Table 4.

Human studies with intramuscular aluminum-adjuvant vaccines.

Study design	Population/Sample	Substances	Outcomes studied	Results	References
DBPC*	Healthy adults, 18–40 years stratified by age (n = 48–50/group)	Al (OH)3 in influenza inactivated whole virus A/H1N1 vaccine; 2 doses (0.5 ml per dose with 0.35 mg Al), 28 days apart 7.5 and 15 μg of hemagglutinin antigen (HA) with and without Al (OH)3 and 45 μg of HA without Al (OH)3 Control group received saline	Immunogenicity endpoints (IEs): hemagglutinin inhibition (HI) and neutralization assays were performed1 Adverse events (AEs): Subjects self-recorded their oral temperature and the presence and severity of injection site reactions (pain, tenderness, redness and swelling) and systemic symptoms (fever, malaise, myalgia, headache, and nausea) on a memory aid during the first 2 months after enrollment. SAEs were defined as life-threatening AEs, or AEs that resulted in significant or persistent disability, congenital anomalies, hospitalizations, or death and were reported during the 7-month study period	308 subjects were enrolled in the study, with 299 receiving both doses of vaccine. Baseline demographic characteristics and pre-immunization status did not differ among groups IEs: Increase in serum hemagglutination-inhibition (HAI) and/or neutralizing antibody after two doses was higher in participants received vaccine formulations without Al adjuvant (7.5 μg − Al and 15 μg − Al groups) compared to 7.5 μg + Al and 15 μg + Al groups (38 and 53% versus 16 and 38%, respectively) AEs: Al adjuvant- containing vaccine increased frequency of local reactions without increased systemic reactogenicity. Inclusion of Al adjuvant reduced immune responses and increased local reactions Al (OH)3 did not enhance HAI or neutralizing antibody responses, and contributed to increased injection site pain	Keitel et al. (2009)
DBPC*	Healthy participants (n = 12,691), stratified by age: (3 to < 12 years (n = 2,828); 12 to < 18 years (n = 2,887); 18–60 years (n = 4710); > 60 years (n = 2,266))	Al (OH)3 in influenza A (H1N1) split-virion (SV) and whole virion (WV) vaccines; 2 doses (0.5 mg Al/ml of SV vaccine and 1.2 mg Al/ml of WV vaccine), 21 days apart SV: 30, 15 or 7.5 μg HA per dose with and without Al (OH)3; WV: 10 or 5 μg HA per dose with Al (OH)3 Control group received sterile water or phosphate buffered saline injection	IEs: Geometric Mean Titre (GMT) of hemagglutination inhibition (HI) antibody and proportion of seroprotected AEs: Participants recorded any adverse events for 30 min after receipt of vaccine or control treatment and solicited adverse or any unsolicited events throughout the study Symptoms of Guillain-Barré syndrome were recorded. Information about serious adverse events (SAEs)2 and adverse events of special interest was obtained by diary cards, spontaneous reports, and hospital admission records throughout the study	All participants received the first dose on day 0, and 12,348 participants received the second dose on day 21 IEs: In groups that received SV formulations with similar antigen content (15 μg) with or without Al adjuvant, GMTs for non-adjuvant formulations (167.8 and 225.0, respectively) were significantly higher than were those for adjuvant formulations AEs: No immediate systemic allergic reactions, serious adverse events, or events suggestive of Guillain-Barré syndrome were reported in any group. The adjuvant formulations had a higher rate of adverse events than non-adjuvant formulations. Increased antigen dose and young age were associated with a higher frequency and severity of adverse effects. The authors mentioned that WV formulation was not given to children or adolescents because of concerns about adverse reactions	Liang et al. (2010)
Analysis of data from Liang et al. (2010) study	Healthy volunteers (n =3,520), stratified by age (3–7, 8–12, 13–18, 19–40, 41–60 and ≥ 61 years)	Al (OH)3 in influenza A (H1N1) split-virion (SV) vaccine formulations; 2 doses (0.5 mg Al/ml per dose), 21 days apart Control group received sterile water or phosphate buffered saline injection	IEs: Increase in GMT from day 0 (vaccination) to day 21, 35 and 42 compared to non-adjuvant vaccine	IEs: Reduced immune response after considering time post-vaccination, age and gender was reported in Al-adjuvant-contained vaccine group. Peak immune response (GMT) was observed on day 35 in non-adjuvant group. Highest GMTs for adjuvant group were observed on day 41	Yin et al. (2011)
DBPC*	Healthy adults (males and females), 23–42 years (n = 5–30/randomly assigned for each group, stratified by gender with a 1: 1 allocation ratio)	Al (OH)3 in influenza A/H1N1 monovalent vaccine; 2 doses (0.25 mg per dose), 21 days apart 7.5 and 3.5 μg (HA) with Al (OH)3 (Group I and Group II, respectively Control group received phosphate buffered saline	IEs3: Percentage seroconversion4 at day 21 (%) after first and second vaccination, the proportion of seroprotected participants (with post-vaccination HI antibody titer ≥ 1: 40) (%), increase in GMT measured before and 21 days after each vaccination AEs: Participants recorded the occurrence of unsolicited and solicited local (pain, bruising, redness, and swelling), and systemic (fever, chills, malaise, muscle aches, arthralgia, nausea, and headache) symptoms during three days after each vaccination	Of 357 subjects assessed, 266 underwent randomization. The age and gender distributions were similar among the groups. 100% (n = 266) received the first vaccination and 94.4% (n = 251) received the second vaccination. The age and gender distributions were similar among groups IEs: Seroconversion at day 21 (after first/second vaccination [mean (95% Confidence Interval (CI)]: Group I: 47.6(25.7–70.2)/60.0(36.1–80.9) Group II: 26.9(11.6–47.8)/48.0(27.8–68.7) Control group: 0(0–52.2)/0(0–52.2) Proportion of seroprotected participants (after first/second vaccination) [mean (95% Confidence Interval (CI)] Group 1: 57.1(34.0–78.2)/70.0(45.7–88.1) Group II: 38.5(20.2–59.4)/52.0(31.3–72.2) Control: 0(0–52.2)/0(0–52.2) Increase in GMT (after first/second vaccination[mean (95% Confidence Interval (CI)]): Group I: 36.2(22.6–58.0)/38.6(27.1–55.2) Group II: 21.7(15.2–31.0)/33.9(23.1–49.6) Control group: 10(5.4–18.4)/10(5.4–18.4) AEs: No deaths or other SAEs were reported. No local adverse events were reported by Group II participants and by 54% Group I participants. Mild and moderate pain (19 and 27%), moderate redness and swelling (4 and 4%, respectively) were the most frequent local events reported by participants from Group I. Only mild pain at the injection site was reported by Control group participants (10%) Systemic reactions: Malaise, nausea and headache were reported more often by participants from Group I than Group II (8, 8, and 23% versus 3, 3, and 7%, respectively)	Precioso et al. (2011)
DBPC*	Healthy volunteers, 3–77 years, stratified by age (young children, 3–11 years of age, n = 440), adolescents, 12–17 years of age, n = 550), adults, 18–60 years of age, n = 660), and the elderly, 61 years or older, n = 550)	Al (OH)3 in influenza A/H1N1 monovalent, split-virus vaccine; 2 doses (administered volume not reported), 1.2 mg alum/ml of vaccine), 21 days apart 30 and 15 μg of HA with and without Al (OH)3, 7.5 μg of HA with Al (OH)3 Control group received phosphate- buffered saline	IEs: Proportions of seroprotected subjects (with an increase in the HI titer by a factor of 4 or more) on day 21 after the first dose and on day 35 (14 days after the second dose) AEs: The presence of any systemic reaction or injection-site reaction 30 min after injection and during 21 days after the first dose and 14 days after the second dose	2,200 subjects received one dose, and 2,103 (95.6%) received the second dose of vaccine or phosphate-buffered saline IEs: Reduced immune response was seen in younger and older subjects after first vaccination compared to adolescents and adults. Vaccine without adjuvant was associated with greater immune responses than was vaccine with adjuvant AEs: No serious vaccine-related adverse events were reported. A higher rate of local injection-site reactions was associated with Al adjuvant and the second dose (p < 0.001 and p = 0.002, respectively). A higher rate of systemic reactions was associated with age only. The most common injection-site reaction in all groups was injection site pain. In the Al adjuvant groups the proportion of systemic reactions was less than the control	Zhu et al. (2009)
RCT**	Medically stable, 65 years and older (n = 57–120/group)	Al (OH)3 in inactivated subvirion influenza A/H5N1 vaccine; 2 doses (0.25–0.5 ml per dose, 1.2 mg Al per ml), 28 days apart 3.75, 7.5, 15 and 45, μg of HA were formulated with or without Al (OH)3 Control group was not included in the study	IEs: Microneutralization (Neut) and HAI assays AEs: Nurses recorded acute events during 15 min after each immunization. Participants recorded their oral temperature and the presence and severity of injection site findings (pain, tenderness, redness, and swelling) and systemic symptoms (feverishness, malaise, myalgias, headache, and nausea) during 7 days after each immunization; nurses interviewed patients in the clinic on days 2 and 8 after each vaccination, follow up information was collected 28 days after each vaccination and 6 months after the second vaccination, the interim medical history was reviewed	600 subjects were enrolled in the study; 599 received the first vaccination and 545 received the second. No differences in gender, ethnicity, race, or age were noted between the vaccine groups. GMTs and Neut before vaccination were similar among all groups IEs: Significant dose-related increase in antibody response at 28 days after the second vaccination in both the adjuvant and non-adjuvant groups (p < 0.01) was observed. Antibody responses to the vaccine were not influenced by Al(OH)3 at any dose of HA AEs: Participants who received vaccine with Al(OH)3 had increased injection site tenderness with HA doses (except at 45 μg HA) during 7 days after the first and the second vaccinations (p ≤ 0.01) and pain after the first vaccination only compared to vaccine without Al(OH)3. In the 45 μg HA dose group, the frequencies of tenderness and pain increased after the first vaccination compared to the second vaccination. No gender-related differences in injection site reactions were noted. There were no HA dose-related increases in systemic reactions in either Al(OH)3 adjuvant or non-adjuvant groups	Brady et al. (2009)
RCT**	Healthy children, stratified by age (0.5–3 years, 3–18 years, and 9–17 years (n = 30 participants per each group)	Al (OH)3 influenza monovalent A/H5N1 vaccine formulations; 2 doses (0.25–0.5 ml per dose with 1.2 mg Al/ml of vaccine), 21 days apart 30 and 15 μg of HA with and without Al adjuvant, respectively, and 7.5 and 3.5 μg of HA without Al adjuvant No control group	IEs: Increase in GMT from vaccination day 0 to day 21 AEs: Parents recorded adverse events occurring up to day 21 after vaccination. The daily occurrence of solicited systemic and injection site reactions were recorded up to day 7 following vaccination. During the following visit, investigators collected information from the children and their parents and assessed whether they were vaccine-related	IEs: The full dose (30 μg + Al) formulation was more immunogenic than the half dose (7.5 μg − Al) in all age groups. In the full dose (30 μg + Al) group, the proportion of subjects with GMTs ≥ 32 after the second vaccination was 60% (9–17 years), 70% (3–8 years) and 50% (0.6–3 years) and in the half-dose (15 μg + Al) group – 30% (0.5–3 years). In the full dose (30 μg + Al) group, neutralizing antibody response 21 days after two injections was 92% (9–17 years), 106% (3–8 years) and 72% (0.5–3 years); in the half dose (15 μg + Al) group, response was 60.2% (0.5–3 years) AEs: In group given 30 μg + Al(OH)3 pain was reported in 40% and 63% of 9–17 and 3–8 year old participants, respectively. Complaints of tenderness at the injection site in 44% of 0.5–3 years old participants. Pain was the most frequently reported event in children aged 0.5–3 years who received half-dose (15 μg + Al) formulation. Systemic reactions were headache 10% (9–17 years), myalgia 40% (3–8 years), vomiting 30%, irritability 30%, abnormal crying 50%, anorexia 36% (0.5–3 years). In the half dose (15 μg + Al) group, one child (2 years) had musculo-papule rash for 1 day and another (2 years old) had an injection site papule and mild itching that resolved after 2 days	Chotpitayasunondh et al. (2008)
RCT**	Healthy females (n = 960), stratified by age: 9–14, 15–19, and 30–25 years (n = 240–241/group)	Al (OH)3 in the human papillomavirus (HPV) – 16/18 ASO46 adjuvanted vaccine 2 doses (0.5 ml) of 20/20 F7 at 0, 6 months, 40/40F at 0, 6 months, 40/40 F8 at 0, 2 months, or 3 doses of 20/20 F at 0, 1 or 6 months Control dose contained 0.5 mg Al(OH)3.	IEs: Geometric mean antibody titer (GMT) one month after the last active dose; antibody concentrations to HPV-16 and HPV-18 were measured by the enzyme-linked immunosorbent assay (ElISA) and antibody concentrations greater than or equal to the lower limit of detection for each assay were pre-specified to indicate seropositivity9 AEs: Parents or participants recorded solicited local symptoms (pain, redness or swelling at injection site) and general symptoms (fever, headache, fatigue, gastrointestinal symptoms, arthralgia, myalgia, rash or urticaria) occurring 30 min and 7 days after each vaccination were recorded using a diary card. SAEs, other medically significant conditions (i.e., AEs prompting emergency room or physician visits that were not related to common diseases), new onset chronic diseases including new onset autoimmune diseases and pregnancies occurring through month 24 were documented. Pregnancies were followed until delivery. New onset chronic diseases and new onset autoimmune diseases (potential autoimmune events, which excluded allergy-related events or isolated signs and symptoms) were identified by comparing all reported AEs with a pre-defined list of potential chronic diseases derived from the Medical Dictionary for Regulatory Activities	961 girls and young women were enrolled into study. 960 received at least one vaccine injection IEs: The kinetics of antibodies against both HPV-16 and HPV-18 in the 2-dose vaccine groups for girls (9–14 years) were similar to those observed in the licensed 3-dose vaccine group for young women (15–25 years) AEs: No participants withdrew from the study due to an AE or SAE. Pain was the most frequently reported local symptom (81 to 86% of all doses across groups). No urticaria or rash was observed within 30 min after any vaccine dose in any group. Headache, fatigue and myalgia were the most frequently reported systemic complaints. In total cohort (n = 721) through month 24, no adverse events leading to premature discontinuation of vaccine were reported. Medically-significant adverse effects and new onset autoimmune diseases were reported at a similar frequency across groups	Romanowski et al. (2011)
RCT**	Healthy adolescents, 10–18 years of age, randomly assigned to three groups stratified by the received dose (n = 209–224/group)	Al (OH)3 in combined diphtheria-tetanus-acellular pertussis (dTpa) vaccine; 1 dose (0.5 ml per dose with 0.133, 0.3 or 0.5 mg Al per 0.5 ml dose of vaccine) All three vaccine formulations were different only in their total Al content All antigens were fully adsorbed with Al (OH)3 Vaccine formulations were preservative-free No control group was included	IEs10: Booster response rate to all vaccine antigens (diphtheria and tetanus or pertussis) and post-vaccination increase of geometric mean antibody concentration (GMC) induced by each of the formulations at 1 month after booster administration AEs: Patients self-monitored adverse events to record local redness, swelling and pain, systematic symptoms of fatigue, fever, headache, malaise and vomiting at the day of vaccination and during 14 days after vaccination; follow-up information on unsolicited symptoms, SAEs were collected from patients during 30 post-vaccination days	647 subjects were vaccinated. 214 (33%) received the 0.133 mg Al formulation, 209 (32%) − 0.3 mg Al formulation and 224 (35%) − 0.3 mg Al formulation. All subjects were included in the safety analysis and 631 subjects – in immunogenicity analysis. The demographic profiles of the three groups were comparable. All groups were similar in their pre-vaccination serological status IEs: The booster immune response to diphtheria and tetanus was not significantly different among different groups. Post-vaccination anti-PT GMC was significantly higher in the 0.5 mg Al group compared to both groups with reduced Al content (p < 0.0167). Among the three dTpa formulations, the 0.5 and 0.3 mg Al doses produced a PT response within clinically acceptable limits Initial serological status influenced the immune response in all groups. Among participants seronegative prior to booster vaccination, post-vaccination GMT concentrations were reduced and booster response rates were increased AEs: No significant differences among study groups in local or systemic effects were observed. The incidence of fever, headache, fatigue, and gastrointestinal distress had an onset within 2 days of follow up and were similar between groups. 65% in each group reported at least one systemic symptom. Systemic events tended to increase with increasing Al dose. Solicited general symptoms were rare but tended to increase with increased Al dose. A significant difference among study groups was found only for fatigue (grade 3) with onset within 14 days post-vaccination (number/percentage of subjects/95% CI) [4/1.9 (0.5–4.7), 9/4.3 (2.0–8.0), and 18/8.0 (4.8–12.4) for 0.133, 0.3 and 0.5 mg Al dose groups, respectively].	Theeten et al. (2005)
Prospective observational study	Healthy children, 6–7 years old (n = 243)	Al (OH)3 in tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccines; single dose (0.33 mg Al (OH)3/dose). All children received government-provided diphtheria-pertussis and tetatus (DPwT) vaccine for the first 3 doses No control group was included	AEs: Redness, induration, tenderness, itching, fever, headache, vomiting were recorded by the physician at 1, 2, 4, and 7 days post-injection. Solicited adverse events included injection site redness, induration, tenderness, itching, fever, headache, and gastrointestinal symptoms were recorded according to the children’s description	A total 263 children were evaluated and 243 were enrolled in the study. AEs: Increased local skin redness 47 (19%) children, induration in 57 (23%), tenderness in 130 (53%), and fever in 12 (5%) children. Twenty-one (9%) participants reported itching around the injection site, with or without local redness and induration. Redness and induration resolved in 7 days and fever resolved on day 4. The adverse events were not associated with gender or BMI above the mean No seizures, major neurologic reactions or other rare events were observed; reported adverse events after Tdap vaccination were mild	Wei et al. (2011)
Prospective observational study	Healthy adults, health care workers, from 30 to ≥ 50 years (n = 207)	All participants received the tetanus-diphtheria-acellular pertussis (Tdap) vaccine (no other details available)	Post-vaccination AE (up to 5 years after last vaccination): Local adverse events (pain, redness, and swelling) and systemic adverse events (e.g., fever, headache, and fatigue), as well as entire limb swelling were recorded. Unsolicited adverse events that occurred after Tdap vaccination were also recorded. Specific severity categories were not provided on the survey	268 eligible subjects were identified and 207 were included in the survey AEs: 167 participants (81%) reported at least 1 adverse event: 0.5% reported severe fever, headache, and fatigue, 12 (6%) reported pain. Female gender was an independent predictor of local adverse events (odds ratio (OR), 3.06 [95% confidence interval, 1.51–6.23]). Local adverse events were also more common among those who received the Tdap vaccine less than 5 years after receipt of tetanus-diphtheria vaccine. Systemic adverse events were more common among those < 30 years age (OR, 4.15 [95% confidence interval, 1.94–8.86]). Limited details available regarding study design and outcomes	Sandora et al. (2009)
Meta-analysis	12,375 children (up to 18 months and 10–16 years of age)	Al (OH)3 adjuvant-containing vaccines	Summary data from studies on adverse events following administration of Al (OH)3-containing vaccines	AEs: Vaccines with Al (OH)3 increased erythema and induration compared to non-adjuvanted vaccines (OR) 1.87 [95% CI 1.57–2.24]) and significantly fewer reactions of all types (OR 0.21 [95% CI 0.15–0.28]). Frequencies of local reactions of all types, collapse or convulsions, and persistent crying or screaming did not differ between the cohorts. There was no association between Al adjuvant-containing vaccines and onset of local induration or swelling. Increased local pain was reported up to 14 days (OR 2•05 [95% CI 1.25–3.38])	Jefferson et al. (2004)
Meta-analysis	18 randomized clinical trials (n = 18,444)	Al adjuvant-containing vaccines	IEs: Seroconversion11 and seroresponse/seroprotection12 AEs: Nurses and/or participants recorded fever, any systemic reaction, injection- site pain and any local reaction during the first 7–10 days after vaccination. Serious events (life-threatening events, or events resulting in persistent disability, hospitalization or death) were recorded separately	IEs: Comparing Al adjuvanted to Al non- adjuvanted vaccines at equal dose, Al adjuvant vaccines were less immunogenic than non- adjuvant formulations at any age, especially after single dose injection AEs: Direct-comparison meta-analyses showed that Al adjuvanted vaccines at the same dose compared to the non-adjuvanted vaccines significantly increased the risk of local reactions, specifically injection site pain. AEs definition was not always fully standardized and similar across trials. Potential limitations to the database include some non-randomized trials that were used in the proportion meta- analyses	Manzoli et al. (2011)
Integrated analysis	Integrated analysis of data contributed by > 68,500 participants	HPV Al adjuvant- containing vaccines	Immunogenicity endpoints and adverse events	AEs: At mean follow-up to 21.4 months the combined HPV-16/18, HSV and HBV vaccines and the separate HPV-16/18 vaccines failed to show increased relative risks for autoimmune disorders in participants receiving vaccines containing Al adjuvants compared with controls (relative risk of 0.98 for the HPV-16/18, HSV and HBV analysis and 0.92 for the HPV-16/18 analysis). No significant difference in neuroinflammatory disorders (relative risk of 1.00 for the HPV-16/18, HSV and HBV vaccine analysis, and 0.67 for the HPV-16/18 vaccine) were found. According to study design, both participants who received Al adjuvant – containing vaccines and those that received Al(OH) alone were included in the control group3	Verstraeten et al. (2008)

^*DBPC double-blind, placebo-controlled.

^**RCT randomized controlled trial.

¹A significant antibody (sero-) response for both assays was defined as a 4-fold or greater increase in antibody titer after immunization (if antibody was detectable in the pre-immunization sample) or an increase in titer from < 10 before immunization to ≥ 40 after immunization.

²A serious adverse event (SAE) was defined as any untoward medical occurrence that resulted in death, life-threatening medical conditions, persistent or substantial disability or incapacity, admission to hospital, or extended length of an existing hospital admission.

³Subjects with pre-vaccination hemagglutination-inhibition (HI) antibody titer were excluded from the analyses.

⁴Seroconvertion: Pre-vaccination hemagglutination-inhibition (HI) antibody titer < 1:10 and post-vaccination HI antibody titer ≥ 1:40, or pre-vaccination HI antibody titer ≥ 1:10 and a post-vaccination increase by a factor of four or more.

⁵Participants with post-vaccination hemagglutination-inhibition (HI) antibody titer ≥ 1:40.

⁶ASO4 adjuvant contained 0.5 mg of aluminum hydroxide and 0.05 mg of 3-O-desakyl-4-monophosphoryl lipid A.

⁷20/20F-formulation containing 20 μg of HPV-16 and 20 μg of HPV-18 L1 protein virus-like particles.

⁸40/40F-formulation containing 20 μg of HPV-16 and 20 μg of HPV-18 L1 protein virus-like particles.

⁹≥ 8 ELISA units [EU]/ml for HPV-16 antibodies and ≥ 7 EU/ml for HPV-18 antibodies.

¹⁰Booster response for diphtheria and tetanus antibodies was defined as: post-vaccination increase of at least four times the pre-vaccination antibody concentration or at least four times the cut-off in initially seronegative subjects. Booster response for pertussis antibodies was arbitrarily defined as: Post-vaccination increase of at least two times in case of pre-vaccination concentration ≥ 20 El.U/ml; post-vaccination increase of four times in case of pre-vaccination concentration ≥ 5 and < 20 El.U/ml; post-vaccination concentration at least four times the cut-off in initially seronegative subjects.

¹¹The proportion of subjects with a pre-vaccination hemagglutinination-inhibition – HI – antibody titer (≤ 1:10 and a 3–4 week post-vaccination titer ≥ 1:40, or a pre-vaccination titer > = 1:10 and an increase in the titer by a factor of four or more after vaccination).

¹²The proportion of subjects with post-vaccination HI titers ≥ 1:40.