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van der Boor SC, Alkema M, van Gemert GJ, Teelen K, van de Vegte-Bolmer M, Walk J, van Crevel R, de Mast Q, Ockenhouse CF, Sauerwein RW, McCall MBB. Whole sporozoite immunization with Plasmodium falciparum strain NF135 in a randomized trial. BMC Med 2023; 21:137. [PMID: 37024868 PMCID: PMC10079489 DOI: 10.1186/s12916-023-02788-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 02/15/2023] [Indexed: 04/08/2023] Open
Abstract
BACKGROUND Whole sporozoite immunization under chemoprophylaxis (CPS regime) induces long-lasting sterile homologous protection in the controlled human malaria infection model using Plasmodium falciparum strain NF54. The relative proficiency of liver-stage parasite development may be an important factor determining immunization efficacy. Previous studies show that Plasmodium falciparum strain NF135 produces relatively high numbers of large liver-stage schizonts in vitro. Here, we evaluate this strain for use in CPS immunization regimes. METHODS In a partially randomized, open-label study conducted at the Radboudumc, Nijmegen, the Netherlands, healthy, malaria-naïve adults were immunized by three rounds of fifteen or five NF135-infected mosquito bites under mefloquine prophylaxis (cohort A) or fifteen NF135-infected mosquito bites and presumptive treatment with artemether/lumefantrine (cohort B). Cohort A participants were exposed to a homologous challenge 19 weeks after immunization. The primary objective of the study was to evaluate the safety and tolerability of CPS immunizations with NF135. RESULTS Relatively high liver-to-blood inocula were observed during immunization with NF135 in both cohorts. Eighteen of 30 (60%) high-dose participants and 3/10 (30%) low-dose participants experienced grade 3 adverse events 7 to 21 days following their first immunization. All cohort A participants and two participants in cohort B developed breakthrough blood-stage malaria infections during immunizations requiring rescue treatment. The resulting compromised immunizations induced modest sterile protection against homologous challenge in cohort A (5/17; 29%). CONCLUSIONS These CPS regimes using NF135 were relatively poorly tolerated and frequently required rescue treatment, thereby compromising immunization efficiency and protective efficacy. Consequently, the full potential of NF135 sporozoites for induction of immune protection remains inconclusive. Nonetheless, the high liver-stage burden achieved by this strain highlights it as an interesting potential candidate for novel whole sporozoite immunization approaches. TRIAL REGISTRATION The trial was registered at ClinicalTrials.gov under identifier NCT03813108.
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Affiliation(s)
- Saskia C van der Boor
- Department of Medical Microbiology, Radboud Center for Infectious Diseases, Radboud University Medical Center, Geert Grooteplein Zuid 28, 6525 GA, Nijmegen, The Netherlands
| | - Manon Alkema
- Department of Medical Microbiology, Radboud Center for Infectious Diseases, Radboud University Medical Center, Geert Grooteplein Zuid 28, 6525 GA, Nijmegen, The Netherlands
| | - Geert-Jan van Gemert
- Department of Medical Microbiology, Radboud Center for Infectious Diseases, Radboud University Medical Center, Geert Grooteplein Zuid 28, 6525 GA, Nijmegen, The Netherlands
| | - Karina Teelen
- Department of Medical Microbiology, Radboud Center for Infectious Diseases, Radboud University Medical Center, Geert Grooteplein Zuid 28, 6525 GA, Nijmegen, The Netherlands
| | - Marga van de Vegte-Bolmer
- Department of Medical Microbiology, Radboud Center for Infectious Diseases, Radboud University Medical Center, Geert Grooteplein Zuid 28, 6525 GA, Nijmegen, The Netherlands
| | - Jona Walk
- Department of Medical Microbiology, Radboud Center for Infectious Diseases, Radboud University Medical Center, Geert Grooteplein Zuid 28, 6525 GA, Nijmegen, The Netherlands
- Present affiliation: TropIQ Health Sciences, Transistorweg 5-C02, 6534 AT, Nijmegen, The Netherlands
| | - Reinout van Crevel
- Department of Internal Medicine, Radboud Center for Infectious Diseases, Radboud University Medical Centre, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | - Quirijn de Mast
- Department of Internal Medicine, Radboud Center for Infectious Diseases, Radboud University Medical Centre, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
| | | | - Robert W Sauerwein
- Department of Medical Microbiology, Radboud Center for Infectious Diseases, Radboud University Medical Center, Geert Grooteplein Zuid 28, 6525 GA, Nijmegen, The Netherlands.
- Present affiliation: TropIQ Health Sciences, Transistorweg 5-C02, 6534 AT, Nijmegen, The Netherlands.
| | - Matthew B B McCall
- Department of Medical Microbiology, Radboud Center for Infectious Diseases, Radboud University Medical Center, Geert Grooteplein Zuid 28, 6525 GA, Nijmegen, The Netherlands.
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Adams-Phipps J, Toomey D, Więcek W, Schmit V, Wilkinson J, Scholl K, Jamrozik E, Osowicki J, Roestenberg M, Manheim D. A Systematic Review of Human Challenge Trials, Designs, and Safety. Clin Infect Dis 2023; 76:609-619. [PMID: 36219704 PMCID: PMC9938741 DOI: 10.1093/cid/ciac820] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 09/29/2022] [Accepted: 10/07/2022] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Few studies have assessed participant safety in human challenge trials (HCTs). Key questions regarding HCTs include how risky such trials have been, how often adverse events (AEs) and serious adverse events (SAEs) occur, and whether risk mitigation measures have been effective. METHODS A systematic search of PubMed and PubMed Central for articles reporting on results of HCTs published between 1980 and 2021 was performed and completed by 7 October 2021. RESULTS Of 2838 articles screened, 276 were reviewed in full. A total of 15 046 challenged participants were described in 308 studies that met inclusion criteria; 286 (92.9%) of these studies reported mitigation measures used to minimize risk to the challenge population. Among 187 studies that reported on SAEs, 0.2% of participants experienced at least 1 challenge-related SAE. Among 94 studies that graded AEs by severity, challenge-related AEs graded "severe" were reported by between 5.6% and 15.8% of participants. AE data were provided as a range to account for unclear reporting. Eighty percent of studies published after 2010 were registered in a trials database. CONCLUSIONS HCTs are increasingly common and used for an expanding list of diseases. Although AEs occur, severe AEs and SAEs are rare. Reporting has improved over time, though not all papers provide a comprehensive report of relevant health impacts. We found very few severe symptoms or SAEs in studies that reported them, but many HCTs did not report relevant safety data. This study was preregistered on PROSPERO as CRD42021247218.
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Affiliation(s)
| | - Danny Toomey
- 1Day Sooner Research Team, Lewes, Delaware, USA
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | | | | | | | - Keller Scholl
- RAND Corporation, Pardee RAND Graduate School, Santa Monica, California, USA
| | - Euzebiusz Jamrozik
- The Ethox Centre & Wellcome Centre for Ethics and the Humanities, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- Monash Bioethics Centre, Monash University, Clayton, VIC, Australia
- Royal Melbourne Hospital Department of Medicine, University of Melbourne, Parkville, VIC, Australia
| | - Joshua Osowicki
- Murdoch Children's Research Institute, Parkville, VIC, Australia
- Infectious Diseases Unit, Department of General Medicine, Royal Children's Hospital Melbourne, Parkville, VIC, Australia
| | - Meta Roestenberg
- Department of Parasitology, Leiden University Medical Centre, Leiden, The Netherlands
- Department of Infectious Diseases, Leiden University Medical Center, Leiden, ZAThe Netherlands
| | - David Manheim
- 1Day Sooner Research Team, Lewes, Delaware, USA
- Technion, Israel Institute of Technology, Haifa, Israel
- ALTER, Association for Long Term Existence and Resilience, Rehovot, Israel
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Bi D, Lin J, Luo X, Lin L, Tang X, Luo X, Lu Y, Huang X. Biochemical characteristics of patients with imported malaria. Front Cell Infect Microbiol 2022; 12:1008430. [DOI: 10.3389/fcimb.2022.1008430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 09/13/2022] [Indexed: 11/11/2022] Open
Abstract
ObjectivesThis study aimed to investigate the clinical and biochemical profiles of patients with imported malaria infection between 1 January 2011 and 30 April 2022 and admitted to the Fourth People’s Hospital of Nanning.MethodsThis cohort study enrolled 170 patients with conformed imported malaria infection. The clinical and biochemical profiles of these participants were analyzed with malaria parasite clearance, and signs and symptoms related to malaria disappearance were defined as the primary outcome. A multivariable logistic regression model was used to evaluate the odds ratios (ORs) with 95% confidence intervals (CIs) for cerebral malaria. The Cox model was used to estimate the hazard ratios (HRs) with 95% CIs for parasite clearance.ResultsAdenosine deaminase and parasitemia were found to be independent risk factors for severe malaria in patients with imported malaria (OR = 1.0088, 95% CI: 1.0010–1.0167, p = 0.0272 and OR = 2.0700, 95% CI: 1.2584–3.4050, p = 0.0042, respectively). A 0.5–standard deviation (SD) increase of variation for urea (HR = 0.6714, 95% CI: 0.4911–0.9180), a 0.5-SD increase of variation for creatinine (HR = 0.4566, 95% CI: 0.2762–0.7548), a 0.25-SD increase of variation for albumin (HR = 0.4947, 95% CI: 0.3197–0.7653), a 0.25-SD increase of variation for hydroxybutyrate dehydrogenase (HR = 0.6129, 95% CI: 0.3995–0.9402), and a 1.0-SD increase of variation for ferritin (HR = 0.5887, 95% CI: 0.3799–0.9125) were associated with a higher risk for increased parasite clearance duration than a low-level change.ConclusionsAspartate aminotransferase, urea, creatinine, albumin, hydroxybutyrate dehydrogenase, and ferritin are useful biochemical indicators in routine clinical practice to evaluate prognosis for imported malaria.
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Shibeshi W, Bagchus W, Yalkinoglu Ö, Tappert A, Engidawork E, Oeuvray C. Reproducibility of malaria sporozoite challenge model in humans for evaluating efficacy of vaccines and drugs: a systematic review. BMC Infect Dis 2021; 21:1274. [PMID: 34930178 PMCID: PMC8686662 DOI: 10.1186/s12879-021-06953-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 12/06/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The development of novel malaria vaccines and antimalarial drugs is limited partly by emerging challenges to conduct field trials in malaria endemic areas, including unknown effects of existing immunity and a reported fall in malaria incidence. As a result, Controlled Human Malaria Infection (CHMI) has become an important approach for accelerated development of malarial vaccines and drugs. We conducted a systematic review of the literature to establish aggregate evidence on the reproducibility of a malaria sporozoite challenge model. METHODS A systematic review of research articles published between 1990 and 2018 on efficacy testing of malaria vaccines and drugs using sporozoite challenge and sporozoite infectivity studies was conducted using Pubmed, Scopus, Embase and Cochrane Library, ClinicalTrials.gov and Trialtrove. The inclusion criteria were randomized and non-randomized, controlled or open-label trials using P. falciparum or P. vivax sporozoite challenges. The data were extracted from articles using standardized data extraction forms and descriptive analysis was performed for evidence synthesis. The endpoints considered were infectivity, prepatent period, parasitemia and safety of sporozoite challenge. RESULTS Seventy CHMI trials conducted with a total of 2329 adult healthy volunteers were used for analysis. CHMI was induced by bites of mosquitoes infected with P. falciparum or P. vivax in 52 trials and by direct venous inoculation of P. falciparum sporozoites (PfSPZ challenge) in 18 trials. Inoculation with P. falciparum-infected mosquitoes produced 100% infectivity in 40 studies and the mean/median prepatent period assessed by thick blood smear (TBS) microscopy was ≤ 12 days in 24 studies. On the other hand, out of 12 infectivity studies conducted using PfSPZ challenge, 100% infection rate was reproduced in 9 studies with a mean or median prepatent period of 11 to 15.3 days as assessed by TBS and 6.8 to 12.6 days by PCR. The safety profile of P. falciparum and P.vivax CHMI was characterized by consistent features of malaria infection. CONCLUSION There is ample evidence on consistency of P. falciparum CHMI models in terms of infectivity and safety endpoints, which supports applicability of CHMI in vaccine and drug development. PfSPZ challenge appears more feasible for African trials based on current evidence of safety and efficacy.
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Affiliation(s)
- Workineh Shibeshi
- Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia.
- Global Health Institute of Merck, Ares Trading S.A., A subsidiary of Merck KGaA, Darmstadt, Germany.
| | - Wilhelmina Bagchus
- Translational Medicine, Merck Serono S.A., An Affiliate of Merck KGaA, Darmstadt, Germany
| | - Özkan Yalkinoglu
- Translational Medicine, Merck Healthcare KGaA, Darmstadt, Germany
| | - Aliona Tappert
- Global Patient Safety, Merck Healthcare KGaA, Darmstadt, Germany
| | - Ephrem Engidawork
- Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Claude Oeuvray
- Global Health Institute of Merck, Ares Trading S.A., A subsidiary of Merck KGaA, Darmstadt, Germany
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Roestenberg M, Walk J, van der Boor SC, Langenberg MCC, Hoogerwerf MA, Janse JJ, Manurung M, Yap XZ, García AF, Koopman JPR, Meij P, Wessels E, Teelen K, van Waardenburg YM, van de Vegte-Bolmer M, van Gemert GJ, Visser LG, van der Ven AJAM, de Mast Q, Natasha KC, Abebe Y, Murshedkar T, Billingsley PF, Richie TL, Sim BKL, Janse CJ, Hoffman SL, Khan SM, Sauerwein RW. A double-blind, placebo-controlled phase 1/2a trial of the genetically attenuated malaria vaccine PfSPZ-GA1. Sci Transl Med 2021; 12:12/544/eaaz5629. [PMID: 32434847 DOI: 10.1126/scitranslmed.aaz5629] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 04/22/2020] [Indexed: 11/02/2022]
Abstract
Immunization with attenuated Plasmodium sporozoites can induce protection against malaria infection, as shown by Plasmodium falciparum (Pf) sporozoites attenuated by radiation in multiple clinical trials. As alternative attenuation strategy with a more homogeneous population of Pf sporozoites (PfSPZ), genetically engineered Plasmodium berghei sporozoites (SPZ) lacking the genes b9 and slarp induced sterile protection against malaria in mice. Consequently, PfSPZ-GA1 Vaccine, a Pf identical double knockout (Pf∆b9∆slarp), was generated as a genetically attenuated malaria parasite vaccine and tested for safety, immunogenicity, and preliminary efficacy in malaria-naïve Dutch volunteers. Dose-escalation immunizations up to 9.0 × 105 PfSPZ of PfSPZ-GA1 Vaccine were well tolerated without breakthrough blood-stage infection. Subsequently, groups of volunteers were immunized three times by direct venous inoculation with cryopreserved PfSPZ-GA1 Vaccine (9.0 × 105 or 4.5 × 105 PfSPZ, N = 13 each), PfSPZ Vaccine (radiation-attenuated PfSPZ, 4.5 × 105 PfSPZ, N = 13), or normal saline placebo at 8-week intervals, followed by exposure to mosquito bite controlled human malaria infection (CHMI). After CHMI, 3 of 25 volunteers from both PfSPZ-GA1 groups were sterilely protected, and the remaining 17 of 22 showed a patency ≥9 days (median patency in controls, 7 days; range, 7 to 9). All volunteers in the PfSPZ Vaccine control group developed parasitemia (median patency, 9 days; range, 7 to 12). Immunized groups exhibited a significant, dose-related increase in anti-Pf circumsporozoite protein (CSP) antibodies and Pf-specific interferon-γ (IFN-γ)-producing T cells. Although no definite conclusion can be drawn on the potential strength of protective efficacy of PfSPZ-GA1 Vaccine, the favorable safety profile and induced immune responses by PfSPZ-GA1 Vaccine warrant further clinical evaluation.
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Affiliation(s)
- Meta Roestenberg
- Department of Parasitology, Leiden University Medical Center, 2333 ZA Leiden, Netherlands.,Department of Infectious Diseases, Leiden University Medical Center, 2333 ZA Leiden, Netherlands
| | - Jona Walk
- Radboudumc Center for Infectious Diseases, Department of Medical Microbiology, Radboud University Medical Center, 6525 GA Nijmegen, Netherlands.,Radboudumc Center for Infectious Diseases, Department of Internal Medicine, Radboud University Medical Center, 6525 GA Nijmegen, Netherlands
| | - Saskia C van der Boor
- Radboudumc Center for Infectious Diseases, Department of Medical Microbiology, Radboud University Medical Center, 6525 GA Nijmegen, Netherlands
| | - Marijke C C Langenberg
- Department of Parasitology, Leiden University Medical Center, 2333 ZA Leiden, Netherlands
| | | | - Jacqueline J Janse
- Department of Parasitology, Leiden University Medical Center, 2333 ZA Leiden, Netherlands
| | - Mikhael Manurung
- Department of Parasitology, Leiden University Medical Center, 2333 ZA Leiden, Netherlands
| | - X Zen Yap
- Radboudumc Center for Infectious Diseases, Department of Medical Microbiology, Radboud University Medical Center, 6525 GA Nijmegen, Netherlands
| | - Amanda Fabra García
- Radboudumc Center for Infectious Diseases, Department of Medical Microbiology, Radboud University Medical Center, 6525 GA Nijmegen, Netherlands
| | - Jan Pieter R Koopman
- Department of Parasitology, Leiden University Medical Center, 2333 ZA Leiden, Netherlands
| | - Pauline Meij
- Interdivisional GMP Facility, Department of Clinical Pharmacy and Toxicology, Leiden University Medical Center, 2333 ZA Leiden, Netherlands
| | - Els Wessels
- Department of Medical Microbiology, Leiden University Medical Center, 2333 ZA Leiden, Netherlands
| | - Karina Teelen
- Radboudumc Center for Infectious Diseases, Department of Medical Microbiology, Radboud University Medical Center, 6525 GA Nijmegen, Netherlands
| | - Youri M van Waardenburg
- Radboudumc Center for Infectious Diseases, Department of Medical Microbiology, Radboud University Medical Center, 6525 GA Nijmegen, Netherlands
| | - Marga van de Vegte-Bolmer
- Radboudumc Center for Infectious Diseases, Department of Medical Microbiology, Radboud University Medical Center, 6525 GA Nijmegen, Netherlands
| | - Geert Jan van Gemert
- Radboudumc Center for Infectious Diseases, Department of Medical Microbiology, Radboud University Medical Center, 6525 GA Nijmegen, Netherlands
| | - Leo G Visser
- Department of Infectious Diseases, Leiden University Medical Center, 2333 ZA Leiden, Netherlands
| | - André J A M van der Ven
- Radboudumc Center for Infectious Diseases, Department of Internal Medicine, Radboud University Medical Center, 6525 GA Nijmegen, Netherlands
| | - Quirijn de Mast
- Radboudumc Center for Infectious Diseases, Department of Internal Medicine, Radboud University Medical Center, 6525 GA Nijmegen, Netherlands
| | | | | | | | | | | | | | - Chris J Janse
- Department of Parasitology, Leiden University Medical Center, 2333 ZA Leiden, Netherlands
| | | | - Shahid M Khan
- Department of Parasitology, Leiden University Medical Center, 2333 ZA Leiden, Netherlands
| | - Robert W Sauerwein
- Radboudumc Center for Infectious Diseases, Department of Medical Microbiology, Radboud University Medical Center, 6525 GA Nijmegen, Netherlands.
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Murphy SC, Deye GA, Sim BKL, Galbiati S, Kennedy JK, Cohen KW, Chakravarty S, KC N, Abebe Y, James ER, Kublin JG, Hoffman SL, Richie TL, Jackson LA. PfSPZ-CVac efficacy against malaria increases from 0% to 75% when administered in the absence of erythrocyte stage parasitemia: A randomized, placebo-controlled trial with controlled human malaria infection. PLoS Pathog 2021; 17:e1009594. [PMID: 34048504 PMCID: PMC8191919 DOI: 10.1371/journal.ppat.1009594] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 06/10/2021] [Accepted: 04/29/2021] [Indexed: 11/18/2022] Open
Abstract
PfSPZ-CVac combines 'PfSPZ Challenge', which consists of infectious Plasmodium falciparum sporozoites (PfSPZ), with concurrent antimalarial chemoprophylaxis. In a previously-published PfSPZ-CVac study, three doses of 5.12x104 PfSPZ-CVac given 28 days apart had 100% vaccine efficacy (VE) against controlled human malaria infection (CHMI) 10 weeks after the last immunization, while the same dose given as three injections five days apart had 63% VE. Here, we conducted a dose escalation trial of similarly condensed schedules. Of the groups proceeding to CHMI, the first study group received three direct venous inoculations (DVIs) of a dose of 5.12x104 PfSPZ-CVac seven days apart and the next full dose group received three DVIs of a higher dose of 1.024x105 PfSPZ-CVac five days apart. CHMI (3.2x103 PfSPZ Challenge) was performed by DVI 10 weeks after the last vaccination. In both CHMI groups, transient parasitemia occurred starting seven days after each vaccination. For the seven-day interval group, the second and third vaccinations were therefore administered coincident with parasitemia from the prior vaccination. Parasitemia was associated with systemic symptoms which were severe in 25% of subjects. VE in the seven-day group was 0% (7/7 infected) and in the higher-dose, five-day group was 75% (2/8 infected). Thus, the same dose of PfSPZ-CVac previously associated with 63% VE when given on a five-day schedule in the prior study had zero VE here when given on a seven-day schedule, while a double dose given on a five-day schedule here achieved 75% VE. The relative contributions of the five-day schedule and/or the higher dose to improved VE warrant further investigation. It is notable that administration of PfSPZ-CVac on a schedule where vaccine administration coincided with blood-stage parasitemia was associated with an absence of sterile protective immunity. Clinical trials registration: NCT02773979.
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Affiliation(s)
- Sean C. Murphy
- Seattle Malaria Clinical Trials Center, Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, United States of America
- Department of Microbiology, University of Washington, Seattle, Washington, United States of America
- Center for Emerging and Re-emerging Infectious Diseases, Seattle, Washington, United States of America
| | - Gregory A. Deye
- Division of Microbiology and Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, United States of America
| | - B. Kim Lee Sim
- Sanaria Inc., Rockville, Maryland, United States of America
| | - Shirley Galbiati
- The Emmes Company, Rockville, Maryland, United States of America
| | | | - Kristen W. Cohen
- Seattle Malaria Clinical Trials Center, Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
| | | | - Natasha KC
- Sanaria Inc., Rockville, Maryland, United States of America
| | - Yonas Abebe
- Sanaria Inc., Rockville, Maryland, United States of America
| | - Eric R. James
- Sanaria Inc., Rockville, Maryland, United States of America
| | - James G. Kublin
- Seattle Malaria Clinical Trials Center, Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, United States of America
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | | | | | - Lisa A. Jackson
- Kaiser Permanente Washington Health Research Institute, Seattle, Washington, United States of America
- * E-mail:
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7
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Holm AE, Gomes LC, Marinho CRF, Silvestre OM, Vestergaard LS, Biering-Sørensen T, Brainin P. Prevalence of Cardiovascular Complications in Malaria: A Systematic Review and Meta-Analysis. Am J Trop Med Hyg 2021; 104:1643-1650. [PMID: 33724926 PMCID: PMC8103436 DOI: 10.4269/ajtmh.20-1414] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 01/02/2021] [Indexed: 12/13/2022] Open
Abstract
Recent studies have suggested that malaria may affect the cardiovascular system. The aim of this systematic review and meta-analysis was to determine the prevalence of cardiovascular complications in symptomatic malaria patients. We searched databases such as Pubmed, Embase, Cochrane, and Web of Science (January 1950-April 2020) for studies reporting on cardiovascular complications in adults and children with malaria. Cardiovascular complications were defined as abnormalities in electrocardiogram (ECG), cardiac biomarkers, and echocardiography on admission or during outpatient examination. Studies of patients with known heart disease or cardiovascular evaluation performed after the start of intravenous antimalarial medication were excluded. The study was registered in International Prospective Register of Systematic Reviews (PROSPERO) (No.: CRD42020167672). The literature search yielded 1,243 studies, and a total of 43 studies with symptomatic malaria patients were included. Clinical studies (n = 12 adults; n = 5 children) comprised 3,117 patients, of which a majority had Plasmodium falciparum (n = 15) and were diagnosed with severe malaria (n = 13). In random-effects models of adults, the pooled prevalence estimate for any cardiovascular complication was 7% (95% CI: 5-9). No meta-analysis was conducted in children, but the range of abnormal ECG was 0-8%, cardiac biomarkers 0-57%, and echocardiography 4-9%. We analyzed 33 cases (n = 10 postmortem), in which the most common cardiovascular pathologies were myocarditis and acute coronary syndrome. All histopathological studies found evidence of parasitized red blood cells in the myocardium. Cardiovascular complications are not uncommon in symptomatic adults and children with malaria. Additional studies investigating malaria and cardiovascular disease are encouraged.
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Affiliation(s)
- Anna Engell Holm
- Federal University of Acre, Campus Floresta, Cruzeiro do Sul, Acre, Brazil
- Department of Cardiology, Herlev-Gentofte Hospital, Hellerup, Denmark
| | - Laura C. Gomes
- Federal University of Acre, Campus Floresta, Cruzeiro do Sul, Acre, Brazil
| | | | | | - Lasse S. Vestergaard
- National Malaria Reference Laboratory, Department of Bacteria, Parasites and Fungi, Statens Serum Institut, Copenhagen, Denmark
| | - Tor Biering-Sørensen
- Department of Cardiology, Herlev-Gentofte Hospital, Hellerup, Denmark
- Faculty of Biomedical Sciences, Copenhagen University, Copenhagen, Denmark
| | - Philip Brainin
- Federal University of Acre, Campus Floresta, Cruzeiro do Sul, Acre, Brazil
- Department of Cardiology, Herlev-Gentofte Hospital, Hellerup, Denmark
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8
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Kingston HWF, Ghose A, Rungpradubvong V, Satitthummanid S, Herdman MT, Plewes K, Leopold SJ, Ishioka H, Mohanty S, Maude RJ, Schultz MJ, Lagrand WK, Hossain MA, Day NPJ, White NJ, Anstey NM, Dondorp AM. Reduced Cardiac Index Reserve and Hypovolemia in Severe Falciparum Malaria. J Infect Dis 2021; 221:1518-1527. [PMID: 31693130 PMCID: PMC7137886 DOI: 10.1093/infdis/jiz568] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Accepted: 11/05/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Impaired microvascular perfusion is central to the development of coma and lactic acidosis in severe falciparum malaria. Refractory hypotension is rare on admission but develops frequently in fatal cases. We assessed cardiac function and volume status in severe falciparum malaria and its prognostic significance. METHODS Patients with severe (N = 101) or acute uncomplicated falciparum malaria (N = 83) were recruited from 2 hospitals in India and Bangladesh, and healthy participants (N = 44) underwent echocardiography. RESULTS Patients with severe malaria had 38% shorter left ventricular (LV) filling times and 25% shorter LV ejection times than healthy participants because of tachycardia; however, stroke volume, LV internal diameter in diastole (LVIDd), and LV internal diameter in systole (LVIDs) indices were similar. A low endocardial fraction shortening (eFS) was present in 17% (9 of 52) of severe malaria patients. Adjusting for preload and afterload, eFS was similar in health and severe malaria. Fatal cases had smaller baseline LVIDd and LVIDs indices, more collapsible inferior vena cavae (IVC), and higher heart rates than survivors. The LVIDs and IVC collapsibility were independent predictors for mortality, together with base excess and Glasgow Coma Scale. CONCLUSIONS Patients with severe malaria have rapid ejection of a normal stroke volume. Fatal cases had features of relative hypovolemia and reduced cardiac index reserve.
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Affiliation(s)
- Hugh W F Kingston
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Australia.,Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom
| | | | - Voravut Rungpradubvong
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Cardiac Center, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Sudarat Satitthummanid
- Division of Cardiology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Cardiac Center, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - M Trent Herdman
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Katherine Plewes
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom
| | - Stije J Leopold
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom
| | - Haruhiko Ishioka
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | | | - Richard J Maude
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom
| | - Marcus J Schultz
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Department of Intensive Care Medicine, Academic Medical Center, University of Amsterdam, The Netherlands
| | - Wim K Lagrand
- Department of Intensive Care Medicine, Academic Medical Center, University of Amsterdam, The Netherlands
| | | | - Nicholas P J Day
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom
| | - Nicholas J White
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom
| | - Nicholas M Anstey
- Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, Darwin, Australia
| | - Arjen M Dondorp
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, Churchill Hospital, Oxford, United Kingdom
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9
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Jamrozik E, Littler K, Bull S, Emerson C, Kang G, Kapulu M, Rey E, Saenz C, Shah S, Smith PG, Upshur R, Weijer C, Selgelid MJ. Key criteria for the ethical acceptability of COVID-19 human challenge studies: Report of a WHO Working Group. Vaccine 2020; 39:633-640. [PMID: 33341309 PMCID: PMC7598752 DOI: 10.1016/j.vaccine.2020.10.075] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 10/21/2020] [Indexed: 12/13/2022]
Abstract
This report of the WHO Working Group for Guidance on Human Challenge Studies in COVID-19 outlines ethical standards for COVID-19 challenge studies. It includes eight Key Criteria related to scientific justification, risk-benefit assessment, consultation and engagement, co-ordination of research, site selection, participant selection, expert review, and informed consent. The document aims to provide comprehensive guidance to scientists, research ethics committees, funders, policymakers, and regulators in deliberations regarding SARS-CoV-2 challenge studies by outlining criteria that would need to be satisfied in order for such studies to be ethically acceptable.
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Affiliation(s)
- Euzebiusz Jamrozik
- The Ethox Centre & Wellcome Centre for Ethics and the Humanities, Nuffield Department of Population Health, University of Oxford, Oxford, Oxfordshire, UK; Monash Bioethics Centre, Monash University, Clayton, Victoria, Australia; Royal Melbourne Hospital Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - Katherine Littler
- Global Health Ethics Unit, World Health Organization, Geneva, Switzerland
| | - Susan Bull
- The Ethox Centre & Wellcome Centre for Ethics and the Humanities, Nuffield Department of Population Health, University of Oxford, Oxford, Oxfordshire, UK
| | - Claudia Emerson
- Institute on Ethics & Policy for Innovation, Department of Philosophy, McMaster University, Hamilton, Ontario, Canada
| | - Gagandeep Kang
- The Wellcome Trust Research Laboratory, Division of Gastrointestinal Sciences, Christian Medical College, Vellore, India
| | - Melissa Kapulu
- KEMRI-Wellcome Trust Research Programme, Centre for Geographic Medicine Research-Coast, Kilifi, Kenya; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Elena Rey
- Centro Internacional de Entrenamiento e Investigaciones Médicas - CIDEIM. Cali, Colombia; Universidad Icesi. Cali, Colombia
| | - Carla Saenz
- Department of Health Systems and Services, Pan American Health Organization, USA
| | - Seema Shah
- Lurie Children's Hospital & Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Peter G Smith
- London School of Hygiene and Tropical Medicine, London, UK
| | - Ross Upshur
- Division of Clinical Public Health, Dalla Lana School of Public Health, Toronto, Canada
| | - Charles Weijer
- Departments of Medicine, Epidemiology & Biostatistics, and Philosophy, Western University, London, Canada
| | - Michael J Selgelid
- Monash Bioethics Centre, Monash University, Clayton, Victoria, Australia
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10
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Watts RE, Odedra A, Marquart L, Webb L, Abd-Rahman AN, Cascales L, Chalon S, Rebelo M, Pava Z, Collins KA, Pasay C, Chen N, Peatey CL, Möhrle JJ, McCarthy JS. Safety and parasite clearance of artemisinin-resistant Plasmodium falciparum infection: A pilot and a randomised volunteer infection study in Australia. PLoS Med 2020; 17:e1003203. [PMID: 32822347 PMCID: PMC7444516 DOI: 10.1371/journal.pmed.1003203] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Accepted: 07/21/2020] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Artemisinin resistance is threatening malaria control. We aimed to develop and test a human model of artemisinin-resistant (ART-R) Plasmodium falciparum to evaluate the efficacy of drugs against ART-R malaria. METHODS AND FINDINGS We conducted 2 sequential phase 1, single-centre, open-label clinical trials at Q-Pharm, Brisbane, Australia, using the induced blood-stage malaria (IBSM) model, whereby healthy participants are intravenously inoculated with blood-stage parasites. In a pilot study, participants were inoculated (Day 0) with approximately 2,800 viable P. falciparum ART-R parasites. In a comparative study, participants were randomised to receive approximately 2,800 viable P. falciparum ART-R (Day 0) or artemisinin-sensitive (ART-S) parasites (Day 1). In both studies, participants were administered a single approximately 2 mg/kg oral dose of artesunate (AS; Day 9). Primary outcomes were safety, ART-R parasite infectivity, and parasite clearance. In the pilot study, 2 participants were enrolled between April 27, 2017, and September 12, 2017, and included in final analyses (males n = 2 [100%], mean age = 26 years [range, 23-28 years]). In the comparative study, 25 participants were enrolled between October 26, 2017, and October 18, 2018, of whom 22 were inoculated and included in final analyses (ART-R infected participants: males n = 7 [53.8%], median age = 22 years [range, 18-40 years]; ART-S infected participants: males n = 5 [55.6%], median age = 28 years [range, 22-35 years]). In both studies, all participants inoculated with ART-R parasites became parasitaemic. A total of 36 adverse events were reported in the pilot study and 277 in the comparative study. Common adverse events in both studies included headache, pyrexia, myalgia, nausea, and chills; none were serious. Seven participants experienced transient severe falls in white cell counts and/or elevations in liver transaminase levels which were considered related to malaria. Additionally, 2 participants developed ventricular extrasystoles that were attributed to unmasking of a predisposition to benign fever-induced tachyarrhythmia. In the comparative study, parasite clearance half-life after AS was significantly longer for ART-R infected participants (n = 13, 6.5 hours; 95% confidence interval [CI] 6.3-6.7 hours) compared with ART-S infected participants (n = 9, 3.2 hours; 95% CI 3.0-3.3 hours; p < 0.001). The main limitation of this study was that the ART-R and ART-S parasite strains did not share the same genetic background. CONCLUSIONS We developed the first (to our knowledge) human model of ART-R malaria. The delayed clearance profile of ART-R parasites after AS aligns with field study observations. Although based on a relatively small sample size, results indicate that this model can be safely used to assess new drugs against ART-R P. falciparum. TRIAL REGISTRATION The studies were registered with the Australian New Zealand Clinical Trials Registry: ACTRN12617000244303 (https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=372357) and ACTRN12617001394336 (https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=373637).
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Affiliation(s)
| | - Anand Odedra
- QIMR Berghofer Medical Research Institute, Brisbane, Australia
| | - Louise Marquart
- QIMR Berghofer Medical Research Institute, Brisbane, Australia
| | - Lachlan Webb
- QIMR Berghofer Medical Research Institute, Brisbane, Australia
| | | | - Laura Cascales
- QIMR Berghofer Medical Research Institute, Brisbane, Australia
| | | | - Maria Rebelo
- QIMR Berghofer Medical Research Institute, Brisbane, Australia
| | - Zuleima Pava
- QIMR Berghofer Medical Research Institute, Brisbane, Australia
| | | | - Cielo Pasay
- QIMR Berghofer Medical Research Institute, Brisbane, Australia
| | - Nanhua Chen
- Australian Army Malaria Institute, Brisbane, Australia
| | | | | | - James S. McCarthy
- QIMR Berghofer Medical Research Institute, Brisbane, Australia
- * E-mail:
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11
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Odedra A, McCarthy JS. Safety Considerations for Malaria Volunteer Infection Studies: A Mini-Review. Am J Trop Med Hyg 2020; 102:934-939. [PMID: 32189610 DOI: 10.4269/ajtmh.19-0351] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Malaria clinical studies entailing the experimental infection of healthy volunteers with Plasmodium parasites by bites from infected mosquitos, injection of cryopreserved sporozoites, or injection of blood-stage parasites provide valuable information for vaccine and drug development. Success of these studies depends on maintaining safety. In this mini-review, we discuss the safety risks and associated mitigation strategies of these three types of experimental malaria infection. We aimed to inform researchers and regulators who are currently involved in or are planning to establish experimental malaria infection studies in endemic or non-endemic settings.
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Affiliation(s)
- Anand Odedra
- QIMR Berghofer Medical Research Institute, Herston, Australia.,Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - James S McCarthy
- The University of Queensland, St Lucia, Australia.,QIMR Berghofer Medical Research Institute, Herston, Australia
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12
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Langenberg MCC, Dekkers OM, Roestenberg M. Are placebo controls necessary in controlled human infection trials for vaccines? THE LANCET. INFECTIOUS DISEASES 2020; 20:e69-e74. [PMID: 32142640 DOI: 10.1016/s1473-3099(20)30020-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 01/02/2020] [Accepted: 01/12/2020] [Indexed: 12/18/2022]
Abstract
Controlled human infection trials, whereby a small group of healthy participants is deliberately exposed to a pathogen under controlled circumstances, can provide preliminary data for vaccine efficacy and for the selection of the most promising candidate vaccines for field trials. Because of the potential harm to participants through the deliberate exposure to a pathogen, the use of smaller groups minimises the cumulative risk. As such, a control group that receives a placebo vaccine followed by controlled exposure to a pathogen should be scientifically well justified. As these types of trials are designed to generate consistent infection rates and thus comparable outcomes across populations and trial sites, data from past studies (historical data) could be used as a valid alternative to placebo groups. In this Personal View, we review this option and highlight the considerations for choosing historical data as a suitable control. For the widespread application of this method, responsibility for the centralisation and sharing of data from controlled human infection trials lies with the scientific community.
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Affiliation(s)
| | - Olaf M Dekkers
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, Netherlands
| | - Meta Roestenberg
- Department of Parasitology, Leiden University Medical Center, Leiden, Netherlands; Department of Infectious Diseases, Leiden University Medical Center, Leiden, Netherlands.
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13
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Kapulu MC, Njuguna P, Hamaluba MM. Controlled Human Malaria Infection in Semi-Immune Kenyan Adults (CHMI-SIKA): a study protocol to investigate in vivo Plasmodium falciparum malaria parasite growth in the context of pre-existing immunity. Wellcome Open Res 2019; 3:155. [PMID: 31803847 PMCID: PMC6871356 DOI: 10.12688/wellcomeopenres.14909.2] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/30/2019] [Indexed: 01/09/2023] Open
Abstract
Malaria remains a major public health burden despite approval for implementation of a partially effective pre-erythrocytic malaria vaccine. There is an urgent need to accelerate development of a more effective multi-stage vaccine. Adults in malaria endemic areas may have substantial immunity provided by responses to the blood stages of malaria parasites, but field trials conducted on several blood-stage vaccines have not shown high levels of efficacy. We will use the controlled human malaria infection (CHMI) models with malaria-exposed volunteers to identify correlations between immune responses and parasite growth rates in vivo. Immune responses more strongly associated with control of parasite growth should be prioritized to accelerate malaria vaccine development. We aim to recruit up to 200 healthy adult volunteers from areas of differing malaria transmission in Kenya, and after confirming their health status through clinical examination and routine haematology and biochemistry, we will comprehensively characterize immunity to malaria using >100 blood-stage antigens. We will administer 3,200 aseptic, purified, cryopreserved Plasmodium falciparum sporozoites (PfSPZ Challenge) by direct venous inoculation. Serial quantitative polymerase chain reaction to measure parasite growth rate in vivo will be undertaken. Clinical and laboratory monitoring will be undertaken to ensure volunteer safety. In addition, we will also explore the perceptions and experiences of volunteers and other stakeholders in participating in a malaria volunteer infection study. Serum, plasma, peripheral blood mononuclear cells and whole blood will be stored to allow a comprehensive assessment of adaptive and innate host immunity. We will use CHMI in semi-immune adult volunteers to relate parasite growth outcomes with antibody responses and other markers of host immunity. Registration: ClinicalTrials.gov identifier NCT02739763.
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Affiliation(s)
- Melissa C. Kapulu
- KEMRI-Wellcome Research Programme, Kilifi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University Oxford, Oxford, UK
| | | | | | - CHMI-SIKA Study Team
- KEMRI-Wellcome Research Programme, Kilifi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University Oxford, Oxford, UK
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14
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Kapulu MC, Njuguna P, Hamaluba MM. Controlled Human Malaria Infection in Semi-Immune Kenyan Adults (CHMI-SIKA): a study protocol to investigate in vivo Plasmodium falciparum malaria parasite growth in the context of pre-existing immunity. Wellcome Open Res 2018; 3:155. [PMID: 31803847 PMCID: PMC6871356 DOI: 10.12688/wellcomeopenres.14909.1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2018] [Indexed: 10/20/2023] Open
Abstract
Malaria remains a major public health burden despite approval for implementation of a partially effective pre-erythrocytic malaria vaccine. There is an urgent need to accelerate development of a more effective multi-stage vaccine. Adults in malaria endemic areas may have substantial immunity provided by responses to the blood stages of malaria parasites, but field trials conducted on several blood-stage vaccines have not shown high levels of efficacy. We will use controlled human malaria infection (CHMI) studies with malaria-exposed volunteers to identify correlations between immune responses and parasite growth rates in vivo. Immune responses more strongly associated with control of parasite growth should be prioritized to accelerate malaria vaccine development. We aim to recruit up to 200 healthy adult volunteers from areas of differing malaria transmission in Kenya, and after confirming their health status through clinical examination and routine haematology and biochemistry, we will comprehensively characterize immunity to malaria using >100 blood-stage antigens. We will administer 3,200 aseptic, purified, cryopreserved Plasmodium falciparum sporozoites (PfSPZ Challenge) by direct venous inoculation. Serial quantitative polymerase chain reaction to measure parasite growth rate in vivo will be undertaken. Clinical and laboratory monitoring will be undertaken to ensure volunteer safety. In addition, we will also explore the perceptions and experiences of volunteers and other stakeholders in participating in a malaria volunteer infection study. Serum, plasma, peripheral blood mononuclear cells and extracted DNA will be stored to allow a comprehensive assessment of adaptive and innate host immunity. We will use CHMI in semi-immune adult volunteers to relate parasite growth outcomes with antibody responses and other markers of host immunity. Registration: ClinicalTrials.gov identifier NCT02739763.
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Affiliation(s)
- Melissa C. Kapulu
- KEMRI-Wellcome Research Programme, Kilifi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University Oxford, Oxford, UK
| | | | | | - CHMI-SIKA Study Team
- KEMRI-Wellcome Research Programme, Kilifi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University Oxford, Oxford, UK
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15
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Roestenberg M, Hoogerwerf MA, Ferreira DM, Mordmüller B, Yazdanbakhsh M. Experimental infection of human volunteers. THE LANCET. INFECTIOUS DISEASES 2018; 18:e312-e322. [PMID: 29891332 DOI: 10.1016/s1473-3099(18)30177-4] [Citation(s) in RCA: 95] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2017] [Revised: 02/08/2018] [Accepted: 03/01/2018] [Indexed: 12/13/2022]
Abstract
Controlled human infection (CHI) trials, in which healthy volunteers are experimentally infected, can accelerate the development of novel drugs and vaccines for infectious diseases of global importance. The use of CHI models is expanding from around 60 studies in the 1970s to more than 120 publications in this decade, primarily for influenza, rhinovirus, and malaria. CHI trials have provided landmark data for several registered drugs and vaccines, and have generated unprecedented scientific insights. Because of their invasive nature, CHI studies demand critical ethical review according to established frameworks. CHI-associated serious adverse events are rarely reported. Novel CHI models need standardised safety data from comparable CHI models to facilitate evidence-based risk assessments, as well as funds to produce challenge inoculum according to regulatory requirements. Advances such as the principle of controlled colonisation, the expansion of models to endemic areas, and the use of genetically attenuated strains will further broaden the scope of CHI trials.
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Affiliation(s)
| | | | | | - Benjamin Mordmüller
- Institute of Tropical Medicine and German Center for Infection Research, partner site Tübingen, University of Tübingen, Tübingen, Germany; Centre de Recherches Médicales de Lambaréné, Lambaréné, Gabon
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16
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Walk J, Schats R, Langenberg MCC, Reuling IJ, Teelen K, Roestenberg M, Hermsen CC, Visser LG, Sauerwein RW. Diagnosis and treatment based on quantitative PCR after controlled human malaria infection. Malar J 2016; 15:398. [PMID: 27495296 PMCID: PMC4974752 DOI: 10.1186/s12936-016-1434-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Accepted: 07/08/2016] [Indexed: 11/29/2022] Open
Abstract
Background Controlled human malaria infection (CHMI) has become well-established in the evaluation of drugs and vaccines. Anti-malarial treatment is usually initiated when thick blood smears are positive by microscopy. This study explores the effects of using the more sensitive qPCR as the primary diagnostic test. Methods 1691 diagnostic blood samples were analysed by microscopy and qPCR from 115 volunteers (55 malaria naïve and 60 having received chemoprophylaxis and sporozoite immunization) who were challenged by five mosquitoes infected with Plasmodium falciparum sporozoites of the NF54 strain. Results Retrospective analysis of different qPCR criteria for diagnosis and treatment, showed that once daily qPCR (threshold 100 parasites/ml) had 99 % sensitivity and 100 % specificity, and shortened the median prepatent period from 10.5 to 7.0 days after CHMI when compared to twice daily measurement of thick blood smears (threshold 4000 parasites/ml). This is expected to result in a 78 % decrease of adverse events before initiation of treatment in future studies. Trial outcome related to infection and protective efficacy remained unchanged. Conclusion The use of qPCR as the primary diagnostic test in CHMI decreases symptoms as well as parasitaemia while obviating the need for twice daily follow-up. The implementation improves safety while reducing the clinical burden and costs without compromising the evaluation of protective efficacy.
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Affiliation(s)
- Jona Walk
- Department of Medical Microbiology and Radboud Center for Infectious Diseases, Radboud university medical center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Remko Schats
- Department of Infectious Diseases, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands
| | - Marijke C C Langenberg
- Department of Infectious Diseases, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands
| | - Isaie J Reuling
- Department of Medical Microbiology and Radboud Center for Infectious Diseases, Radboud university medical center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Karina Teelen
- Department of Medical Microbiology and Radboud Center for Infectious Diseases, Radboud university medical center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Meta Roestenberg
- Department of Medical Microbiology and Radboud Center for Infectious Diseases, Radboud university medical center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Cornelus C Hermsen
- Department of Medical Microbiology and Radboud Center for Infectious Diseases, Radboud university medical center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Leo G Visser
- Department of Infectious Diseases, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands
| | - Robert W Sauerwein
- Department of Medical Microbiology and Radboud Center for Infectious Diseases, Radboud university medical center, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.
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17
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Bijker EM, Sauerwein RW, Bijker WE. Controlled human malaria infection trials: How tandems of trust and control construct scientific knowledge. SOCIAL STUDIES OF SCIENCE 2016; 46:56-86. [PMID: 26983172 DOI: 10.1177/0306312715619784] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Controlled human malaria infections are clinical trials in which healthy volunteers are deliberately infected with malaria under controlled conditions. Controlled human malaria infections are complex clinical trials: many different groups and institutions are involved, and several complex technologies are required to function together. This functioning together of technologies, people, and institutions is under special pressure because of potential risks to the volunteers. In this article, the authors use controlled human malaria infections as a strategic research site to study the use of control, the role of trust, and the interactions between trust and control in the construction of scientific knowledge. The authors argue that tandems of trust and control play a central role in the successful execution of clinical trials and the construction of scientific knowledge. More specifically, two aspects of tandems of trust and control will be highlighted: tandems are sites where trust and control coproduce each other, and tandems link the personal, the technical, and the institutional domains. Understanding tandems of trust and control results in setting some agendas for both clinical trial research and science and technology studies.
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18
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Gómez-Pérez GP, Legarda A, Muñoz J, Sim BKL, Ballester MR, Dobaño C, Moncunill G, Campo JJ, Cisteró P, Jimenez A, Barrios D, Mordmüller B, Pardos J, Navarro M, Zita CJ, Nhamuave CA, García-Basteiro AL, Sanz A, Aldea M, Manoj A, Gunasekera A, Billingsley PF, Aponte JJ, James ER, Guinovart C, Antonijoan RM, Kremsner PG, Hoffman SL, Alonso PL. Controlled human malaria infection by intramuscular and direct venous inoculation of cryopreserved Plasmodium falciparum sporozoites in malaria-naïve volunteers: effect of injection volume and dose on infectivity rates. Malar J 2015; 14:306. [PMID: 26245196 PMCID: PMC4527105 DOI: 10.1186/s12936-015-0817-x] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 07/22/2015] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Controlled human malaria infection (CHMI) by mosquito bite is a powerful tool for evaluation of vaccines and drugs against Plasmodium falciparum malaria. However, only a small number of research centres have the facilities required to perform such studies. CHMI by needle and syringe could help to accelerate the development of anti-malaria interventions by enabling centres worldwide to employ CHMI. METHODS An open-label CHMI study was performed with aseptic, purified, cryopreserved P. falciparum sporozoites (PfSPZ Challenge) in 36 malaria naïve volunteers. In part A, the effect of the inoculation volume was assessed: 18 participants were injected intramuscularly (IM) with a dose of 2,500 PfSPZ divided into two injections of 10 µL (n = 6), 50 µL (n = 6) or 250 µL (n = 6), respectively. In part B, the injection volume that resulted in highest infectivity rates in part A (10 µL) was used to formulate IM doses of 25,000 PfSPZ (n = 6) and 75,000 PfSPZ (n = 6) divided into two 10-µL injections. Results from a parallel trial led to the decision to add a positive control group (n = 6), each volunteer receiving 3,200 PfSPZ in a single 500-µL injection by direct venous inoculation (DVI). RESULTS Four/six participants in the 10-µL group, 1/6 in the 50-µL group and 2/6 in the 250-µL group developed parasitaemia. Geometric mean (GM) pre-patent periods were 13.9, 14.0 and 15.0 days, respectively. Six/six (100%) participants developed parasitaemia in the 25,000 and 75,000 PfSPZ IM and 3,200 PfSPZ DVI groups. GM pre-patent periods were 12.2, 11.4 and 11.4 days, respectively. Injection of PfSPZ Challenge was well tolerated and safe in all groups. CONCLUSIONS IM injection of 75,000 PfSPZ and DVI injection of 3,200 PfSPZ resulted in infection rates and pre-patent periods comparable to the bite of five PfSPZ-infected mosquitoes. Remarkably, it required 23.4-fold more PfSPZ administered IM than DVI to achieve the same parasite kinetics. These results allow for translation of CHMI from research to routine use, and inoculation of PfSPZ by IM and DVI regimens. TRIAL REGISTRATION ClinicalTrials.gov NCT01771848.
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Affiliation(s)
- Gloria P Gómez-Pérez
- ISGlobal, Barcelona Ctr Int Health Res. (CRESIB), Hospital Clínic-Universitat de Barcelona, Barcelona, Spain.
- Department of Infectious Diseases, Centre of Tropical Medicine and Travel Medicine, Academic Medical Center, University of Amsterdam, Meibergdreef 9, PO Box 22660, 1100 DD, Amsterdam, The Netherlands.
| | - Almudena Legarda
- ISGlobal, Barcelona Ctr Int Health Res. (CRESIB), Hospital Clínic-Universitat de Barcelona, Barcelona, Spain.
| | - Jose Muñoz
- ISGlobal, Barcelona Ctr Int Health Res. (CRESIB), Hospital Clínic-Universitat de Barcelona, Barcelona, Spain.
| | | | - María Rosa Ballester
- Drug Research Centre (CIM), Biomedical Research Institute Sant Pau (IIB Sant Pau), Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.
- Department of Pharmacology and Therapeutics, Universitat Autònoma de Barcelona (UAB), Bellaterra, Spain.
| | - Carlota Dobaño
- ISGlobal, Barcelona Ctr Int Health Res. (CRESIB), Hospital Clínic-Universitat de Barcelona, Barcelona, Spain.
| | - Gemma Moncunill
- ISGlobal, Barcelona Ctr Int Health Res. (CRESIB), Hospital Clínic-Universitat de Barcelona, Barcelona, Spain.
| | - Joseph J Campo
- ISGlobal, Barcelona Ctr Int Health Res. (CRESIB), Hospital Clínic-Universitat de Barcelona, Barcelona, Spain.
- Antigen Discovery, Inc, Irvine, CA, USA.
| | - Pau Cisteró
- ISGlobal, Barcelona Ctr Int Health Res. (CRESIB), Hospital Clínic-Universitat de Barcelona, Barcelona, Spain.
| | - Alfons Jimenez
- ISGlobal, Barcelona Ctr Int Health Res. (CRESIB), Hospital Clínic-Universitat de Barcelona, Barcelona, Spain.
| | - Diana Barrios
- ISGlobal, Barcelona Ctr Int Health Res. (CRESIB), Hospital Clínic-Universitat de Barcelona, Barcelona, Spain.
| | - Benjamin Mordmüller
- Institut für Tropenmedizin, Eberhard Karls Universität Tübingen and German Centre for Infection Research, 72074, Tübingen, Germany.
| | - Josefina Pardos
- ISGlobal, Barcelona Ctr Int Health Res. (CRESIB), Hospital Clínic-Universitat de Barcelona, Barcelona, Spain.
| | - Mireia Navarro
- ISGlobal, Barcelona Ctr Int Health Res. (CRESIB), Hospital Clínic-Universitat de Barcelona, Barcelona, Spain.
| | | | | | - Alberto L García-Basteiro
- ISGlobal, Barcelona Ctr Int Health Res. (CRESIB), Hospital Clínic-Universitat de Barcelona, Barcelona, Spain.
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique.
| | - Ariadna Sanz
- ISGlobal, Barcelona Ctr Int Health Res. (CRESIB), Hospital Clínic-Universitat de Barcelona, Barcelona, Spain.
| | - Marta Aldea
- ISGlobal, Barcelona Ctr Int Health Res. (CRESIB), Hospital Clínic-Universitat de Barcelona, Barcelona, Spain.
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique.
| | | | | | | | - John J Aponte
- ISGlobal, Barcelona Ctr Int Health Res. (CRESIB), Hospital Clínic-Universitat de Barcelona, Barcelona, Spain.
| | | | - Caterina Guinovart
- ISGlobal, Barcelona Ctr Int Health Res. (CRESIB), Hospital Clínic-Universitat de Barcelona, Barcelona, Spain.
| | - Rosa M Antonijoan
- Drug Research Centre (CIM), Biomedical Research Institute Sant Pau (IIB Sant Pau), Hospital de la Santa Creu i Sant Pau, Barcelona, Spain.
- Department of Pharmacology and Therapeutics, Universitat Autònoma de Barcelona (UAB), Bellaterra, Spain.
| | - Peter G Kremsner
- Institut für Tropenmedizin, Eberhard Karls Universität Tübingen and German Centre for Infection Research, 72074, Tübingen, Germany.
| | | | - Pedro L Alonso
- ISGlobal, Barcelona Ctr Int Health Res. (CRESIB), Hospital Clínic-Universitat de Barcelona, Barcelona, Spain.
- Centro de Investigação em Saúde de Manhiça, Maputo, Mozambique.
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Darton TC, Blohmke CJ, Moorthy VS, Altmann DM, Hayden FG, Clutterbuck EA, Levine MM, Hill AVS, Pollard AJ. Design, recruitment, and microbiological considerations in human challenge studies. THE LANCET. INFECTIOUS DISEASES 2015; 15:840-51. [PMID: 26026195 DOI: 10.1016/s1473-3099(15)00068-7] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Revised: 01/13/2015] [Accepted: 01/15/2015] [Indexed: 12/26/2022]
Abstract
Since the 18th century a wealth of knowledge regarding infectious disease pathogenesis, prevention, and treatment has been accumulated from findings of infection challenges in human beings. Partly because of improvements to ethical and regulatory guidance, human challenge studies-involving the deliberate exposure of participants to infectious substances-have had a resurgence in popularity in the past few years, in particular for the assessment of vaccines. To provide an overview of the potential use of challenge models, we present historical reports and contemporary views from experts in this type of research. A range of challenge models and practical approaches to generate important data exist and are used to expedite vaccine and therapeutic development and to support public health modelling and interventions. Although human challenge studies provide a unique opportunity to address complex research questions, participant and investigator safety is paramount. To increase the collaborative effort and future success of this area of research, we recommend the development of consensus frameworks and sharing of best practices between investigators. Furthermore, standardisation of challenge procedures and regulatory guidance will help with the feasibility for using challenge models in clinical testing of new disease intervention strategies.
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Affiliation(s)
- Thomas C Darton
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK; National Institute of Health Research (NIHR) Oxford Biomedical Research Centre, Oxford, UK
| | - Christoph J Blohmke
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK; National Institute of Health Research (NIHR) Oxford Biomedical Research Centre, Oxford, UK.
| | - Vasee S Moorthy
- Department of Immunisation, Vaccines and Biologicals, WHO, Geneva, Switzerland
| | | | - Frederick G Hayden
- Department of Medicine, University of Virginia School of Medicine, Charlottesville VA, USA
| | - Elizabeth A Clutterbuck
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK; National Institute of Health Research (NIHR) Oxford Biomedical Research Centre, Oxford, UK
| | - Myron M Levine
- Center for Vaccine Development, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Adrian V S Hill
- The Jenner Institute Laboratories, University of Oxford, Oxford, UK
| | - Andrew J Pollard
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK; National Institute of Health Research (NIHR) Oxford Biomedical Research Centre, Oxford, UK
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Hodgson SH, Juma E, Salim A, Magiri C, Njenga D, Molyneux S, Njuguna P, Awuondo K, Lowe B, Billingsley PF, Cole AO, Ogwang C, Osier F, Chilengi R, Hoffman SL, Draper SJ, Ogutu B, Marsh K. Lessons learnt from the first controlled human malaria infection study conducted in Nairobi, Kenya. Malar J 2015; 14:182. [PMID: 25927522 PMCID: PMC4416324 DOI: 10.1186/s12936-015-0671-x] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 03/15/2015] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Controlled human malaria infection (CHMI) studies, in which healthy volunteers are infected with Plasmodium falciparum to assess the efficacy of novel malaria vaccines and drugs, have become a vital tool to accelerate vaccine and drug development. CHMI studies provide a cost-effective and expeditious way to circumvent the use of large-scale field efficacy studies to deselect intervention candidates. However, to date few modern CHMI studies have been performed in malaria-endemic countries. METHODS An open-label, randomized pilot CHMI study was conducted using aseptic, purified, cryopreserved, infectious P. falciparum sporozoites (SPZ) (Sanaria® PfSPZ Challenge) administered intramuscularly (IM) to healthy Kenyan adults (n = 28) with varying degrees of prior exposure to P. falciparum. The purpose of the study was to establish the PfSPZ Challenge CHMI model in a Kenyan setting with the aim of increasing the international capacity for efficacy testing of malaria vaccines and drugs, and allowing earlier assessment of efficacy in a population for which interventions are being developed. This was part of the EDCTP-funded capacity development of the CHMI platform in Africa. DISCUSSION This paper discusses in detail lessons learnt from conducting the first CHMI study in Kenya. Issues pertinent to the African setting, including community sensitization, consent and recruitment are considered. Detailed reasoning regarding the study design (for example, dose and route of administration of PfSPZ Challenge, criteria for grouping volunteers according to prior exposure to malaria and duration of follow-up post CHMI) are given and changes other centres may want to consider for future studies are suggested. CONCLUSIONS Performing CHMI studies in an African setting presents unique but surmountable challenges and offers great opportunity for acceleration of malaria vaccine and drug development. The reflections in this paper aim to aid other centres and partners intending to use the CHMI model in Africa.
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Affiliation(s)
| | - Elizabeth Juma
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya.
- Centre for Research in Therapeutic Sciences, Strathmore University, Nairobi, Kenya.
| | - Amina Salim
- Kenya Medical Research Institute - Wellcome Trust, Centre for Geographical Medical Research (Coast), Kilifi, Kenya.
| | - Charles Magiri
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya.
| | - Daniel Njenga
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya.
| | - Sassy Molyneux
- Kenya Medical Research Institute - Wellcome Trust, Centre for Geographical Medical Research (Coast), Kilifi, Kenya.
| | - Patricia Njuguna
- Kenya Medical Research Institute - Wellcome Trust, Centre for Geographical Medical Research (Coast), Kilifi, Kenya.
| | - Ken Awuondo
- Kenya Medical Research Institute - Wellcome Trust, Centre for Geographical Medical Research (Coast), Kilifi, Kenya.
| | - Brett Lowe
- Kenya Medical Research Institute - Wellcome Trust, Centre for Geographical Medical Research (Coast), Kilifi, Kenya.
| | | | - Andrew O Cole
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya.
- Centre for Research in Therapeutic Sciences, Strathmore University, Nairobi, Kenya.
| | - Caroline Ogwang
- Kenya Medical Research Institute - Wellcome Trust, Centre for Geographical Medical Research (Coast), Kilifi, Kenya.
| | - Faith Osier
- Kenya Medical Research Institute - Wellcome Trust, Centre for Geographical Medical Research (Coast), Kilifi, Kenya.
| | - Roma Chilengi
- Centre for Infectious Disease Research in Zambia, Lusaka, Zambia.
| | | | | | - Bernhards Ogutu
- Centre for Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya.
- Centre for Research in Therapeutic Sciences, Strathmore University, Nairobi, Kenya.
| | - Kevin Marsh
- Kenya Medical Research Institute - Wellcome Trust, Centre for Geographical Medical Research (Coast), Kilifi, Kenya.
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Hodgson SH, Juma E, Salim A, Magiri C, Kimani D, Njenga D, Muia A, Cole AO, Ogwang C, Awuondo K, Lowe B, Munene M, Billingsley PF, James ER, Gunasekera A, Sim BKL, Njuguna P, Rampling TW, Richman A, Abebe Y, Kamuyu G, Muthui M, Elias SC, Molyneux S, Gerry S, Macharia A, Williams TN, Bull PC, Hill AVS, Osier FH, Draper SJ, Bejon P, Hoffman SL, Ogutu B, Marsh K. Evaluating controlled human malaria infection in Kenyan adults with varying degrees of prior exposure to Plasmodium falciparum using sporozoites administered by intramuscular injection. Front Microbiol 2014; 5:686. [PMID: 25566206 PMCID: PMC4264479 DOI: 10.3389/fmicb.2014.00686] [Citation(s) in RCA: 87] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Accepted: 11/14/2014] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Controlled human malaria infection (CHMI) studies are a vital tool to accelerate vaccine and drug development. As CHMI trials are performed in a controlled environment, they allow unprecedented, detailed evaluation of parasite growth dynamics (PGD) and immunological responses. However, CHMI studies have not been routinely performed in malaria-endemic countries or used to investigate mechanisms of naturally-acquired immunity (NAI) to Plasmodium falciparum. METHODS We conducted an open-label, randomized CHMI pilot-study using aseptic, cryopreserved P. falciparum sporozoites (PfSPZ Challenge) to evaluate safety, infectivity and PGD in Kenyan adults with low to moderate prior exposure to P. falciparum (Pan African Clinical Trial Registry: PACTR20121100033272). RESULTS All participants developed blood-stage infection confirmed by quantitative polymerase chain reaction (qPCR). However one volunteer (110) remained asymptomatic and blood-film negative until day 21 post-injection of PfSPZ Challenge. This volunteer had a reduced parasite multiplication rate (PMR) (1.3) in comparison to the other 27 volunteers (median 11.1). A significant correlation was seen between PMR and screening anti-schizont Enzyme Linked Immunosorbent Assays (ELISA) OD (p = 0.044, R = -0.384) but not when volunteer 110 was excluded from the analysis (p = 0.112, R = -0.313). CONCLUSIONS PfSPZ Challenge is safe and infectious in malaria-endemic populations and could be used to assess the efficacy of malaria vaccines and drugs in African populations. Whilst our findings are limited by sample size, our pilot study has demonstrated for the first time that NAI may impact on PMR post-CHMI in a detectable fashion, an important finding that should be evaluated in further CHMI studies.
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Affiliation(s)
| | - Elizabeth Juma
- Centre for Clinical Research, Kenya Medical Research Institute Nairobi, Kenya ; Centre for Research in Therapeutic Sciences, Strathmore University Nairobi, Kenya
| | - Amina Salim
- Centre for Geographical Medical Research (Coast), Kenya Medical Research Institute - Wellcome Trust Kilifi, Kenya
| | - Charles Magiri
- Centre for Clinical Research, Kenya Medical Research Institute Nairobi, Kenya
| | - Domtila Kimani
- Centre for Geographical Medical Research (Coast), Kenya Medical Research Institute - Wellcome Trust Kilifi, Kenya
| | - Daniel Njenga
- Centre for Clinical Research, Kenya Medical Research Institute Nairobi, Kenya
| | - Alfred Muia
- Centre for Clinical Research, Kenya Medical Research Institute Nairobi, Kenya
| | - Andrew O Cole
- Centre for Clinical Research, Kenya Medical Research Institute Nairobi, Kenya ; Centre for Research in Therapeutic Sciences, Strathmore University Nairobi, Kenya
| | - Caroline Ogwang
- Centre for Geographical Medical Research (Coast), Kenya Medical Research Institute - Wellcome Trust Kilifi, Kenya
| | - Ken Awuondo
- Centre for Geographical Medical Research (Coast), Kenya Medical Research Institute - Wellcome Trust Kilifi, Kenya
| | - Brett Lowe
- Centre for Geographical Medical Research (Coast), Kenya Medical Research Institute - Wellcome Trust Kilifi, Kenya
| | - Marianne Munene
- Centre for Geographical Medical Research (Coast), Kenya Medical Research Institute - Wellcome Trust Kilifi, Kenya
| | | | | | | | | | - Patricia Njuguna
- Centre for Geographical Medical Research (Coast), Kenya Medical Research Institute - Wellcome Trust Kilifi, Kenya
| | | | | | | | - Gathoni Kamuyu
- Centre for Geographical Medical Research (Coast), Kenya Medical Research Institute - Wellcome Trust Kilifi, Kenya
| | - Michelle Muthui
- Centre for Geographical Medical Research (Coast), Kenya Medical Research Institute - Wellcome Trust Kilifi, Kenya
| | - Sean C Elias
- The Jenner Institute, University of Oxford Oxford, UK
| | - Sassy Molyneux
- Centre for Geographical Medical Research (Coast), Kenya Medical Research Institute - Wellcome Trust Kilifi, Kenya
| | - Stephen Gerry
- Centre for Statistics in Medicine, University of Oxford Oxford, UK
| | - Alex Macharia
- Centre for Geographical Medical Research (Coast), Kenya Medical Research Institute - Wellcome Trust Kilifi, Kenya
| | - Thomas N Williams
- Centre for Geographical Medical Research (Coast), Kenya Medical Research Institute - Wellcome Trust Kilifi, Kenya ; Department of Medicine, Imperial College London London, UK
| | - Peter C Bull
- Centre for Geographical Medical Research (Coast), Kenya Medical Research Institute - Wellcome Trust Kilifi, Kenya
| | | | - Faith H Osier
- Centre for Geographical Medical Research (Coast), Kenya Medical Research Institute - Wellcome Trust Kilifi, Kenya
| | | | - Philip Bejon
- Centre for Geographical Medical Research (Coast), Kenya Medical Research Institute - Wellcome Trust Kilifi, Kenya
| | | | - Bernhards Ogutu
- Centre for Clinical Research, Kenya Medical Research Institute Nairobi, Kenya ; Centre for Research in Therapeutic Sciences, Strathmore University Nairobi, Kenya
| | - Kevin Marsh
- Centre for Geographical Medical Research (Coast), Kenya Medical Research Institute - Wellcome Trust Kilifi, Kenya
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Shekalaghe S, Rutaihwa M, Billingsley PF, Chemba M, Daubenberger CA, James ER, Mpina M, Ali Juma O, Schindler T, Huber E, Gunasekera A, Manoj A, Simon B, Saverino E, Church LWP, Hermsen CC, Sauerwein RW, Plowe C, Venkatesan M, Sasi P, Lweno O, Mutani P, Hamad A, Mohammed A, Urassa A, Mzee T, Padilla D, Ruben A, Lee Sim BK, Tanner M, Abdulla S, Hoffman SL. Controlled human malaria infection of Tanzanians by intradermal injection of aseptic, purified, cryopreserved Plasmodium falciparum sporozoites. Am J Trop Med Hyg 2014; 91:471-480. [PMID: 25070995 PMCID: PMC4155546 DOI: 10.4269/ajtmh.14-0119] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Controlled human malaria infection (CHMI) by mosquito bite has been used to assess anti-malaria interventions in > 1,500 volunteers since development of methods for infecting mosquitoes by feeding on Plasmodium falciparum (Pf) gametocyte cultures. Such CHMIs have never been used in Africa. Aseptic, purified, cryopreserved Pf sporozoites, PfSPZ Challenge, were used to infect Dutch volunteers by intradermal injection. We conducted a double-blind, placebo-controlled trial to assess safety and infectivity of PfSPZ Challenge in adult male Tanzanians. Volunteers were injected intradermally with 10,000 (N = 12) or 25,000 (N = 12) PfSPZ or normal saline (N = 6). PfSPZ Challenge was well tolerated and safe. Eleven of 12 and 10 of 11 subjects, who received 10,000 and 25,000 PfSPZ respectively, developed parasitemia. In 10,000 versus 25,000 PfSPZ groups geometric mean days from injection to Pf positivity by thick blood film was 15.4 versus 13.5 (P = 0.023). Alpha-thalassemia heterozygosity had no apparent effect on infectivity. PfSPZ Challenge was safe, well tolerated, and infectious.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Stephen L. Hoffman
- *Address correspondence to Stephen L. Hoffman, Sanaria Inc., 9800 Medical Center Drive, Rockville, MD 20850. E-mail:
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Martins AC, Lins JB, Santos LMN, Fernandes LN, Malafronte RS, Maia TC, Ribera MCV, Ribera RB, da Silva-Nunes M. Vivax malaria in an Amazonian child with dilated cardiomyopathy. Malar J 2014; 13:61. [PMID: 24548824 PMCID: PMC3945074 DOI: 10.1186/1475-2875-13-61] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Accepted: 02/14/2014] [Indexed: 12/17/2022] Open
Abstract
A child living in the Brazilian Amazon region who had had vivax malaria at the age of 11 months was admitted three months later with a history of progressive dyspnoea and fever, which culminated in respiratory distress and severe dilated cardiomyopathy at hospital admission in a malaria-free area. She received treatment for cardiac insufficiency and was tested for malaria with two thick blood smears, which were negative. There was general improvement of cardiorespiratory function in the next two weeks, but in the third week of hospital admission, there was re-appearance of fever, severe anaemia, severe plaquetopaenia, and respiratory distress. A third thick blood smear was positive for Plasmodium vivax mono-infection, which was confirmed by molecular methods. A serological panel with the most prevalent infectious agents known to cause myocarditis was performed, and specific anti-cytomegalovirus (CMV) IgM and elevated levels of anti-CMV IgG were also detected in the serum. After treatment for malaria, there was improvement of respiratory distress, although cardiac function did not recover. She was discharged home with drugs for cardiac insufficiency and is currently under follow-up with a paediatric cardiologist as an outpatient. This report presents a young child with several episodes of vivax malaria who suffers from cardiac insufficiency, probably related to CMV-induced myocarditis.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Monica da Silva-Nunes
- Health Sciences Centre, Federal University of Acre, BR 364 KM 04, Rio Branco, Acre, Brazil.
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van Meer MPA, Bastiaens GJH, Boulaksil M, de Mast Q, Gunasekera A, Hoffman SL, Pop G, van der Ven AJAM, Sauerwein RW. Idiopathic acute myocarditis during treatment for controlled human malaria infection: a case report. Malar J 2014; 13:38. [PMID: 24479524 PMCID: PMC3909449 DOI: 10.1186/1475-2875-13-38] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Accepted: 01/27/2014] [Indexed: 11/10/2022] Open
Abstract
A 23-year-old healthy male volunteer took part in a clinical trial in which the volunteer took chloroquine chemoprophylaxis and received three intradermal doses at four-week intervals of aseptic, purified Plasmodium falciparum sporozoites to induce protective immunity against malaria. Fifty-nine days after the last administration of sporozoites and 32 days after the last dose of chloroquine the volunteer underwent controlled human malaria infection (CHMI) by the bites of five P. falciparum-infected mosquitoes. Eleven days post-CHMI a thick blood smear was positive (6 P. falciparum/μL blood) and treatment was initiated with atovaquone/proguanil (Malarone®). On the second day of treatment, day 12 post-CHMI, troponin T, a marker for cardiac tissue damage, began to rise above normal, and reached a maximum of 1,115 ng/L (upper range of normal = 14 ng/L) on day 16 post-CHMI. The volunteer had one ~20 minute episode of retrosternal chest pain and heavy feeling in his left arm on day 14 post-CHMI. ECG at the time revealed minor repolarization disturbances, and cardiac MRI demonstrated focal areas of subepicardial and midwall delayed enhancement of the left ventricle with some oedema and hypokinesia. A diagnosis of myocarditis was made. Troponin T levels were normal within 16 days and the volunteer recovered without clinical sequelae. Follow-up cardiac MRI at almost five months showed normal function of both ventricles and disappearance of oedema. Delayed enhancement of subepicardial and midwall regions decreased, but was still present. With the exception of a throat swab that was positive for rhinovirus on day 14 post-CHMI, no other tests for potential aetiologies of the myocarditis were positive. A number of possible aetiological factors may explain or have contributed to this case of myocarditis including, i) P. falciparum infection, ii) rhinovirus infection, iii) unidentified pathogens, iv) hyper-immunization (the volunteer received six travel vaccines between the last immunization and the CHMI), v) atovaquone/proguanil treatment, or vi) a combination of these factors. Definitive aetiology and pathophysiological mechanism for the myocarditis have not been established.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Robert W Sauerwein
- Department of Medical Microbiology, Radboud University Medical Center, Nijmegen, The Netherlands.
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Myocardial Dysfunction: A Primary Cause of Death Due To Severe Malaria in A Plasmodium falciparum-Infected Humanized Mouse Model. IRANIAN JOURNAL OF PARASITOLOGY 2013; 8:499-509. [PMID: 25516729 PMCID: PMC4266112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/20/2013] [Accepted: 09/11/2013] [Indexed: 11/19/2022]
Abstract
BACKGROUND Our study aimed at substantiating the recent claim of myocardial complications in severe malaria by experimentally inducing severe Plasmodium falciparum infection in a humanized mouse model employed as human surrogate. METHODS Twenty five humanized mice were inoculated with standard in vitro cultured P. falciparum and blood extracts collected from the inner cardiac muscles of infected mice that died were examined for the presence of the infectious cause of death. The therapeutic effect of quinine on 7 mice severely infected with P. falciparum was also evaluated. RESULTS All the 25 humanized mice inoculated with the in vitro cultured P. falciparum revealed peripheral parasitemia with a total of 10 deaths recorded. Postmortem examination of the inner cardiac muscles of the dead mice also revealed massive sequestration of mature P. falciparum as well as significant infiltration of inflammatory cells such as lymphocytes and monocytes. Postmortem evaluation of the inner cardiac muscles of the P. falciparum-infected mice after quinine therapy showed significant decline in parasite density with no death of mice recorded. CONCLUSIONS Data obtained from our study significantly corroborated the findings of myocardial dysfunction as the primary cause of death in recent case reports of humans infected with P. falciparum.
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McCarthy JS, Griffin PM, Sekuloski S, Bright AT, Rockett R, Looke D, Elliott S, Whiley D, Sloots T, Winzeler EA, Trenholme KR. Experimentally induced blood-stage Plasmodium vivax infection in healthy volunteers. J Infect Dis 2013; 208:1688-94. [PMID: 23908484 DOI: 10.1093/infdis/jit394] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Major impediments to development of vaccines and drugs for Plasmodium vivax malaria are the inability to culture this species and the extreme difficulty in undertaking clinical research by experimental infection. METHODS A parasite bank was collected from a 49-year-old woman with P. vivax infection, characterized, and used in an experimental infection study. RESULTS The donor made a full recovery from malaria after collection of a parasite bank, which tested negative for agents screened for in blood donations. DNA sequence analysis of the isolate indicated that it was clonal. Two subjects inoculated with the isolate became polymerase chain reaction positive on days 8 and 9, with onset of symptoms and positive blood smears on day 14, when they were treated with artemether-lumefantrine, with rapid clinical and parasitologic response. Transcripts of the parasite gene pvs25 that is expressed in gametocytes, the life cycle stage infectious to mosquitoes, were first detected on days 11 and 12. CONCLUSIONS This experimental system results in in vivo parasite growth, probably infectious to mosquitoes. It offers the opportunity to undertake studies previously impossible in P. vivax that will facilitate a better understanding of the pathology of vivax malaria and development of antimalarial drugs and vaccines. Trial Registration. ANZCTR: 12612001096842.
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Laurens MB, Billingsley P, Richman A, Eappen AG, Adams M, Li T, Chakravarty S, Gunasekera A, Jacob CG, Sim BKL, Edelman R, Plowe CV, Hoffman SL, Lyke KE. Successful human infection with P. falciparum using three aseptic Anopheles stephensi mosquitoes: a new model for controlled human malaria infection. PLoS One 2013; 8:e68969. [PMID: 23874828 PMCID: PMC3712927 DOI: 10.1371/journal.pone.0068969] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2012] [Accepted: 05/31/2013] [Indexed: 11/18/2022] Open
Abstract
UNLABELLED Controlled human malaria infection (CHMI) is a powerful method for assessing the efficacy of anti-malaria vaccines and drugs targeting pre-erythrocytic and erythrocytic stages of the parasite. CHMI has heretofore required the bites of 5 Plasmodium falciparum (Pf) sporozoite (SPZ)-infected mosquitoes to reliably induce Pf malaria. We reported that CHMI using the bites of 3 PfSPZ-infected mosquitoes reared aseptically in compliance with current good manufacturing practices (cGMP) was successful in 6 participants. Here, we report results from a subsequent CHMI study using 3 PfSPZ-infected mosquitoes reared aseptically to validate the initial clinical trial. We also compare results of safety, tolerability, and transmission dynamics in participants undergoing CHMI using 3 PfSPZ-infected mosquitoes reared aseptically to published studies of CHMI using 5 mosquitoes. Nineteen adults aged 18-40 years were bitten by 3 Anopheles stephensi mosquitoes infected with the chloroquine-sensitive NF54 strain of Pf. All 19 participants developed malaria (100%); 12 of 19 (63%) on Day 11. The mean pre-patent period was 258.3 hours (range 210.5-333.8). The geometric mean parasitemia at first diagnosis by microscopy was 9.5 parasites/µL (range 2-44). Quantitative polymerase chain reaction (qPCR) detected parasites an average of 79.8 hours (range 43.8-116.7) before microscopy. The mosquitoes had a geometric mean of 37,894 PfSPZ/mosquito (range 3,500-152,200). Exposure to the bites of 3 aseptically-raised, PfSPZ-infected mosquitoes is a safe, effective procedure for CHMI in malaria-naïve adults. The aseptic model should be considered as a new standard for CHMI trials in non-endemic areas. Microscopy is the gold standard used for the diagnosis of Pf malaria after CHMI, but qPCR identifies parasites earlier. If qPCR continues to be shown to be highly specific, and can be made to be practical, rapid, and standardized, it should be considered as an alternative for diagnosis. TRIAL REGISTRATION ClinicalTrials.gov NCT00744133 NCT00744133.
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Affiliation(s)
- Matthew B Laurens
- Howard Hughes Medical Institute/Center for Vaccine Development, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
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Sengupta A, Ghosh S, Sharma S, Sonawat HM. 1H NMR metabonomics indicates continued metabolic changes and sexual dimorphism post-parasite clearance in self-limiting murine malaria model. PLoS One 2013; 8:e66954. [PMID: 23826178 PMCID: PMC3691208 DOI: 10.1371/journal.pone.0066954] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Accepted: 05/13/2013] [Indexed: 11/18/2022] Open
Abstract
Malaria, a mosquito-borne disease caused by Plasmodium spp. is considered to be a global threat, specifically for the developing countries. In human subjects considerable information exists regarding post-malarial physiology. However, most murine malarial models are lethal, and most studies deal with acute phases occurring as disease progresses. Much less is known regarding physiological status post-parasite clearance. We have assessed the physiological changes at the organ levels using (1)H NMR based metabonomics in a non lethal self-clearing murine malarial model of P. chabaudi parasites and Balb/C, far beyond the parasite clearance point. The results showed distinct metabolic states between uninfected and infected mice at the peak parasitemia, as well as three weeks post-parasite clearance. Our data also suggests that the response at the peak infection as well as recovery exhibited distinct sexual dimorphism. Specifically, we observed accumulation of acetylcholine in the brain metabolic profile of both the sexes. This might have important implication in understanding the pathophysiology of the post malarial neurological syndromes. In addition, the female liver showed high levels of glucose, dimethylglycine, methylacetoacetate and histidine after three weeks post-parasite clearance, while the males showed accumulation of branched chain amino acids, lysine, glutamine and bile acids.
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Affiliation(s)
- Arjun Sengupta
- Department of Chemical Sciences, Tata Institute of Fundamental Research, Mumbai, India
| | - Soumita Ghosh
- Department of Chemical Sciences, Tata Institute of Fundamental Research, Mumbai, India
| | - Shobhona Sharma
- Department of Biological Sciences, Tata Institute of Fundamental Research, Mumbai, India
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Abstract
A 40-year-old healthy manual labourer from a malaria endemic area with no known risk factors for atherosclerotic coronary vascular disease was admitted to our hospital with a history of fever with chills and rigours. Physical examination revealed tachypnoea and icterus. Peripheral smear showed trophozoites of Plasmodium vivax and thrombocytopaenia. The patient was administered artesunate. Six hours after admission, he complained of severe substernal chest pain. A 12-lead ECG revealed ST elevations in leads I, II and aVL. Troponin T and creatine kinase MB were elevated and the random blood sugar was 49 mg%. Echocardiogram revealed left ventricle lateral wall hypokinesia. Hypoglycaemia was corrected. A provisional diagnosis of acute coronary syndrome as a complication of malaria or its treatment was made. He was treated with low molecular weight heparin and nitrates. The patient improved symptomatically. A repeat ECG was normal.
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Affiliation(s)
- Smitha Bhat
- Department of Medicine, Father Muller Medical College, Mangalore, Karnataka, India.
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Roestenberg M, Bijker EM, Sim BKL, Billingsley PF, James ER, Bastiaens GJH, Teirlinck AC, Scholzen A, Teelen K, Arens T, van der Ven AJAM, Gunasekera A, Chakravarty S, Velmurugan S, Hermsen CC, Sauerwein RW, Hoffman SL. Controlled human malaria infections by intradermal injection of cryopreserved Plasmodium falciparum sporozoites. Am J Trop Med Hyg 2012; 88:5-13. [PMID: 23149582 PMCID: PMC3541746 DOI: 10.4269/ajtmh.2012.12-0613] [Citation(s) in RCA: 120] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Controlled human malaria infection with sporozoites is a standardized and powerful tool for evaluation of malaria vaccine and drug efficacy but so far only applied by exposure to bites of Plasmodium falciparum (Pf)-infected mosquitoes. We assessed in an open label Phase 1 trial, infection after intradermal injection of respectively 2,500, 10,000, or 25,000 aseptic, purified, vialed, cryopreserved Pf sporozoites (PfSPZ) in three groups (N = 6/group) of healthy Dutch volunteers. Infection was safe and parasitemia developed in 15 of 18 volunteers (84%), 5 of 6 volunteers in each group. There were no differences between groups in time until parasitemia by microscopy or quantitative polymerase chain reaction, parasite kinetics, clinical symptoms, or laboratory values. This is the first successful infection by needle and syringe with PfSPZ manufactured in compliance with regulatory standards. After further optimization, the use of such PfSPZ may facilitate and accelerate clinical development of novel malaria drugs and vaccines.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Stephen L. Hoffman
- *Address correspondence to Stephen L. Hoffman, Sanaria Inc., 9800 Medical Center Drive, Rockville, MD 20850. E-mail:
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Chianura L, Errante IC, Travi G, Rossotti R, Puoti M. Hyperglycemia in severe falciparum malaria: a case report. Case Rep Crit Care 2012; 2012:312458. [PMID: 25161774 PMCID: PMC4010067 DOI: 10.1155/2012/312458] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Accepted: 10/13/2012] [Indexed: 12/04/2022] Open
Abstract
Occasionally, malaria may present with unusual signs and symptoms. We report a case of an uncommon presentation of Plasmodium falciparum infection in a 59-year-old Ethiopian immigrant, which initially presented with hyperglycaemia and multiple organ dysfunction syndrome (MODS). Reports of unusual presentations of malaria are few and cases of severe malaria with hyperglycaemia are rarely described. As hyperglycaemia is associated to most severe malaria and high mortality, our aim is to catch the attention of the physicians on this entity.
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Affiliation(s)
- Leonardo Chianura
- Department of Infectious Diseases, Niguarda Cà Granda Hospital, Piazza Ospedale Maggiore 3, 20162 Milano, Italy
| | - Isabella Corinna Errante
- Department of Infectious Diseases, Niguarda Cà Granda Hospital, Piazza Ospedale Maggiore 3, 20162 Milano, Italy
| | - Giovanna Travi
- Department of Infectious Diseases, Niguarda Cà Granda Hospital, Piazza Ospedale Maggiore 3, 20162 Milano, Italy
| | - Roberto Rossotti
- Department of Infectious Diseases, Niguarda Cà Granda Hospital, Piazza Ospedale Maggiore 3, 20162 Milano, Italy
| | - Massimo Puoti
- Department of Infectious Diseases, Niguarda Cà Granda Hospital, Piazza Ospedale Maggiore 3, 20162 Milano, Italy
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Comparison of clinical and parasitological data from controlled human malaria infection trials. PLoS One 2012; 7:e38434. [PMID: 22701640 PMCID: PMC3372522 DOI: 10.1371/journal.pone.0038434] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2012] [Accepted: 05/09/2012] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Exposing healthy human volunteers to Plasmodium falciparum-infected mosquitoes is an accepted tool to evaluate preliminary efficacy of malaria vaccines. To accommodate the demand of the malaria vaccine pipeline, controlled infections are carried out in an increasing number of centers worldwide. We assessed their safety and reproducibility. METHODS We reviewed safety and parasitological data from 128 malaria-naïve subjects participating in controlled malaria infection trials conducted at the University of Oxford, UK, and the Radboud University Nijmegen Medical Center, The Netherlands. Results were compared to a report from the US Military Malaria Vaccine Program. RESULTS We show that controlled human malaria infection trials are safe and demonstrate a consistent safety profile with minor differences in the frequencies of arthralgia, fatigue, chills and fever between institutions. But prepatent periods show significant variation. Detailed analysis of Q-PCR data reveals highly synchronous blood stage parasite growth and multiplication rates. CONCLUSIONS Procedural differences can lead to some variation in safety profile and parasite kinetics between institutions. Further harmonization and standardization of protocols will be useful for wider adoption of these cost-effective small-scale efficacy trials. Nevertheless, parasite growth rates are highly reproducible, illustrating the robustness of controlled infections as a valid tool for malaria vaccine development.
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Schwartz L, Brown GV, Genton B, Moorthy VS. A review of malaria vaccine clinical projects based on the WHO rainbow table. Malar J 2012; 11:11. [PMID: 22230255 PMCID: PMC3286401 DOI: 10.1186/1475-2875-11-11] [Citation(s) in RCA: 172] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2011] [Accepted: 01/09/2012] [Indexed: 12/14/2022] Open
Abstract
Development and Phase 3 testing of the most advanced malaria vaccine, RTS,S/AS01, indicates that malaria vaccine R&D is moving into a new phase. Field trials of several research malaria vaccines have also confirmed that it is possible to impact the host-parasite relationship through vaccine-induced immune responses to multiple antigenic targets using different platforms. Other approaches have been appropriately tested but turned out to be disappointing after clinical evaluation. As the malaria community considers the potential role of a first-generation malaria vaccine in malaria control efforts, it is an apposite time to carefully document terminated and ongoing malaria vaccine research projects so that lessons learned can be applied to increase the chances of success for second-generation malaria vaccines over the next 10 years. The most comprehensive resource of malaria vaccine projects is a spreadsheet compiled by WHO thanks to the input from funding agencies, sponsors and investigators worldwide. This spreadsheet, available from WHO's website, is known as "the rainbow table". By summarizing the published and some unpublished information available for each project on the rainbow table, the most comprehensive review of malaria vaccine projects to be published in the last several years is provided below.
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Affiliation(s)
- Lauren Schwartz
- Initiative for Vaccine Research, Department of Immunization, Vaccines & Biologicals, World Health Organization, Avenue Appia 20, 1211-CH 27, Geneva, Switzerland
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Herr J, Mehrfar P, Schmiedel S, Wichmann D, Brattig NW, Burchard GD, Cramer JP. Reduced cardiac output in imported Plasmodium falciparum malaria. Malar J 2011; 10:160. [PMID: 21658247 PMCID: PMC3130699 DOI: 10.1186/1475-2875-10-160] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2011] [Accepted: 06/09/2011] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Volume substitution remains subject of controversy in the light of effusions and oedema potentially complicating this highly febrile disease. Understanding the role of myocardial and circulatory function appears to be essential for clinical management. In the present study, cardiac function and cardiac proteins have been assessed and correlated with parasitological and immunologic parameters in patients with imported Plasmodium falciparum malaria. METHODS In a prospective case-control study, 28 patients with uncomplicated and complicated P. falciparum malaria were included and findings were compared with 26 healthy controls. Cardiac function parameters were assessed by an innovative non-invasive method based on the re-breathing technique. In addition, cardiac enzymes and pro- and anti-inflammatory cytokines were measured and assessed with respect to clinical symptoms and conditions of malaria. RESULTS Cardiac index (CI) as a measurement of cardiac output (CO) was 21% lower in malaria patients than in healthy controls (2.7 l/min/m2 versus 3.4 l/min/m2; P < 0.001). In contrast, systemic vascular resistance index (SVRI) was increased by 29% (32.6 mmHg⋅m2/(l/min) versus 23.2 mmHg⋅m2/(l/min); P < 0.001). This correlated with increased cardiac proteins in patients versus controls: pro-BNP 139.3 pg/ml versus 60.4 pg/ml (P = 0.03), myoglobin 43.6 μg/l versus 27.8 μg/l (P = < 0.001). All measured cytokines were significantly increased in patients with malaria. CI, SVRI as well as cytokine levels did not correlate with blood parasite density. CONCLUSIONS The results support previous reports suggesting impaired cardiac function contributing to clinical manifestations in P. falciparum malaria. Findings may be relevant for fluid management and should be further explored in endemic regions.
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Affiliation(s)
- Johanna Herr
- University Medical Center Hamburg-Eppendorf, Section Tropical Medicine, Bernhard-Nocht-Strasse 74, 20359 Hamburg, Germany
| | - Parisa Mehrfar
- University Medical Center Hamburg-Eppendorf, Section Tropical Medicine, Bernhard-Nocht-Strasse 74, 20359 Hamburg, Germany
| | - Stefan Schmiedel
- University Medical Center Hamburg-Eppendorf, Section Tropical Medicine, Bernhard-Nocht-Strasse 74, 20359 Hamburg, Germany
| | - Dominic Wichmann
- University Medical Center-Hamburg-Eppendorf, Department Intensive Care Medicine, Martinistr. 52, 20246 Hamburg, Germany
| | - Norbert W Brattig
- Bernhard Nocht Institute for Tropical Medicine, Department of Molecular Medicine, Bernhard-Nocht-Strasse 74, 20359 Hamburg, Germany
| | - Gerd D Burchard
- University Medical Center Hamburg-Eppendorf, Section Tropical Medicine, Bernhard-Nocht-Strasse 74, 20359 Hamburg, Germany
- Bernhard Nocht Institute for Tropical Medicine, Clinical Research Group, Bernhard-Nocht-Strasse 74, 20359 Hamburg, Germany
| | - Jakob P Cramer
- University Medical Center Hamburg-Eppendorf, Section Tropical Medicine, Bernhard-Nocht-Strasse 74, 20359 Hamburg, Germany
- Bernhard Nocht Institute for Tropical Medicine, Clinical Research Group, Bernhard-Nocht-Strasse 74, 20359 Hamburg, Germany
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Roestenberg M, Teirlinck AC, McCall MBB, Teelen K, Makamdop KN, Wiersma J, Arens T, Beckers P, van Gemert G, van de Vegte-Bolmer M, van der Ven AJAM, Luty AJF, Hermsen CC, Sauerwein RW. Long-term protection against malaria after experimental sporozoite inoculation: an open-label follow-up study. Lancet 2011; 377:1770-6. [PMID: 21514658 DOI: 10.1016/s0140-6736(11)60360-7] [Citation(s) in RCA: 217] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND We have shown that immunity to infection with Plasmodium falciparum can be induced experimentally in malaria-naive volunteers through immunisation by bites of infected mosquitoes while simultaneously preventing disease with chloroquine prophylaxis. This immunity was associated with parasite-specific production of interferon γ and interleukin 2 by pluripotent effector memory cells in vitro. We aim to explore the persistence of protection and immune responses in the same volunteers. METHODS In an open-label study at the Radboud University Nijmegen Medical Centre (Nijmegen, Netherlands), from November to December, 2009, we rechallenged previously immune volunteers (28 months after immunisation) with the bites of five mosquitoes infected with P falciparum. Newly recruited malaria-naive volunteers served as infection controls. Our primary outcome was the detection of blood-stage parasitaemia by microscopy. We assessed the kinetics of parasitaemia with real-time quantitative PCR (rtPCR) and recorded clinical signs and symptoms. In-vitro production of interferon γ and interleukin 2 by effector memory T cells was studied after stimulation with sporozoites and red blood cells infected with P falciparum. Differences in cellular immune responses between the study groups were assessed with the Mann-Whitney test. This study is registered with ClinicalTrials.gov, number NCT00757887. FINDINGS Four of six immune volunteers were microscopically negative after rechallenge. rtPCR-based detection of blood-stage parasites in these individuals was negative throughout follow-up. Patent parasitaemia was delayed in the remaining two immunised volunteers. In-vitro assays showed the long-term persistence of parasite-specific pluripotent effector memory T-cell responses in protected volunteers. The four protected volunteers reported several mild to moderate adverse events, of which the most commonly reported symptom was headache (one to three episodes per volunteer). The two patients with delayed patency had adverse events similar to those in the control group. INTERPRETATION Artificially induced immunity lasts longer than generally recorded after natural exposure; providing a new avenue of research into the mechanisms of malaria immunity. FUNDING Dioraphte Foundation.
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Affiliation(s)
- Meta Roestenberg
- Department of Medical Microbiology, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands
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Costenaro P, Benedetti P, Facchin C, Mengoli C, Pellizzer G. Fatal Myocarditis in Course of Plasmodium falciparum Infection: Case Report and Review of Cardiac Complications in Malaria. Case Rep Med 2011; 2011:202083. [PMID: 21541220 PMCID: PMC3085333 DOI: 10.1155/2011/202083] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2011] [Accepted: 02/21/2011] [Indexed: 11/17/2022] Open
Abstract
We describe a fatal case of imported malaria where the sole finding revealed at the postmortem evaluation was an acute lymphocytic myocarditis with myocardiolysis. This case recalls the potential importance of myocardial injury in the prognosis of malaria and prompts a reevaluation of current perspectives on the pathogenesis of severe falciparum infection. In the light of this, we have reviewed the cases of cardiac complications in malaria published to date.
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Affiliation(s)
- Paola Costenaro
- Scuola di Specializzazione in Malattie Infettive, Università degli Studi di Padova, Via Giustiniani, 35122 Padova, Italy
| | - Paolo Benedetti
- Unità Operativa di Malattie infettive e Tropicali, Ospedale S. Bortolo, Viale F. Rodolfi 37, 36100 Vicenza, Italy
| | - Chiara Facchin
- Unità Operativa di Malattie infettive e Tropicali, Ospedale S. Bortolo, Viale F. Rodolfi 37, 36100 Vicenza, Italy
| | - Carlo Mengoli
- Scuola di Specializzazione in Malattie Infettive, Università degli Studi di Padova, Via Giustiniani, 35122 Padova, Italy
| | - Giampietro Pellizzer
- Unità Operativa di Malattie infettive e Tropicali, Ospedale S. Bortolo, Viale F. Rodolfi 37, 36100 Vicenza, Italy
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Sauerwein RW, Roestenberg M, Moorthy VS. Experimental human challenge infections can accelerate clinical malaria vaccine development. Nat Rev Immunol 2011; 11:57-64. [PMID: 21179119 DOI: 10.1038/nri2902] [Citation(s) in RCA: 212] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Malaria is one of the most frequently occurring infectious diseases worldwide, with almost 1 million deaths and an estimated 243 million clinical cases annually. Several candidate malaria vaccines have reached Phase IIb clinical trials, but results have often been disappointing. As an alternative to these Phase IIb field trials, the efficacy of candidate malaria vaccines can first be assessed through the deliberate exposure of participants to the bites of infectious mosquitoes (sporozoite challenge) or to an inoculum of blood-stage parasites (blood-stage challenge). With an increasing number of malaria vaccine candidates being developed, should human malaria challenge models be more widely used to reduce cost and time investments? This article reviews previous experience with both the sporozoite and blood-stage human malaria challenge models and provides future perspectives for these models in malaria vaccine development.
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Affiliation(s)
- Robert W Sauerwein
- Robert W. Sauerwein and Meta Roestenberg are at the Department of Medical Microbiology, Radboud University Nijmegen Medical Centre, HB Nijmegen, The Netherlands
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38
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Lyke KE, Laurens M, Adams M, Billingsley PF, Richman A, Loyevsky M, Chakravarty S, Plowe CV, Sim BKL, Edelman R, Hoffman SL. Plasmodium falciparum malaria challenge by the bite of aseptic Anopheles stephensi mosquitoes: results of a randomized infectivity trial. PLoS One 2010; 5:e13490. [PMID: 21042404 PMCID: PMC2958836 DOI: 10.1371/journal.pone.0013490] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2010] [Accepted: 09/17/2010] [Indexed: 11/21/2022] Open
Abstract
Background Experimental infection of malaria-naïve volunteers by the bite of Plasmodium falciparum-infected mosquitoes is a preferred means to test the protective effect of malaria vaccines and drugs. The standard model relies on the bite of five infected mosquitoes to induce malaria. We examined the efficacy of malaria transmission using mosquitoes raised aseptically in compliance with current Good Manufacturing Practices (cGMPs). Methods and Findings Eighteen adults aged 18–40 years were randomized to receive 1, 3 or 5 bites of Anopheles stephensi mosquitoes infected with the chloroquine-sensitive NF54 strain of P. falciparum. Seventeen participants developed malaria; fourteen occurring on Day 11. The mean prepatent period was 10.9 days (9–12 days). The geometric mean parasitemia was 15.7 parasites/µL (range: 4–70) by microscopy. Polymerase chain reaction (PCR) detected parasites 3.1 (range: 0–4) days prior to microscopy. The geometric mean sporozoite load was 16,753 sporozoites per infected mosquito (range: 1,000–57,500). A 1-bite participant withdrew from the study on Day 13 post-challenge and was PCR and smear negative. Conclusions The use of aseptic, cGMP-compliant P. falciparum-infected mosquitoes is safe, is associated with a precise prepatent period compared to the standard model and appears more efficient than the standard approach, as it led to infection in 100% (6/6) of volunteers exposed to three mosquito bites and 83% (5/6) of volunteers exposed to one mosquito bite. Trial Registration ClinicalTrials.gov NCT00744133
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Affiliation(s)
- Kirsten E Lyke
- Center for Vaccine Development, University of Maryland School of Medicine, Baltimore, Maryland, United States of America.
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