Phase I clinical trial of a recombinant malaria vaccine consisting of the circumsporozoite repeat region of Plasmodium falciparum coupled to hepatitis B surface antigen

A systematic review on malaria and dengue vaccines for the effective management of these mosquito borne diseases: Improving public health

Insect vector-borne diseases (VBDs) pose significant global health challenges, particularly in tropical and subtropical regions. The WHO has launched the "Global Vector Control Response (GVCR) 2017-2030" to address these diseases, emphasizing a comprehensive approach to vector control. This systematic review investigates the potential of malaria and dengue vaccines in controlling mosquito-borne VBDs, aiming to alleviate disease burdens and enhance public health. Following PRISMA 2020 guidelines, the review incorporated 39 new studies out of 934 identified records. It encompasses various studies assessing malaria and dengue vaccines, emphasizing the significance of vaccination as a preventive measure. The findings indicate variations in vaccine efficacy, duration of protection, and safety considerations for each disease, influencing public health strategies. The review underscores the urgent need for vaccines to combat the increasing burden of VBDs like malaria and dengue, advocating for ongoing research and investment in vaccine development.

Mosquirix™ RTS, S/AS01 Vaccine Development, Immunogenicity, and Efficacy

Malaria is a parasitic infection caused by bites from Plasmodium falciparum (P. falciparum)-infected mosquitoes with a present scale of symptoms ranging from moderate fever to neurological disorders. P. falciparum is the most lethal of the five strains of malaria, and is a major case of morbidity and mortality in endemic regions. Recent advancements in malaria diagnostic tools and prevention strategies have improved conjugation antimalarial therapies using fumigation and long-lasting insecticidal sprays, thus lowering malarial infections. Declines in the total number of infected individuals have been correlated with antimalarial drugs. Despite this, malaria remains a major health threat, affecting more than 30 million men, women, and children around the globe, and 20 percent of all children around the globe have malaria parasites in their blood. To overcome this life-threatening condition, novel therapeutic strategies, including immunization, are urgently needed to tackle this infection around the world. In line with this, the development of the RTS, S vaccine was a significant step forward in the fight against malaria. RTS, S is a vaccine for P. falciparum in which R specifies central repeat units, T the T-cell epitopes, and S indicates surface antigen. The RTS, S/AS01 malarial vaccine was synthesized and screened in several clinical trials between 2009 and 2014, involving thousands of young children in seven African countries, showing that children who received the vaccine did not suffer from severe malaria. Mosquirix™ was approved by the World Health Organization in 2021, indicating it to be safe and advocating its integration into routine immunization programs and existing malaria control measures. This paper examines the various stages of the vaccine’s development, including the evaluation of its immunogenicity and efficacy on the basis of a total of 2.3 million administered doses through a routine immunization program. The protection and effectiveness provided by the vaccine are strong, and evidence shows that it can be effectively delivered through the routine child immunization platform. The economic cost of the vaccine remains to be considered.

A VLP for validation of the Plasmodium falciparum circumsporozoite protein junctional epitope for vaccine development

Malaria continues to be a pressing global health issue, causing nearly half a million deaths per year. An effective malaria vaccine could radically improve our ability to control and eliminate this pathogen. The most advanced malaria vaccine, RTS,S, confers only 30% protective efficacy under field conditions, and hence the search continues for improved vaccines. New antigens and formulations are always first developed at a pre-clinical level. This paper describes the development of a platform to supplement existing tools of pre-clinical malaria vaccine development, by displaying linear peptides on a virus-like particle (VLP). Peptides from PfCSP, particularly from outside the normal target of neutralizing antibodies, the central NANP repeat region, are screened for evidence of protective efficacy. One peptide, recently identified as a target of potent neutralizing antibodies and lying at the junction between the N-terminal domain and the central repeat region of PfCSP, is found to confer protective efficacy against malaria sporozoite challenge in mice when presented on the Qβ VLP. The platform is also used to explore the effects of increasing numbers of NANP unit repeats, and including a universal CD4⁺ T-cell epitope from tetanus toxin, on immunogenicity and protective efficacy. The VLP-peptide platform is shown to be of use in screening malaria peptides for protective efficacy and answering basic vaccinology questions in a pre-clinical setting.

Circumsporozoite Surface Protein-based malaria vaccines: a review

Malaria represents a serious public health problem, presenting with high rates of incidence, morbidity and mortality in tropical and subtropical regions of the world. According to the World Health Organization, in 2018 there were 228 million cases and 405 thousand deaths caused by this disease in the world, affecting mainly children and pregnant women in Africa. Despite the programs carried out to control this disease, drug resistance and invertebrate vector resistance to insecticides have generated difficulties. An efficient vaccine against malaria would be a strategy with a high impact on the eradication and control of this disease. Researches aimed at developing vaccines have focused on antigens of high importance for the survival of the parasite such as the Circumsporozoite Surface Protein, involved in the pre-erythrocytic cycle during parasites invasion in hepatocytes. Currently, RTS’S is the most promising vaccine for malaria and was constructed using CSP; its performance was evaluated using two types of adjuvants: AS01 and AS02. The purpose of this review was to provide a bibliographic survey of historical researches that led to the development of RTS’S and its performance analysis over the decade. The search for new adjuvants to be associated with this antigen seems to be a way to obtain higher percentages of protection for a future malaria vaccine.

RTS,S/AS01 vaccine (Mosquirix™): an overview

Malaria is an illness caused by Plasmodium parasites transmitted to humans by infected mosquitoes. Of the five species that infect humans, P. falciparum exacts the highest toll in terms of human morbidity and mortality, and therefore represents a major public health threat in endemic areas. Recent advances in control efforts have reduced malaria incidence and prevalence, including rapid diagnostic testing, highly effective artemisinin combination therapy, use of insecticide-treated bednets, and indoor residual spraying. But, reductions in numbers of cases have stalled over the last few years, and incidence may have increased. As this concerning trend calls for new tools to combat the disease, the RTS,S vaccine has arrived just in time. The vaccine was created in 1987 and began pilot implementation in endemic countries in 2019. This first-generation malaria vaccine demonstrates modest efficacy against malaria illness and holds promise as a public health tool, especially for children in high-transmission areas where mortality is high.

RTS,S/AS02A for malaria

Malaria prevention and treatment is becoming increasingly difficult as drug-resistant strains of parasites spread globally and affordable antimalarial drugs become ineffective. Therefore, there is a need for a safe and effective vaccine. In recent years, significant technological advances and an increase in funding for malaria vaccine research, including better public-private collaboration, have increased optimism that highly effective vaccines can be developed. RTS,S/AS02A is a novel pre-erythrocytic vaccine based on the Plasmodium falciparum circumsporozoite surface protein. Among all candidate vaccines developed thus far, only the RTS,S/AS02A vaccine has consistently been demonstrated to be well tolerated and provide significant protective efficacy in challenge studies and clinical trials in malaria-endemic countries.

Pre-erythrocytic malaria vaccines: identifying the targets

Pre-erythrocytic malaria vaccines target Plasmodium during its sporozoite and liver stages, and can prevent progression to blood-stage disease, which causes a million deaths each year. Whole organism sporozoite vaccines induce sterile immunity in animals and humans and guide subunit vaccine development. A recombinant protein-in-adjuvant pre-erythrocytic vaccine called RTS,S reduces clinical malaria without preventing infection in field studies and additional antigens may be required to achieve sterile immunity. Although few vaccine antigens have progressed to human testing, new insights into parasite biology, expression profiles and immunobiology have offered new targets for intervention. Future advances require human trials of additional antigens, as well as platforms to induce the durable antibody and cellular responses including CD8(+) T cells that contribute to sterile protection.

Vaccines

Since vaccination was documented by Edward Jenner in 1798, it has become the most successful means of preventing infectious diseases, saving millions of lives every year. However, application of vaccines is currently not limited to the prevention of infectious diseases. Vaccines in the pipeline include anti-drug abuse vaccines (nicotine, cocaine) and vaccines against allergies, cancer, and Alzheimer’s disease.

Novel adjuvants for B cell immune responses

PURPOSE OF REVIEW

To summarize recent progress in the development of adjuvants with a special focus on adjuvants that enhance B-cell responses to protein-based vaccines. Both established and new experimental approaches are described and also briefly we discuss how adjuvants and virus-based vaccines interact with the immune system.

RECENT FINDINGS

Two new adjuvants were recently approved for human applications and many others are in preclinical or clinical testing. Significant advances were made to describe the mechanism of action of adjuvants. For example, aluminum hydroxide salts were shown to engage Nalp3, a member of the cytosolic NOD-like receptors and activation of B cells via invariant natural killer cell presentation of alpha-galactosylceramide was described. The effects of Toll-like receptor ligands on B-cell differentiation were further characterized and a peptide derived from IPS-1, a cytosolic signaling molecule, was shown to provide adjuvant effect. Stimulation of protective antibodies against HIV-1 may require extensive antibody affinity maturation, thus long-term exposure or repeated administration of antigen may be needed to induce effective B-cell responses.

SUMMARY

Advances in our understanding of how specific signaling pathways link innate and adaptive immunity provides a basis for the design of improved adjuvants to promote broad and potent B-cell responses.

Immunological mechanisms underlying protection mediated by RTS,S: a review of the available data

The RTS,S/AS candidate malaria vaccine has demonstrated efficacy against a variety of endpoints in Phase IIa and Phase IIb trials over more than a decade. A multi-country phase III trial of RTS,S/AS01 is now underway with submission as early as 2012, if vaccine safety and efficacy are confirmed. The immunologic basis for how the vaccine protects against both infection and disease remains uncertain. It is, therefore, timely to review the information currently available about the vaccine with regard to how it impacts the human-Plasmodium falciparum host-pathogen relationship. In this article, what is known about mechanisms involved in partial protection against malaria induced by RTS,S is reviewed.

Plasmodium falciparum malaria vaccines in development

The development and implementation of a malaria vaccine would constitute a major breakthrough for global health. Recently, numerous new candidates have entered clinical testing, following strategies that are as diverse as the malaria cycle is complex. While promising results have been obtained, some candidate vaccines have not fulfilled expectations. The challenges are not merely scientific; further progresses will require the development of competent investigator networks, partnerships between academics, industry and funding agencies, and continuous political commitment. In this review, we present the developmental status of all malaria vaccine candidates that are currently in human clinical testing against Plasmodium falciparum, as well as selected malaria vaccine candidates at preclinical development stage, and discuss the main challenges facing the field of malaria vaccine development.

Multiple copies of a tumor epitope in a recombinant hepatitis B surface antigen (HBsAg) vaccine enhance CTL responses, but not tumor protection

We propose the replacement of endogenous epitopes with foreign epitopes to exploit the highly immunogenic hepatitis B surface antigen (HBsAg) as a vaccine vector to elicit disease-protective cytotoxic T-lymphocyte (CTL) responses. Locations were defined within the HBsAg gene where replacements of DNA encoding HBsAg epitopes may be made to generate functional recombinant (r) HBsAg DNA vaccines. We demonstrate that rHBsAg DNA vaccines encoding multiple copies of a model tumor epitope from human papillomavirus (HPV) elicit enhanced CTL responses compared to rHBsAg DNA vaccines encoding a single copy. We show that rHBsAg DNA vaccines elicit a marked prophylactic and long-lived therapeutic protection against epitope expressing tumor, although protective efficacy was not improved by increasing the number of copies of the tumor epitope DNA. These results demonstrate the efficacy of HBsAg as a vector for the delivery of foreign CTL epitopes using the epitope replacement strategy, and have implications for rHBsAg vaccine design. The results also have implications for the derivation of a therapeutic vaccine for HPV-associated squamous carcinoma.

Malaria vaccine developments

Large gains in the reduction of malaria mortality in the early 20th century were lost in subsequent decades. Malaria now kills 2-3 million people yearly. Implementation of malaria control technologies such as insecticide-treated bednets and chemotherapy could reduce mortality substantially, but an effective malaria vaccine is also needed. Advances in vaccine technology and immunology are being used to develop malaria subunit vaccines. Novel approaches that might yield effective vaccines for other diseases are being evaluated first in malaria. We describe progress in malaria vaccine development in the past 5 years: reasons for cautious optimism, the type of vaccine that might realistically be expected, and how the process could be hastened. Although exact predictions are not possible, if sufficient funding were mobilised, a deployable, effective malaria vaccine is a realistic medium-term to long-term goal.

Current status of malaria vaccine development

There is an urgent need to develop an effective vaccine against malaria--a disease that has approximately 10% of the world population at risk of infection at any given time. The economic burden this disease puts on the medico-social set-up of countries in Sub-Saharan Africa and South East Asia is phenomenal. Increasing drug resistance and failure of vector control strategies have necessitated the search for a suitable vaccine that could be integrated into the extended program of immunization for countries in the endemic regions. Malaria vaccine development has seen a surge of activity in the last decade or so owing largely to the advances made in the fields of genetic engineering and biotechnology. This revolution has brought sweeping changes in the understanding of the biology of the parasite and has helped formulate newer more effective strategies to combat the disease. Latest developments in the field of malaria vaccine development will be discussed in this chapter.

Conversion of poorly immunogenic malaria repeat sequences into a highly immunogenic vaccine candidate

The recent success of a Plasmodium falciparum malaria vaccine consisting of circumsporozoite protein (CSP) T and B cell epitopes has rekindled interest in the development of a pre-erythrocytic vaccine. In order to optimize immunogenicity, well-characterized CSP-specific neutralizing B cell epitopes and a universal T cell epitope were combined with an efficient and flexible particulate carrier platform, the hepatitis B core antigen (HBcAg), to produce a novel pre-erythrocytic vaccine candidate. The vaccine candidate, V12.PF3.1, is a potent immunogen in mice eliciting unprecedented levels (greater than 10(6) titers) of sporozoite-binding antibodies after only two doses. The anti-sporozoite antibodies are long lasting, represent all IgG isotypes, and antibody production is not genetically restricted. CSP-specific CD4+ T cells are also primed by V12.PF3.1 immunization in a majority of murine strains. Furthermore, the hybrid HBcAg-CS particles can be produced inexpensively in bacterial expression systems. These and other characteristics suggest that V12.PF3.1 represents an efficient and economical P. falciparum vaccine candidate for use separately or in combination with other formulations.

Technologies for the design, discovery, formulation and administration of vaccines

This paper summarizes major technologies, with emphasis on applications to preventive vaccines for infectious diseases. A limited number of examples of each technology are provided.

New technologies for making vaccines

Technologies for making active vaccines fall into 3 general groups: live, subunit (killed or inactivated) and genetic. Each of these groups is further divisible into multiple categories, which include recombinant-derived antigens as well as native microorganisms and their components. In addition, there are new enabling technologies such as delivery systems and vectors which can be applied to these approaches. Most disease targets, whether infectious or noninfectious in origin, can be approached by the application of several different vaccine technologies, as can be tested during the discovery phase of research. The criteria for choosing early in a development program which of the vaccine technologies are likely to ultimately be most fruitful for a given application include: knowledge of the pathogenesis of the given infection/disease; technical feasibility; immunobiology and associated mechanisms; preclinical efficacy profile; anticipated clinical safety; regulatory; manufacturing; and marketing. All of these criteria should be considered together in making selections for an R&D program. This paper is reviewing the major vaccine technologies and relevant examples of how these criteria are used to make decisions in vaccine development.

Protein particle vaccines against malaria

Many viral coat proteins retain the ability to assemble into virus-like particles when produced as recombinant proteins. These small particles are highly immunogenic, and in many cases can be used to carry epitopes or antigens from other pathogens. Most particle-forming proteins can tolerate only small additions or alterations to their sequence, but Hepatitis B virus surface antigen (HBsAg) and the yeast-derived Ty particle are exceptionel in their ability to form particles with long N- or C-terminal extensions. Both have been used to produce hybrid particles carrying Plasmodium sequences. These have been shown to be highly immunogenic in animal studies and also in human phase I trials, in the case of HBsAg. Recently, six out of seven human volunteers were protected against sporozoite challenge by a recombinant HBsAg particle vaccine, the most encouraging result to date for any pre-erythrocytic malaria vaccine. Here, Sarah Gilbert and Adrian Hill review the prospects for the future development of protein particle vaccines against malaria.

A preliminary evaluation of a recombinant circumsporozoite protein vaccine against Plasmodium falciparum malaria. RTS,S Malaria Vaccine Evaluation Group

BACKGROUND

The candidate vaccines against malaria are poorly immunogenic and thus have been ineffective in preventing infection. We developed a vaccine based on the circumsporozoite protein of Plasmodium falciparum that incorporates adjuvants selected to enhance the immune response.

METHODS

The antigen consists of a hybrid in which the circumsporozoite protein fused to hepatitis B surface antigen (HBsAg) is expressed together with unfused HBsAg. We evaluated three formulations of this antigen in an unblinded trial in 46 subjects who had never been exposed to malaria.

RESULTS

Two of the vaccine formulations were highly immunogenic. Four subjects had adverse systemic reactions that may have resulted from the intensity of the immune response after the second dose, which led us to reduce the third dose. Twenty-two vaccinated subjects and six unimmunized controls underwent a challenge consisting of bites from mosquitoes infected with P. falciparum. Malaria developed in all six control subjects, seven of eight subjects who received vaccine 1, and five of seven subjects who received vaccine 2. In contrast, only one of seven subjects who received vaccine 3 became infected (relative risk of infection, 0.14; 95 percent confidence interval, 0.02 to 0.88; P<0.005).

CONCLUSIONS

A recombinant vaccine based on fusion of the circumsporozoite protein and HBsAg plus a potent adjuvant can protect against experimental challenge with P. falciparum sporozoites. After additional studies of protective immunity and the vaccination schedule, field trials are indicated for this new vaccine against P. falciparum malaria.

Antibody and clinical responses in volunteers to immunization with malaria peptide-diptheria toxoid conjugates

Twenty residue peptides from the 185-200-kD and 45-kD merozoite surface antigens of the malaria parasite Plasmodium falciparum were covalently linked to diphtheria toxoid as a carrier and used to immunize human volunteers with aluminium hydroxide as an adjuvant. Significant antibody levels were elicited by two boosting injections. The antibodies reacted with acetone-methanol fixed merozoite membranes in an immunofluorescence assay, but no inhibition of merozoite reinvasion could be detected in in vitro cultures containing the antibodies. Antibody levels against the immunizing peptides declined markedly within 77 days after the third injection. No hypersensitivity was observed against the peptides. However, the volunteers developed hypersensitivity against diphteria toxoid, and in particular a pronounced type III (Arthus) hypersensitivity after three injections with the toxoid. This effect might appear to limit the use of peptide-diphtheria toxoid conjugates for human immunization. Several biochemical, haematological and immunological tests done on the volunteers showed no other adverse effects from the immunizations.

Selective stimulation of murine cytotoxic T cell and antibody responses by particulate or monomeric hepatitis B virus surface (S) antigen

In the murine system, we tested in vivo the immunogenicity of different preparations of the yeast-derived surface antigen (S-antigen or S-protein) of hepatitis B virus (HBV). Native S-protein molecules self-assemble into stable 22-nm particles. BALB/c mice immunized with low doses of native S-particles without adjuvants efficiently generated an H-2 class I-restricted CD8+ cytotoxic T lymphocyte (CTL) response, and developed easily detectable serum antibody titers against conformational determinants of the native S-particle or linear epitopes of the denatured S-protein. Disruption of S-particles with sodium dodecyl sulfate and beta-2-mercaptoethanol generated p24 S-monomers. Injection of an equal dose of S-monomers into mice efficiently primed CTL, but did not stimulate an antibody response against conformational or linear epitopes of the native or denatured S-protein. In vivo priming of CTL by S-particles or S-monomers required "endogenous" processing of the antigen because the injection of an equimolar (or higher) dose of an antigenic, S-derived 12-mer peptide into mice did not prime CTL. Native (particulate) or denatured (monomeric) S-antigen injected with mineral oil (incomplete Freund's adjuvant) or aluminum hydroxide failed to stimulate a CTL response. Hence, different preparations can be produced from a small protein antigen which specifically stimulate selected compartments of the immune system.

Engineered human vaccines

The limitations of human vaccines in use at present and the design requirements for a new generation of human vaccines are discussed. The progress in engineering of human vaccines for bacteria, viruses, parasites, and cancer is reviewed, and the data from human studies with the engineered vaccines are discussed, especially for cancer and AIDS vaccines. The final section of the review deals with the possible future developments in the field of engineered human vaccines and the requirement for effective new human adjuvants.

Malaria vaccines

The development of an effective malaria vaccine is a feasible goal. Most of the vaccines being developed today are subunit vaccines derived from selected parasite antigens or their immunologically active fragments. The precise characterization of protective immune responses against Plasmodium parasites remains a fundamental part of present research aimed at obtaining a malaria vaccine(s).