03, Table 3). As expected the MR was lower between 9 and

17 months of age (58 deaths/3231 pyrs, MR = 18/1000). There was no longer any significant negative effect of receiving NVAS compared with placebo in the early MV group (Table 3, Fig. 2) Between 4.5 and 17 months of age, due to the strong negative effect observed up to 9 months of age, NVAS compared with placebo was associated with significantly increased mortality in early MV recipients, Dabrafenib price overall (5.39 (1.62, 17.99)) and in males (11.31 (1.50, 85.47)), again resulting in a significant interaction between NVAS and early MV (p = 0.008, Table 3). When we censored follow-up at the time of the first vitamin A opportunity occurring after the children had reached 6 months of age, the results

remained largely unchanged (from 4.5 to 17 months of age the estimate for NVAS versus placebo was 4.28 (1.25–14.62); 8.16 (1.05–63.42) in males). We conducted a reanalysis of VITA I–III to assess the effect of neonatal VAS on infant HCS assay mortality if we censored children when they received early MV. The estimates for the three trials are shown in Table 1. The combined estimate for the three trials was 1.08 (0.90, 1.30); 0.89 (0.69, 1.16) in males and 1.31 (1.01, 1.70) in females (p for same effect in males and females = 0.04). In this analysis we combined information on children who had participated first in an NVAS trial, and subsequently in an early MV trial, and found significant interactions between the two immune-modulatory interventions. Having received NVAS as compared with placebo was associated with a strong negative effect on overall mortality after receiving early MV. The negative effect was pronounced from 4.5 to 8 months of age. It was significant in its own

right among males. None of the three NVAS trials from Guinea-Bissau found a beneficial effect [1], [2] and [3]. Some children from all three trials also participated in the early MV trial, and a negative interaction between else NVAS and early MV could have led to an underestimation of the benefits of NVAS for children, who follow the currently recommended vaccination schedule. However, a reanalysis of the three trials with censoring at the time of early MV still showed no beneficial effect of NVAS and a significant negative effect in females. Hence, early MV does not explain the lack of beneficial effect of NVAS in Guinea-Bissau. Though this analysis should not be interpreted as a 2-by-2 factorial trial it still has some of the strengths of a trial, as the children were randomized to both treatments. However, it is a relatively small study, it was not sized to study interactions, and it may be subject to random fluctuations in mortality among subgroups.