A randomized, placebo-controlled, double-blind Phase 2 trial comparing the reactogenicity and immunogenicity of a single ≥2x108 colony forming units [cfu] standard-dose versus a ≥2x109 cfu high-dose of CVD 103-HgR live attenuated oral cholera vaccine, with Shanchol inactivated oral vaccine as an open label immunologic comparator
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High-dose vs standard-dose live oral cholera vaccineAbstract
Reactive immunization with a single-dose cholera vaccine that could rapidly (within days) protect immunologically-naïve individuals during “virgin soil” epidemics would facilitate cholera control. One dose of attenuated Vibrio cholerae O1 classical Inaba vaccine CVD 103-HgR (VaxchoraTM) containing >2x108 colony forming units (cfu) induces vibriocidal antibody seroconversion (correlate of protection) in >90% of U.S. adults. A previous CVD 103-HgR commercial formulation required >2x109 cfu to elicit high seroconversion in developing country populations. We compared vibriocidal responses of Malians (18-45 years old) randomized to ingest a single >2x108 cfu standard-dose (N=50) or >2x109 cfu high-dose (N=50) of PaxVax CVD 103-HgR with buffer, or two doses (N=50) of ShancholTM inactivated cholera vaccine (the immunologic comparator). To maintain blinding, participants were dosed twice, 2 weeks apart; CVD 103-HgR recipients ingested placebo weeks before or after ingesting vaccine. Seroconversion (>4-fold vibriocidal titer rise) between baseline and 14 days after CVD 103-HgR, and following the first and second dose of Shanchol were the main outcomes measured. By day 14 post-vaccination, seroconversion after a single standard-dose of CVD 103-HgR was 71.7% (33/46) and 83.3% (40/48) after high-dose. Seroconversion following first-dose Shanchol 56.0% (28/50) was significantly lower compared with high-dose CVD 103-HgR (p=0.003). High-dose CVD 103-HgR vibriocidal geometric mean titer (GMT) exceeded standard-dose GMT at day 14 (214 vs 95, p=0.045) and was ~2-fold higher than day 7 and day 14 GMT following the first Shanchol dose (p>0.05). High-dose CVD 103-HgR is recommended for accelerated evaluation in developing countries to assess efficacy and practicality in field situations. (ClinicalTrials.gov number, NCT02145377)Description
Additional authors: Haidara, Fadima C.; Kotloff, Karen L.; Pasetti, Marcela F.; Blackwelder, William C.; Traore, Awa; Tamboura, Boubou; Doumbia, Moussa; Diallo, Fatoumata; Coulibaly, Flanon; Onwuchekwa, Uma; Kodio, Mamoudou; Tennant, Sharon M.; Reymann, Mardi; Lam, Diana F.; Gurwith, Marc; Lock, Michael; Yonker, Thomas; Smith, Jonathan; Simon, Jakub K.; and Levine, Michael M.Keyword
immunogenicitylive oral vaccine
reactive vaccination
single-dose vaccine
Cholera Vaccines
Mali
Vaccination
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http://hdl.handle.net/10713/7401Collections
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New tools for var gene assembly and analysis of genetic diversity of var2csa, the locus encoding a placental malaria vaccine candidate antigen: vaccine development implicationsEncoded by the var gene family, highly variable Plasmodium falciparum erythrocyte membrane protein-1 (PfEMP1) proteins mediate tissue-specific cytoadherence of infected erythrocytes (iEs), resulting in immune evasion and severe malaria disease. Sequencing and assembling the 40-60 var gene complement for individual infections has been notoriously difficult, impeding molecular epidemiological studies and the assessment of var-encoded proteins as subunit vaccine candidates. VAR2CSA, a member of this family, mediates the binding of iEs to chondroitin sulfate A, a surface-associated molecule expressed in placental cells, and plays a central role in the pathogenesis of placental malaria. VAR2CSA is a target of naturally-acquired immunity and, as such, is a leading vaccine candidate against placental malaria. The gene encoding the VAR2CSA is technically challenging to sequence. Published var2csa sequences, mostly limited to specific domains, have been generated through the sequencing of cloned PCR amplicons using capillary electrophoresis, a method that is both time-consuming and costly. We developed and validated novel tools to assemble var gene sequences from clinical samples, with a focus on var2csa. These tools include Exon-Targeted Hybrid Assembly (ETHA), which is based on a combination of Pacific Biosciences (PacBio) and Illumina data, an amplicon sequencing of var2csa using PacBio, and a pipeline to reconstruct var2csa from short sequence reads. Using ETHA, we characterized the repertoire of var genes in samples from uncomplicated malaria infections in children from a single Malian village and showed them to be as genetically diverse as vars from isolates from around the globe. The amplicon sequencing allowed us to recover a segment encoding the first four domains in the 5' end of VAR2CSA (~5kb), and the full-length of the VAR2CSA's extracellular region from clinical malaria samples. The reconstruction of var2csa from short reads permitted us to generate a worldwide set of var2csa sequences. We used the VAR2CSA sequences to show that despite the extreme sequence variation, VAR2CSA from around the globe shared conserved motifs supporting the feasibility of VAR2CSA-based vaccines. The findings presented in this work will aid the understanding of malaria pathogenesis and inform the design of malaria vaccines based on PfEMP1, in particular VAR2CSA-based vaccines.
