 (0.97–1.24) 206 5.52 (4.97–6.14)

(continued on next page)

1930 J. Wysocki et al. / Vaccine 35 (2017) 1926–1935

Table 1 (continued)

Serotype After infant series After toddler dose

Groupa Nb GMCc (95% CI)d Ratio (95% CI)d P-valuee Nb GMCc (95% CI)d Ratio (95% CI)d P-valuee

7F
Group 1 138 1.94 (1.74–2.16) 0.90 (0.79–1.03) 0.2412 130 3.79 (3.42–4.19) 0.95 (0.84–1.08) 0.6572
Group 3 148 1.83 (1.65–2.03) 0.85 (0.75–0.98) 0.0275 142 3.56 (3.23–3.92) 0.89 (0.79–1.01) 0.2514
Group 2 155 2.22 (2.01–2.46) 1.03 (0.91–1.18) 0.6652 144 3.89 (3.54–4.28) 0.98 (0.86–1.11) 0.7918
Group 4 146 2.28 (2.06–2.53) 1.06 (0.93–1.21) 0.8414 139 3.97 (3.60–4.38) 1.00 (0.88–1.13) 0.9872
Group 5 210 2.15 (1.97–2.34) 206 3.98 (3.67–4.31)
19A
Group 1 137 2.70 (2.38–3.07) 0.90 (0.76–1.06) 0.2412 129 7.11 (6.22–8.12) 0.92 (0.78–1.09) 0.6304
Group 3 148 2.53 (2.24–2.86) 0.84 (0.72–0.99) 0.0387 142 7.31 (6.43–8.30) 0.95 (0.80–1.12) 0.6922
Group 2 155 3.39 (3.01–3.82) 1.13 (0.96–1.32) 0.3121 144 7.99 (7.04–9.06) 1.04 (0.88–1.22) 0.7918
Group 4 146 3.14 (2.77–3.55) 1.04 (0.89–1.22) 0.8414 139 7.35 (6.47–8.36) 0.95 (0.81–1.13) 0.9765
Group 5 210 3.02 (2.72–3.34) 206 7.71 (6.94–8.57)

Note: P values for comparison of the antipyretic groups with control are adjusted using the false discovery rate procedure.
Abbreviations: CI = confidence interval; GMC = Geometric LSMean Concentration; IgG = immunoglobulin G; LSMean = least squares mean; mITT = modified intent-to-treat.
**
P < 0.0125.
***
P < 0.001.
a
Group 1, delayed paracetamol; Group 3, concomitant paracetamol; Group 2, delayed ibuprofen; Group 4, concomitant ibuprofen; Group 5, control.
b
N = number of subjects with a determinate IgG concentration to the given serotype.
c
GMCs were calculated using all subjects with available data for the specified blood draw.
d
CIs are back transformations of CIs based on analysis of log-transformed IgG values using ANOVA with the antipyretic regimen group as a fixed effect. The ratio and
related CIs are back transformed from the difference of the LSMean of a specific antipyretic group minus the LSMean of controls.
e
P-values are adjusted using the false discovery rate procedure.

With a dropout rate of approximately 15% and a 10:10:10:10:12 pants in each group (mITT population) achieved an OPA level  L-
randomization ratio, 908 subjects needed to be enrolled. Although LOQ for each serotype except serotype 1 (Table S6).
the dropout rate for Group 5 was the same as for the other groups, Immune responses to DTaP/HBV/IPV/Hib antigens were
to achieve 150 evaluable subjects, additional subjects were assessed 1 month after the infant series and toddler dose. IgG geo-
recruited for Group 5 with the expectation that some subjects metric means for anti-pertussis FHA and anti-tetanus antibodies
would receive antipyretics as per standard recommendation. after the infant series were significantly (P < 0.0125) lower in
Group 4 compared with Group 5 (pertussis FHA ratio, 0.73 [95%
CI, 0.64–0.85], and tetanus, 0.74 [95% CI, 0.63–0.87]), but Groups
3. Results
1, 3, and 2 showed no significant differences for any DTaP/HBV/
IPV/Hib antigens (Table 2). There were no statistically significant
3.1. Subjects and immunogenicity
differences in geometric means between Groups 1–4 and Group
5 for any of these antigens after the toddler dose (Table 2). The
Between August 2011 and January 2013, 908 subjects were
majority of subjects also achieved the prespecified level of anti-
enrolled and randomized into 1 of 5 groups. Groups 1 and 3
body for each antigen after the infant series and toddler dose
received paracetamol (delayed and concomitant, respectively),
(Table S7).
and Groups 2 and 4 received ibuprofen (delayed and concomitant,
respectively). Group 5 received no prophylactic antipyretics (con-
trol) (Fig. 1). Nine hundred (99.1%) subjects completed the infant 3.2. Safety endpoints for the infant series and toddler dose
vaccination series and blood draw, and 892 (98.2%) completed
the toddler vaccination dose and blood draw (Fig. 1). The infant For all groups, fever was generally mild and of short duration
series mITT population included 800 (88.1%) subjects whose mean (mean  1.5 days). In Group 5, approximately 10–20% of subjects
age was 65.7 ± 9.6 days at dose 1, and 47% of whom were female; reported fever on days 1 or 2 after any dose (Fig. 2A), and approx-
all study groups were demographically similar (Table S1). Fewer imately 5–10% received an antipyretic agent to treat fever (Fig. 2B).
than 10% of subjects in any group missed any doses of protocol- At any vaccine dose, Groups 1 and 2 (delayed treatment) had more
specified antipyretics (Table S2). fever on day 1 than Groups 3 and 4, with the percentage of subjects
After the infant series, pneumococcal IgG GMCs among Groups reporting fever increasing on day 2 in Group 2. Subjects in Group 2
1 and 3 were lower than Group 5 for all serotypes, reaching statis- reported more fever on day 2 than Group 1 (Fig. 2A). Relatively few
tical significance (P < 0.0125) in Group 3 for 5 of 13 serotypes (ser- subjects in Groups 3 and 4 experienced fever on day 1. After all
otypes 3, 4, 5, 6B, and 23F) (Table 1). IgG GMCs in Groups 2 and 4 doses, day 2 fever rates were higher among Groups 2 and 4 (range,
were not significantly different from Group 5 (Table 1). There were 17.3–41.0%) compared with Groups 1 and 3 (range, 11.8–26.8%) or
no significant differences in IgG GMCs among groups after the tod- Group 5 (range, 13.2–21.9%) (Fig. 2A).
dler dose (Table 1). Similarly, no significant differences were Adverse events reflected events common among the study pop-
observed in the percentage of subjects in any group who achieved ulation and were numerically similar across groups during the
the prespecified level of serotype-specific pneumococcal IgG infant series (35–40%) and after the toddler dose (15–20%). The
(0.35 mg/mL) for the infant and toddler mITT populations (Tables number of subjects reporting SAEs during the study were similar
S3 and S4). across groups, ranging from 3–11 (1.7–6.4%) during the infant ser-
In the subset of subjects in which functional antibody responses ies, 6–14 (3.5–8.0%) after the infant series, and 1–3 (0.5–1.8%) after
were assessed, pneumococcal OPA GMTs after the infant series the toddler dose. All SAEs resolved, and none were considered by
were not significantly different for any antipyretic group versus the investigator to be related to study vaccine. Only 1 subject with-
controls, although a slight numerical reduction was observed in drew from the study due to an AE. The event (somnolence) was
Group 3 (Table S5). After the infant series, the majority of partici- considered related to ibuprofen and subsequently resolved.
 J. Wysocki et al. / Vaccine 35 (2017) 1926–1935 1931

Table 2
Concomitant vaccine antigen GMs 1 month after the infant series and toddler dose (mITT immunogenicity population).

After infant series After toddler dose

Antigen (Units) nb GMc (95% CI)c Ratioc to Control (95% CI) nb GMc (95% CI)c Ratioc to Control (95% CI)
Groupa
Hib PRP (mg/mL)
Group 1 136 0.54 (0.44–0.66) 0.93 (0.71–1.22) 126 9.65 (7.74–12.03) 1.08 (0.81–1.43)
Group 3 144 0.49 (0.40–0.60) 0.85 (0.65–1.11) 141 8.25 (6.69–10.16) 0.92 (0.70–1.21)
Group 2 146 0.59 (0.49–0.73) 1.03 (0.79–1.34) 135 9.35 (7.55–11.57) 1.04 (0.79–1.37)
Group 4 139 0.51 (0.42–0.63) 0.89 (0.68–1.16) 138 7.84 (6.35–9.68) 0.87 (0.67–1.16)
Group 5 198 0.58 (0.49–0.69) 202 8.96 (7.53–10.67)
Pertussis PT (EU/mL)
Group 1 132 40.86 (36.49–45.76) 0.91 (0.79–1.06) 123 77.43 (68.12–88.02) 1.05 (0.89–1.23)
Group 3 141 40.27 (36.09–44.93) 0.90 (0.78–1.04) 141 73.72 (65.40–83.10) 1.00 (0.85–1.16)
Group 2 143 43.51 (39.02–48.51) 0.97 (0.84–1.12) 137 76.93 (68.13–86.87) 1.04 (0.89–1.22)
Group 4 131 39.26 (35.04–43.98) 0.88 (0.76–1.01) 136 73.38 (64.96–82.90) 0.99 (0.85–1.16)
Group 5 193 44.85 (40.84–49.25) 199 74.01 (66.91–81.86)
Pertussis FHA (EU/mL)
Group 1 132 46.29 (41.49–51.65) 9.6 (0.83–1.10) 123 115.55 (104.32–128.00) 0.99 (0.87–1.12)
Group 3 141 41.32 (37.16–45.94) 0.85 (0.74–0.98) 141 123.56 (112.30–135.95) 1.06 (0.93–1.20)
Group 2 143 40.65 (36.59–45.16) 0.84 (0.73–9.6) 137 117.87 (106.98–129.87) 1.01 (0.89–1.14)
Group 4 131 35.55 (31.85–39.68) 0.73 (0.64–0.85)*** 136 108.11 (98.09–119.16) 0.92 (0.81–1.05)
Group 5 193 48.42 (44.22–53.01) 199 117.01 (107.97–126.81)
Pertussis PRN (EU/mL)
Group 1 132 72.90 (63.26–84.01) 0.86 (0.72–1.04) 123 158.28 (136.30–183.81) 0.92 (0.76–1.11)
Group 3 141 65.82 (57.38–75.50) 0.78 (0.65–0.93) 141 160.96 (139.98–185.08) 0.93 (0.78–1.12)
Group 2 143 71.26 (62.18–81.66) 0.84 (0.70–1.01) 137 156.98 (136.24–180.87) 0.91 (0.76–1.09)
Group 4 131 68.53 (59.44–79.02) 0.81 (0.67–0.97) 136 158.71 (137.67–182.97) 0.92 (0.76–1.10)
Group 5 193 84.57 (75.21–95.09) 199 172.80 (153.64–194.36)
Tetanus (IU/mL)
Group 1 132 0.73 (0.65–0.83) 0.90 (0.77–1.06) 123 2.54 (2.28–2.83) 0.96 (0.83–1.10)
Group 3 141 0.69 (0.61–0.77) 0.84 (0.72–0.98) 141 2.60 (2.35–2.88) 0.98 (0.86–1.12)
Group 2 143 0.70 (0.62–0.79) 0.86 (0.74–1.00) 137 2.50 (2.26–2.77) 0.94 (0.82–1.07)
Group 4 131 0.60 (0.53–0.68) 0.74 (0.63–0.87)** 136 2.29 (2.07–2.54) 0.86 (0.75–0.98)
Group 5 193 0.82 (0.74–0.90) 199 2.66 (2.44–2.89)
Diphtheria (IU/mL)
Group 1 132 0.62 (0.56–0.69) 0.95 (0.82–1.09) 123 1.64 (1.49–1.80) 0.86 (0.76–0.97)
Group 3 141 0.61 (0.55–0.68) 0.93 (0.81–1.07) 141 1.69 (1.54–1.84) 0.89 (0.79–0.99)
Group 2 143 0.68 (0.61–0.75) 1.03 (0.90–1.19) 137 1.94 (1.77–2.12) 1.02 (0.91–1.14)
Group 4 131 0.65 (0.59–0.73) 1.00 (0.87–1.15) 136 1.87 (1.71–2.04) 0.98 (0.87–1.10)
Group 5 193 0.65 (0.60–0.72) 199 1.90 (1.77–2.05)
HBV (mIU/mL)
Group 1 105 756.42 (589.71–970.26) 1.03 (0.75–1.42) 119 4868.61 (3750.57–6319.94) 1.26 (0.90–1.76)
Group 3 120 689.34 (546.12–870.11) 0.94 (0.69–1.28) 133 4250.41 (3320.88–5440.13) 1.10 (0.80–1.52)
Group 2 116 770.93 (608.34–976.98) 1.05 (0.77–1.44) 131 4148.04 (3234.82–5319.08) 1.07 (0.78–1.48)
Group 4 112 599.12 (470.78–762.43) 0.82 (0.60–1.12) 133 4263.28 (3330.93–5456.60) 1.10 (0.80–1.52)
Group 5 156 733.29 (597.81–899.46) 191 3866.37 (3146.78–4750.52)

Poliomyelitis
Type 1 (titer)
Group 1 89 68.11 (53.14–87.30) 0.95 (0.69–1.30) 123 399.56 (332.13–480.68) 0.98 (0.78–1.24)
Group 3 93 67.43 (52.89–85.96) 0.94 (0.68–1.28) 141 443.97 (373.58–527.63) 1.09 (0.87–1.37)
Group 2 105 66.59 (52.98–83.68) 0.92 (0.68–1.25) 133 426.63 (357.15–509.62) 1.05 (0.83–1.32)
Group 4 84 70.66 (54.73–91.23) 0.98 (0.71–1.36) 136 415.45 (348.48–495.29) 1.02 (0.81–1.28)
Group 5 135 72.02 (58.88–88.10) 201 406.37 (351.67–469.59)
Type 2 (titer)
Group 1 89 79.60 (61.54–102.95) 1.18 (0.85–1.65) 123 613.18 (515.30–729.65) 0.99 (0.79–1.23)
Group 3 93 62.12 (48.30–79.90) 0.92 (0.66–1.28) 141 587.56 (499.47–691.18) 0.95 (0.77–1.17)
Group 2 105 73.52 (58.01–93.16) 1.09 (0.80–1.50) 133 586.30 (496.01–693.03) 0.94 (0.76–1.17)
Group 4 84 55.17 (42.33–71.89) 0.82 (0.58–1.15) 136 605.78 (513.44–714.73) 0.98 (0.79–1.21)
Group 5 135 67.37 (54.67–83.02) 201 621.07 (542.07–711.57)
Type 3 (titer)
Group 1 89 246.22 (192.84–314.38) 1.07 (0.78–1.46) 123 1205.80 (1001.18–1452.24) 0.97 (0.77–1.23)
Group 3 93 257.92 (203.08–327.56) 1.12 (0.82–1.52) 141 1210.29 (1017.32–1439.87) 0.98 (0.78–1.23)
Group 2 105 184.03 (146.96–230.46) 0.80 (0.59–1.08) 133 1045.57 (874.35–1250.32) 0.84 (0.67–1.06)
Group 4 84 218.85 (170.18–281.44) 0.95 (0.69–1.31) 136 1187.11 (994.68–1416.76) 0.96 (0.76–1.21)
Group 5 135 231.02 (189.44–281.72) 201 1237.86 (1070.27–1431.70)

Note: P values for comparison of the antipyretic groups with control are adjusted using the false discovery rate procedure.
Abbreviations: GM = geometric mean; LSMean = least squares mean; mITT = modified intent-to-treat.
**
P < 0.0125.
***
P < 0.001
a
Group 1, delayed paracetamol; Group 3, concomitant paracetamol; Group 2, delayed ibuprofen; Group 4, concomitant ibuprofen; Group 5, control.
b
n = number of subjects with a determinate antibody concentration or titer to the given antigen.
c
GMs were calculated using all subjects with available data for the specified blood draw. CIs are back transformations of CIs based on analysis of log-transformed antibody
values using ANOVA with the antipyretic regimen group as a fixed effect. The ratio and related CIs are back transformed from the difference of the LSMean of a specific
antipyretic group minus the LSMean of controls.
1932 J. Wysocki et al. / Vaccine 35 (2017) 1926–1935

Fig. 2. Incidence of Fever (  38 °C) and Non-Protocol-Specified Antipyretic Use in the First 2 Days After Each Vaccine Dose. (A) Percentage of subjects reporting fever 1 or
2 days postvaccination. (B) Percentage of subjects using non-protocol-specified antipyretic medication in the first 2 days postvaccination. Subject numbers reporting from
each group are shown in legends. G1, delayed paracetamol; G3, concomitant paracetamol; G2, delayed ibuprofen; G4, concomitant ibuprofen; G5, control.

4. Discussion reached statistical significance for only some serotypes (serotypes

3, 4, 5, 6B, and 23F). It is not clear whether this response diminu-
This study is the first randomized controlled trial designed to tion is of clinical significance. Although the percentages of subjects
assess effects of multiple dosing regimens of two commonly used with IgG concentrations 0.35 mg/mL, the accepted correlate of
antipyretics on PCV13 and DTaP/HBV/IPV/Hib immunogenicity in protection against IPD on a population basis [18], were not sub-
a large number of infants and toddlers. These results demonstrate stantially different, other benefits of pneumococcal conjugate vac-
that prophylactic administration of antipyretics to prevent cination that may require higher antibody levels, such as
vaccination-associated fever may interfere with immune responses protection against otitis media and reduction of nasopharyngeal
to vaccine antigens. These effects differ by vaccine antigen and colonization leading to indirect effects in the unvaccinated popula-
antipyretic agent, and may have a total dose- and/or time- tion, may not be fully realized [20].
dependent administration component. Ibuprofen had no apparent effect on pneumococcal responses
Changes in pneumococcal immunogenicity were associated but did appear to affect immune responses to pertussis antigens
with coadministration with paracetamol when given during the and tetanus toxoid in DTaP/HBV/IPV/Hib. The role of FHA in the
primary infant series. While interference was most evident when pathogenesis of clinical pertussis disease is unclear. The reduction
paracetamol was administered prophylactically concurrent with in response to pertussis FHA after the infant series is of potential
vaccination, some effects were observed when the first dose was concern, given the relatively lower immunity conferred to young
delayed 6–8 h; however, these effects after delayed administration infants by acellular pertussis vaccines compared with whole-cell
did not achieve statistical significance. In all antipyretic groups, pertussis vaccines [21,22], and the propensity for pertussis FHA
functional antibody levels were not significantly different than in immunity to wane over time [23].
controls, suggesting an acceptable level of protection was elicited This study’s findings are generally consistent with those of Pry-
in Group 3 despite reduced IgG GMCs for certain serotypes. Addi- mula et al., in which immune responses were reduced in subjects
tionally, while IgG GMCs were overall lower among subjects receiving prophylactic paracetamol compared with controls
receiving paracetamol concurrently with vaccination, this finding (though that study evaluated neither ibuprofen nor multiple
 J. Wysocki et al. / Vaccine 35 (2017) 1926–1935 1933

antipyretic dosing regimens) [5]. The same group examined effects those studies did not consistently prevent postvaccination fever
of paracetamol prophylaxis on immune responses to a meningo- [1,2,6,43]. Ibuprofen recipients in the current study in fact experi-
coccal serogroup B vaccine coadministered with DTaP/HBV/IPV/ enced fever more frequently 2 days after the infant series of vacci-
Hib and PCV7, and found only non-significant reductions in nations than those who received no prophylactic antipyretic.
immunogenicity in paracetamol recipients for all 3 vaccines [24].
Those results, however, do not eliminate the possibility of anti-
5. Conclusions
pyretic interference, as trends in pneumococcal GMC ratios sug-
gested an effect of paracetamol despite satisfactory immune
The prophylactic use of antipyretics, especially when adminis-
responses [24].
tered concomitantly with vaccination, may interfere with immune
Consistent with previous experience regarding the coadminis-
responses to routine vaccines in infants. The effects vary by vac-
tration of PCV13 and DTaP/HBV/IPV/Hib vaccines, fever was com-
cine, antipyretic agent, and timing of administration. The clinical
mon, self-limiting, and nearly always mild. Expected fever rates
significance of these findings is unclear, as the immune responses
on the day of vaccination were lowest for groups receiving
elicited are likely to be sufficient to prevent disease in populations
antipyretics at vaccination; in subjects receiving delayed
with high immunization rates. Despite the relative reduction in
antipyretics, fever rates were similar to controls. Paracetamol
immune responses associated with antipyretic use, priming by
recipients reported fever less frequently overall than ibuprofen
the infant series is adequate for a robust response after toddler
recipients. Additionally, subjects receiving ibuprofen on day 1
vaccination. Nonetheless, the data suggest that prophylactic use
experienced more fever on day 2 than other groups, including con-
of over-the-counter antipyretics, especially during the primary
trols, yielding what may be a ‘‘rebound effect” in fever, which to
infant series of vaccinations, should be considered with caution.
our knowledge has not been described previously. Differences in
fever patterns among groups cannot be easily explained, but may
be related to characteristics of each antipyretic agent. Although Author Contribution statements
paracetamol and ibuprofen are generally effective and well-
tolerated, the risk of adverse reactions and accidental overdose All authors approved and agreed to submit the final article for
associated with their use in infants and young children [25–29] publication.
cannot be discounted when considering the value of fever preven- Jacek Wysocki: Dr. Wysocki coordinated clinical recruitment of
tion, especially given that vaccination-associated fever is most subjects, participated in data acquisition, and contributed to
often benign and self-limited [1,5,6]. manuscript development, which included review of drafts and
This study was conducted in Poland due to relatively low per- approval of the final submitted manuscript.
missive use of antipyretics [30]. A possible study limitation, how- Kimberly J. Center: Dr. Center participated in the conceptual-
ever, is the ethnic homogeneity across the subject population. ization and design of the study, monitored the safety of participat-
Paracetamol and ibuprofen have variable metabolic properties in ing subjects during the study, participated in analysis and
different ethnic groups [31–33], suggesting that immune responses interpretation of the data, and contributed to manuscript develop-
in more diverse populations may not follow the trends reported ment, which included review of drafts and approval of the final
here. Furthermore, larger sample numbers may be required to con- submitted manuscript.
firm the emerging trend of lower OPA responses in paracetamol Jerzy Brzostek: Dr. Brzostek participated in the acquisition of
recipients versus controls. Despite a smaller data set, per-protocol data and contributed to manuscript development, which included
infant immunogenicity results were, overall, consistent with those review of drafts and approval of the final submitted manuscript.
of the mITT and all-available populations, demonstrating that ade- Ewa Majda-Stanislawska: Dr. Majda-Stanislawska participated
quate subject numbers were achieved to reach robust conclusions. in the acquisition of data and contributed to manuscript develop-
The clinical significance of these findings is not known, but sug- ment, which included review of drafts and approval of the final
gests that optimal immune response is obtained without prophy- submitted manuscript.
lactic antipyretics. In animals, ibuprofen has been shown to Henryk Szymanski: Dr. Szymanski participated in the acquisi-
interfere with the antigen-presenting capability of dendritic cells tion of data and contributed to manuscript development, which
[34], which play a key role in the development of primary immune included review of drafts and approval of the final submitted
responses. Other in vitro and in vivo studies in human cells and manuscript.
knock-out mice demonstrated that commonly used antipyretic Leszek Szenborn: Dr. Szenborn was involved in recruiting sub-
agents may have negative effects on intracellular signaling path- jects, collecting data, and contributed to manuscript development,
ways, cyclooxygenase activity that stimulates prostaglandin which included review of drafts and approval of the final submit-
release, and on B lymphocytes and antibody production [35–37]. ted manuscript.
Paracetamol may interfere with leukocyte migration toward the Hanna Czajka: Dr. Czajka participated in the acquisition of data
injection site or downstream events such as antigen presentation and contributed to manuscript development, which included
by dendritic cells. However, the exact mechanism of these effects review of drafts and approval of the final submitted manuscript.
remains unclear [38]. Such observations have led to concern about Barbara Hasiec: Dr. Hasiec participated in the acquisition of
antipyretic effects on immune responses to vaccines. Despite our data and contributed to manuscript development, which included
findings, the vaccines studied here continue to be highly effective review of drafts and approval of the final submitted manuscript.
in populations with high immunization rates, such as those in Jerzy Dziduch: Dr. Dziduch participated in the acquisition of
countries with robust national immunization programs [39–42]. data and contributed to manuscript development, which included
The remarkable effectiveness of pediatric vaccines in such settings review of drafts and approval of the final submitted manuscript.
suggests that the observable response diminution may have lim- Teresa Jackowska: Dr. Jackowska participated in the acquisi-
ited clinical relevance on a population basis. However, the poten- tion of data and contributed to manuscript development, which
tial for reduced immune responses to vaccine antigens should be included review of drafts and approval of the final submitted
considered when contemplating the use of prophylactic antipyret- manuscript.
ics around the time of vaccination. This conclusion is bolstered by Anita Witor: Dr. Witor participated in the acquisition of data
other studies that do not support routine prophylactic use of and contributed to manuscript development, which included
antipyretics in the setting of vaccination, because antipyretics in review of drafts and approval of the final submitted manuscript.
1934 J. Wysocki et al. / Vaccine 35 (2017) 1926–1935

_
Elzbieta Kopińska: Dr. Kopińska participated in the acquisition to Pfizer, for their contributions for the statistical analyses. The
of data and contributed to manuscript development, which authors also thank Margaret Fisher, MD, of Monmouth Medical
included review of drafts and approval of the final submitted Center, Drexel University College of Medicine, for her critical
manuscript. review of the manuscript. Dr. Fisher has no conflicts of interest
Ryszard Konior: Dr. Konior participated in the acquisition of to declare. Medical writing support for all drafts was provided by
data and contributed to manuscript development, which included Jill E. Kolesar, PhD, at Complete Healthcare Communications, LLC,
review of drafts and approval of the final submitted manuscript. and was funded by Pfizer Inc.
Peter C. Giardina: Dr. Giardina supported the acquisition of
data and contributed to manuscript development, which included
review of drafts and approval of the final submitted manuscript. Appendix A. Supplementary material
Vani Sundaraiyer: Dr. Sundaraiyer participated in the statisti-
cal analysis, analysis and interpretation of the data, and con- Supplementary data associated with this article can be found, in
tributed to manuscript development, which included review of the online version, at http://dx.doi.org/10.1016/j.vaccine.2017.02.
drafts and approval of the final submitted manuscript. 035.
Scott Patterson: Dr. Patterson participated in the conceptual-
ization and design of the study, the statistical analysis, analysis References
and interpretation of the data, and contributed to manuscript
development, which included review of drafts and approval of [1] Rose MA, Juergens C, Schmoele-Thoma B, Gruber WC, Baker S, Zielen S. An
the final submitted manuscript. open-label randomized clinical trial of prophylactic paracetamol
coadministered with 7-valent pneumococcal conjugate vaccine and
William C. Gruber: Dr. Gruber supported the conceptualization hexavalent diphtheria toxoid, tetanus toxoid, 3-component acellular
and design of the study, participated in data analysis, and con- pertussis, hepatitis B, inactivated polio virus, and Haemophilus influenzae
tributed to manuscript development, which included review of type b vaccine. BMC Pediatr 2013;13:98. http://dx.doi.org/10.1186/1471-
2431-13-98. pii 10.1186.
drafts and approval of the final submitted manuscript. [2] Dhingra B, Mishra D. Immediate versus as-needed acetaminophen for post-
Daniel A. Scott: Dr. Scott participated in the conceptualization immunisation pyrexia. Ann Trop Paediatr 2011;31:339–44. http://dx.doi.org/
and design of the study, monitored the safety of participating sub- 10.1179/1465328111Y.0000000039.
[3] Franck L, Gay CL, Lynch M, Lee KA. Infant sleep after immunization:
jects during the study, participated in analysis and interpretation randomized controlled trial of prophylactic acetaminophen. Pediatrics
of the data, and contributed to manuscript development, which 2011;128:1100–8. http://dx.doi.org/10.1542/peds.2011-1712. pii 10.1542.
included review of drafts and approval of the final submitted [4] Jackson LA, Peterson D, Dunn J, Hambidge SJ, Dunstan M, Starkovich P, et al. A
randomized placebo-controlled trial of acetaminophen for prevention of post-
manuscript.
vaccination fever in infants. PLoS ONE 2011;6:e20102. http://dx.doi.org/
Alejandra Gurtman: Dr. Gurtman participated in the conceptu- 10.1371/journal.pone.0020102. doi PONE-D-11-00903 pii.
alization and design of the study, monitored the safety of partici- [5] Prymula R, Siegrist CA, Chlibek R, Zemlickova H, Vackova M, Smetana J, et al.
Effect of prophylactic paracetamol administration at time of vaccination on
pating subjects during the study, participated in analysis and
febrile reactions and antibody responses in children: two open-label,
interpretation of the data, and contributed to manuscript develop- randomised controlled trials. Lancet 2009;374:1339–50.
ment, which included review of drafts and approval of the final [6] Manley J, Taddio A. Acetaminophen and ibuprofen for prevention of adverse
submitted manuscript. reactions associated with childhood immunization. Ann Pharmacother
2007;41:1227–32. http://dx.doi.org/10.1345/aph.1H647. pii 10.1345.
[7] Das RR, Panigrahi I, Naik SS. The effect of prophylactic antipyretic
administration on post-vaccination adverse reactions and antibody response
Funding Statement and role of the sponsor
in children: a systematic review. PLoS ONE 2014;9:e106629.
[8] Taddio A, Manley J, Potash L, Ipp M, Sgro M, Shah V. Routine immunization
This study was sponsored by Pfizer Inc. Authors employed by practices: use of topical anesthetics and oral analgesics. Pediatrics 2007;120:
e637–43.
Pfizer were involved in the study design, collection, interpretation,
[9] Thompson A, Gurtman A, Patterson S, Juergens C, Laudat F, Emini EA, et al.
and analysis of data, and in the preparation of the manuscript. Safety of 13-valent pneumococcal conjugate vaccine in infants and children:
meta-analysis of 13 clinical trials in 9 countries. Vaccine 2013;31:5289–95.
[10] Quataert SA, Rittenhouse-Olson K, Kirch CS, Hu B, Secor S, Strong N, et al.
Conflict of interest statement Assignment of weight-based antibody units for 13 serotypes to a human
antipneumococcal standard reference serum, lot 89-S(f). Clin Diagn Lab
Immunol 2004;11:1064–9. http://dx.doi.org/10.1128/CDLI.11.6.1064-
JW has served as principal investigator in clinical trials spon-
1069.2004 [pii] 10.1128/CDLI.11.6.1064-1069.2004 [doi].
sored by GlaxoSmithKline, Pfizer, and Novartis and has received [11] Wernette CM, Frasch CE, Madore D, Carlone G, Goldblatt D, Plikaytis B, et al.
grants from the same for participation in conferences. HC has Enzyme-linked immunosorbent assay for quantitation of human antibodies to
pneumococcal polysaccharides. Clin Diagn Lab Immunol 2003;10:514–9.
served as a principal investigator in clinical studies sponsored by
[12] World Health Organization. Recommendations to assure the quality, safety
Pfizer, Novartis, and GlaxoSmithKline. EMS has served as principal and efficacy of pneumococcal conjugate vaccines. WHO Technical Report
investigator in clinical trials sponsored by Pfizer. LS has served as Series 2009; Annex 2: No. 927. Available at: <http://www.who.int/biologicals/
principal investigator in clinical trials sponsored by GlaxoSmithK- areas/vaccines/pneumo/Pneumo_final_23APRIL_2010.pdf>. [accessed
September 1, 2015].
line, Pfizer, Baxter, and Novartis and has received grants from these [13] Cooper D, Yu X, Sidhu M, Nahm MH, Fernsten P, Jansen KU. The 13-valent
vaccine producers and from Sanofi Pasteur for participation in con- pneumococcal conjugate vaccine (PCV13) elicits cross-functional
ferences. JB, HS, BH, JD, TJ, AW, EK, and RK have no conflicts of opsonophagocytic killing responses in humans to Streptococcus pneumoniae
serotypes 6C and 7A. Vaccine 2011;29:7207–11. http://dx.doi.org/10.1016/
interest to declare. VS is employed by inVentiv Health Clinical, j.vaccine.2011.06.056.
LLC, a company contracted by Pfizer Inc. KJC, PCG, SP, WCG, DAS, [14] Farr RS. A quantitative immunochemical measure of the primary interaction
and AG are employees of Pfizer Inc. between I BSA and antibody. J Infect Dis 1958;103:239–62.
[15] Wood DJ, Heath AB. The second international standard for anti-poliovirus sera
types 1, 2 and 3. Biologicals 1992;20:203–11.
Acknowledgments [16] van Gageldonk PG, van Schaijk FG, van der Klis FR, Berbers GA. Development
and validation of a multiplex immunoassay for the simultaneous
determination of serum antibodies to Bordetella pertussis, diphtheria and
We thank the families who participated in this study, the study tetanus. J Immunol Methods 2008;335:79–89.
Ò
investigators, nurses, and coordinators, the clinical testing labora- [17] INFANRIX hexa (DTaP/HBV/IPV/Hib). Full Prescribing Information,
tory staff, and the clinical research associates and scientists at Pfi- GlaxoSmithKline Inc., Rixensart, Belgium, 2010.
[18] World Health Organization. Annex 3: recommendations to assure the quality,
zer Inc. We thank James Trammel, MS, and Gang Sun, MS, MBA, safety and efficacy of pneumococcal conjugate vaccines. Replacement of WHO
employees of inVentiv Health Clinical, LLC, and paid consultants technical report series, no. 927, annex 2. World Health Organization, Geneva,
 J. Wysocki et al. / Vaccine 35 (2017) 1926–1935 1935

Switzerland. Available at: <http://www.who.int/biologicals/vaccines/TRS_ [32] Critchley JA, Critchley LA, Anderson PJ, Tomlinson B. Differences in the single-
977_Annex_3.pdf>. [accessed September 1, 2015]. oral-dose pharmacokinetics and urinary excretion of paracetamol and its
[19] Benjamini Y, Hochberg Y. Controlling the false discovery rate: a practical and conjugates between Hong Kong Chinese and Caucasian subjects. J Clin Pharm
powerful approach to multiple testing. J Roy Statist Soc Ser B 1995;57 Ther 2005;30:179–84.
(1):289–300. [33] Garcia-Martin E, Martinez C, Ladero JM, Agundez JA. Interethnic and
[20] Dagan R, Juergens C, Trammel J, Patterson S, Greenberg D, Givon-Lavi N, et al. intraethnic variability of CYP2C8 and CYP2C9 polymorphisms in healthy
Modeling pneumococcal nasopharyngeal acquisition as a function of individuals. Mol Diagn Ther 2006;10:29–40.
anticapsular serum antibody concentrations after pneumococcal conjugate [34] Kim HJ, Lee YH, Im SA, Kim K, Lee CK. Cyclooxygenase inhibitors, aspirin and
vaccine administration. Vaccine 2016;34:4313–20. ibuprofen, inhibit MHC-restricted antigen presentation in dendritic cells.
[21] Stehr K, Cherry JD, Heininger U, Schmitt-Grohe S, uberall M, Laussucq S, et al. A Immune Netw 2010;10:92–8.
comparative efficacy trial in Germany in infants who received either the [35] Bancos S, Bernard MP, Topham DJ, Phipps RP. Ibuprofen and other widely used
Lederle/Takeda acellular pertussis component DTP (DTaP) vaccine, the Lederle non-steroidal anti-inflammatory drugs inhibit antibody production in human
whole-cell component DTP vaccine, or DT vaccine. Pediatrics 1998;101:1–11. cells. Cell Immunol 2009;258:18–28.
[22] Simondon F, Preziosi MP, Yam A, Kane CT, Chabirand L, Iteman I, et al. A [36] Ryan EP, Pollock SJ, Murant TI, Bernstein SH, Felgar RE, Phipps RP. Activated
randomized double-blind trial comparing a two-component acellular to a human B lymphocytes express cyclooxygenase-2 and cyclooxygenase
whole-cell pertussis vaccine in Senegal. Vaccine 1997;15:1606–12. inhibitors attenuate antibody production. J Immunol 2005;174:2619–26.
[23] Klein NP, Bartlett J, Rowhani-Rahbar A, Fireman B, Baxter R. Waning protection [37] Bernard MP, Bancos S, Chapman TJ, Ryan EP, Treanor JJ, Rose RC, et al. Chronic
after fifth dose of acellular pertussis vaccine in children. N Engl J Med inhibition of cyclooxygenase-2 attenuates antibody responses against vaccinia
2012;367:1012–9. infection. Vaccine 2010;28:1363–72.
[24] Prymula R, Esposito S, Vincenzo Zuccotti G, Xie F, Toneatto D, Kohl I, et al. A [38] Saleh E, Moody MA, Walter EB. Effect of antipyretic analgesics on immune
phase 2 randomized controlled trial of a multicomponent meningococcal responses to vaccination. Hum Vaccin Immunother 2016;12:2391–402.
serogroup B vaccine (I): efects of prophylactic paracetamol on [39] Vestrheim DF, Lovoll O, Aaberge IS, Caugant DA, Hoiby EA, Bakke H, et al.
immunogenicity and reactogenicity of routine infant vaccines and 4CMenB. Effectiveness of a 2+1 dose schedule pneumococcal conjugate vaccination
Hum Vaccin Immunother 2014;10:1993–2004. programme on invasive pneumococcal disease among children in Norway.
[25] Crook J. Fever management: evaluating the use of ibuprofen and paracetamol. Vaccine 2008;26:3277–81. http://dx.doi.org/10.1016/j.vaccine.2008.03.087.
Paediatr Nurs 2010;22:22–6. [40] Isaacman DJ, McIntosh ED, Reinert RR. Burden of invasive pneumococcal
[26] Yoon JS, Jeong DC, Oh JW, Lee KY, Lee HS, Koh YY, et al. The effects and safety of disease and serotype distribution among Streptococcus pneumoniae isolates in
dexibuprofen compared with ibuprofen in febrile children caused by upper young children in Europe: impact of the 7-valent pneumococcal conjugate
respiratory tract infection. Br J Clin Pharmacol 2008;66:854–60. vaccine and considerations for future conjugate vaccines. Int J Infect Dis
[27] Sherman JM, Sood SK. Current challenges in the diagnosis and management of 2010;14:e197–209. http://dx.doi.org/10.1016/j.ijid.2009.05.010.
fever. Curr Opin Pediatr 2012;24:400–6. [41] Miller E, Andrews NJ, Waight PA, Slack MP, George RC. Effectiveness of the new
[28] Temple AR, Temple BR, Kuffner EK. Dosing and antipyretic efficacy of oral serotypes in the 13-valent pneumococcal conjugate vaccine. Vaccine
acetaminophen in children. Clin Ther 2013;35(1361–1375):e1–e45. 2011;29:9127–31. http://dx.doi.org/10.1016/j.vaccine.2011.09.112.
[29] van den Anker JN. Optimising the management of fever and pain in children. [42] Picazo J, Ruiz-Contreras J, Casado-Flores J, Giangaspro E, Garcia-de-Miguel MJ,
Int J Clin Pract 2013;67:26–32. http://dx.doi.org/10.1111/ijcp12056. Hernandez-Sampelayo T, et al. Impact of introduction of conjugate vaccines in
[30] Gadzinowski J, Albrecht P, Hasiec B, Konior R, Dziduch J, Witor A, et al. Phase 3 the vaccination schedule on the incidence of pediatric invasive pneumococcal
trial evaluating the immunogenicity, safety, and tolerability of manufacturing disease requiring hospitalization in Madrid 2007 to 2011. Pediatr Infect Dis J
scale 13-valent pneumococcal conjugate vaccine. Vaccine 2011;29:2947–55. 2007;32(2013):656–61. http://dx.doi.org/10.1097/INF.0b013e31827e8594.
[31] Critchley JA, Nimmo GR, Gregson CA, Woolhouse NM, Prescott LF. Inter-subject [43] Yalçin SS, Gumus A, Yurdakok K. Prophylactic use of acetaminophen in
and ethnic differences in paracetamol metabolism. Br J Clin Pharmacol children vaccinated with diphtheria-tetanus-pertussis. World J Pediatr
1986;22:649–57. 2008;4:127–9. http://dx.doi.org/10.1007/s12519-008-0025-7.