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Abstract
BACKGROUND Tuberculosis causes more deaths than any other infectious disease globally. Bacillus Calmette-Guérin (BCG) is the only available vaccine, but protection is incomplete and variable. The modified Vaccinia Ankara virus expressing antigen 85A (MVA85A) is a viral vector vaccine produced to prevent tuberculosis. OBJECTIVES To assess and summarize the effects of the MVA85A vaccine boosting BCG in humans. SEARCH METHODS We searched the Cochrane Infectious Diseases Group Specialized Register; Central Register of Controlled Trials (CENTRAL); MEDLINE (PubMed); Embase (Ovid); and four other databases. We searched the WHO ICTRP and ClinicalTrials.gov. All searches were run up to 10 May 2018. SELECTION CRITERIA We evaluated randomized controlled trials of MVA85A vaccine given with BCG in people regardless of age or HIV status. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the eligibility and risk of bias of trials, and extracted and analyzed data. The primary outcome was active tuberculosis disease. We summarized dichotomous outcomes using risk ratios (RR) and risk differences (RD), with 95% confidence intervals (CI). Where appropriate, we combined data in meta-analyses. Where meta-analysis was inappropriate, we summarized results narratively. MAIN RESULTS The search identified six studies relating to four Phase 2 randomized controlled trials enrolling 3838 participants. Funding was by government bodies, charities, and philanthropic donors. Five studies included infants, one of them infants born to HIV-positive mothers. One study included adults living with HIV. All trials included authors from Oxford University who led the laboratory development of the vaccine. Participants received intradermal MVA85A after BCG in some studies, and before selective deferred BCG in HIV-exposed infants.The largest trial in 2797 African children was well conducted with low risk of bias for most parameters. Risk of bias was uncertain for selective reporting because there were no precise case definition endpoints for active tuberculosis published prior to the trial analysis.MVA85A added to BCG compared to BCG alone probably has no effect on the risk of developing microbiologically confirmed tuberculosis (RR 0.97, 95% CI 0.58 to 1.62; 3439 participants, 2 trials; moderate-certainty evidence), or the risk of starting on tuberculosis treatment (RR 1.10, 95% CI 0.92 to 1.33; 3687 participants, 3 trials; moderate-certainty evidence). MVA85A probably has no effect on the risk of developing latent tuberculosis (RR 1.01, 95% CI 0.85 to 1.21; 3831 participants, 4 trials; moderate-certainty evidence). Vaccinating people with MVA85A in addition to BCG did not cause life-threatening serious adverse effects (RD 0.00, 95% CI -0.00 to 0.00; 3692 participants, 3 trials; high-certainty evidence). Vaccination with MVA85A is probably associated with an increased risk of local skin adverse effects (3187 participants, 3 trials; moderate-certainty evidence), but not systemic adverse effect related to vaccination (144 participants, 1 trial; low-certainty evidence). This safety profile is consistent with Phase 1 studies which outlined a transient, superficial reaction local to the injection site and mild short-lived symptoms such as malaise and fever. AUTHORS' CONCLUSIONS MVA85A delivered by intradermal injection in addition to BCG is safe but not effective in reducing the risk of developing tuberculosis.
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Affiliation(s)
| | - Sophie Jullien
- Jigme Dorji Wangchuck National Referral HospitalThimphuBhutan
| | - Paul Garner
- Liverpool School of Tropical MedicineDepartment of Clinical SciencesPembroke PlaceLiverpoolMerseysideUKL3 5QA
| | - Samuel Johnson
- Liverpool School of Tropical MedicineDepartment of Clinical SciencesPembroke PlaceLiverpoolMerseysideUKL3 5QA
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2
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Nemes E, Hesseling AC, Tameris M, Mauff K, Downing K, Mulenga H, Rose P, van der Zalm M, Mbaba S, Van As D, Hanekom WA, Walzl G, Scriba TJ, McShane H, Hatherill M. Safety and Immunogenicity of Newborn MVA85A Vaccination and Selective, Delayed Bacille Calmette-Guerin for Infants of Human Immunodeficiency Virus-Infected Mothers: A Phase 2 Randomized, Controlled Trial. Clin Infect Dis 2018; 66:554-563. [PMID: 29028973 PMCID: PMC5849090 DOI: 10.1093/cid/cix834] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 10/23/2017] [Indexed: 12/20/2022] Open
Abstract
Background Vaccination of human immunodeficiency virus (HIV)-infected infants with bacille Calmette-Guérin (BCG) is contraindicated. HIV-exposed newborns need a new tuberculosis vaccination strategy that protects against tuberculosis early in life and avoids the potential risk of BCG disease until after HIV infection has been excluded. Methods This double-blind, randomized, controlled trial compared newborn MVA85A prime vaccination (1 × 108 PFU) vs Candin® control, followed by selective, deferred BCG vaccination at age 8 weeks for HIV-uninfected infants and 12 months follow-up for safety and immunogenicity. Results A total of 248 HIV-exposed infants were enrolled. More frequent mild-moderate reactogenicity events were seen after newborn MVA85A vaccination. However, no significant difference was observed in the rate of severe or serious adverse events, HIV acquisition (n = 1 per arm), or incident tuberculosis disease (n = 5 MVA85A; n = 3 control) compared to the control arm. MVA85A vaccination induced modest but significantly higher Ag85A-specific interferon gamma (IFNγ)+ CD4+ T cells compared to control at weeks 4 and 8 (P < .0001). BCG did not further boost this response in MVA85A vaccinees. The BCG-induced Ag85A-specific IFNγ+ CD4+ T-cell response at weeks 16 and 52 was of similar magnitude in the control arm compared to the MVA85A arm at all time points. Proliferative capacity, functional profiles, and memory phenotype of BCG-specific CD4 responses were similar across study arms. Conclusions MVA85A prime vaccination of HIV-exposed newborns was safe and induced an early modest antigen-specific immune response that did not interfere with, or enhance, immunogenicity of subsequent BCG vaccination. New protein-subunit and viral-vectored tuberculosis vaccine candidates should be tested in HIV-exposed newborns. Clinical Trials Registration NCT01650389.
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Affiliation(s)
- Elisa Nemes
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease & Molecular Medicine and Division of Immunology, Department of Science & Technology/National Research Foundation, University of Cape Town
| | - Anneke C Hesseling
- Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences
| | - Michele Tameris
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease & Molecular Medicine and Division of Immunology, Department of Science & Technology/National Research Foundation, University of Cape Town
| | - Katya Mauff
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease & Molecular Medicine and Division of Immunology, Department of Science & Technology/National Research Foundation, University of Cape Town
| | - Katrina Downing
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease & Molecular Medicine and Division of Immunology, Department of Science & Technology/National Research Foundation, University of Cape Town
| | - Humphrey Mulenga
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease & Molecular Medicine and Division of Immunology, Department of Science & Technology/National Research Foundation, University of Cape Town
| | - Penelope Rose
- Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences
| | - Marieke van der Zalm
- Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences
| | - Sharon Mbaba
- Desmond Tutu Tuberculosis Centre, Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences
| | - Danelle Van As
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease & Molecular Medicine and Division of Immunology, Department of Science & Technology/National Research Foundation, University of Cape Town
| | - Willem A Hanekom
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease & Molecular Medicine and Division of Immunology, Department of Science & Technology/National Research Foundation, University of Cape Town
| | - Gerhard Walzl
- DST/NRF Centre of Excellence for Biomedical Tuberculosis Research/Medical Research Council Centre for Molecular and Cellular Biology, Division of Molecular Biology and Human Genetics, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Thomas J Scriba
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease & Molecular Medicine and Division of Immunology, Department of Science & Technology/National Research Foundation, University of Cape Town
| | | | - Mark Hatherill
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease & Molecular Medicine and Division of Immunology, Department of Science & Technology/National Research Foundation, University of Cape Town
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Kashangura R, Jullien S, Garner P, Young T, Johnson S. MVA85A vaccine to enhance BCG for preventing tuberculosis. Hippokratia 2018. [DOI: 10.1002/14651858.cd012915] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
| | - Sophie Jullien
- Jigme Dorji Wangchuck National Referral Hospital; Thimphu Bhutan
| | - Paul Garner
- Liverpool School of Tropical Medicine; Department of Clinical Sciences; Pembroke Place Liverpool Merseyside UK L3 5QA
| | - Taryn Young
- Stellenbosch University; Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences; PO Box 241 Cape Town South Africa 8000
- South African Medical Research Council; Cochrane South Africa; PO Box 19070 Tygerberg Cape Town South Africa 7505
| | - Samuel Johnson
- Liverpool School of Tropical Medicine; Department of Clinical Sciences; Pembroke Place Liverpool Merseyside UK L3 5QA
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Méndez-Samperio P. Global Efforts in the Development of Vaccines for Tuberculosis: Requirements for Improved Vaccines Against Mycobacterium tuberculosis. Scand J Immunol 2017; 84:204-10. [PMID: 27454335 DOI: 10.1111/sji.12465] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 07/13/2016] [Indexed: 11/28/2022]
Abstract
Currently, more than 9.0 million people develop acute pulmonary tuberculosis (TB) each year and about 1.5 million people worldwide die from this infection. Thus, developing vaccines to prevent active TB disease remains a priority. This article discusses recent progress in the development of new vaccines against TB and focusses on the main requirements for development of improved vaccines against Mycobacterium tuberculosis (M. tb). Over the last two decades, significant progress has been made in TB vaccine development, and some TB vaccine candidates have currently completed a phase III clinical trial. The potential public health benefits of these vaccines are possible, but it will need much more effort, including new global governance investment on this research. This investment would certainly be less than the annual global financial toll of TB treatment.
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Affiliation(s)
- P Méndez-Samperio
- Departamento de Inmunología, Escuela Nacional de Ciencias Biológicas, IPN, CD México, México.
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McShane H. From AIDS to TB vaccines--A career in infectious diseases and translational vaccinology. Hum Vaccin Immunother 2016; 12:5-7. [PMID: 26558654 DOI: 10.1080/21645515.2015.1100912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Affiliation(s)
- Helen McShane
- a The Jenner Institute; Nuffield Department of Clinical Medicine; University of Oxford ; Oxford , UK
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Muturi-Kioi V, Lewis D, Launay O, Leroux-Roels G, Anemona A, Loulergue P, Bodinham CL, Aerssens A, Groth N, Saul A, Podda A. Neutropenia as an Adverse Event following Vaccination: Results from Randomized Clinical Trials in Healthy Adults and Systematic Review. PLoS One 2016; 11:e0157385. [PMID: 27490698 PMCID: PMC4974007 DOI: 10.1371/journal.pone.0157385] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 05/26/2016] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND In the context of early vaccine trials aimed at evaluating the safety profile of novel vaccines, abnormal haematological values, such as neutropenia, are often reported. It is therefore important to evaluate how these trials should be planned not to miss potentially important safety signals, but also to understand the implications and the clinical relevance. METHODOLOGY We report and discuss the results from five clinical trials (two with a new Shigella vaccine in the early stage of clinical development and three with licensed vaccines) where the absolute neutrophil counts (ANC) were evaluated before and after vaccination. Additionally, we have performed a systematic review of the literature on cases of neutropenia reported during vaccine trials to discuss our results in a more general context. PRINCIPAL FINDINGS Both in our clinical trials and in the literature review, several cases of neutropenia have been reported, in the first two weeks after vaccination. However, neutropenia was generally transient and had a benign clinical outcome, after vaccination with either multiple novel candidates or well-known licensed vaccines. Additionally, the vaccine recipients with neutropenia frequently had lower baseline ANC than non-neutropenic vaccinees. In many instances neutropenia occurred in subjects of African descent, known to have lower ANC compared to western populations. CONCLUSIONS It is important to include ANC and other haematological tests in early vaccine trials to identify potential safety signals. Post-vaccination neutropenia is not uncommon, generally transient and clinically benign, but many vaccine trials do not have a sampling schedule that allows its detection. Given ethnic variability in the level of circulating neutrophils, normal ranges taking into account ethnicity should be used for determination of trial inclusion/exclusion criteria and classification of neutropenia related adverse events. TRIAL REGISTRATION ClinicalTrials.gov NCT02017899, NCT02034500, NCT01771367, NCT01765413, NCT02523287.
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Affiliation(s)
| | - David Lewis
- Surrey Clinical Research Centre, University of Surrey, Guildford, United Kingdom
| | - Odile Launay
- Université Paris Descartes, Sorbonne Paris cité, and Inserm CIC 1417, F-CRIN I-Reivac, Assistance Publique Hôpitaux de Paris, CIC Cochin-Pasteur, Paris, France
| | | | | | - Pierre Loulergue
- Université Paris Descartes, Sorbonne Paris cité, and Inserm CIC 1417, F-CRIN I-Reivac, Assistance Publique Hôpitaux de Paris, CIC Cochin-Pasteur, Paris, France
| | - Caroline L. Bodinham
- Surrey Clinical Research Centre, University of Surrey, Guildford, United Kingdom
| | | | | | - Allan Saul
- Novartis Vaccines Institute for Global Health, Siena, Italy
| | - Audino Podda
- Novartis Vaccines Institute for Global Health, Siena, Italy
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Ahsan MJ. Recent advances in the development of vaccines for tuberculosis. THERAPEUTIC ADVANCES IN VACCINES 2015; 3:66-75. [PMID: 26288734 DOI: 10.1177/2051013615593891] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Tuberculosis (Tb) continues to be a dreadful infection worldwide with nearly 1.5 million deaths in 2013. Furthermore multi/extensively drug-resistant Tb (MDR/XDR-Tb) worsens the condition. Recently approved anti-Tb drugs (bedaquiline and delamanid) have the potential to induce arrhythmia and are recommended in patients with MDR-Tb when other alternatives fail. The goal of elimination of Tb by 2050 will not be achieved without an effective new vaccine. The recent advancement in the development of Tb vaccines is the keen focus of this review. To date, Bacille Calmette Guerin (BCG) is the only licensed Tb vaccine in use, however its efficacy in pulmonary Tb is variable in adolescents and adults. There are nearly 15 vaccine candidates in various phases of clinical trials, includes five protein or adjuvant vaccines, four viral-vectored vaccines, three mycobacterial whole cell or extract vaccines, and one each of the recombinant live and the attenuated Mycobacterium tuberculosis (Mtb) vaccine.
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Affiliation(s)
- Mohamed Jawed Ahsan
- Department of Pharmaceutical Chemistry, Maharishi Arvind College of Pharmacy, Jaipur, Rajasthan 303 039, India
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Reither K, Katsoulis L, Beattie T, Gardiner N, Lenz N, Said K, Mfinanga E, Pohl C, Fielding KL, Jeffery H, Kagina BM, Hughes EJ, Scriba TJ, Hanekom WA, Hoff ST, Bang P, Kromann I, Daubenberger C, Andersen P, Churchyard GJ. Safety and immunogenicity of H1/IC31®, an adjuvanted TB subunit vaccine, in HIV-infected adults with CD4+ lymphocyte counts greater than 350 cells/mm3: a phase II, multi-centre, double-blind, randomized, placebo-controlled trial. PLoS One 2014; 9:e114602. [PMID: 25490675 PMCID: PMC4260867 DOI: 10.1371/journal.pone.0114602] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2014] [Accepted: 10/22/2014] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Novel tuberculosis vaccines should be safe, immunogenic, and effective in various population groups, including HIV-infected individuals. In this phase II multi-centre, double-blind, placebo-controlled trial, the safety and immunogenicity of the novel H1/IC31 vaccine, a fusion protein of Ag85B-ESAT-6 (H1) formulated with the adjuvant IC31, was evaluated in HIV-infected adults. METHODS HIV-infected adults with CD4+ T cell counts >350/mm3 and without evidence of active tuberculosis were enrolled and followed until day 182. H1/IC31 vaccine or placebo was randomly allocated in a 5:1 ratio. The vaccine was administered intramuscularly at day 0 and 56. Safety assessment was based on medical history, clinical examinations, and blood and urine testing. Immunogenicity was determined by a short-term whole blood intracellular cytokine staining assay. RESULTS 47 of the 48 randomised participants completed both vaccinations. In total, 459 mild or moderate and 2 severe adverse events were reported. There were three serious adverse events in two vaccinees classified as not related to the investigational product. Local injection site reactions were more common in H1/IC31 versus placebo recipients (65.0% vs. 12.5%, p = 0.015). Solicited systemic and unsolicited adverse events were similar by study arm. The baseline CD4+ T cell count and HIV viral load were similar by study arm and remained constant over time. The H1/IC31 vaccine induced a persistent Th1-immune response with predominately TNF-α and IL-2 co-expressing CD4+ T cells, as well as polyfunctional IFN-γ, TNF-α and IL-2 expressing CD4+ T cells. CONCLUSION H1/IC31 was well tolerated and safe in HIV-infected adults with a CD4+ Lymphocyte count greater than 350 cells/mm3. The vaccine did not have an effect on CD4+ T cell count or HIV-1 viral load. H1/IC31 induced a specific and durable Th1 immune response. TRIAL REGISTRATION Pan African Clinical Trials Registry (PACTR) PACTR201105000289276.
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Affiliation(s)
- Klaus Reither
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University Basel, Basel, Switzerland
- Ifakara Health Institute, Bagamoyo, Tanzania
- * E-mail:
| | | | | | | | - Nicole Lenz
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University Basel, Basel, Switzerland
| | | | | | - Christian Pohl
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University Basel, Basel, Switzerland
- Ifakara Health Institute, Bagamoyo, Tanzania
| | | | - Hannah Jeffery
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Benjamin M. Kagina
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine and School of Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Elisabeth J. Hughes
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine and School of Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Thomas J. Scriba
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine and School of Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Willem A. Hanekom
- South African Tuberculosis Vaccine Initiative, Institute of Infectious Disease and Molecular Medicine and School of Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Søren T. Hoff
- Statens Serum Institute, Department of Infectious Disease Immunology, Copenhagen, Denmark
| | - Peter Bang
- Statens Serum Institute, Department of Vaccine Development, Copenhagen, Denmark
| | - Ingrid Kromann
- Statens Serum Institute, Department of Vaccine Development, Copenhagen, Denmark
| | - Claudia Daubenberger
- Swiss Tropical and Public Health Institute, Basel, Switzerland
- University Basel, Basel, Switzerland
| | - Peter Andersen
- Statens Serum Institute, Department of Infectious Disease Immunology, Copenhagen, Denmark
| | - Gavin J. Churchyard
- Aurum Institute, Johannesburg, South Africa
- London School of Hygiene and Tropical Medicine, London, United Kingdom
- School of Public Health, University of Witwatersrand, Johannesburg, South Africa
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Leunda A, Baldo A, Goossens M, Huygen K, Herman P, Romano M. Novel GMO-Based Vaccines against Tuberculosis: State of the Art and Biosafety Considerations. Vaccines (Basel) 2014; 2:463-99. [PMID: 26344627 PMCID: PMC4494264 DOI: 10.3390/vaccines2020463] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Revised: 04/24/2014] [Accepted: 05/06/2014] [Indexed: 12/13/2022] Open
Abstract
Novel efficient vaccines are needed to control tuberculosis (TB), a major cause of morbidity and mortality worldwide. Several TB vaccine candidates are currently in clinical and preclinical development. They fall into two categories, the one of candidates designed as a replacement of the Bacille Calmette Guérin (BCG) to be administered to infants and the one of sub-unit vaccines designed as booster vaccines. The latter are designed as vaccines that will be administered to individuals already vaccinated with BCG (or in the future with a BCG replacement vaccine). In this review we provide up to date information on novel tuberculosis (TB) vaccines in development focusing on the risk assessment of candidates composed of genetically modified organisms (GMO) which are currently evaluated in clinical trials. Indeed, these vaccines administered to volunteers raise biosafety concerns with respect to human health and the environment that need to be assessed and managed.
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Affiliation(s)
- Amaya Leunda
- Biosafety and Biotechnology Unit, Scientific Institute of Public Health, 14 Juliette Wytsman Street, Brussels 1050, Belgium.
| | - Aline Baldo
- Biosafety and Biotechnology Unit, Scientific Institute of Public Health, 14 Juliette Wytsman Street, Brussels 1050, Belgium.
| | - Martine Goossens
- Biosafety and Biotechnology Unit, Scientific Institute of Public Health, 14 Juliette Wytsman Street, Brussels 1050, Belgium.
| | - Kris Huygen
- Immunology Unit, Scientific Institute of Public Health, 642 Engeland Street, Brussels 1180, Belgium.
| | - Philippe Herman
- Biosafety and Biotechnology Unit, Scientific Institute of Public Health, 14 Juliette Wytsman Street, Brussels 1050, Belgium.
| | - Marta Romano
- Immunology Unit, Scientific Institute of Public Health, 642 Engeland Street, Brussels 1180, Belgium.
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