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Meta-Analysis
. 2013 Jul 5;2013(7):CD009029.
doi: 10.1002/14651858.CD009029.pub2.

Vaccines for preventing enterotoxigenic Escherichia coli (ETEC) diarrhoea

Tanvir Ahmed  1 , Taufiqur R Bhuiyan, K Zaman, David Sinclair, Firdausi Qadri
Affiliations
Meta-Analysis

Vaccines for preventing enterotoxigenic Escherichia coli (ETEC) diarrhoea

Tanvir Ahmed et al. Cochrane Database Syst Rev. .

Abstract

Background: Infection with enterotoxigenic Escherichia coli (ETEC) bacteria is a common cause of diarrhoea in adults and children in developing countries and is a major cause of 'travellers' diarrhoea' in people visiting or returning from endemic regions. A killed whole cell vaccine (Dukoral®), primarily designed and licensed to prevent cholera, has been recommended by some groups to prevent travellers' diarrhoea in people visiting endemic regions. This vaccine contains a recombinant B subunit of the cholera toxin that is antigenically similar to the heat labile toxin of ETEC. This review aims to evaluate the clinical efficacy of this vaccine and other vaccines designed specifically to protect people against diarrhoea caused by ETEC infection.

Objectives: To evaluate the efficacy, safety, and immunogenicity of vaccines for preventing ETEC diarrhoea.

Search methods: We searched the Cochrane Infectious Disease Group Specialized Register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, LILACS, and http://clinicaltrials.gov up to December 2012.

Selection criteria: Randomized controlled trials (RCTs) and quasi-RCTs comparing use of vaccines to prevent ETEC with use of no intervention, a control vaccine (either an inert vaccine or a vaccine normally given to prevent an unrelated infection), an alternative ETEC vaccine, or a different dose or schedule of the same ETEC vaccine in healthy adults and children living in endemic regions, intending to travel to endemic regions, or volunteering to receive an artificial challenge of ETEC bacteria.

Data collection and analysis: Two authors independently assessed each trial for eligibility and risk of bias. Two independent reviewers extracted data from the included studies and analyzed the data using Review Manager (RevMan) software. We reported outcomes as risk ratios (RR) with 95% confidence intervals (CI). We assessed the quality of the evidence using the GRADE approach.

Main results: Twenty-four RCTs, including 53,247 participants, met the inclusion criteria. Four studies assessed the protective efficacy of oral cholera vaccines when used to prevent diarrhoea due to ETEC and seven studies assessed the protective efficacy of ETEC-specific vaccines. Of these 11 studies, seven studies presented efficacy data from field trials and four studies presented efficacy data from artificial challenge studies. An additional 13 trials contributed safety and immunological data only. Cholera vaccinesThe currently available, oral cholera killed whole cell vaccine (Dukoral®) was evaluated for protection of people against 'travellers' diarrhoea' in a single RCT in people arriving in Mexico from the USA. We did not identify any statistically significant effects on ETEC diarrhoea or all-cause diarrhoea (one trial, 502 participants, low quality evidence).Two earlier trials, one undertaken in an endemic population in Bangladesh and one undertaken in people travelling from Finland to Morocco, evaluated a precursor of this vaccine containing purified cholera toxin B subunit rather than the recombinant subunit in Dukoral®. Short term protective efficacy against ETEC diarrhoea was demonstrated, lasting for around three months (RR 0.43, 95% CI 0.26 to 0.71; two trials, 50,227 participants). This vaccine is no longer available. ETEC vaccinesAn ETEC-specific, killed whole cell vaccine, which also contains the recombinant cholera toxin B-subunit, was evaluated in people travelling from the USA to Mexico or Guatemala, and from Austria to Latin America, Africa, or Asia. We did not identify any statistically significant differences in ETEC-specific diarrhoea or all-cause diarrhoea (two trials, 799 participants), and the vaccine was associated with increased vomiting (RR 2.0, 95% CI 1.16 to 3.45; nine trials, 1528 participants). The other ETEC-specific vaccines in development have not yet demonstrated clinically important benefits.

Authors' conclusions: There is currently insufficient evidence from RCTs to support the use of the oral cholera vaccine Dukoral® for protecting travellers against ETEC diarrhoea. Further research is needed to develop safe and effective vaccines to provide both short and long-term protection against ETEC diarrhoea.

PubMed Disclaimer

Conflict of interest statement

We certify that we have no affiliations with or involvement in any organization or entity with a direct financial interest in the subject matter of the review (eg employment, consultancy, stock ownership, honoraria, and expert testimony).

Figures

1
1
Study flow diagram.
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1 Cholera killed whole cell vaccine (Cholera WC‐BS) versus placebo, Outcome 1 ETEC diarrhoea.
1.2
1.2. Analysis
Comparison 1 Cholera killed whole cell vaccine (Cholera WC‐BS) versus placebo, Outcome 2 Severe ETEC diarrhoea.
1.3
1.3. Analysis
Comparison 1 Cholera killed whole cell vaccine (Cholera WC‐BS) versus placebo, Outcome 3 All‐cause diarrhoea.
1.4
1.4. Analysis
Comparison 1 Cholera killed whole cell vaccine (Cholera WC‐BS) versus placebo, Outcome 4 Adverse events.
2.1
2.1. Analysis
Comparison 2 Cholera killed whole cell vaccine with recombinant B‐subunit (Cholera WC‐rCTB) versus placebo, Outcome 1 ETEC diarrhoea.
2.2
2.2. Analysis
Comparison 2 Cholera killed whole cell vaccine with recombinant B‐subunit (Cholera WC‐rCTB) versus placebo, Outcome 2 All‐cause diarrhoea.
2.3
2.3. Analysis
Comparison 2 Cholera killed whole cell vaccine with recombinant B‐subunit (Cholera WC‐rCTB) versus placebo, Outcome 3 ETEC diarrhoea (Scerpella 1995a subgroup analysis excluding cases of ETEC occurring < 7 days after vaccination).
2.4
2.4. Analysis
Comparison 2 Cholera killed whole cell vaccine with recombinant B‐subunit (Cholera WC‐rCTB) versus placebo, Outcome 4 Immunological response: > 4‐fold increase in toxin‐specific IgG antibody responses in serum/plasma.
3.1
3.1. Analysis
Comparison 3 ETEC killed whole cell vaccine with recombinant cholera B‐subunit (ETEC WC‐rCTB) versus placebo, Outcome 1 ETEC diarrhoea.
3.2
3.2. Analysis
Comparison 3 ETEC killed whole cell vaccine with recombinant cholera B‐subunit (ETEC WC‐rCTB) versus placebo, Outcome 2 Severe ETEC diarrhoea.
3.3
3.3. Analysis
Comparison 3 ETEC killed whole cell vaccine with recombinant cholera B‐subunit (ETEC WC‐rCTB) versus placebo, Outcome 3 All‐cause diarrhoea.
3.4
3.4. Analysis
Comparison 3 ETEC killed whole cell vaccine with recombinant cholera B‐subunit (ETEC WC‐rCTB) versus placebo, Outcome 4 Adverse events: ETEC WC‐rCTB versus placebo (after first dose).
3.5
3.5. Analysis
Comparison 3 ETEC killed whole cell vaccine with recombinant cholera B‐subunit (ETEC WC‐rCTB) versus placebo, Outcome 5 Immunological response: > 2‐fold increase in CFA/I‐specific IgA antibody response in serum/plasma.
3.6
3.6. Analysis
Comparison 3 ETEC killed whole cell vaccine with recombinant cholera B‐subunit (ETEC WC‐rCTB) versus placebo, Outcome 6 Immunological response: > 2‐fold increase in toxin‐specific IgA antibody responses in serum/plasma.
4.1
4.1. Analysis
Comparison 4 Live attenuated cholera vaccine (CVD 103‐HgR) versus placebo, Outcome 1 ETEC diarrhoea.
4.2
4.2. Analysis
Comparison 4 Live attenuated cholera vaccine (CVD 103‐HgR) versus placebo, Outcome 2 Moderate to severe ETEC diarrhoea.
4.3
4.3. Analysis
Comparison 4 Live attenuated cholera vaccine (CVD 103‐HgR) versus placebo, Outcome 3 All‐cause diarrhoea.
5.1
5.1. Analysis
Comparison 5 Live attenuated ETEC vaccine (PTL‐003) versus placebo, Outcome 1 ETEC diarrhoea.
5.2
5.2. Analysis
Comparison 5 Live attenuated ETEC vaccine (PTL‐003) versus placebo, Outcome 2 Moderate to severe ETEC diarrhoea.
5.3
5.3. Analysis
Comparison 5 Live attenuated ETEC vaccine (PTL‐003) versus placebo, Outcome 3 Adverse events (after first dose).
5.4
5.4. Analysis
Comparison 5 Live attenuated ETEC vaccine (PTL‐003) versus placebo, Outcome 4 Immunological response: > 2‐fold increase in TSA.
6.1
6.1. Analysis
Comparison 6 Transcutaneous LT patch versus placebo, Outcome 1 ETEC diarrhoea.
6.2
6.2. Analysis
Comparison 6 Transcutaneous LT patch versus placebo, Outcome 2 Moderate to severe ETEC diarrhoea.
6.3
6.3. Analysis
Comparison 6 Transcutaneous LT patch versus placebo, Outcome 3 All‐cause diarrhoea.
6.4
6.4. Analysis
Comparison 6 Transcutaneous LT patch versus placebo, Outcome 4 Adverse events.
6.5
6.5. Analysis
Comparison 6 Transcutaneous LT patch versus placebo, Outcome 5 Immunological response.
7.1
7.1. Analysis
Comparison 7 Hyperimmune anti‐E. coli CFA versus placebo, Outcome 1 All‐cause diarrhoea.
7.2
7.2. Analysis
Comparison 7 Hyperimmune anti‐E. coli CFA versus placebo, Outcome 2 Adverse events.
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