The ORVAC trial protocol: a phase IV, double-blind, randomised, placebo-controlled clinical trial of a third scheduled dose of Rotarix rotavirus vaccine in Australian Indigenous infants to improve protection against gastroenteritis

INTRODUCTION

Rotavirus vaccines were introduced into the Australian National Immunisation Program in 2007. Despite this, Northern Territory Indigenous children continue to be hospitalised with rotavirus at a rate more than 20 times higher than non-Indigenous children in other Australian jurisdictions, with evidence of waning protection in the second year of life. We hypothesised that scheduling an additional (third) dose of oral human rotavirus vaccine (Rotarix, GlaxoSmithKline) for children aged 6 to <12 months would improve protection against clinically significant all-cause gastroenteritis.

METHODS AND ANALYSIS

This Bayesian adaptive clinical trial will investigate whether routinely scheduling an additional dose of Rotarix for Australian Indigenous children aged 6 to <12 months old confers significantly better protection against clinically important all-cause gastroenteritis than the current two-dose schedule at 2 and 4 months old. There are two coprimary endpoints: (1) seroconversion from baseline serum anti-rotavirus immunoglobulin A (IgA) titre <20 U/mL prior to an additional dose of Rotarix/placebo to serum anti-rotavirus IgA titre >20 U/mL following the administration of the additional dose of Rotarix/placebo and (2) time from randomisation to medical attendance (up to age 36 months old) for which the primary reason is acute gastroenteritis/diarrhoea. Secondary endpoints include the change in anti-rotavirus IgA log titre, time to hospitalisation for all-cause diarrhoea and for rotavirus-confirmed gastroenteritis/diarrhoea, and rotavirus notification. Analysis will be based on Bayesian inference with adaptive sample size.

ETHICS, REGISTRATION AND DISSEMINATION

Ethics approval has been granted by Central Australian Human Research Ethics Committee (HREC-16-426) and Human Research Ethics Committee of the Northern Territory Department of Health and Menzies School of Health Research (HREC-2016-2658). Study investigators will ensure the trial is conducted in accordance with the principles of the Declaration of Helsinki and with the ICH Guidelines for Good Clinical Practice. Individual participant consent will be obtained. Results will be disseminated via peer-reviewed publication. The trial is registered with Clinicaltrials.gov (NCT02941107) and important modifications to this protocol will be updated.

TRIAL REGISTRATION NUMBER

NCT02941107; Pre-results.

Molecular characterization of rotavirus diarrhea among children aged under five years in the Philippines, 2013-2015

With the availability of new and existing rotavirus vaccines, credible and reliable data on burden of rotavirus-associated disease are needed to enable evidence-based decision making regarding the introduction of rotavirus vaccines. The national rotavirus surveillance program in the Philippines, a sentinel-based surveillance, was established in 2012 to determine the proportion of laboratory-confirmed rotavirus cases among children under five years with acute gastroenteritis and to describe the geographic distribution and molecular epidemiology of rotavirus in the country. During 2013 to 2015, rotavirus infection was the cause of acute gastroenteritis among children under five years admitted to hospitals or evaluated in emergency rooms, constituting more than one-third of gastroenteritis hospitalizations at the sentinel site hospitals. The predominant genotype observed was G1P[8]. Although a rotavirus surveillance network has been established, findings suggest the need to strengthen the network in the country and to continue monitoring prevalent rotavirus strains to help identify the possible emergence of new strains.

Hospital-based surveillance for rotavirus diarrhea in Ulaanbaatar, Mongolia, April 2009 through March 2016

BACKGROUND

Diarrheal disease is one of the leading causes of illness and death in young children in the world, especially the developing countries. Diarrheal disease results in about half a million childhood death per year, ranking second among all causes worldwide. Diarrheal disease due to rotavirus infection is currently the most common cause of severe diarrhea in infants and young children worldwide. Rotavirus immunization of infants is a safe and effective public health intervention for rotavirus infection control and expected to lead to a reduction of childhood morbidity and mortality.

METHODS

We conducted hospital-based surveillance at two representative hospitals in Mongolia to estimate the burden of hospitalizations for rotavirus diarrhea among children aged <5 years and to describe strain distribution patterns during 6-year study period. Fecal specimens were tested by rotavirus antigen detection enzyme immunoassay (EIA). Specimens that tested positive for rotavirus were further characterized to determine the genotype of strains by reverse-transcriptase polymerase chain reaction.

RESULTS

Between April 2009 and March 2016, among 7076 eligible children with diarrhea 6078 patients were enrolled nationally. Forty-six percent (2794/6078) of EIA a specimens were positive for rotavirus. Ninety-three percent (5649/6078) of hospitalizations for diarrhea involved children less than 2 years. No deaths were recorded due to rotavirus diarrhea. The most common genotype was G3P [8] (47.7%) followed by G9P [6] (14.4%), G2P [4] (12%), and G9P [8] (7.1%).

CONCLUSIONS

This study found a relatively high prevalence of severe rotavirus-associated diarrhea disease in Mongolia and infants were the most affected. It highlights the urgent need for introduction of rotavirus vaccine into the national immunization program. Continued surveillance is crucial and pre-vaccine introduction rotavirus genotype patterns in Mongolia are valuable and can be followed post-introduction to assess vaccine impact.

Rotavirus infection induces transient pancreatic involution and hyperglycemia in weanling mice

Rotavirus is a ubiquitous double-stranded RNA virus responsible for most cases of infantile gastroenteritis. It infects pancreatic islets in vitro and is implicated as a trigger of autoimmune destruction of islet beta cells leading to type 1 diabetes, but pancreatic pathology secondary to rotavirus infection in vivo has not been documented. To address this issue, we inoculated 3 week-old C57Bl/6 mice at weaning with rhesus rotavirus, which is closely related to human rotaviruses and known to infect mouse islets in vitro. Virus was quantified in tissues by culture-isolation and enzyme-linked immunosorbent assay. A requirement for viral double stranded RNA was investigated in toll-like receptor 3 (TLR3)-deficient mice. Cell proliferation and apoptosis, and insulin expression, were analyzed by immunohistochemistry. Following rotavirus inoculation by gavage, two phases of mild, transient hyperglycemia were observed beginning after 2 and 8 days. In the first phase, widespread apoptosis of pancreatic cells was associated with a decrease in pancreas mass and insulin production, without detectable virus in the pancreas. These effects were mimicked by injection of the double-stranded RNA mimic, polyinosinic-polycytidylic acid, and were TLR3-dependent. By the second phase, the pancreas had regenerated but islets were smaller than normal and viral antigen was then detected in the pancreas for several days. These findings directly demonstrate pathogenic effects of rotavirus infection on the pancreas in vivo, mediated initially by the interaction of rotavirus double-stranded RNA with TLR3.

Characterization of the gastrointestinal microbiota in health and inflammatory bowel disease

The enteric bacterial flora play a key role in maintaining health. Inflammatory bowel disease is associated with quantitative and qualitative alterations in the microbiota. Early characterization of the microbiota involved culture-dependent techniques. The advent of metagenomic techniques, however, allows for structural and functional characterization using culture-independent methods. Changes in diversity, together with quantitative alterations in specific bacterial species, have been identified. The functional significance of these changes, and their pathogenic role, remain to be elucidated.

First Words

Acute gastroenteritis is a common illness occurring in the neonatal period and throughout life in humans and animals. Infections with viral, bacterial or protozoal pathogens can precipitate the rapid onset of life-threatening symptoms, including diarrhoea, vomiting, fever and dehydration due to fluid and electrolyte loss.

Is there a relationship between foetal position and both preferred lying posture after birth and pattern of subsequent postural deformity in non-ambulant people with cerebral palsy?

BACKGROUND

A pattern of postural deformity was observed in a previous study that included an association between direction of spinal curvature and direction of windsweeping with more windswept deformities occurring to the right and lateral spinal curvatures occurring convex to the left. The direction of this pattern was found to be associated with preferred lying posture in early life. The aim of this study was to test the association between foetal position and both the preferred lying posture after birth, and the direction of subsequent postural deformity in non-ambulant children with cerebral palsy (CP).

METHODS

A retrospective cohort study was carried out involving 60 participants at level five on the gross motor function classification for CP. Foetal position during the last month of pregnancy was taken from antenatal records and parents were interviewed to identify preferred lying posture in the first year of life. At the time of the physical assessment ages ranged from 1 year and 1 month to 19 years with a median age of 13 years and 1 month.

RESULTS

Foetal presentation was found to be associated with the preferred lying posture with participants carried in a left occipito-anterior/lateral position more likely to adopt a supine head right lying posture, and vice versa. An association was also observed between the foetal position and asymmetrical postural deformity occurring later in life with participants carried in a left occipito-anterior/lateral presentation more likely to have a convex left spinal curve, a lower left pelvic obliquity, and a windswept hip pattern to the right.

CONCLUSIONS

Clinicians should be aware of the association between foetal presentation, asymmetrical lying posture, and the direction of subsequent postural deformity for severely disabled children. A hypothesis is described that might help to explain these findings.

Rotavirus diarrhoea and Aboriginal Children

Rotavirus is the most common cause of paediatric gastroenteritis worldwide. In Australia, Aboriginal children are at the greatest risk of severe disease. The continual changes in dominant strains pose challenges to vaccine success. However, early evidence suggests that rotavirus vaccination will be successful in reducing the impact of rotavirus disease on Australia?s most susceptible population.

New oligonucleotide primers for P-typing of rotavirus strains: Strategies for typing previously untypeable strains

BACKGROUND

The use of molecular methods for rotavirus characterisation provides increased sensitivity for typing, and allows the identification of putative reassortant strains. However, due to the constant accumulation of point mutations through genetic drift; and to the emergence of novel genotypes; and possibly zoonotic transmission and subsequent reassortment, the reagents and methods used for genotyping require close monitoring and updating.

OBJECTIVES

To design and evaluate a new VP4 consensus oligonucleotide primer pair that provides increased sensitivity and allows typing of strains that were untypeable using available methods.

STUDY DESIGN

A total of 489 rotavirus-positive faecal specimens from studies conducted between 1996 and 2006 were used for the evaluation of the new VP4 primers which was performed in the WHO Rotavirus Collaborating and Reference centres in the US, Australia, South Africa and the UK.

RESULTS

The new primer pair allowed P-typing of rotavirus strains and provided increased sensitivity, allowing typing of a significant number of strains that previously could not be P-typed.

CONCLUSIONS

This study highlights the importance of a constant reconsideration of primer sequences employed for the molecular typing of rotaviruses.

Rotavirus vaccines in developed countries

PURPOSE OF REVIEW

Rotavirus is the most common cause of diarrhoea and dehydration in early childhood. The recent licensure in many nations of vaccines against rotavirus offers promise to significantly reduce this toll. The present review describes recent developments regarding rotavirus vaccines and the challenges they face.

RECENT FINDINGS

Rotavirus causes significant morbidity and impact upon healthcare systems, at both inpatient and outpatient levels. An earlier rotavirus vaccine, since withdrawn, was temporally associated with intussusception causing small bowel obstruction, especially in infants receiving their first dose at an older age. Large-scale safety and efficacy studies of two new live, oral, attenuated vaccines have shown excellent efficacy against severe rotavirus gastroenteritis. Importantly, both studies detected no association with intussusception with these new vaccines when administered at the scheduled ages. Developed using different rotavirus vaccinology philosophies, questions remain regarding their coverage against new rotavirus serotypes. Ongoing intussusception surveillance following introduction should answer whether they may be safely administered beyond scheduled ages.

SUMMARY

Safe, efficacious rotavirus vaccines are available in many developed countries, offering significant promise to reduce the burden of gastroenteritis and dehydration. The impact of these vaccines upon not only morbidity, but also circulating rotavirus serotypes, will be monitored with interest.

Preventing rotavirus gastroenteritis: do you have the facts?

From 1 July 2007 two new rotavirus vaccines licensed for use in Australia (RotaTeq CSL Biotherapies/Merck and Rotarix Glaxo Smith Kline) will be funded for the National Immunisation Program. The vaccines differ with respect to their composition and the timing and mode of administration. Both have been evaluated in huge randomised trials and shown to be highly effective in preventing rotavirus gastroenteritis, including severe disease requiring hospital admission. Neither has been associated with an increased rate of intussusception; however, surveillance for adverse effects following vaccination will be important. As rotavirus infection is ubiquitous in young children, funding of this vaccine will significantly decrease the enormous morbidity and costs associated with this disease in our community.

Molecular epidemiology of adenovirus isolates from patients diagnosed with intussusception in Melbourne, Australia

Twenty-one intussusception (IS)-associated and 59 temporally linked adenoviral isolates from clinical infections were compared. Species C (15/21 IS- and 32/59 non-IS-associated isolates) dominated. Of these, serotype 2 (AdV-2) (7/15 IS-associated isolates) and serotype 1 (AdV-1) (16/32 non-IS-associated isolates) were the most commonly identified serotypes. DNA restriction analysis of AdV-2 isolates identified six genomic types; of these, type D2 (3/7 IS- and 8/11 non-IS-associated isolates) was the dominant type after BamHI and SmaI digestion. IS-associated isolates are similar to circulating non-IS-associated strains.

Rotavirus serotype G9P[8] and acute gastroenteritis outbreak in children, Northern Australia

Amino acid substitutions on the VP7 and NSP4 proteins were identified in regions known to influence function and may have contributed to the emergence and increased dominance of the outbreak strains.

During 2001, an outbreak of severe acute gastroenteritis swept through Central and northern Australia and caused serious disruption to health services. We tracked and characterized the rotavirus strain implicated in the outbreak. Comparison of the electropherotypes of outbreak samples suggested that one G9P[8] strain was likely responsible for the outbreak. Samples were obtained from geographically distinct regions of Australia where the epidemic had occurred. The outbreak strains showed identical nucleotide sequences in genes encoding three rotavirus proteins, VP7, VP8, and NSP4, but they were distinct from G9P[8] strains isolated in previous years. Several of the amino acid substitutions on the VP7 and NSP4 proteins were identified in regions known to influence function and may have contributed to the emergence and increased dominance of the outbreak strains. Rotavirus serotype surveillance should continue with methods capable of identifying new and emerging types.

Report of the Australian Rotavirus Surveillance Program 2003-2004

The National Rotavirus Reference Centre together with collaborating laboratories Australia-wide has conducted rotavirus surveillance since June 1999. This report describes the serotypes of rotavirus strains responsible for the hospitalisation of children with acute gastroenteritis during the period 1 July 2003 to 30 June 2004. We examined 688 faecal samples using monoclonal antibody immunoassays, reverse transcription-polymerase chain reaction and polyacrylamide gel analysis. This revealed that serotype G1 has re-emerged as the major serotype nationally, representing 40 per cent of all strains, followed by serotype G3 (25.7%) serotype G2 (17.1%) and serotype G9 (11.7%). However, there is substantial geographic variation in the prevalence of rotavirus serotypes. These findings have implications for vaccine development strategies which have targeted prevention of disease due to serotypes G1-G4.

Genetic and antigenic characterization of rotavirus serotype G9 strains isolated in Australia between 1997 and 2001

Rotavirus serotype G9 is recognized as the most widespread of the emerging serotypes, emerging since 1996 as a frequent cause of severe acute gastroenteritis in children from many countries covering all continents of the world. This study characterized serotype G9 strains collected in three widely separated Australian centers from 1997 to 2001. All G9 strains possessed the VP4 P[8] and VP6 subgroup II genes. The overall prevalence of the G9 strains increased in Australia, from 0.6% of the strains found in 1997 to 29% of the strains found in 2001. The prevalence of G9 relative to all other serotypes varied from year to year and with geographic location. In Melbourne (representing east coast urban centers), G9 made up 11 to 26% of all of the strains found from 1999 to 2001. In Perth (representing west coast urban centers), G9 made up less than 2% of the strains found in 1997 to 2000 but increased to 18.6% of the strains found in 2001. In Alice Springs (representing widely dispersed settlements in northern arid regions), G9 made up 0 to 5% of the strains found from 1997 to 2000 and was the dominant strain in 2001, making up 68.9% of all of the strains found. Three distinct antigenic groups based on reaction with neutralizing monoclonal antibodies (N-MAbs) were identified, including a dominant group (63%) that cross-reacted with the serotype G4 N-MAb. Phylogenetic analysis of the VP7-encoding gene from Australian strains, compared with a worldwide collection of G9 strains, showed that the Australian G9 strains made up a genetic group distinct from other serotype G9 strains identified in the United States and Africa. Future epidemiological studies of the occurrence of G9 strains should combine reverse transcription-PCR and typing with G1 to G4 and G9 N-MAbs to determine the extent of G9 and G4 cross-reactions among rotavirus strains, in order to assess the need to incorporate G9 strains into new candidate vaccines.

Report of the Australian Rotavirus Surveillance Program, 2001/2002

The National Rotavirus Reference Centre together with collaborating laboratories Australia-wide has conducted rotavirus surveillance since June 1999. The serotypes of rotavirus strains that are responsible for the hospitalisation of children with acute gastroenteritis were determined for the period 1 June 2001 to 31 June 2002. We examined 754 rotavirus samples using a combination of monoclonal antibody immunoassay, reverse transcription-polymerase chain reaction, and Northern hybridisation. For the first time, serotype G9 strains were the most prevalent type nationally (40.4%) and found in 8 of the 9 centres. Serotype G1 strains were the second most prevalent type (38.9%), identified in 5 of the centres. These findings have important implications for vaccine development strategies which target serotypes G1-G4.

Surveillance of viral pathogens in Australia: Rotavirus

For many years, a sentinel laboratory system, the Laboratory Virology and Serology Reporting Scheme (LabVISE) has been collecting data on viral pathogens of public health importance in Australia. This report is one in a series of articles focussing on the epidemiology and public health aspects of viruses and viral groups under surveillance by LabVISE, which are of current public health interest.

Report of the Australian Rotavirus Surveillance Program, 2000/2001

The National Rotavirus Reference Centre together with 15 collaborating laboratories Australia-wide conducted rotavirus surveillance from June 1999. The serotypes of rotaviruses that are responsible for the hospitalisation of children with acute diarrhoea were determined for the period June 2000 to May 2001. We examined 1108 rotavirus specimens using a combination of monoclonal antibody immunoassay, reverse transcription-PCR, and Northern hybridisation. Serotype G1 strains were the most prevalent overall (49.5%), and found in all centres. Serotype G9 rotaviruses, which were first identified in 1997, were second in importance (18.1%). Serotype G2 viruses were next (12.5%), followed by the re-emergence of serotype G4 viruses (9.7%). The findings of this study have implications for vaccine development strategies where protection against serotypes additional to G1-G4 may be required.

Rotavirus antigenicity is affected by the genetic context and glycosylation of VP7

Rotavirus variants resistant to neutralization were selected using monoclonal antibodies (N-MAbs) raised to VP7 of rotavirus G types 2, 3, and 6. Their neutralization resistance patterns and deduced VP7 amino acid sequences were obtained. Variants selected by two G2-specific N-MAbs from the homologous parent virus RV-5 showed single amino acid (aa) mutations in the antigenic A region. However, variants selected from reassortant virus RV-5 x SA11 (all genes from SA11 virus except that encoding VP7, which was from RV-5 virus) fell into two neutralization resistance groups. The first group showed identical mutations to the variants selected from RV-5 virus. The second group showed antigenic C region mutations, either alone or in combination with a mutation at aa 69. Variants selected from G3 parent viruses glycosylated at position 238 had a mutation at aa 96 in the A region, otherwise a C-region mutation at 211 was selected. Mutations at amino acid positions 94 or 96 were selected by monoclonal antibodies specific for each of the three serotypes. G3-specific monoclonal antibodies also selected mutations at position 148 and the new position of 264. This latter mutation resulted in substitution of aspartic acid for glycine and was located in a highly conserved and hydrophobic region of VP7. A G2-specific N-MAb selected variants with a mutation at aa 190 producing a new, utilized glycosylation site which we propose to be in new antigenic site E. The positions of mutations in antigenic variants and their antigenicity were determined by parental background genes and VP7 glycosylation.

Characteristics and location of cross-reactive and serotype-specific neutralization sites on VP7 of human G type 9 rotaviruses

The neutralization antigens of human rotavirus VP7 were studied by producing eight neutralizing monoclonal antibodies to G type 9 rotaviruses F45 and WI61 and selecting antigenic variants resistant to neutralization by these monoclonal antibodies. Neutralization resistance patterns and sequence analysis of the antigenic variants indicated the presence of overlapping serotype-specific and serotype cross-reactive epitopes in antigenic region A, and one distinct type-specific epitope. Cross-reactive monoclonal antibodies were more tolerant of amino acid sequence change than type-specific monoclonal antibodies. The existence of a new antigenic region, F, including amino acids 235 to 242 was confirmed. This region contained a cross-reactive epitope not detectable in the presence of glycosylation at amino acid 238. This glycosylation also affected neutralization by a cross-reactive monoclonal antibody directed to antigenic region C. Antigenic regions A, B, C, and F all contain epitopes shared between G types, of which at least two (C and F) are affected by glycosylation.

Relation of VP7 amino acid sequence to monoclonal antibody neutralization of rotavirus and rotavirus monotype

The neutralization epitopes of the VP7 of human rotavirus RV-4 were studied by using five neutralizing mouse monoclonal antibodies to select virus variants resistant to neutralization by each of the antibodies. Antibody resistance patterns and sequence analysis of the RV-4 variants revealed that at least four sites on VP7, located at amino acids 94 (region A), 147 to 148 (region B), 213 (region C), and 291, are involved in neutralization of the human G1 rotavirus RV-4. The A-region site elicited antibody cross-reactive between G types and showed species-restricted immunodominance not related to carbohydrate attachment. The monotype 1b rotavirus M37 lacked this site. The B region contained strain-specific and cross-reactive sites, absent in monotype 1c rotaviruses. The C-region site was present in all G1 rotaviruses tested. Monotype 1a rotaviruses contained all these sites of neutralization. Virus monotype and sensitivity to monoclonal antibody neutralization usually related to the presence of a particular amino acid(s) at or next to the positions at which the mutations were selected in the virus variants.

Influence of menstrual cycle and gender on alprazolam pharmacokinetics

The effects of menstrual cycle phases and gender on alprazolam pharmacokinetics were evaluated in normal volunteers. Alprazolam (1 mg) was administered to seven women during the late follicular and luteal phases of the menstrual cycle and to eight men on one occasion. No difference in alprazolam pharmacokinetic parameters was observed during the menstrual cycle phases. Mean alprazolam clearance (+/- SD) was 0.0037 +/- 0.0009 ml/hr during the follicular phase and 0.0036 +/- 0.001 ml/hr during the luteal phase (p greater than 0.05, difference not significant). With use of weight as a covariant, there was no difference in alprazolam pharmacokinetic parameters between women and men. Mean alprazolam clearance (+/- SD) was 0.0036 +/- 0.0009 ml/hr in women compared with 0.0041 +/- 0.0006 ml/hr in men (p greater than 0.05, difference not significant). Although alprazolam metabolism was similar on the 2 days tested, alterations may occur at other times during the menstrual cycle. Further investigation is needed to understand the effects of menstrual cycle phases and gender on drug metabolism.