The Lancet  
Nov 03, 2012  Volume 380  Number 9853  p1531 – 1620  e8 – 9
http://www.thelancet.com/journals/lancet/issue/current

Comment
Dengue vaccine development: a 75% solution?
Scott B Halstead

Preview
A completed clinical trial of vaccine efficacy should be cause for celebration for the billions of people who live in the 128 countries where dengue viruses (DENV) are transmitted.1,2 However, the celebration will be muted this time, as was the case after announcement of results of early clinical trials of vaccines for malaria and HIV.3,4 The low efficacies reported from trials of malaria and HIV vaccines were not entirely unexpected, since these pathogens are known for antigenic complexity and for their ability to successfully evade immune elimination.

Articles
Protective efficacy of the recombinant, live-attenuated, CYD tetravalent dengue vaccine in Thai schoolchildren: a randomised, controlled phase 2b trial
Arunee Sabchareon, Derek Wallace, Chukiat Sirivichayakul, Kriengsak Limkittikul, Pornthep Chanthavanich, Saravudh Suvannadabba, Vithaya Jiwariyavej, Wut Dulyachai, Krisana Pengsaa, T Anh Wartel, Annick Moureau, Melanie Saville, Alain Bouckenooghe, Simonetta Viviani, Nadia G Tornieporth, Jean Lang

Summary
Background
Roughly half the world’s population live in dengue-endemic countries, but no vaccine is licensed. We investigated the efficacy of a recombinant, live, attenuated tetravalent dengue vaccine.

Methods
In this observer-masked, randomised, controlled, monocentre, phase 2b, proof-of-concept trial, healthy Thai schoolchildren aged 4—11 years were randomly assigned (2:1) to receive three injections of dengue vaccine or control (rabies vaccine or placebo) at months 0, 6, and 12. Randomisation was by computer-generated permuted blocks of six and participants were assigned with an interactive response system. Participants were actively followed up until month 25. All acute febrile illnesses were investigated. Dengue viraemia was confirmed by serotype-specific RT-PCR and non-structural protein 1 ELISA. The primary objective was to assess protective efficacy against virologically confirmed, symptomatic dengue, irrespective of severity or serotype, occurring 1 month or longer after the third injection (per-protocol analysis). This trial is registered at ClinicalTrials.gov, NCT00842530.

Findings
4002 participants were assigned to vaccine (n=2669) or control (n=1333). 3673 were included in the primary analysis (2452 vaccine, 1221 control). 134 cases of virologically confirmed dengue occurred during the study. Efficacy was 30·2% (95% CI −13·4 to 56·6), and differed by serotype. Dengue vaccine was well tolerated, with no safety signals after 2 years of follow-up after the first dose.

Interpretation
These data show for the first time that a safe vaccine against dengue is possible. Ongoing large-scale phase 3 studies in various epidemiological settings will provide pivotal data for the CYD dengue vaccine candidate.

Funding
Sanofi Pasteur.