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Tomljenovic L, McHenry LB. A reactogenic "placebo" and the ethics of informed consent in Gardasil HPV vaccine clinical trials: A case study from Denmark. INTERNATIONAL JOURNAL OF RISK & SAFETY IN MEDICINE 2024; 35:159-180. [PMID: 38788092 DOI: 10.3233/jrs-230032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2024]
Abstract
BACKGROUND Medical ethics guidelines require of clinical trial investigators and sponsors to inform prospective trial participants of all known and potential risks associated with investigational medical products, and to obtain their free informed consent. These guidelines also require that clinical research be so designed as to minimize harms and maximize benefits. OBJECTIVE To examine Merck's scientific rationale for using a reactogenic aluminum-containing "placebo" in Gardasil HPV vaccine pre-licensure clinical trials. METHODS We examined the informed consent form and the recruitment brochure for the FUTURE II Gardasil vaccine trial conducted in Denmark; and we interviewed several FUTURE II trial participants and their treating physicians. We also reviewed regulatory documentation related to Gardasil vaccine approval process and the guidelines on evaluation of adjuvants used in human vaccines. RESULTS It was found that the vaccine manufacturer Merck made several inaccurate statements to trial participants that compromised their right to informed consent. First, even though the study protocol listed safety testing as one of the study's primary objectives, the recruitment brochure emphasized that FUTURE II was not a safety study, and that the vaccine had already been proven safe. Second, the advertising material for the trial and the informed consent forms stated that the placebo was saline or an inactive substance, when, in fact, it contained Merck's proprietary highly reactogenic aluminum adjuvant which does not appear to have been properly evaluated for safety. Several trial participants experienced chronic disabling symptoms, including some randomized to the adjuvant "placebo" group. CONCLUSION In our view, the administration of a reactive placebo in Gardasil clinical trials was without any possible benefit, needlessly exposed study subjects to risks, and was therefore a violation of medical ethics. The routine use of aluminum adjuvants as "placebos" in vaccine clinical trials is inappropriate as it hinders the discovery of vaccine-related safety signals.
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Affiliation(s)
| | - Leemon B McHenry
- Department of Philosophy, California State University, Northridge, CA, USA
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Angrand L, Masson JD, Rubio-Casillas A, Nosten-Bertrand M, Crépeaux G. Inflammation and Autophagy: A Convergent Point between Autism Spectrum Disorder (ASD)-Related Genetic and Environmental Factors: Focus on Aluminum Adjuvants. TOXICS 2022; 10:toxics10090518. [PMID: 36136483 PMCID: PMC9502677 DOI: 10.3390/toxics10090518] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 08/19/2022] [Accepted: 08/25/2022] [Indexed: 05/10/2023]
Abstract
Autism spectrum disorder (ASD), schizophrenia, and bipolar disorder are genetically complex and heterogeneous neurodevelopmental disorders (NDDs) resulting from genetic factors and gene-environment (GxE) interactions for which onset occurs in early brain development. Recent progress highlights the link between ASD and (i) immunogenetics, neurodevelopment, and inflammation, and (ii) impairments of autophagy, a crucial neurodevelopmental process involved in synaptic pruning. Among various environmental factors causing risk for ASD, aluminum (Al)-containing vaccines injected during critical periods have received special attention and triggered relevant scientific questions. The aim of this review is to discuss the current knowledge on the role of early inflammation, immune and autophagy dysfunction in ASD as well as preclinical studies which question Al adjuvant impacts on brain and immune maturation. We highlight the most recent breakthroughs and the lack of epidemiological, pharmacokinetic and pharmacodynamic data constituting a "scientific gap". We propose additional research, such as genetic studies that could contribute to identify populations at genetic risk, improving diagnosis, and potentially the development of new therapeutic tools.
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Affiliation(s)
- Loïc Angrand
- Univ Paris Est Créteil, INSERM, IMRB, F-94010 Créteil, France; (L.A.); (J.-D.M.)
- Ecole Nationale Vétérinaire d’Alfort IMRB, F-94700 Maisons-Alfort, France
- INSERM UMR-S 1270, 75005 Paris, France;
- Sorbonne Université, Campus Pierre et Marie Curie, 75005 Paris, France
- Institut du Fer à Moulin, 75005 Paris, France
| | - Jean-Daniel Masson
- Univ Paris Est Créteil, INSERM, IMRB, F-94010 Créteil, France; (L.A.); (J.-D.M.)
- Ecole Nationale Vétérinaire d’Alfort IMRB, F-94700 Maisons-Alfort, France
| | - Alberto Rubio-Casillas
- Biology Laboratory, Autlán Regional Preparatory School, University of Guadalajara, Autlán 48900, Jalisco, Mexico;
- Autlán Regional Hospital, Health Secretariat, Autlán 48900, Jalisco, Mexico
| | - Marika Nosten-Bertrand
- INSERM UMR-S 1270, 75005 Paris, France;
- Sorbonne Université, Campus Pierre et Marie Curie, 75005 Paris, France
- Institut du Fer à Moulin, 75005 Paris, France
| | - Guillemette Crépeaux
- Univ Paris Est Créteil, INSERM, IMRB, F-94010 Créteil, France; (L.A.); (J.-D.M.)
- Ecole Nationale Vétérinaire d’Alfort IMRB, F-94700 Maisons-Alfort, France
- Correspondence:
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Badran G, Angrand L, Masson JD, Crépeaux G, David MO. Physico-chemical properties of aluminum adjuvants in vaccines: Implications for toxicological evaluation. Vaccine 2022; 40:4881-4888. [PMID: 35810062 DOI: 10.1016/j.vaccine.2022.06.064] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 05/27/2022] [Accepted: 06/18/2022] [Indexed: 12/13/2022]
Abstract
Aluminum salts have been used as adjuvants in human vaccines since 1932. The most used adjuvants are Al oxyhydroxide (AlOOH) and Al hydroxyphosphate (AlOHPO4). Al adjuvants have different physico-chemical properties. The differences in these properties are not well documented and not considered by the Food and Drug Administration (FDA), though they can largely influence biological effects of the adjuvants which are particulate components. In this study, different physico-chemical properties including the shape, size and charge of particles have been evaluated under different conditions in three Al adjuvants containing-vaccines and two corresponding commercial adjuvants suspensions. The results showed that the two Al adjuvants have different shapes, sizes and charges but both form aggregates. In addition, a clear effect of dilution on the size of the aggregates was observed. Moreover, different sizes of Al particles were measured for both Al oxyhydroxide adjuvant alone or in the vaccine, at identical concentrations, displaying the impact of adsorbed proteins on the size of aggregates in the case of the vaccine. Taken together, this paper suggests the importance to evaluate, before any biological and especially toxicological impact study, the whole physico-chemical properties of Al particle without restricting to the sole evaluation of the injected concentration. Furthermore, any modification of these mentioned parameters during manipulation, before animal or cell exposure, should be considered. In a more global way, the fixed "safe dose" of Al adjuvants should be specific for each type of Al adjuvant independently or for a mix of the two compounds, due to their different properties.
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Affiliation(s)
- Ghidaa Badran
- Univ Paris Est Créteil, INSERM, IMRB, F-94010 Créteil, France; Université Paris-Saclay, Inserm, Univ Evry, Structure-Activité des Biomolécules Normales et Pathologiques, U1204, 91025 Evry, France
| | - Loïc Angrand
- Univ Paris Est Créteil, INSERM, IMRB, F-94010 Créteil, France; EnvA, IMRB, F-94700 Maisons-Alfort, France
| | - Jean-Daniel Masson
- Univ Paris Est Créteil, INSERM, IMRB, F-94010 Créteil, France; EnvA, IMRB, F-94700 Maisons-Alfort, France
| | - Guillemette Crépeaux
- Univ Paris Est Créteil, INSERM, IMRB, F-94010 Créteil, France; EnvA, IMRB, F-94700 Maisons-Alfort, France
| | - Marie-Odile David
- Université Paris-Saclay, Inserm, Univ Evry, Structure-Activité des Biomolécules Normales et Pathologiques, U1204, 91025 Evry, France.
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Masson JD, Angrand L, Badran G, de Miguel R, Crépeaux G. Clearance, biodistribution, and neuromodulatory effects of aluminum-based adjuvants. Systematic review and meta-analysis: what do we learn from animal studies? Crit Rev Toxicol 2022; 52:403-419. [PMID: 36112128 DOI: 10.1080/10408444.2022.2105688] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Aluminum (Al) salts are commonly used as adjuvants in human and veterinary vaccines for almost a century. Despite this long history of use and the very large number of exposed individuals, data in the literature concerning the fate of these molecules after injection and their potential effects on the nervous system is limited. In the context of (i) an increase of exposure to Al salts through vaccination; (ii) the absence of safety values determined by health regulators; (iii) the lack of robustness of the studies used as references to officially claim Al adjuvant innocuity; (iv) the publication of several animal studies investigating Al salts clearance/biopersistence and neurotoxicity; we have examined in this review all published studies performed on animals and assessing Al adjuvants kinetics, biodistribution, and neuromodulation since the first work of A. Glenny in the 1920s. The diversity of methodological approaches, results, and potential weaknesses of the 31 collected studies are exposed. A large range of protocols has been used, including a variety of exposure schedule and analyses methods, making comparisons between studies uneasy. Nevertheless, published data highlight that when biopersistence, translocation, or neuromodulation were assessed, they were documented whatever the different in vivo models and methods used. Moreover, the studies pointed out the crucial importance of the different Al adjuvant physicochemical properties and host genetic background on their kinetics, biodistribution, and neuromodulatory effects. Regarding the state of the art on this key public health topic, further studies are clearly needed to determine the exact safety level of Al salts.
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Affiliation(s)
- J-D Masson
- INSERM, IMRB, Univ Paris Est Créteil, Créteil, France
| | - L Angrand
- INSERM, IMRB, Univ Paris Est Créteil, Créteil, France.,École Nationale Vétérinaire d'Alfort, IMRB, Maisons-Alfort, France
| | - G Badran
- INSERM, IMRB, Univ Paris Est Créteil, Créteil, France.,Laboratoire SABNP, Université d'Evry Val d'Essonne, Paris, France
| | - R de Miguel
- Department of Animal Pathology, University of Zaragoza, Zaragoza, Spain
| | - G Crépeaux
- INSERM, IMRB, Univ Paris Est Créteil, Créteil, France.,École Nationale Vétérinaire d'Alfort, IMRB, Maisons-Alfort, France
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Bairwa SC, Shaw CA, Kuo M, Yoo J, Tomljenovic L, Eidi H. Cytokines profile in neonatal and adult wild-type mice post-injection of U. S. pediatric vaccination schedule. Brain Behav Immun Health 2021; 15:100267. [PMID: 34589773 PMCID: PMC8474652 DOI: 10.1016/j.bbih.2021.100267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 05/02/2021] [Accepted: 05/03/2021] [Indexed: 11/09/2022] Open
Abstract
Introduction A recent study from our laboratory demonstrated a number of neurobehavioral abnormalities in mice colony injected with a mouse-weight equivalent dose of all vaccines that are administered to infants in their first 18 months of life according to the U. S. pediatric vaccination schedule. Cytokines have been studied extensively as blood immune and inflammatory biomarkers, and their association with neurodevelopmental disorders. Given the importance of cytokines in early neurodevelopment, we aimed to investigate the potential post-administration effects of the U. S. pediatric vaccines on circulatory cytokines in a mouse model. In the current study, cytokines have been assayed at early and late time points in mice vaccinated early in postnatal life and compared with placebo controls. Materials and methods Newborn mouse pups were divided into three groups: i) vaccine (V1), ii) vaccine × 3 (V3) and iii) placebo control. V1 group was injected with mouse weight-equivalent of the current U. S. pediatric vaccine schedule. V3 group was injected with same vaccines but at triple the dose and the placebo control was injected with saline. Pups were also divided according to the sampling age into two main groups: acute- and chronic-phase group. Blood samples were collected at postnatal day (PND) 23, two days following vaccine schedule for the acute-phase group or at 67 weeks post-vaccination for the chronic-phase groups. Fifteen cytokines were analyzed: GM-CSF, IFN-γ, IL-1β, IL-2, IL-4, IL-5, IL-6, IL-9, IL-10, IL-12p70, IL-13, IL-17A, MCP-1, TNF-α, and VEGF-A. Wilcoxon Rank Sum test or unpaired Student's t-test was performed where applicable. Results IL-5 levels in plasma were significantly elevated in the V1 and V3 group compared with the control only in the acute-phase group. The elevation of IL-5 levels in the two vaccine groups were significant irrespective of whether the sexes were combined or analyzed separately. Other cytokines (VEGF-A, TNF-α, IL-10, MCP-1, GM-CSF, IL-6, and IL-13) were also impacted, although to a lesser extent and in a sex-dependent manner. In the acute-phase group, females showed a significant increase in IL-10 and MCP-1 levels and a decrease in VEGF-A levels in both V1 and V3 group compared to controls. In the acute-phase, a significant increase in MCP-1 levels in V3 group and CM-CSF levels in V1 and V3 group and decrease in TNF-α levels in V1 group were observed in treated males as compared with controls. In chronic-phase females, levels of VEGF-A in V1 and V3 group, TNF-α in V3 group, and IL-13 in V1 group were significantly decreased in contrast with controls. In chronic-phase males, TNF-α levels were significantly increased in V1 group and IL-6 levels decreased in V3 group in comparison to controls. The changes in levels of most tested cytokines were altered between the early and the late postnatal assays. Conclusions IL-5 levels significantly increased in the acute-phase of the treatment in the plasma of both sexes that were subjected to V1 and V3 injections. These increases had diminished by the second test assayed at week 67. These results suggest that a profound, albeit transient, effect on cytokine levels may be induced by the whole vaccine administration supporting our recently published observations regarding the behavioral abnormalities in the same mice. These observations support the view that the administration of whole pediatric vaccines in a neonatal period may impact at least short-term CNS functions in mice.
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Affiliation(s)
- S C Bairwa
- Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - C A Shaw
- Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, British Columbia, Canada.,Department of Pathology, University of British Columbia, Vancouver, British Columbia, Canada.,Program in Neuroscience, University of British Columbia, Vancouver, British Columbia, Canada.,Program in Experimental Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - M Kuo
- Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - J Yoo
- Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - L Tomljenovic
- Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - H Eidi
- Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, British Columbia, Canada.,French Agency for Veterinary Medicinal Products (ANMV) - French Agency for Food, Environmental and Occupational Health Safety (ANSES), Fougères, France
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