1
|
Baltas I, Gilchrist M, Koutoumanou E, Gibani MM, Meiring JE, Otu A, Hettle D, Thompson A, Price JR, Crepet A, Atomode A, Crocker-Buque T, Spinos D, Guyver H, Tausan M, Somasunderam D, Thoburn M, Chan C, Umpleby H, Sharp B, Chivers C, Vaghela DS, Shah RJ, Foster J, Hume A, Smith C, Asif A, Mermerelis D, Reza MA, Haigh DA, Lamb T, Karatzia L, Bramley A, Kadam N, Kavallieros K, Garcia-Arias V, Democratis J, Waddington CS, Moore LSP, Aiken AM. Exploring the views of infection consultants in England on a novel delinked funding model for antimicrobials: the SMASH study. JAC Antimicrob Resist 2023; 5:dlad091. [PMID: 37533762 PMCID: PMC10391702 DOI: 10.1093/jacamr/dlad091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 07/10/2023] [Indexed: 08/04/2023] Open
Abstract
Objectives A novel 'subscription-type' funding model was launched in England in July 2022 for ceftazidime/avibactam and cefiderocol. We explored the views of infection consultants on important aspects of the delinked antimicrobial funding model. Methods An online survey was sent to all infection consultants in NHS acute hospitals in England. Results The response rate was 31.2% (235/753). Most consultants agreed the model is a welcome development (69.8%, 164/235), will improve treatment of drug-resistant infections (68.5%, 161/235) and will stimulate research and development of new antimicrobials (57.9%, 136/235). Consultants disagreed that the model would lead to reduced carbapenem use and reported increased use of cefiderocol post-implementation. The presence of an antimicrobial pharmacy team, requirement for preauthorization by infection specialists, antimicrobial stewardship ward rounds and education of infection specialists were considered the most effective antimicrobial stewardship interventions. Under the new model, 42.1% (99/235) of consultants would use these antimicrobials empirically, if risk factors for antimicrobial resistance were present (previous infection, colonization, treatment failure with carbapenems, ward outbreak, recent admission to a high-prevalence setting).Significantly higher insurance and diversity values were given to model antimicrobials compared with established treatments for carbapenem-resistant infections, while meropenem recorded the highest enablement value. Use of both 'subscription-type' model drugs for a wide range of infection sites was reported. Respondents prioritized ceftazidime/avibactam for infections by bacteria producing OXA-48 and KPC and cefiderocol for those producing MBLs and infections with Stenotrophomonas maltophilia, Acinetobacter spp. and Burkholderia cepacia. Conclusions The 'subscription-type' model was viewed favourably by infection consultants in England.
Collapse
Affiliation(s)
| | - Mark Gilchrist
- Imperial College Healthcare NHS Trust, London, UK
- Department of Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
| | - Eirini Koutoumanou
- Population, Policy & Practice Research and Teaching Department, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Malick M Gibani
- Department of Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
| | - James E Meiring
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Akaninyene Otu
- Department of Microbiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - David Hettle
- Department of Infection Sciences, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Ameeka Thompson
- Department of Infection Sciences, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - James R Price
- Brighton and Sussex Medical School, University of Sussex, Brighton, UK
- University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Anna Crepet
- University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | | | | | - Dimitrios Spinos
- Department of ENT, Head and Neck Surgery, Gloucester Royal Hospital, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK
| | - Hudson Guyver
- James Paget University Hospitals NHS Foundation Trust, Norfolk, UK
| | - Matija Tausan
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | | | - Maxwell Thoburn
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Cathleen Chan
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Helen Umpleby
- Hampshire Hospitals NHS Foundation Trust, Hampshire, UK
| | - Bethany Sharp
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Callum Chivers
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | - Ronak J Shah
- Imperial College Healthcare NHS Trust, London, UK
| | - Jonathan Foster
- Directorate of Pharmacy, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Amy Hume
- Directorate of Pharmacy, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Christopher Smith
- Department of Infectious Disease, Faculty of Medicine, Imperial College London, London, UK
| | - Ammara Asif
- Hull University Teaching Hospitals NHS Trust, Hull, UK
| | | | | | | | - Thomas Lamb
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Vientiane, Lao People’s Democratic Republic
| | | | | | - Nikhil Kadam
- Mid and South Essex NHS Trust, Westcliff-on-Sea, UK
| | | | | | - Jane Democratis
- Wexham Park Hospital, Frimley Health NHS Foundation Trust, Slough, UK
| | | | - Luke S P Moore
- Imperial College Healthcare NHS Trust, London, UK
- Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
- Imperial College London, NIHR Health Protection Research Unit on Healthcare Associated Infections and Antimicrobial Resistance, London, UK
| | - Alexander M Aiken
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| |
Collapse
|
2
|
Stafford A, Rimmer S, Gilchrist M, Sun K, Davies EP, Waddington CS, Chiu C, Armstrong-James D, Swaine T, Davies F, Gómez CHM, Kumar V, ElHaddad A, Awad Z, Smart C, Mora-Peris B, Muir D, Randell P, Peters J, Chand M, Warrell CE, Rampling T, Cooke G, Dhanji S, Campbell V, Davies C, Osman S, Abbara A. Use of cidofovir in a patient with severe mpox and uncontrolled HIV infection. Lancet Infect Dis 2023; 23:e218-e226. [PMID: 36773621 PMCID: PMC9908088 DOI: 10.1016/s1473-3099(23)00044-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 12/20/2022] [Accepted: 12/29/2022] [Indexed: 02/11/2023]
Abstract
A 48-year-old man with poorly controlled HIV presented with severe human monkeypox virus (hMPXV) infection, having completed 2 weeks of tecovirimat at another hospital. He had painful, ulcerating skin lesions on most of his body and oropharyngeal cavity, with subsequent Ludwig's angina requiring repeated surgical interventions. Despite commencing a second, prolonged course of tecovirimat, he did not objectively improve, and new lesions were still noted at day 24. Discussion at the UK National Health Service England High Consequence Infectious Diseases Network recommended the use of 3% topical and then intravenous cidofovir, which was given at 5 mg/kg; the patient made a noticeable improvement after the first intravenous dose. He received further intravenous doses at 7 days and 21 days after the dose and was discharged at day 52. Cidofovir is not licensed for use in treatment of hMPXV infection. Data for cidofovir use in hMPXV are restricted to studies in animals. Four other documented cases of cidofovir use against hMPXV have been reported in the USA in 2022, but we present its first use in the UK. The scarcity of studies into the use of cidofovir in this condition clearly shows the need for robust studies to assess efficacy, optimum dosage, timing, and route of administration.
Collapse
Affiliation(s)
- Adam Stafford
- Department of Infectious Diseases, Imperial College NHS Healthcare Trust, St Mary's Hospital, London, UK
| | - Stephanie Rimmer
- Department of Infectious Diseases, Imperial College NHS Healthcare Trust, St Mary's Hospital, London, UK
| | - Mark Gilchrist
- Department of Infectious Diseases, Imperial College NHS Healthcare Trust, St Mary's Hospital, London, UK,Department of Infectious Diseases, Imperial College London, London, UK
| | - Kristi Sun
- Department of Infectious Diseases, Imperial College NHS Healthcare Trust, St Mary's Hospital, London, UK
| | - Ella P Davies
- Department of Infectious Diseases, Imperial College NHS Healthcare Trust, St Mary's Hospital, London, UK
| | - Claire S Waddington
- Department of Infectious Diseases, Imperial College NHS Healthcare Trust, St Mary's Hospital, London, UK
| | - Christopher Chiu
- Department of Infectious Diseases, Imperial College NHS Healthcare Trust, St Mary's Hospital, London, UK,Department of Infectious Diseases, Imperial College London, London, UK
| | - Darius Armstrong-James
- Department of Infectious Diseases, Imperial College NHS Healthcare Trust, St Mary's Hospital, London, UK,Department of Infectious Diseases, Imperial College London, London, UK
| | - Thomas Swaine
- Department of Infectious Diseases, Imperial College NHS Healthcare Trust, St Mary's Hospital, London, UK
| | - Frances Davies
- Department of Infectious Diseases, Imperial College NHS Healthcare Trust, St Mary's Hospital, London, UK,Department of Infectious Diseases, Imperial College London, London, UK
| | - Carlos H M Gómez
- Department of Intensive Care Medicine, Imperial College NHS Healthcare Trust, St Mary's Hospital, London, UK
| | - Vagish Kumar
- Department of Intensive Care Medicine, Imperial College NHS Healthcare Trust, St Mary's Hospital, London, UK
| | - Ahmad ElHaddad
- Department of Intensive Care Medicine, Imperial College NHS Healthcare Trust, St Mary's Hospital, London, UK
| | - Zaid Awad
- Department of Ear, Nose and Throat, Imperial College NHS Healthcare Trust, St Mary's Hospital, London, UK
| | - Christopher Smart
- Department of Intensive Care Medicine, Imperial College NHS Healthcare Trust, St Mary's Hospital, London, UK
| | - Borja Mora-Peris
- Department of HIV, Imperial College NHS Healthcare Trust, St Mary's Hospital, London, UK,Department of Infectious Diseases, Imperial College London, London, UK
| | - David Muir
- Department of Infectious Diseases, Imperial College NHS Healthcare Trust, St Mary's Hospital, London, UK,Department of Infectious Diseases, Imperial College London, London, UK
| | - Paul Randell
- Department of Infectious Diseases, Imperial College NHS Healthcare Trust, St Mary's Hospital, London, UK,Department of Infectious Diseases, Imperial College London, London, UK
| | - Joanna Peters
- Department of Infectious Diseases, Imperial College NHS Healthcare Trust, St Mary's Hospital, London, UK
| | - Meera Chand
- United Kingdom Health Security Agency, Colindale, UK
| | | | | | - Graham Cooke
- Department of Infectious Diseases, Imperial College NHS Healthcare Trust, St Mary's Hospital, London, UK,Department of Infectious Diseases, Imperial College London, London, UK
| | - Sara Dhanji
- Department of Intensive Care Medicine, Imperial College NHS Healthcare Trust, St Mary's Hospital, London, UK
| | - Vivienne Campbell
- Department of Speech and Language Therapy, Imperial College NHS Healthcare Trust, St Mary's Hospital, London, UK
| | - Carys Davies
- Department of Intensive Care Medicine, Imperial College NHS Healthcare Trust, St Mary's Hospital, London, UK
| | - Sana Osman
- Department of Intensive Care Medicine, Imperial College NHS Healthcare Trust, St Mary's Hospital, London, UK
| | - Aula Abbara
- Department of Infectious Diseases, Imperial College NHS Healthcare Trust, St Mary's Hospital, London, UK; Department of Infectious Diseases, Imperial College London, London, UK.
| |
Collapse
|
3
|
Wiegand M, Cowan SL, Waddington CS, Halsall DJ, Keevil VL, Tom BDM, Taylor V, Gkrania-Klotsas E, Preller J, Goudie RJB. Development and validation of a dynamic 48-hour in-hospital mortality risk stratification for COVID-19 in a UK teaching hospital: a retrospective cohort study. BMJ Open 2022; 12:e060026. [PMID: 36691139 PMCID: PMC9445230 DOI: 10.1136/bmjopen-2021-060026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 07/13/2022] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVES To develop a disease stratification model for COVID-19 that updates according to changes in a patient's condition while in hospital to facilitate patient management and resource allocation. DESIGN In this retrospective cohort study, we adopted a landmarking approach to dynamic prediction of all-cause in-hospital mortality over the next 48 hours. We accounted for informative predictor missingness and selected predictors using penalised regression. SETTING All data used in this study were obtained from a single UK teaching hospital. PARTICIPANTS We developed the model using 473 consecutive patients with COVID-19 presenting to a UK hospital between 1 March 2020 and 12 September 2020; and temporally validated using data on 1119 patients presenting between 13 September 2020 and 17 March 2021. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome is all-cause in-hospital mortality within 48 hours of the prediction time. We accounted for the competing risks of discharge from hospital alive and transfer to a tertiary intensive care unit for extracorporeal membrane oxygenation. RESULTS Our final model includes age, Clinical Frailty Scale score, heart rate, respiratory rate, oxygen saturation/fractional inspired oxygen ratio, white cell count, presence of acidosis (pH <7.35) and interleukin-6. Internal validation achieved an area under the receiver operating characteristic (AUROC) of 0.90 (95% CI 0.87 to 0.93) and temporal validation gave an AUROC of 0.86 (95% CI 0.83 to 0.88). CONCLUSIONS Our model incorporates both static risk factors (eg, age) and evolving clinical and laboratory data, to provide a dynamic risk prediction model that adapts to both sudden and gradual changes in an individual patient's clinical condition. On successful external validation, the model has the potential to be a powerful clinical risk assessment tool. TRIAL REGISTRATION The study is registered as 'researchregistry5464' on the Research Registry (www.researchregistry.com).
Collapse
Affiliation(s)
- Martin Wiegand
- Faculty of Infectious Diseases, London School of Hygiene & Tropical Medicine, London, UK
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
| | - Sarah L Cowan
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - David J Halsall
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Victoria L Keevil
- Department of Medicine, University of Cambridge, Cambridge, UK
- Department of Medicine for the Elderly, Addenbrooke's Hospital, Cambridge, UK
| | - Brian D M Tom
- MRC Biostatistics Unit, University of Cambridge, Cambridge, UK
| | - Vince Taylor
- Cancer Research UK, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Jacobus Preller
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | |
Collapse
|
4
|
Salerno-Gonçalves R, Fresnay S, Magder L, Darton TC, Waddington CS, Blohmke CJ, Angus B, Levine MM, Pollard AJ, Sztein MB. Mucosal-Associated Invariant T cells exhibit distinct functional signatures associated with protection against typhoid fever. Cell Immunol 2022; 378:104572. [PMID: 35772315 PMCID: PMC9377420 DOI: 10.1016/j.cellimm.2022.104572] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 06/15/2022] [Accepted: 06/16/2022] [Indexed: 11/26/2022]
Abstract
First demonstration of cytokine-secreting MAIT cell kinetics after human challenge with Salmonella enterica serovar Typhi. MAIT cell's functional signatures and association with typhoid fever protection. Predictive value of MAIT cell cytokine pattern. Lack of association between the number of cytokines expressed by MAIT cells and prevention against typhoid fever.
We have previously demonstrated that Mucosal-Associated Invariant T (MAIT) cells secrete multiple cytokines after exposure to Salmonella enterica serovar Typhi (S. Typhi), the causative agent of typhoid fever in humans. However, whether cytokine secreting MAIT cells can enhance or attenuate the clinical severity of bacterial infections remain debatable. This study characterizes human MAIT cell functions in subjects participating in a wild-type S. Typhi human challenge model. Here, we found that MAIT cells exhibit distinct functional signatures associated with protection against typhoid fever. We also observed that the cytokine patterns of MAIT cell responses, rather than the average number of cytokines expressed, are more predictive of typhoid fever outcomes. These results might enable us to objectively, based on functional parameters, identify cytokine patterns that may serve as predictive biomarkers during natural infection and vaccination.
Collapse
|
5
|
Middleton BF, Danchin M, Jones MA, Leach AJ, Cunliffe N, Kirkwood CD, Carapetis J, Gallagher S, Kirkham LA, Granland C, McNeal M, Marsh JA, Waddington CS, Snelling TL. OUP accepted manuscript. J Infect Dis 2022; 226:1537-1544. [PMID: 35134951 PMCID: PMC9624458 DOI: 10.1093/infdis/jiac038] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 01/30/2022] [Indexed: 11/25/2022] Open
Abstract
Background Rotarix (GlaxoSmithKline) oral rotavirus vaccine is licensed as 2 doses in the first 6 months of life. In settings with high child mortality rates, clinical protection conferred by 2 doses of Rotarix is reduced. We assessed vaccine immune response when an additional dose of Rotarix was given to Australian Aboriginal children 6 to <12 months old. Methods ORVAC is a 2-stage, double-blind, randomized, placebo-controlled trial. Australian Aboriginal children 6 to <12 months old who had received 1 or 2 prior doses of Rotarix rotavirus vaccine were randomized 1:1 to receive an additional dose of Rotarix or matched placebo. The primary immunological end point was seroresponse defined as an anti-rotavirus immunoglobulin A level ≥20 AU/mL, 28–56 days after the additional dose of Rotarix or placebo. Results Between March 2018 and August 2020, a total of 253 infants were enrolled. Of these, 178 infants (70%) had analyzable serological results after follow-up; 89 were randomized to receive Rotarix, and 89 to receive placebo. The proportion with seroresponse was 85% after Rotarix compared with 72% after placebo. There were no occurrences of intussusception or any serious adverse events. Conclusions An additional dose of Rotarix administered to Australian Aboriginal infants 6 to <12 months old increased the proportion with a vaccine seroresponse. Clinical Trials Registration NCT02941107.
Collapse
Affiliation(s)
- Bianca F Middleton
- Correspondence: Bianca F. Middleton, Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, PO Box 41096, Casuarina, Northern Territory, Australia ()
| | - Margie Danchin
- Vaccine Uptake Group, Murdoch Children’s Research Institute, Melbourne, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
- Department of General Medicine, Royal Children’s Hospital, Melbourne, Australia
| | - Mark A Jones
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, Perth, Australia
- School of Public Health, University of Sydney, Sydney, Australia
| | - Amanda J Leach
- Child Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | - Nigel Cunliffe
- Clinical Infection, Microbiology and Immunology, University of Liverpool, Liverpool, United Kingdom
| | - Carl D Kirkwood
- Enteric and Diarrheal Diseases, Bill and Melinda Gates Foundation, Seattle, USA
| | - Jonathan Carapetis
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, Perth, Australia
- Centre for Child Health Research, University of Western Australia, Perth, Australia
| | - Sarah Gallagher
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Australia
| | - Lea-Ann Kirkham
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, Perth, Australia
- Centre for Child Health Research, University of Western Australia, Perth, Australia
| | - Caitlyn Granland
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, Perth, Australia
| | - Monica McNeal
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, USA
- Division of Infectious Disease, Cincinnati Children’s Hospital Medical Centre, Cincinnati, USA
| | - Julie A Marsh
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, Perth, Australia
| | - Claire S Waddington
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge, United Kingdom
| | - Thomas L Snelling
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, Perth, Australia
- School of Public Health, University of Sydney, Sydney, Australia
- School of Public Health, Curtin University, Perth, Australia
| |
Collapse
|
6
|
Osowicki J, Azzopardi KI, Fabri L, Frost HR, Rivera-Hernandez T, Neeland MR, Whitcombe AL, Grobler A, Gutman SJ, Baker C, Wong JMF, Lickliter JD, Waddington CS, Pandey M, Schuster T, Cheng AC, Pollard AJ, McCarthy JS, Good MF, Dale JB, Batzloff M, Moreland NJ, Walker MJ, Carapetis JR, Smeesters PR, Steer AC. A controlled human infection model of Streptococcus pyogenes pharyngitis (CHIVAS-M75): an observational, dose-finding study. Lancet Microbe 2021; 2:e291-e299. [PMID: 35544165 DOI: 10.1016/s2666-5247(20)30240-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 12/17/2020] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Streptococcus pyogenes is a leading cause of infection-related morbidity and mortality. A reinvigorated vaccine development effort calls for new clinically relevant human S pyogenes experimental infection models to support proof of concept evaluation of candidate vaccines. We describe the initial Controlled Human Infection for Vaccination Against S pyogenes (CHIVAS-M75) study, in which we aimed to identify a dose of emm75 S pyogenes that causes acute pharyngitis in at least 60% of volunteers when applied to the pharynx by swab. METHODS This observational, dose-finding study was done in a clinical trials facility in Melbourne (VIC, Australia). Groups of healthy volunteers aged 18-40 years, at low risk of complicated S pyogenes disease, and without high type-specific anti-emm75 IgG antibodies against the challenge strain were challenged and closely monitored as inpatients for up to 6 days, and then as outpatients for 6 months. Antibiotics were started upon diagnosis (clinical signs and symptoms of pharyngitis and a positive rapid molecular test) or after 5 days in those without pharyngitis. Rapid test results were confirmed by standard bacterial culture. After a sentinel participant, cohorts of five and then ten participants were challenged, with protocol-directed dose-escalation or de-escalation for subsequent cohorts. The primary outcome was the proportion of participants at each dose level with pharyngitis by day 5 after challenge. The study is registered with ClinicalTrials.gov, NCT03361163. FINDINGS Between July 10, 2018, and Sept 23, 2019, 25 healthy adults were challenged with emm75 S pyogenes and included in analyses. Pharyngitis was diagnosed in 17 (85%; 95% CI 62-97) of 20 participants at the starting dose level (1-3 × 105 colony-forming units [CFU]/mL). This high proportion prompted dose de-escalation. At the lower dose level (1-3 × 104 CFU/mL), pharyngitis was diagnosed in one of five participants. Immunological, biochemical, and microbiological results supported the clinical picture, with acute symptomatic pharyngitis characterised by pharyngeal colonisation by S pyogenes accompanied by significantly elevated C-reactive protein and inflammatory cytokines (eg, interferon-γ and interleukin-6), and modest serological responses to streptolysin O and deoxyribonuclease B. There were no severe (grade 3) or serious adverse events related to challenge. INTERPRETATION We have established a reliable pharyngitis human infection model with reassuring early safety findings to accelerate development of vaccines and other interventions to control disease due to S pyogenes. FUNDING Australian National Health and Medical Research Council.
Collapse
Affiliation(s)
- Joshua Osowicki
- Tropical Diseases Research Group, Murdoch Children's Research Institute, Melbourne, VIC, Australia; Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia; Infectious Diseases Unit, Department of General Medicine, Royal Children's Hospital Melbourne, Melbourne, VIC, Australia.
| | - Kristy I Azzopardi
- Tropical Diseases Research Group, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Loraine Fabri
- Tropical Diseases Research Group, Murdoch Children's Research Institute, Melbourne, VIC, Australia; Paediatric Department, Academic Children Hospital Queen Fabiola, Université Libre de Bruxelles, Brussels, Belgium
| | - Hannah R Frost
- Tropical Diseases Research Group, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Tania Rivera-Hernandez
- Unidad de Investigación Médica en Inmunoquímica, Hospital de Especialidades del Centro Médico Nacional Siglo XXI, Instituto Mexicano del Seguro Social, Mexico City, Mexico; School of Chemistry and Molecular Biosciences and Australian Infectious Diseases Research Centre, The University of Queensland, Brisbane, QLD, Australia
| | - Melanie R Neeland
- Epigenetics Research Group, Murdoch Children's Research Institute, Melbourne, VIC, Australia; Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
| | - Alana L Whitcombe
- Department of Molecular Medicine and Pathology, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Anneke Grobler
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Melbourne, VIC, Australia; Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
| | - Sarah J Gutman
- Department of Cardiology, The Alfred Hospital, Melbourne, VIC, Australia; Imaging Research, Baker Heart and Diabetes Institute, Melbourne, VIC, Australia; Department of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
| | - Ciara Baker
- Tropical Diseases Research Group, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | | | | | - Claire S Waddington
- Department of Medicine, University of Cambridge, Cambridge, UK; Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia
| | - Manisha Pandey
- The Institute for Glycomics, Griffith University, Gold Coast, QLD, Australia
| | - Tibor Schuster
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Melbourne, VIC, Australia; Department of Family Medicine, McGill University, Montreal, QC, Canada
| | - Allen C Cheng
- Infection Prevention and Healthcare Epidemiology Unit, The Alfred Hospital, Melbourne, VIC, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Andrew J Pollard
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK; National Institute for Health Research, Oxford Biomedical Research Centre, Oxford, UK
| | - James S McCarthy
- School of Medicine, The University of Queensland, Brisbane, QLD, Australia; QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
| | - Michael F Good
- The Institute for Glycomics, Griffith University, Gold Coast, QLD, Australia
| | - James B Dale
- Department of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Michael Batzloff
- The Institute for Glycomics, Griffith University, Gold Coast, QLD, Australia
| | - Nicole J Moreland
- Department of Molecular Medicine and Pathology, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Mark J Walker
- School of Chemistry and Molecular Biosciences and Australian Infectious Diseases Research Centre, The University of Queensland, Brisbane, QLD, Australia
| | - Jonathan R Carapetis
- Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, Perth, WA, Australia; Faculty of Health and Medical Sciences, University of Western Australia, Perth, WA, Australia; Tropical Diseases Research Group, Murdoch Children's Research Institute, Melbourne, VIC, Australia; Department of Paediatric Infectious Diseases, Perth Children's Hospital, Perth, WA, Australia
| | - Pierre R Smeesters
- Tropical Diseases Research Group, Murdoch Children's Research Institute, Melbourne, VIC, Australia; Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia; Paediatric Department, Academic Children Hospital Queen Fabiola, Université Libre de Bruxelles, Brussels, Belgium; Molecular Bacteriology Laboratory, Université Libre de Bruxelles, Brussels, Belgium
| | - Andrew C Steer
- Tropical Diseases Research Group, Murdoch Children's Research Institute, Melbourne, VIC, Australia; Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia; Infectious Diseases Unit, Department of General Medicine, Royal Children's Hospital Melbourne, Melbourne, VIC, Australia
| |
Collapse
|
7
|
Perez Chacon G, Estcourt MJ, Totterdell J, Campbell DE, Perrett KP, Marsh JA, Richmond PC, Wood N, Gold MS, Holt PG, Waddington CS, Snelling TL. OPTIMUM study protocol: an adaptive randomised controlled trial of a mixed whole-cell/acellular pertussis vaccine schedule. BMJ Open 2020; 10:e042838. [PMID: 33334840 PMCID: PMC7747585 DOI: 10.1136/bmjopen-2020-042838] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Combination vaccines containing whole-cell pertussis antigens were phased out from the Australian national immunisation programme between 1997 and 1999 and replaced by the less reactogenic acellular pertussis (aP) antigens. In a large case-control study of Australian children born during the transition period, those with allergist diagnosed IgE-mediated food allergy were less likely to have received whole-cell vaccine in early infancy than matched population controls (OR: 0.77 (95% CI, 0.62 to 0.95)). We hypothesise that a single dose of whole-cell vaccine in early infancy is protective against IgE-mediated food allergy. METHODS AND ANALYSIS This adaptive double-blind randomised controlled trial is investigating whether a mixed whole-cell/aP vaccine schedule prevents allergic disease in the first year of life. The primary outcome is IgE-mediated food allergy by 12 months of age. Secondary outcomes include new onset of atopic dermatitis by 6 or 12 months of age; sensitisation to at least one allergen by 12 months of age; seroconversion in anti-pertussis toxin IgG titres after vaccination with aP booster at 18 months of age; and solicited systemic and local adverse events following immunisation with pertussis-containing vaccines. Analyses will be performed using a Bayesian group sequential design. ETHICS AND DISSEMINATION This study has been approved by the Child and Adolescent Health Service Human Research Ethics Committee, Perth, Western Australia (RGS 00019). The investigators will ensure that this trial is conducted in accordance with the principles of the Declaration of Helsinki and with the International Conference on Harmonisation Guidelines for Good Clinical Practice. Individual consent will be requested. Parents will be reimbursed reasonable travel and parking costs to attend the study visits. The dissemination of these research findings will follow the National Health and Medical Research Council of Australia Open Access Policy. TRIAL REGISTRATION NUMBER ACTRN12617000065392p.
Collapse
Affiliation(s)
- Gladymar Perez Chacon
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, Nedlands, Western Australia, Australia
- School of Public Health, Curtin University, Bentley, Western Australia, Australia
| | - Marie J Estcourt
- Health and Clinical Analytics Lab, School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - James Totterdell
- Health and Clinical Analytics Lab, School of Public Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Dianne E Campbell
- Department of Allergy and Immunology, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
- Discipline of Child and Adolescent Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Kirsten P Perrett
- Royal Children's Hospital, Murdoch Children's Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, The University of Melbourne, Melbourne, Victoria, Australia
| | - Julie A Marsh
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, Nedlands, Western Australia, Australia
| | - Peter C Richmond
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, Nedlands, Western Australia, Australia
- Division of Paediatrics, School of Medicine, Perth Children's Hospital, The University of Western Australia, Nedlands, Western Australia, Australia
| | - Nicholas Wood
- Discipline of Child and Adolescent Health, The University of Sydney, Sydney, New South Wales, Australia
- The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - Michael S Gold
- Discipline of Paediatrics, School of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Patrick G Holt
- The University of Western Australia, Telethon Kids Institute, Nedlands, Western Australia, Australia
| | - Claire S Waddington
- Department of Medicine, University of Cambridge, Cambridge, Cambridgeshire, UK
| | - Thomas L Snelling
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, Nedlands, Western Australia, Australia
| |
Collapse
|
8
|
Rapaka RR, Wahid R, Fresnay S, Booth JS, Darton TC, Jones C, Waddington CS, Levine MM, Pollard AJ, Sztein MB. Human Salmonella Typhi exposure generates differential multifunctional cross-reactive T-cell memory responses against Salmonella Paratyphi and invasive nontyphoidal Salmonella. Clin Transl Immunology 2020; 9:e1178. [PMID: 33005416 PMCID: PMC7512505 DOI: 10.1002/cti2.1178] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 08/16/2020] [Accepted: 08/17/2020] [Indexed: 12/19/2022] Open
Abstract
Objective There are no vaccines for most of the major invasive Salmonella strains causing severe infection in humans. We evaluated the specificity of adaptive T memory cell responses generated after Salmonella Typhi exposure in humans against other major invasive Salmonella strains sharing capacity for dissemination. Methods T memory cells from eleven volunteers who underwent controlled oral challenge with wtS. Typhi were characterised by flow cytometry for cross‐reactive cellular cytokine/chemokine effector responses or evidence of degranulation upon stimulation with autologous B‐lymphoblastoid cells infected with either S. Typhi, Salmonella Paratyphi A (PA), S. Paratyphi B (PB) or an invasive nontyphoidal Salmonella strain of the S. Typhimurium serovar (iNTSTy). Results Blood T‐cell effector memory (TEM) responses after exposure to S. Typhi in humans evolve late, peaking weeks after infection in most volunteers. Induced multifunctional CD4+ Th1 and CD8+ TEM cells elicited after S. Typhi challenge were cross‐reactive with PA, PB and iNTSTy. The magnitude of multifunctional CD4+ TEM cell responses to S. Typhi correlated with induction of cross‐reactive multifunctional CD8+ TEM cells against PA, PB and iNTSTy. Highly multifunctional subsets and T central memory and T effector memory cells that re‐express CD45 (TEMRA) demonstrated less heterologous T‐cell cross‐reactivity, and multifunctional Th17 elicited after S. Typhi challenge was not cross‐reactive against other invasive Salmonella. Conclusion Gaps in cross‐reactive immune effector functions in human T‐cell memory compartments were highly dependent on invasive Salmonella strain, underscoring the importance of strain‐dependent vaccination in the design of T‐cell‐based vaccines for invasive Salmonella.
Collapse
Affiliation(s)
- Rekha R Rapaka
- Center for Vaccine Development and Global Health University of Maryland School of Medicine Baltimore MD USA.,Department of Medicine University of Maryland School of Medicine Baltimore MD USA
| | - Rezwanul Wahid
- Center for Vaccine Development and Global Health University of Maryland School of Medicine Baltimore MD USA.,Department of Pediatrics University of Maryland School of Medicine Baltimore MD USA
| | - Stephanie Fresnay
- Center for Vaccine Development and Global Health University of Maryland School of Medicine Baltimore MD USA.,Department of Pediatrics University of Maryland School of Medicine Baltimore MD USA.,Present address: Stephanie Fresnay GlaxoSmithKline Rockville MD USA
| | - Jayaum S Booth
- Center for Vaccine Development and Global Health University of Maryland School of Medicine Baltimore MD USA.,Department of Pediatrics University of Maryland School of Medicine Baltimore MD USA
| | - Thomas C Darton
- Oxford Vaccine Group Department of Paediatrics University of Oxford and the NIHR Oxford Biomedical Research Centre Oxford UK.,Present address: Thomas C Darton University of Sheffield Medical School Sheffield UK
| | - Claire Jones
- Oxford Vaccine Group Department of Paediatrics University of Oxford and the NIHR Oxford Biomedical Research Centre Oxford UK
| | - Claire S Waddington
- Oxford Vaccine Group Department of Paediatrics University of Oxford and the NIHR Oxford Biomedical Research Centre Oxford UK.,Present address: University of Cambridge Cambridge UK
| | - Myron M Levine
- Center for Vaccine Development and Global Health University of Maryland School of Medicine Baltimore MD USA.,Department of Medicine University of Maryland School of Medicine Baltimore MD USA.,Department of Pediatrics University of Maryland School of Medicine Baltimore MD USA
| | - Andrew J Pollard
- Oxford Vaccine Group Department of Paediatrics University of Oxford and the NIHR Oxford Biomedical Research Centre Oxford UK
| | - Marcelo B Sztein
- Center for Vaccine Development and Global Health University of Maryland School of Medicine Baltimore MD USA.,Department of Medicine University of Maryland School of Medicine Baltimore MD USA.,Department of Pediatrics University of Maryland School of Medicine Baltimore MD USA
| |
Collapse
|
9
|
Estcourt MJ, Campbell DE, Gold MS, Richmond P, Allen KJ, Quinn HE, Marsh JA, Peters RL, Valerio C, Dai D, Waddington CS, Wood NJ, McIntyre PB, Holt PG, Snelling TL. Whole-Cell Pertussis Vaccination and Decreased Risk of IgE-Mediated Food Allergy: A Nested Case-Control Study. J Allergy Clin Immunol Pract 2019; 8:2004-2014. [PMID: 31891824 DOI: 10.1016/j.jaip.2019.12.020] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 11/25/2019] [Accepted: 12/10/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND Rates of food allergy have increased markedly in Australia and other high- income countries in recent years. On the basis of ecological observations, and the known immunologic characteristics of whole-cell pertussis (wP) compared with acellular pertussis (aP) vaccines, we hypothesized that wP vaccination in infancy protects against the development of food allergy. OBJECTIVE To determine whether infants who receive wP in infancy were less likely to develop IgE-mediated food allergy than those who received aP. METHODS Retrospective cohort-nested case-control study of Australian children born in the period 1997 to 1999, the period of transition from using wP-containing to aP-containing vaccines. Children diagnosed with IgE-mediated food allergy were individually matched to 10 controls by date of birth, socioeconomic decile, and jurisdiction of birth. The odds ratio of vaccination with wP versus aP among cases and matched controls was calculated using conditional logistic regression. RESULTS The odds ratio of receiving the first dose as wP (rather than aP) among cases of food allergy compared with controls was 0.77 (95% CI, 0.62-0.95). The results of secondary analyses (any dose as wP vs aP-only, and wP-only vs aP-only) were broadly similar. CONCLUSIONS Australian infants who received wP vaccines were less likely to be diagnosed with food allergy in childhood than contemporaneous children who received aP vaccines. If a protective effect is confirmed in a randomized controlled trial, wP or mixed wP and aP vaccination schedules could form part of an effective strategy for combating the rise in food allergies.
Collapse
Affiliation(s)
- Marie J Estcourt
- Wesfarmers Centre of Vaccines & Infectious Diseases, Telethon Kids Institute, Nedlands, WA, Australia; School of Population and Global Health, University of Western Australia, Crawley, WA, Australia
| | - Dianne E Campbell
- Department of Allergy and Immunology, The Children's Hospital at Westmead, Westmead, NSW, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Michael S Gold
- School of Medicine, University of Adelaide, Women's and Children's Health Network, North Adelaide, SA, Australia
| | - Peter Richmond
- Wesfarmers Centre of Vaccines & Infectious Diseases, Telethon Kids Institute, Nedlands, WA, Australia; Division of Paediatrics, School of Medicine, University of Western Australia and Immunology Department, Perth Children's Hospital, Nedlands, WA, Australia
| | - Katrina J Allen
- Centre for Food and Allergy Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia; University of Melbourne Department of Paediatrics, Royal Children's Hospital Melbourne, Melbourne, VIC, Australia
| | - Helen E Quinn
- National Centre for Immunisation Research and Surveillance, Kids Research, Sydney Children's Hospitals Network, Westmead, NSW, Australia; Discipline of Child and Adolescent Health, The University of Sydney Children's Hospital, Westmead Clinical School, Westmead, NSW, Australia
| | - Julie A Marsh
- Wesfarmers Centre of Vaccines & Infectious Diseases, Telethon Kids Institute, Nedlands, WA, Australia; School of Population and Global Health, University of Western Australia, Crawley, WA, Australia
| | - Rachel L Peters
- Centre for Food and Allergy Research, Murdoch Children's Research Institute, Melbourne, VIC, Australia; University of Melbourne Department of Paediatrics, Royal Children's Hospital Melbourne, Melbourne, VIC, Australia
| | - Carolina Valerio
- Department of Allergy and Immunology, The Children's Hospital at Westmead, Westmead, NSW, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Danyi Dai
- Department of Allergy and Immunology, The Children's Hospital at Westmead, Westmead, NSW, Australia; Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Claire S Waddington
- Wesfarmers Centre of Vaccines & Infectious Diseases, Telethon Kids Institute, Nedlands, WA, Australia; Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Nicholas J Wood
- National Centre for Immunisation Research and Surveillance, Kids Research, Sydney Children's Hospitals Network, Westmead, NSW, Australia; Discipline of Child and Adolescent Health, The University of Sydney Children's Hospital, Westmead Clinical School, Westmead, NSW, Australia
| | - Peter B McIntyre
- National Centre for Immunisation Research and Surveillance, Kids Research, Sydney Children's Hospitals Network, Westmead, NSW, Australia; Discipline of Child and Adolescent Health, The University of Sydney Children's Hospital, Westmead Clinical School, Westmead, NSW, Australia
| | - Patrick G Holt
- Human Immunology, Telethon Kids Institute, Perth Children's Hospital, Nedlands, WA, Australia
| | - Thomas L Snelling
- Wesfarmers Centre of Vaccines & Infectious Diseases, Telethon Kids Institute, Nedlands, WA, Australia; School of Public Health, Curtin University, Bentley, WA, Australia.
| |
Collapse
|
10
|
Middleton BF, Jones MA, Waddington CS, Danchin M, McCallum C, Gallagher S, Leach AJ, Andrews R, Kirkwood C, Cunliffe N, Carapetis J, Marsh JA, Snelling T. 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. BMJ Open 2019; 9:e032549. [PMID: 31727664 PMCID: PMC6886966 DOI: 10.1136/bmjopen-2019-032549] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Bianca Fleur Middleton
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Mark A Jones
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, West Perth, Western Australia, Australia
| | - Claire S Waddington
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, West Perth, Western Australia, Australia
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Margaret Danchin
- Vaccine and Immunisation Research Group, Murdoch Childrens Research Institute, Parkville, Victoria, Australia
- Department of Paediatrics, University of Melbourne, Parkville, Victoria, Australia
| | - Carly McCallum
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, West Perth, Western Australia, Australia
| | - Sarah Gallagher
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, Northern Territory, Australia
| | - Amanda Jane Leach
- Child Health Division, Menzies School of Health Research, Charles Darwin Univesity, Darwin, Northern Territory, Australia
| | - Ross Andrews
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Brisbane, Queensland, Australia
| | - Carl Kirkwood
- Enteric and Diarrheal Diseases, Bill and Melinda Gates Foundation, Seattle, Washington, USA
| | - Nigel Cunliffe
- Clinical Infection, Microbiology and Immunology, University of Liverpool, Liverpool, UK
| | - Jonathan Carapetis
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, West Perth, Western Australia, Australia
- Faculty of Health and Medical Sciences, Centre for Child Health Research, University of Western Australia, Crawley, Western Australia, Australia
| | - Julie A Marsh
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, West Perth, Western Australia, Australia
| | - Tom Snelling
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, West Perth, Western Australia, Australia
| |
Collapse
|
11
|
Oguti B, Gibani M, Darlow C, Waddington CS, Jin C, Plested E, Campbell D, Jones C, Darton TC, Pollard AJ. Factors influencing participation in controlled human infection models: a pooled analysis from six enteric fever studies. Wellcome Open Res 2019. [DOI: 10.12688/wellcomeopenres.15469.1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background: Enteric fever is an acute febrile-illness caused by infection with the human-restricted Salmonella serovars Typhi and Paratyphi. Controlled human infection models (CHIM) of S. Typhi and Paratyphi infection are used to accelerate vaccine development and to better understand host-pathogen interactions. The primary motivations for participants to take part in these studies are unknown. We studied participant motivations, attitudes and the factors influencing CHIM study participation. Methods: Participant surveys were nested in six enteric fever CHIM studies conducted at a single centre in Oxford, UK, between 2011 and 2017. All eligible participants received one invitation to complete an anonymous, self-administered paper or online survey on either day 28 or 60 after challenge. A descriptive analysis was performed on these pooled data. All studies were included, to minimize selection bias. Results: Survey response rates varied from 33.0%-86.1%, yielding 201 participants. In the cohort, 113/198(57.0%) were educated to bachelor’s level, 61.6% were employed, 30.3% were students and 4.6% were unemployed. The most commonly cited motivations for CHIM study participation were a desire to contribute to the progression of medicine (170/201; 84.6%); the prospect of financial reimbursement (166/201; 82.6%) and curiosity about clinical trials (117/201; 57.2%). The majority of respondents (139/197; 70.6%) reported that most people advised them against participation. Conclusion: Motivation to participate in a CHIM study was multi-factorial and heavily influenced by internal drivers beyond monetary reimbursement alone. High educational attainment and employment may be protective factors against financial inducement; however, further research is needed, particularly with CHIM studies expanding to low-income and middle-income countries.
Collapse
|
12
|
Osowicki J, Azzopardi KI, Baker C, Waddington CS, Pandey M, Schuster T, Grobler A, Cheng AC, Pollard AJ, McCarthy JS, Good MF, Walker MJ, Dale JB, Batzloff MR, Carapetis JR, Smeesters PR, Steer AC. Controlled human infection for vaccination against Streptococcus pyogenes (CHIVAS): Establishing a group A Streptococcus pharyngitis human infection study. Vaccine 2019; 37:3485-3494. [PMID: 31101422 DOI: 10.1016/j.vaccine.2019.03.059] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 03/14/2019] [Accepted: 03/26/2019] [Indexed: 12/17/2022]
Abstract
Group A Streptococcus (GAS) is a highly-adapted and human-restricted pathogen responsible for a high global burden of disease across a diverse clinical spectrum. Vaccine development has been impeded by scientific, regulatory, and commercial obstacles. Human infection studies (HIS) are increasingly contributing to drug, diagnostics, and vaccine development, reducing uncertainty at early stages, especially for pathogens with animal models that incompletely reproduce key elements of human disease. We review the small number of historical GAS HIS and present the study protocol for a dose-ranging inpatient study in healthy adults. The primary objective of the study is to establish a new GAS pharyngitis HIS with an attack rate of at least 60% as a safe and reliable platform for vaccine evaluation and pathogenesis research. According to an adaptive dose-ranging study design, emm75 GAS doses manufactured in keeping with principles of Good Manufacturing Practice will be directly applied by swab to the pharynx of carefully screened healthy adult volunteers at low risk of severe complicated GAS disease. Participants will remain as closely monitored inpatients for up to six days, observed for development of the primary outcome of acute symptomatic pharyngitis, as defined by clinical and microbiological criteria. All participants will be treated with antibiotics and followed as outpatients for six months. An intensive sampling schedule will facilitate extensive studies of host and organism dynamics during experimental pharyngitis. Ethics approval has been obtained and the study has been registered at ClinicalTrials.gov (NCT03361163).
Collapse
Affiliation(s)
- Joshua Osowicki
- Tropical Diseases, Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Department of Paediatrics, University of Melbourne, Victoria, Australia; Infectious Diseases Unit, Department of General Medicine, The Royal Children's Hospital Melbourne, Victoria, Australia.
| | - Kristy I Azzopardi
- Tropical Diseases, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Ciara Baker
- Tropical Diseases, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Claire S Waddington
- Telethon Kids Institute, University of Western Australia and Perth Children's Hospital, Perth, Australia; Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Manisha Pandey
- The Institute for Glycomics, Griffith University, Gold Coast, Queensland, Australia
| | - Tibor Schuster
- Clinical Epidemiology and Biostatistics Unit, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia; Department of Family Medicine, McGill University, Montreal, Quebec, Canada
| | - Anneke Grobler
- Department of Paediatrics, University of Melbourne, Victoria, Australia; Clinical Epidemiology and Biostatistics Unit, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia
| | - Allen C Cheng
- Infection Prevention and Healthcare Epidemiology Unit, The Alfred Hospital, Melbourne, Victoria, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Andrew J Pollard
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, United Kingdom; National Institute for Health Research, Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - James S McCarthy
- QIMR Berghofer Medical Research Institute, Brisbane, Australia; School of Medicine, University of Queensland, Brisbane, Australia
| | - Michael F Good
- The Institute for Glycomics, Griffith University, Gold Coast, Queensland, Australia
| | - Mark J Walker
- School of Chemistry and Molecular Biosciences and Australian Infectious Diseases Research Centre, The University of Queensland, St Lucia, Queensland, Australia
| | - James B Dale
- University of Tennessee Health Science Center, Department of Medicine, Memphis, TN, USA
| | - Michael R Batzloff
- The Institute for Glycomics, Griffith University, Gold Coast, Queensland, Australia
| | - Jonathan R Carapetis
- Telethon Kids Institute, University of Western Australia and Perth Children's Hospital, Perth, Australia
| | - Pierre R Smeesters
- Tropical Diseases, Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Department of Paediatrics, University of Melbourne, Victoria, Australia; Paediatric Department, Academic Children Hospital Queen Fabiola, Université Libre de Bruxelles, Brussels, Belgium; Molecular Bacteriology Laboratory, Université Libre de Bruxelles, Brussels, Belgium
| | - Andrew C Steer
- Tropical Diseases, Murdoch Children's Research Institute, Melbourne, Victoria, Australia; Department of Paediatrics, University of Melbourne, Victoria, Australia; Infectious Diseases Unit, Department of General Medicine, The Royal Children's Hospital Melbourne, Victoria, Australia
| |
Collapse
|
13
|
Brownell P, Piccolo F, Waddington CS, White R, Jones S, Fysh E, Manners D. Addressing barriers to timely lung cancer diagnosis and treatment in an outer metropolitan Western Australian hospital. Intern Med J 2019; 49:279-280. [DOI: 10.1111/imj.14205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 11/11/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Phoebe Brownell
- Department of Respiratory Medicine; St John of God Health Care; Perth Western Australia Australia
| | - Francesco Piccolo
- Department of Respiratory Medicine; St John of God Health Care; Perth Western Australia Australia
| | - Claire S. Waddington
- Department of Respiratory Medicine; St John of God Health Care; Perth Western Australia Australia
| | - Rohen White
- Department of Radiation Oncology; Sir Charles Gairdner Hospital; Perth Western Australia Australia
| | - Simon Jones
- Department of Respiratory Medicine; St John of God Health Care; Perth Western Australia Australia
| | - Edward Fysh
- Department of Respiratory Medicine; St John of God Health Care; Perth Western Australia Australia
| | - David Manners
- Department of Respiratory Medicine; St John of God Health Care; Perth Western Australia Australia
- Curtin Medical School; Curtin University; Perth Western Australia Australia
| |
Collapse
|
14
|
Lim C, Currie GE, Waddington CS, Wu Y, Setijo S, Leask J, Marsh JA, Snelling TL. Identification of the determinants of incomplete vaccination in Australian children. Vaccine X 2019; 1:100010. [PMID: 31384732 PMCID: PMC6668241 DOI: 10.1016/j.jvacx.2019.100010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 01/06/2019] [Accepted: 01/08/2019] [Indexed: 11/25/2022] Open
Abstract
Demographic/social factors, vaccine beliefs, and vaccination status were captured. Most parents are supportive of vaccination. Many parents incorrectly reported their child as fully vaccinated. Incomplete vaccination was associated with demographic and socio-economic factors.
Background and aims We aimed to understand the risk factors associated with incomplete vaccination, which may help to identify and prioritise opportunities to intervene. Methods Consenting parents of children <6 years old attending an outpatient clinic completed a questionnaire, which captured demographic information and their level of agreement with belief statements about vaccination using a 7-point Likert scale. Vaccination status was determined from the Australian Childhood Immunisation Register and deemed either “complete” (no doses overdue) or “incomplete” (1 or more doses overdue) at the time of questionnaire completion. Results Of 589 children of respondents, 116 (20%) had an incomplete vaccination status. Of these, nearly two-thirds (63%) of parents believed that their child was, in fact, fully-vaccinated. Compared to those with a complete vaccine status, children with an incomplete vaccine status were more likely to be born overseas (p < 0.001), have a larger family size (p = 0.02) and to have parents with lower educational attainment (p = 0.001). Parents of children with an incomplete status reported more doubt about the importance of vaccination and greater concern about vaccine safety, compared to parents of children with a complete status. Conclusion Most parents are supportive of vaccination. Sociodemographic factors may contribute more to the risk of incomplete vaccination than attitudes or beliefs. Some parents are unaware of their child’s vaccination status, suggesting that simple and modern reminders may assist parents to keep up to date.
Collapse
Affiliation(s)
- Christopher Lim
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, WA, Australia
| | - Grace E Currie
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, WA, Australia
| | - Claire S Waddington
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, WA, Australia.,Department of Medicine, School of Clinical Medicine, University of Cambridge, UK
| | - Yue Wu
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, WA, Australia
| | - Sharon Setijo
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, WA, Australia
| | - Julie Leask
- Faculty of Medicine and Health, Susan Wakil School of Nursing and Midwifery, University of Sydney, NSW, Australia
| | - Julie A Marsh
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, WA, Australia.,School of Mathematics and Statistics, University of Western Australia, WA, Australia
| | - Thomas L Snelling
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, WA, Australia.,Perth Children's Hospital, WA, Australia.,School of Public Health, Curtin University, WA, Australia.,Menzies School of Health Research and Charles Darwin University, NT, Australia
| |
Collapse
|
15
|
Waddington CS, McLeod C, Morris P, Bowen A, Naunton M, Carapetis J, Grimwood K, Robins-Browne R, Kirkwood CD, Baird R, Green D, Andrews R, Fearon D, Francis J, Marsh JA, Snelling T. The NICE-GUT trial protocol: a randomised, placebo controlled trial of oral nitazoxanide for the empiric treatment of acute gastroenteritis among Australian Aboriginal children. BMJ Open 2018; 8:e019632. [PMID: 29391385 PMCID: PMC5829923 DOI: 10.1136/bmjopen-2017-019632] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Diarrhoeal disease is the second leading cause of death in children under 5 years globally, killing 525 000 annually. Australian Aboriginal and Torres Strait Islander (hereafter Aboriginal) children suffer a high burden of disease. Randomised trials in other populations suggest nitazoxanide accelerates recovery for children with Giardia, amoebiasis, Cryptosporidium, Rotavirus and Norovirus gastroenteritis, as well as in cases where no enteropathogens are found. METHODS AND ANALYSIS This double blind, 1:1 randomised, placebo controlled trial is investigating the impact of oral nitazoxanide on acute gastroenteritis in hospitalised Australian Aboriginal children aged 3 months to <5 years. Dosing is based on age-based dosing. The primary endpoint is the time to resolution of 'significant illness' defined as the time from randomisation to the time of clinical assessment as medically ready for discharge, or to the time of actual discharge from hospital, whichever occurs first. Secondary endpoints include duration of hospitalisation, symptom severity during the period of significant illness and following treatment, duration of rehydration and drug safety. Patients will be followed for medically significant events for 60 days. Analysis is based on Bayesian inference. Subgroup analysis will occur by pathogen type (bacteria, virus or parasite), rotavirus vaccination status, age and illness severity. ETHICS AND DISSEMINATION Ethics approval has been granted by the Central Australian Human Research Ethics Committee (HREC-14-221) and the Human Research Ethics Committee of the Northern Territory Department of Health and Menzies School of Health Research (HREC2014-2172). Study investigators will ensure that the trial is conducted in accordance with the principles of the Declaration of Helsinki. Individual participant consent will be obtained. Results will be disseminated via peer-reviewed publication. TRIAL REGISTRATION NUMBER ACTRN12614000381684.
Collapse
Affiliation(s)
- Claire S Waddington
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, Subiaco, Australia
| | - Charlie McLeod
- Infectious Diseases Department, Princess Margaret Hospital for Children, Perth, Australia
| | - Peter Morris
- Menzies School of Health Research, Casuarina, Australia
- Department of Paediatrics, Royal Darwin Hospital, Darwin, Australia
| | - Asha Bowen
- Infectious Diseases Department, Princess Margaret Hospital for Children, Perth, Australia
- Menzies School of Health Research, Casuarina, Australia
| | - Mark Naunton
- Department of Pharmacy, University of Canberra, Bruce, Canberra, Australia
| | - Jonathan Carapetis
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, Subiaco, Australia
- Infectious Diseases Department, Princess Margaret Hospital for Children, Perth, Australia
| | - Keith Grimwood
- Queensland Children’s Medical Research Institute, Brisbane, Queensland, Australia
| | - Roy Robins-Browne
- Department of Microbiology and Immunology, University of Melbourne, Melbourne, Victoria, Australia
| | - Carl D Kirkwood
- Murdoch Children’s Research Institute, Parkville, Victoria, Australia
| | - Robert Baird
- Department of Microbiology, Royal Darwin Hospital, Darwin, Australia
| | - David Green
- Department of Paediatrics, Alice Springs Hospital, Alice Springs, Australia
| | - Ross Andrews
- Menzies School of Health Research, Casuarina, Australia
| | - Deborah Fearon
- Department of Paediatrics, Alice Springs Hospital, Alice Springs, Australia
| | - Joshua Francis
- Menzies School of Health Research, Casuarina, Australia
- Department of Paediatrics, Royal Darwin Hospital, Darwin, Australia
| | - Julie A Marsh
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, Subiaco, Australia
- Centre for Applied Statistics, University of Western Australia, Crawley, Australia
| | - Thomas Snelling
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, Subiaco, Australia
| |
Collapse
|
16
|
Estcourt MJ, Marsh JA, Campbell DE, Gold MS, Allen KJ, Richmond P, Waddington CS, Snelling TL. Protocol for Pertussis Immunisation and Food Allergy (PIFA): a case-control study of the association between pertussis vaccination in infancy and the risk of IgE-mediated food allergy among Australian children. BMJ Open 2018; 8:e020232. [PMID: 29391374 PMCID: PMC5878256 DOI: 10.1136/bmjopen-2017-020232] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
INTRODUCTION Atopic diseases, including food allergy, have become a predominant cause of chronic illness among children in developed countries. In Australia, a rise in hospitalisations among infants coded as anaphylaxis to foods coincided with the replacement of whole-cell pertussis (wP) vaccine with subunit acellular pertussis (aP) vaccine on the national immunisation schedule in the late 1990s. Atopy is characterised by a tendency to mount T helper type 2 (Th2) responses to otherwise innocuous environmental antigens. Compared with infants who receive aP as their first pertussis vaccine, those who receive wP appear less likely to mount Th2 immune responses to either vaccine or extraneous antigens. We therefore speculate that removal of wP from the vaccine schedule contributed to the observed rise in IgE-mediated food allergy among Australian infants. METHODS AND ANALYSIS This is a retrospective individually matched case-control study among a cohort of Australian children born from 1997 to 1999, the period of transition from wP to aP vaccines; we include in the cohort children listed on Australia's comprehensive population-based immunisation register as having received a first dose of either pertussis vaccine by 16 weeks old. 500 cohort children diagnosed as having IgE-mediated food allergy at specialist allergy clinics will be included as cases. Controls matched to each case by date and jurisdiction of birth and regional socioeconomic index will be sampled from the immunisation register. Conditional logistic regression will be used to estimate OR (±95% CI) of receipt of wP (vs aP) as the first vaccine dose among cases compared with controls. ETHICS AND DISSEMINATION The study is approved by all relevant human research ethics committees: Western Australia Child and Adolescent Health Services (2015052EP), Women's and Children's Hospital (HREC/15/WCHN/162), Royal Children's Hospital (35230A) and Sydney Children's Hospital Network (HREC/15/SCHN/405). Outcomes will be disseminated through publication and scientific presentation. TRIAL REGISTRATION NUMBER NCT02490007.
Collapse
Affiliation(s)
- Marie J Estcourt
- Wesfarmers Centre of Vaccines & Infectious Diseases, Telethon Kids Institute, West Perth, Western Australia, Australia
- School of Population and Global Health, University of Western Australia, Crawley, Western Australia, Australia
| | - Julie A Marsh
- Wesfarmers Centre of Vaccines & Infectious Diseases, Telethon Kids Institute, West Perth, Western Australia, Australia
- Centre for Applied Statistics, University of Western Australia, Crawley, Western Australia, Australia
| | - Dianne E Campbell
- Department of Allergy and Immunology, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Michael S Gold
- School of Medicine, University of Adelaide, Women's and Children's Health Network, North Adelaide, South Australia, Australia
| | - Katrina J Allen
- Centre for Food and Allergy Research, Murdoch Children's Research Institute, Melbourne, Australia
- Department of Paediatrics, University of Melbourne, Royal Children's Hospital Melbourne, Victoria, Australia
| | - Peter Richmond
- Wesfarmers Centre of Vaccines & Infectious Diseases, Telethon Kids Institute, West Perth, Western Australia, Australia
- Child Health Research, Princess Margaret Hospital for Children, Subiaco, Western Australia, Australia
| | - Claire S Waddington
- Wesfarmers Centre of Vaccines & Infectious Diseases, Telethon Kids Institute, West Perth, Western Australia, Australia
- Child Health Research, Princess Margaret Hospital for Children, Subiaco, Western Australia, Australia
| | - Thomas L Snelling
- Wesfarmers Centre of Vaccines & Infectious Diseases, Telethon Kids Institute, West Perth, Western Australia, Australia
- School of Public Health, Curtin University, Bentley, Western Australia, Australia
| |
Collapse
|
17
|
Darton TC, Jones C, Dongol S, Voysey M, Blohmke CJ, Shrestha R, Karkey A, Shakya M, Arjyal A, Waddington CS, Gibani M, Carter MJ, Basnyat B, Baker S, Pollard AJ. Assessment and Translation of the Antibody-in-Lymphocyte Supernatant (ALS) Assay to Improve the Diagnosis of Enteric Fever in Two Controlled Human Infection Models and an Endemic Area of Nepal. Front Microbiol 2017; 8:2031. [PMID: 29109704 PMCID: PMC5660281 DOI: 10.3389/fmicb.2017.02031] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Accepted: 10/04/2017] [Indexed: 11/17/2022] Open
Abstract
New diagnostic tests for enteric fever are urgently needed to assist with timely antimicrobial treatment of patients and to measure the efficacy of prevention measures such as vaccination. In a novel translational approach, here we use two recently developed controlled human infection models (CHIM) of enteric fever to evaluate an antibody-in-lymphocyte supernatant (ALS) assay, which can detect recent IgA antibody production by circulating B cells in ex vivo mononuclear cell culture. We calculated the discriminative ability of the ALS assay to distinguish diagnosed cases in the two CHIM studies in Oxford, prior to evaluating blood culture-confirmed diagnoses of patients presenting with fever to hospital in an endemic areas of Kathmandu, Nepal. Antibody responses to membrane preparations and lipopolysaccharide provided good sensitivity (>90%) for diagnosing systemic infection after oral challenge with Salmonella Typhi or S. Paratyphi A. Assay specificity was moderate (~60%) due to imperfect sensitivity of blood culture as the reference standard and likely unrecognized subclinical infection. These findings were augmented through the translation of the assay into the endemic setting in Nepal. Anti-MP IgA responses again exhibited good sensitivity (86%) but poor specificity (51%) for detecting blood culture-confirmed enteric fever cases (ROC AUC 0.79, 95%CI 0.70–0.88). Patients with anti-MP IgA ALS titers in the upper quartile exhibited a clinical syndrome synonymous with enteric fever. While better reference standards are need to assess enteric fever diagnostics, routine use of this ALS assay could be used to rule out infection and has the potential to double the laboratory detection rate of enteric fever in this setting over blood culture alone.
Collapse
Affiliation(s)
- Thomas C Darton
- Oxford Vaccine Group, Centre for Clinical Vaccinology and Tropical Medicine, Department of Paediatrics, University of Oxford, National Institute for Health Research Oxford Biomedical Research Centre, Oxford, United Kingdom.,Wellcome Trust Major Overseas Programme, Hospital for Tropical Diseases, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Claire Jones
- Oxford Vaccine Group, Centre for Clinical Vaccinology and Tropical Medicine, Department of Paediatrics, University of Oxford, National Institute for Health Research Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Sabina Dongol
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Kathmandu, Nepal
| | - Merryn Voysey
- Oxford Vaccine Group, Centre for Clinical Vaccinology and Tropical Medicine, Department of Paediatrics, University of Oxford, National Institute for Health Research Oxford Biomedical Research Centre, Oxford, United Kingdom.,Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Christoph J Blohmke
- Oxford Vaccine Group, Centre for Clinical Vaccinology and Tropical Medicine, Department of Paediatrics, University of Oxford, National Institute for Health Research Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Rajendra Shrestha
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Kathmandu, Nepal
| | - Abhilasha Karkey
- Wellcome Trust Major Overseas Programme, Hospital for Tropical Diseases, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Kathmandu, Nepal
| | - Mila Shakya
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Kathmandu, Nepal
| | - Amit Arjyal
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Kathmandu, Nepal
| | - Claire S Waddington
- Oxford Vaccine Group, Centre for Clinical Vaccinology and Tropical Medicine, Department of Paediatrics, University of Oxford, National Institute for Health Research Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Malick Gibani
- Oxford Vaccine Group, Centre for Clinical Vaccinology and Tropical Medicine, Department of Paediatrics, University of Oxford, National Institute for Health Research Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Michael J Carter
- Oxford Vaccine Group, Centre for Clinical Vaccinology and Tropical Medicine, Department of Paediatrics, University of Oxford, National Institute for Health Research Oxford Biomedical Research Centre, Oxford, United Kingdom.,Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Kathmandu, Nepal
| | - Buddha Basnyat
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Kathmandu, Nepal
| | - Stephen Baker
- Wellcome Trust Major Overseas Programme, Hospital for Tropical Diseases, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Andrew J Pollard
- Oxford Vaccine Group, Centre for Clinical Vaccinology and Tropical Medicine, Department of Paediatrics, University of Oxford, National Institute for Health Research Oxford Biomedical Research Centre, Oxford, United Kingdom
| |
Collapse
|
18
|
Dobinson HC, Gibani MM, Jones C, Thomaides-Brears HB, Voysey M, Darton TC, Waddington CS, Campbell D, Milligan I, Zhou L, Shrestha S, Kerridge SA, Peters A, Stevens Z, Podda A, Martin LB, D'Alessio F, Thanh DP, Basnyat B, Baker S, Angus B, Levine MM, Blohmke CJ, Pollard AJ. Evaluation of the Clinical and Microbiological Response to Salmonella Paratyphi A Infection in the First Paratyphoid Human Challenge Model. Clin Infect Dis 2017; 64:1066-1073. [PMID: 28158395 PMCID: PMC5439345 DOI: 10.1093/cid/cix042] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 02/01/2017] [Indexed: 12/14/2022] Open
Abstract
Background. To expedite the evaluation of vaccines against paratyphoid fever, we aimed to develop the first human challenge model of Salmonella enterica serovar Paratyphi A infection. Methods. Two groups of 20 participants underwent oral challenge with S. Paratyphi A following sodium bicarbonate pretreatment at 1 of 2 dose levels (group 1: 1–5 × 103 colony-forming units [CFU] and group 2: 0.5–1 × 103 CFU). Participants were monitored in an outpatient setting with daily clinical review and collection of blood and stool cultures. Antibiotic treatment was started when prespecified diagnostic criteria were met (temperature ≥38°C for ≥12 hours and/or bacteremia) or at day 14 postchallenge. Results. The primary study objective was achieved following challenge with 1–5 × 103 CFU (group 1), which resulted in an attack rate of 12 of 20 (60%). Compared with typhoid challenge, paratyphoid was notable for high rates of subclinical bacteremia (at this dose, 11/20 [55%]). Despite limited symptoms, bacteremia persisted for up to 96 hours after antibiotic treatment (median duration of bacteremia, 53 hours [interquartile range, 24–85 hours]). Shedding of S. Paratyphi A in stool typically preceded onset of bacteremia. Conclusions. Challenge with S. Paratyphi A at a dose of 1–5 × 103 CFU was well tolerated and associated with an acceptable safety profile. The frequency and persistence of bacteremia in the absence of clinical symptoms was notable, and markedly different from that seen in previous typhoid challenge studies. We conclude that the paratyphoid challenge model is suitable for the assessment of vaccine efficacy using endpoints that include bacteremia and/or symptomatology. Clinical Trials Registration. NCT02100397.
Collapse
Affiliation(s)
- Hazel C Dobinson
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, and the National Institute for Health Research Oxford Biomedical Research Centre, Oxford, UK
| | - Malick M Gibani
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, and the National Institute for Health Research Oxford Biomedical Research Centre, Oxford, UK
| | - Claire Jones
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, and the National Institute for Health Research Oxford Biomedical Research Centre, Oxford, UK
| | - Helena B Thomaides-Brears
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, and the National Institute for Health Research Oxford Biomedical Research Centre, Oxford, UK
| | - Merryn Voysey
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, and the National Institute for Health Research Oxford Biomedical Research Centre, Oxford, UK.,Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom
| | - Thomas C Darton
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, and the National Institute for Health Research Oxford Biomedical Research Centre, Oxford, UK
| | - Claire S Waddington
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, and the National Institute for Health Research Oxford Biomedical Research Centre, Oxford, UK
| | - Danielle Campbell
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, and the National Institute for Health Research Oxford Biomedical Research Centre, Oxford, UK
| | - Iain Milligan
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, and the National Institute for Health Research Oxford Biomedical Research Centre, Oxford, UK
| | - Liqing Zhou
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, and the National Institute for Health Research Oxford Biomedical Research Centre, Oxford, UK
| | - Sonu Shrestha
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, and the National Institute for Health Research Oxford Biomedical Research Centre, Oxford, UK
| | - Simon A Kerridge
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, and the National Institute for Health Research Oxford Biomedical Research Centre, Oxford, UK
| | - Anna Peters
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, and the National Institute for Health Research Oxford Biomedical Research Centre, Oxford, UK
| | - Zoe Stevens
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, and the National Institute for Health Research Oxford Biomedical Research Centre, Oxford, UK
| | - Audino Podda
- GSK Vaccines Institute for Global Health, Siena, Italy
| | | | | | - Duy Pham Thanh
- Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Buddha Basnyat
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Kathmandu, Nepal
| | - Stephen Baker
- Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.,London School of Hygiene and Tropical Medicine, London, UK
| | - Brian Angus
- Nuffield Department of Medicine, University of Oxford, United Kingdom
| | - Myron M Levine
- Center for Vaccine Development, University of Maryland School of Medicine, Baltimore
| | - Christoph J Blohmke
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, and the National Institute for Health Research Oxford Biomedical Research Centre, Oxford, UK
| | - Andrew J Pollard
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, and the National Institute for Health Research Oxford Biomedical Research Centre, Oxford, UK
| |
Collapse
|
19
|
Salerno-Goncalves R, Luo D, Fresnay S, Magder L, Darton TC, Jones C, Waddington CS, Blohmke CJ, Angus B, Levine MM, Pollard AJ, Sztein MB. Challenge of Humans with Wild-type Salmonella enterica Serovar Typhi Elicits Changes in the Activation and Homing Characteristics of Mucosal-Associated Invariant T Cells. Front Immunol 2017; 8:398. [PMID: 28428786 PMCID: PMC5382150 DOI: 10.3389/fimmu.2017.00398] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 03/21/2017] [Indexed: 12/20/2022] Open
Abstract
Gastrointestinal infections by Salmonella enterica serovar Typhi (S. Typhi) are rare in industrialized countries. However, they remain a major public health problem in the developing world with an estimated 26.9 million new cases annually and significant mortality when untreated. Recently, we provided the first direct evidence that CD8+ MAIT cells are activated and have the potential to kill cells exposed to S. Typhi, and that these responses are dependent on bacterial load. However, MAIT cell kinetics and function during bacterial infections in humans remain largely unknown. In this study, we characterize the human CD8+ MAIT cell immune response to S. Typhi infection in subjects participating in a challenge clinical trial who received a low- or high dose of wild-type S. Typhi. We define the kinetics of CD8+ MAIT cells as well as their levels of activation, proliferation, exhaustion/apoptosis, and homing potential. Regardless of the dose, in volunteers resistant to infection (NoTD), the levels of CD8+ MAIT cells after S. Typhi challenge fluctuated around their baseline values (day 0). In contrast, volunteers susceptible to the development of typhoid disease (TD) exhibited a sharp decline in circulating MAIT cells during the development of typhoid fever. Interestingly, MAIT cells from low-dose TD volunteers had higher levels of CD38 coexpressing CCR9, CCR6, and Ki67 during the development of typhoid fever than high-dose TD volunteers. No substantial perturbations on the levels of these markers were observed in NoTD volunteers irrespective of the dose. In sum, we describe, for the first time, that exposure to an enteric bacterium, in this case S. Typhi, results in changes in MAIT cell activation, proliferation, and homing characteristics, suggesting that MAIT cells are an important component of the human host response to bacterial infection.
Collapse
Affiliation(s)
| | - David Luo
- Center for Vaccine Development, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Stephanie Fresnay
- Center for Vaccine Development, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Laurence Magder
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Thomas C Darton
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Claire Jones
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Claire S Waddington
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Christoph J Blohmke
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Brian Angus
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Myron M Levine
- Center for Vaccine Development, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Andrew J Pollard
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford, UK
| | - Marcelo B Sztein
- Center for Vaccine Development, University of Maryland School of Medicine, Baltimore, MD, USA
| |
Collapse
|
20
|
Fresnay S, McArthur MA, Magder LS, Darton TC, Jones C, Waddington CS, Blohmke CJ, Angus B, Levine MM, Pollard AJ, Sztein MB. Importance of Salmonella Typhi-Responsive CD8+ T Cell Immunity in a Human Typhoid Fever Challenge Model. Front Immunol 2017; 8:208. [PMID: 28303138 PMCID: PMC5332428 DOI: 10.3389/fimmu.2017.00208] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 02/15/2017] [Indexed: 01/25/2023] Open
Abstract
Typhoid fever, caused by the human-restricted organism Salmonella enterica serovar Typhi (S. Typhi), constitutes a major global health problem. The development of improved attenuated vaccines is pressing, but delayed by the lack of appropriate preclinical models. Herein, we report that high levels of S. Typhi-responsive CD8+ T cells at baseline significantly correlate with an increased risk of disease in humans challenged with a high dose (~104 CFU) wild-type S. Typhi. Typhoid fever development was associated with higher multifunctional S. Typhi-responsive CD8+ T effector memory cells at baseline. Early decreases of these cells in circulation following challenge were observed in both S. Typhi-responsive integrin α4β7− and integrin α4β7+ CD8+ T effector memory (TEM) cells, suggesting their potential to home to both mucosal and extra-intestinal sites. Participants with higher baseline levels of S. Typhi-responsive CD8+ T memory cells had a higher risk of acquiring disease, but among those who acquired disease, those with a higher baseline responses took longer to develop disease. In contrast, protection against disease was associated with low or absent S. Typhi-responsive T cells at baseline and no changes in circulation following challenge. These data highlight the importance of pre-existing S. Typhi-responsive immunity in predicting clinical outcome following infection with wild-type S. Typhi and provide novel insights into the complex mechanisms involved in protective immunity to natural infection in a stringent human model with a high challenge dose. They also contribute important information on the immunological responses to be assessed in the appraisal and selection of new generation typhoid vaccines.
Collapse
Affiliation(s)
- Stephanie Fresnay
- Center for Vaccine Development, University of Maryland School of Medicine , Baltimore, MD , USA
| | - Monica A McArthur
- Center for Vaccine Development, University of Maryland School of Medicine , Baltimore, MD , USA
| | - Laurence S Magder
- Department of Epidemiology and Public Health, University of Maryland School of Medicine , Baltimore, MD , USA
| | - Thomas C Darton
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, NIHR Oxford Biomedical Research Centre , Oxford , UK
| | - Claire Jones
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, NIHR Oxford Biomedical Research Centre , Oxford , UK
| | - Claire S Waddington
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, NIHR Oxford Biomedical Research Centre , Oxford , UK
| | - Christoph J Blohmke
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, NIHR Oxford Biomedical Research Centre , Oxford , UK
| | - Brian Angus
- Nuffield Department of Medicine, University of Oxford , Oxford , UK
| | - Myron M Levine
- Center for Vaccine Development, University of Maryland School of Medicine , Baltimore, MD , USA
| | - Andrew J Pollard
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, NIHR Oxford Biomedical Research Centre , Oxford , UK
| | - Marcelo B Sztein
- Center for Vaccine Development, University of Maryland School of Medicine , Baltimore, MD , USA
| |
Collapse
|
21
|
Darton TC, Zhou L, Blohmke CJ, Jones C, Waddington CS, Baker S, Pollard AJ. Blood culture-PCR to optimise typhoid fever diagnosis after controlled human infection identifies frequent asymptomatic cases and evidence of primary bacteraemia. J Infect 2017; 74:358-366. [PMID: 28130144 PMCID: PMC5345565 DOI: 10.1016/j.jinf.2017.01.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Revised: 01/11/2017] [Accepted: 01/14/2017] [Indexed: 01/09/2023]
Abstract
Background Improved diagnostics for typhoid are needed; a typhoid controlled human infection model may accelerate their development and translation. Here, we evaluated a blood culture-PCR assay for detecting infection after controlled human infection with S. Typhi and compared test performance with optimally performed blood cultures. Methodology/Principal findings Culture-PCR amplification of blood samples was performed alongside daily blood culture in 41 participants undergoing typhoid challenge. Study endpoints for typhoid diagnosis (TD) were fever and/or bacteraemia. Overall, 24/41 (59%) participants reached TD, of whom 21/24 (86%) had ≥1 positive blood culture (53/674, 7.9% of all cultures) or 18/24 (75%) had ≥1 positive culture-PCR assay result (57/684, 8.3%). A further five non-bacteraemic participants produced culture-PCR amplicons indicating infection; overall sensitivity/specificity of the assay compared to the study endpoints were 70%/65%. We found no significant difference between blood culture and culture-PCR methods in ability to identify cases (12 mismatching pairs, p = 0.77, binomial test). Clinical and stool culture metadata demonstrated that additional culture-PCR amplification positive individuals likely represented true cases missed by blood culture, suggesting the overall attack rate may be 30/41 (73%) rather than 24/41 (59%). Several participants had positive culture-PCR results soon after ingesting challenge providing new evidence for occurrence of an early primary bacteraemia. Conclusions/Significance Overall the culture-PCR assay performed well, identifying extra typhoid cases compared with routine blood culture alone. Despite limitations to widespread field-use, the benefits of increased diagnostic yield, reduced blood volume and faster turn-around-time, suggest that this assay could enhance laboratory typhoid diagnostics in research applications and high-incidence settings. Culture in ox-bile/tryptone soy broth selectively enriches for bile-tolerant Salmonella Typhi while lysing human cells. PCR sensitivity for detecting typhoid in clinical blood is limited by very low level bacteraemia during clinical illness. PCR amplification of S. Typhi fliC-d in pre-cultured blood can accurately identify typhoid infection in challenge study participants. Daily culture-PCR of blood collected from challenge study participants suggests primary bacteraemia occurs 12–36 h after S. Typhi ingestion. Additional use of culture-PCR demonstrates the true attack rate after typhoid challenge is markedly higher (75%) than previously assumed (60%).
Collapse
Affiliation(s)
- Thomas C Darton
- Oxford Vaccine Group, Department of Paediatrics and the NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom; The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam.
| | - Liqing Zhou
- Oxford Vaccine Group, Department of Paediatrics and the NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
| | - Christoph J Blohmke
- Oxford Vaccine Group, Department of Paediatrics and the NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
| | - Claire Jones
- Oxford Vaccine Group, Department of Paediatrics and the NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
| | - Claire S Waddington
- Oxford Vaccine Group, Department of Paediatrics and the NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
| | - Stephen Baker
- The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam; Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, Oxford University, Oxford, United Kingdom
| | - Andrew J Pollard
- Oxford Vaccine Group, Department of Paediatrics and the NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
| |
Collapse
|
22
|
Darton TC, Jones C, Blohmke CJ, Waddington CS, Zhou L, Peters A, Haworth K, Sie R, Green CA, Jeppesen CA, Moore M, Thompson BAV, John T, Kingsley RA, Yu LM, Voysey M, Hindle Z, Lockhart S, Sztein MB, Dougan G, Angus B, Levine MM, Pollard AJ. Using a Human Challenge Model of Infection to Measure Vaccine Efficacy: A Randomised, Controlled Trial Comparing the Typhoid Vaccines M01ZH09 with Placebo and Ty21a. PLoS Negl Trop Dis 2016; 10:e0004926. [PMID: 27533046 PMCID: PMC4988630 DOI: 10.1371/journal.pntd.0004926] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2016] [Accepted: 07/25/2016] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Typhoid persists as a major cause of global morbidity. While several licensed vaccines to prevent typhoid are available, they are of only moderate efficacy and unsuitable for use in children less than two years of age. Development of new efficacious vaccines is complicated by the human host-restriction of Salmonella enterica serovar Typhi (S. Typhi) and lack of clear correlates of protection. In this study, we aimed to evaluate the protective efficacy of a single dose of the oral vaccine candidate, M01ZH09, in susceptible volunteers by direct typhoid challenge. METHODS AND FINDINGS We performed a randomised, double-blind, placebo-controlled trial in healthy adult participants at a single centre in Oxford (UK). Participants were allocated to receive one dose of double-blinded M01ZH09 or placebo or 3-doses of open-label Ty21a. Twenty-eight days after vaccination, participants were challenged with 104CFU S. Typhi Quailes strain. The efficacy of M01ZH09 compared with placebo (primary outcome) was assessed as the percentage of participants reaching pre-defined endpoints constituting typhoid diagnosis (fever and/or bacteraemia) during the 14 days after challenge. Ninety-nine participants were randomised to receive M01ZH09 (n = 33), placebo (n = 33) or 3-doses of Ty21a (n = 33). After challenge, typhoid was diagnosed in 18/31 (58.1% [95% CI 39.1 to 75.5]) M01ZH09, 20/30 (66.7% [47.2 to 87.2]) placebo, and 13/30 (43.3% [25.5 to 62.6]) Ty21a vaccine recipients. Vaccine efficacy (VE) for one dose of M01ZH09 was 13% [95% CI -29 to 41] and 35% [-5 to 60] for 3-doses of Ty21a. Retrospective multivariable analyses demonstrated that pre-existing anti-Vi antibody significantly reduced susceptibility to infection after challenge; a 1 log increase in anti-Vi IgG resulting in a 71% decrease in the hazard ratio of typhoid diagnosis ([95% CI 30 to 88%], p = 0.006) during the 14 day challenge period. Limitations to the study included the requirement to limit the challenge period prior to treatment to 2 weeks, the intensity of the study procedures and the high challenge dose used resulting in a stringent model. CONCLUSIONS Despite successfully demonstrating the use of a human challenge study to directly evaluate vaccine efficacy, a single-dose M01ZH09 failed to demonstrate significant protection after challenge with virulent Salmonella Typhi in this model. Anti-Vi antibody detected prior to vaccination played a major role in outcome after challenge. TRIAL REGISTRATION ClinicalTrials.gov (NCT01405521) and EudraCT (number 2011-000381-35).
Collapse
Affiliation(s)
- Thomas C. Darton
- Oxford Vaccine Group, Department of Paediatrics, and the NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
| | - Claire Jones
- Oxford Vaccine Group, Department of Paediatrics, and the NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
| | - Christoph J. Blohmke
- Oxford Vaccine Group, Department of Paediatrics, and the NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
| | - Claire S. Waddington
- Oxford Vaccine Group, Department of Paediatrics, and the NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
| | - Liqing Zhou
- Oxford Vaccine Group, Department of Paediatrics, and the NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
| | - Anna Peters
- Oxford Vaccine Group, Department of Paediatrics, and the NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
| | - Kathryn Haworth
- Oxford Vaccine Group, Department of Paediatrics, and the NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
| | - Rebecca Sie
- Oxford Vaccine Group, Department of Paediatrics, and the NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
| | - Christopher A. Green
- Oxford Vaccine Group, Department of Paediatrics, and the NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
| | - Catherine A. Jeppesen
- Oxford Vaccine Group, Department of Paediatrics, and the NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
| | - Maria Moore
- Oxford Vaccine Group, Department of Paediatrics, and the NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
| | - Ben A. V. Thompson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Tessa John
- Oxford Vaccine Group, Department of Paediatrics, and the NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
| | - Robert A. Kingsley
- Microbial Pathogenesis Group, Wellcome Trust Sanger Institute, Hinxton, United Kingdom
| | - Ly-Mee Yu
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Merryn Voysey
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Zoe Hindle
- Emergent Product Development UK Ltd, Emergent BioSolutions, Wokingham, United Kingdom
| | - Stephen Lockhart
- Emergent Product Development UK Ltd, Emergent BioSolutions, Wokingham, United Kingdom
| | - Marcelo B. Sztein
- Center for Vaccine Development, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Gordon Dougan
- Microbial Pathogenesis Group, Wellcome Trust Sanger Institute, Hinxton, United Kingdom
| | - Brian Angus
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Myron M. Levine
- Center for Vaccine Development, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Andrew J. Pollard
- Oxford Vaccine Group, Department of Paediatrics, and the NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
| |
Collapse
|
23
|
Toapanta FR, Bernal PJ, Fresnay S, Magder LS, Darton TC, Jones C, Waddington CS, Blohmke CJ, Angus B, Levine MM, Pollard AJ, Sztein MB. Oral Challenge with Wild-Type Salmonella Typhi Induces Distinct Changes in B Cell Subsets in Individuals Who Develop Typhoid Disease. PLoS Negl Trop Dis 2016; 10:e0004766. [PMID: 27300136 PMCID: PMC4907489 DOI: 10.1371/journal.pntd.0004766] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 05/17/2016] [Indexed: 11/19/2022] Open
Abstract
A novel human oral challenge model with wild-type Salmonella Typhi (S. Typhi) was recently established by the Oxford Vaccine Group. In this model, 104 CFU of Salmonella resulted in 65% of participants developing typhoid fever (referred here as typhoid diagnosis -TD-) 6-9 days post-challenge. TD was diagnosed in participants meeting clinical (oral temperature ≥38°C for ≥12h) and/or microbiological (S. Typhi bacteremia) endpoints. Changes in B cell subpopulations following S. Typhi challenge remain undefined. To address this issue, a subset of volunteers (6 TD and 4 who did not develop TD -NoTD-) was evaluated. Notable changes included reduction in the frequency of B cells (cells/ml) of TD volunteers during disease days and increase in plasmablasts (PB) during the recovery phase (>day 14). Additionally, a portion of PB of TD volunteers showed a significant increase in activation (CD40, CD21) and gut homing (integrin α4β7) molecules. Furthermore, all BM subsets of TD volunteers showed changes induced by S. Typhi infections such as a decrease in CD21 in switched memory (Sm) CD27+ and Sm CD27- cells as well as upregulation of CD40 in unswitched memory (Um) and Naïve cells. Furthermore, changes in the signaling profile of some BM subsets were identified after S. Typhi-LPS stimulation around time of disease. Notably, naïve cells of TD (compared to NoTD) volunteers showed a higher percentage of cells phosphorylating Akt suggesting enhanced survival of these cells. Interestingly, most these changes were temporally associated with disease onset. This is the first study to describe differences in B cell subsets directly related to clinical outcome following oral challenge with wild-type S. Typhi in humans.
Collapse
Affiliation(s)
- Franklin R. Toapanta
- Center for Vaccine Development, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
- * E-mail: (FRT); (MBS)
| | - Paula J. Bernal
- Center for Vaccine Development, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Stephanie Fresnay
- Center for Vaccine Development, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Laurence S. Magder
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Thomas C. Darton
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford and the NIHR Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Claire Jones
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford and the NIHR Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Claire S. Waddington
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford and the NIHR Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Christoph J. Blohmke
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford and the NIHR Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Brian Angus
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Myron M. Levine
- Center for Vaccine Development, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Andrew J. Pollard
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford and the NIHR Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Marcelo B. Sztein
- Center for Vaccine Development, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
- * E-mail: (FRT); (MBS)
| |
Collapse
|
24
|
Blohmke CJ, Darton TC, Jones C, Suarez NM, Waddington CS, Angus B, Zhou L, Hill J, Clare S, Kane L, Mukhopadhyay S, Schreiber F, Duque-Correa MA, Wright JC, Roumeliotis TI, Yu L, Choudhary JS, Mejias A, Ramilo O, Shanyinde M, Sztein MB, Kingsley RA, Lockhart S, Levine MM, Lynn DJ, Dougan G, Pollard AJ. Interferon-driven alterations of the host's amino acid metabolism in the pathogenesis of typhoid fever. J Exp Med 2016; 213:1061-77. [PMID: 27217537 PMCID: PMC4886356 DOI: 10.1084/jem.20151025] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 04/08/2016] [Indexed: 12/30/2022] Open
Abstract
Enteric fever, caused by Salmonella enterica serovar Typhi, is an important public health problem in resource-limited settings and, despite decades of research, human responses to the infection are poorly understood. In 41 healthy adults experimentally infected with wild-type S. Typhi, we detected significant cytokine responses within 12 h of bacterial ingestion. These early responses did not correlate with subsequent clinical disease outcomes and likely indicate initial host-pathogen interactions in the gut mucosa. In participants developing enteric fever after oral infection, marked transcriptional and cytokine responses during acute disease reflected dominant type I/II interferon signatures, which were significantly associated with bacteremia. Using a murine and macrophage infection model, we validated the pivotal role of this response in the expression of proteins of the host tryptophan metabolism during Salmonella infection. Corresponding alterations in tryptophan catabolites with immunomodulatory properties in serum of participants with typhoid fever confirmed the activity of this pathway, and implicate a central role of host tryptophan metabolism in the pathogenesis of typhoid fever.
Collapse
Affiliation(s)
- Christoph J. Blohmke
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford and the NIHR Oxford Biomedical Research Centre, Oxford OX3 7LE, England, UK
| | - Thomas C. Darton
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford and the NIHR Oxford Biomedical Research Centre, Oxford OX3 7LE, England, UK
| | - Claire Jones
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford and the NIHR Oxford Biomedical Research Centre, Oxford OX3 7LE, England, UK
| | - Nicolas M. Suarez
- Center for Vaccines and Immunity, The Research Institute at Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus, OH 43210
| | - Claire S. Waddington
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford and the NIHR Oxford Biomedical Research Centre, Oxford OX3 7LE, England, UK
| | - Brian Angus
- Nuffield Department of Medicine, University of Oxford, OX1 2JD, England, UK
| | - Liqing Zhou
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford and the NIHR Oxford Biomedical Research Centre, Oxford OX3 7LE, England, UK
| | - Jennifer Hill
- Microbial Pathogenesis Group, The Wellcome Trust Sanger Institute, Hinxton CB10 1SA, England, UK
| | - Simon Clare
- Microbial Pathogenesis Group, The Wellcome Trust Sanger Institute, Hinxton CB10 1SA, England, UK
| | - Leanne Kane
- Microbial Pathogenesis Group, The Wellcome Trust Sanger Institute, Hinxton CB10 1SA, England, UK
| | - Subhankar Mukhopadhyay
- Microbial Pathogenesis Group, The Wellcome Trust Sanger Institute, Hinxton CB10 1SA, England, UK
| | - Fernanda Schreiber
- Microbial Pathogenesis Group, The Wellcome Trust Sanger Institute, Hinxton CB10 1SA, England, UK
| | - Maria A. Duque-Correa
- Microbial Pathogenesis Group, The Wellcome Trust Sanger Institute, Hinxton CB10 1SA, England, UK
| | - James C. Wright
- Proteomic Mass Spectrometry, The Wellcome Trust Sanger Institute, Hinxton CB10 1SA, England, UK
| | | | - Lu Yu
- Proteomic Mass Spectrometry, The Wellcome Trust Sanger Institute, Hinxton CB10 1SA, England, UK
| | - Jyoti S. Choudhary
- Proteomic Mass Spectrometry, The Wellcome Trust Sanger Institute, Hinxton CB10 1SA, England, UK
| | - Asuncion Mejias
- Center for Vaccines and Immunity, The Research Institute at Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus, OH 43210
| | - Octavio Ramilo
- Center for Vaccines and Immunity, The Research Institute at Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus, OH 43210
| | - Milensu Shanyinde
- Nuffield Department of Primary Care Health Sciences, University of Oxford, OX1 2JD, England, UK
| | - Marcelo B. Sztein
- Center for Vaccine Development, University of Maryland School of Medicine, Baltimore, MD 21201
| | - Robert A. Kingsley
- Microbial Pathogenesis Group, The Wellcome Trust Sanger Institute, Hinxton CB10 1SA, England, UK
| | - Stephen Lockhart
- Emergent Product Development UK, Emergent BioSolutions, Wokingham RG41 5TU, England, UK
| | - Myron M. Levine
- Center for Vaccine Development, University of Maryland School of Medicine, Baltimore, MD 21201
| | - David J. Lynn
- EMBL Australia Group, South Australian Health and Medical Research Institute, North Terrace, Adelaide, SA 5000, Australia,School of Medicine, Flinders University, Bedford Park, SA 5042, Australia
| | - Gordon Dougan
- Microbial Pathogenesis Group, The Wellcome Trust Sanger Institute, Hinxton CB10 1SA, England, UK
| | - Andrew J. Pollard
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford and the NIHR Oxford Biomedical Research Centre, Oxford OX3 7LE, England, UK
| |
Collapse
|
25
|
Fresnay S, McArthur MA, Magder L, Darton TC, Jones C, Waddington CS, Blohmke CJ, Angus B, Levine MM, Pollard AJ, Sztein MB. Salmonella Typhi-specific multifunctional CD8+ T cells play a dominant role in protection from typhoid fever in humans. J Transl Med 2016; 14:62. [PMID: 26928826 PMCID: PMC4772330 DOI: 10.1186/s12967-016-0819-7] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 02/17/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Typhoid fever, caused by the human-restricted organism Salmonella Typhi (S. Typhi), is a major public health problem worldwide. Development of novel vaccines remains imperative, but is hampered by an incomplete understanding of the immune responses that correlate with protection. METHODS Recently, a controlled human infection model was re-established in which volunteers received ~10(3) cfu wild-type S. Typhi (Quailes strain) orally. Twenty-one volunteers were evaluated for their cell-mediated immune (CMI) responses. Ex vivo PBMC isolated before and up to 1 year after challenge were exposed to three S. Typhi-infected targets, i.e., autologous B lymphoblastoid cell-lines (B-LCL), autologous blasts and HLA-E restricted AEH B-LCL cells. CMI responses were evaluated using 14-color multiparametric flow cytometry to detect simultaneously five intracellular cytokines/chemokines (i.e., IL-17A, IL-2, IFN-g, TNF-a and MIP-1b) and a marker of degranulation/cytotoxic activity (CD107a). RESULTS Herein we provide the first evidence that S. Typhi-specific CD8+ responses correlate with clinical outcome in humans challenged with wild-type S. Typhi. Higher multifunctional S. Typhi-specific CD8+ baseline responses were associated with protection against typhoid and delayed disease onset. Moreover, following challenge, development of typhoid fever was accompanied by decreases in circulating S. Typhi-specific CD8+ T effector/memory (TEM) with gut homing potential, suggesting migration to the site(s) of infection. In contrast, protection against disease was associated with low or no changes in circulating S. Typhi-specific TEM. CONCLUSIONS These studies provide novel insights into the protective immune responses against typhoid disease that will aid in selection and development of new vaccine candidates.
Collapse
Affiliation(s)
- Stephanie Fresnay
- Center for Vaccine Development, University of Maryland School of Medicine, 685 W. Baltimore Street, Suite 480, Baltimore, MD, 21201, USA.
| | - Monica A McArthur
- Center for Vaccine Development, University of Maryland School of Medicine, 685 W. Baltimore Street, Suite 480, Baltimore, MD, 21201, USA.
| | - Laurence Magder
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA.
| | - Thomas C Darton
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford and the NIHR Oxford Biomedical Research Centre, Oxford, UK.
| | - Claire Jones
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford and the NIHR Oxford Biomedical Research Centre, Oxford, UK.
| | - Claire S Waddington
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford and the NIHR Oxford Biomedical Research Centre, Oxford, UK.
| | - Christoph J Blohmke
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford and the NIHR Oxford Biomedical Research Centre, Oxford, UK.
| | - Brian Angus
- Nuffield Department of Medicine, University of Oxford, Oxford, UK.
| | - Myron M Levine
- Center for Vaccine Development, University of Maryland School of Medicine, 685 W. Baltimore Street, Suite 480, Baltimore, MD, 21201, USA.
| | - Andrew J Pollard
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford and the NIHR Oxford Biomedical Research Centre, Oxford, UK.
| | - Marcelo B Sztein
- Center for Vaccine Development, University of Maryland School of Medicine, 685 W. Baltimore Street, Suite 480, Baltimore, MD, 21201, USA.
| |
Collapse
|
26
|
Darton TC, Blohmke CJ, Giannoulatou E, Waddington CS, Jones C, Sturges P, Webster C, Drakesmith H, Pollard AJ, Armitage AE. Rapidly Escalating Hepcidin and Associated Serum Iron Starvation Are Features of the Acute Response to Typhoid Infection in Humans. PLoS Negl Trop Dis 2015; 9:e0004029. [PMID: 26394303 PMCID: PMC4578949 DOI: 10.1371/journal.pntd.0004029] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 08/03/2015] [Indexed: 12/15/2022] Open
Abstract
Background Iron is a key pathogenic determinant of many infectious diseases. Hepcidin, the hormone responsible for governing systemic iron homeostasis, is widely hypothesized to represent a key component of nutritional immunity through regulating the accessibility of iron to invading microorganisms during infection. However, the deployment of hepcidin in human bacterial infections remains poorly characterized. Typhoid fever is a globally significant, human-restricted bacterial infection, but understanding of its pathogenesis, especially during the critical early phases, likewise is poorly understood. Here, we investigate alterations in hepcidin and iron/inflammatory indices following experimental human typhoid challenge. Methodology/Principal Findings Fifty study participants were challenged with Salmonella enterica serovar Typhi and monitored for evidence of typhoid fever. Serum hepcidin, ferritin, serum iron parameters, C-reactive protein (CRP), and plasma IL-6 and TNF-alpha concentrations were measured during the 14 days following challenge. We found that hepcidin concentrations were markedly higher during acute typhoid infection than at baseline. Hepcidin elevations mirrored the kinetics of fever, and were accompanied by profound hypoferremia, increased CRP and ferritin, despite only modest elevations in IL-6 and TNF-alpha in some individuals. During inflammation, the extent of hepcidin upregulation associated with the degree of hypoferremia. Conclusions/Significance We demonstrate that strong hepcidin upregulation and hypoferremia, coincident with fever and systemic inflammation, are hallmarks of the early innate response to acute typhoid infection. We hypothesize that hepcidin-mediated iron redistribution into macrophages may contribute to S. Typhi pathogenesis by increasing iron availability for macrophage-tropic bacteria, and that targeting macrophage iron retention may represent a strategy for limiting infections with macrophage-tropic pathogens such as S. Typhi. An adequate supply of iron is essential for both human hosts and their infecting pathogens. Hepcidin is the human hormone that controls the quantity and distribution of iron throughout the body. During infections, hepcidin activity may redistribute iron away from serum and into macrophages, potentially affecting pathogen replication, depending on the niche of the invading microbe. However, the involvement of hepcidin in human bacterial infections remains poorly investigated. Similarly, the pathogenesis of typhoid fever, caused by infection with Salmonella Typhi is also poorly understood. We therefore investigated the behaviour of hepcidin and other iron/inflammation-related parameters during the course of typhoid fever in human volunteers challenged experimentally with Salmonella Typhi. Hepcidin concentrations rose rapidly during acute typhoid infection, in parallel with fever. Hepcidin induction was accompanied by a rapid decline in serum iron concentrations, likely reflecting iron sequestration in macrophages (a preferred replication site of Salmonella Typhi). The extent of hepcidin upregulation associated with the extent of serum iron starvation. We hypothesize that hepcidin activity during acute typhoid infection in humans may elevate iron levels in the niche used by the pathogen for replication. Targeting macrophage iron retention should be evaluated as a potential strategy for limiting typhoid fever.
Collapse
Affiliation(s)
- Thomas C. Darton
- Oxford Vaccine Group, Centre for Clinical Vaccinology and Tropical Medicine, Department of Paediatrics, University of Oxford, and National Institute for Health Research Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Christoph J. Blohmke
- Oxford Vaccine Group, Centre for Clinical Vaccinology and Tropical Medicine, Department of Paediatrics, University of Oxford, and National Institute for Health Research Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Eleni Giannoulatou
- Victor Chang Cardiac Research Institute, Darlinghurst, New South Wales, Australia
| | - Claire S. Waddington
- Oxford Vaccine Group, Centre for Clinical Vaccinology and Tropical Medicine, Department of Paediatrics, University of Oxford, and National Institute for Health Research Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Claire Jones
- Oxford Vaccine Group, Centre for Clinical Vaccinology and Tropical Medicine, Department of Paediatrics, University of Oxford, and National Institute for Health Research Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Pamela Sturges
- Department of Biochemistry, Birmingham Heartlands Hospital, Heart of England NHS Foundation Trust, Birmingham, United Kingdom
| | - Craig Webster
- Department of Biochemistry, Birmingham Heartlands Hospital, Heart of England NHS Foundation Trust, Birmingham, United Kingdom
| | - Hal Drakesmith
- BRC Blood Theme, NIHR Oxford Biomedical Research Centre, Oxford, United Kingdom
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom
| | - Andrew J. Pollard
- Oxford Vaccine Group, Centre for Clinical Vaccinology and Tropical Medicine, Department of Paediatrics, University of Oxford, and National Institute for Health Research Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Andrew E. Armitage
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford, John Radcliffe Hospital, Oxford, United Kingdom
- * E-mail:
| |
Collapse
|
27
|
McArthur MA, Fresnay S, Magder LS, Darton TC, Jones C, Waddington CS, Blohmke CJ, Dougan G, Angus B, Levine MM, Pollard AJ, Sztein MB. Activation of Salmonella Typhi-specific regulatory T cells in typhoid disease in a wild-type S. Typhi challenge model. PLoS Pathog 2015; 11:e1004914. [PMID: 26001081 PMCID: PMC4441490 DOI: 10.1371/journal.ppat.1004914] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Accepted: 04/27/2015] [Indexed: 12/12/2022] Open
Abstract
Salmonella Typhi (S. Typhi), the causative agent of typhoid fever, causes significant morbidity and mortality worldwide. Currently available vaccines are moderately efficacious, and identification of immunological responses associated with protection or disease will facilitate the development of improved vaccines. We investigated S. Typhi-specific modulation of activation and homing potential of circulating regulatory T cells (Treg) by flow and mass cytometry using specimens obtained from a human challenge study. Peripheral blood mononuclear cells were obtained from volunteers pre- and at multiple time-points post-challenge with wild-type S. Typhi. We identified differing patterns of S. Typhi-specific modulation of the homing potential of circulating Treg between volunteers diagnosed with typhoid (TD) and those who were not (No TD). TD volunteers demonstrated up-regulation of the gut homing molecule integrin α4ß7 pre-challenge, followed by a significant down-regulation post-challenge consistent with Treg homing to the gut. Additionally, S. Typhi-specific Treg from TD volunteers exhibited up-regulation of activation molecules post-challenge (e.g., HLA-DR, LFA-1). We further demonstrate that depletion of Treg results in increased S. Typhi-specific cytokine production by CD8+ TEM in vitro. These results suggest that the tissue distribution of activated Treg, their characteristics and activation status may play a pivotal role in typhoid fever, possibly through suppression of S. Typhi-specific effector T cell responses. These studies provide important novel insights into the regulation of immune responses that are likely to be critical in protection against typhoid and other enteric infectious diseases.
Collapse
Affiliation(s)
- Monica A. McArthur
- Center for Vaccine Development, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Stephanie Fresnay
- Center for Vaccine Development, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Laurence S. Magder
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Thomas C. Darton
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford and the National Institute for Health Research Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Claire Jones
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford and the National Institute for Health Research Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Claire S. Waddington
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford and the National Institute for Health Research Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Christoph J. Blohmke
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford and the National Institute for Health Research Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Gordon Dougan
- Microbial Pathogenesis Group, Wellcome Trust Sanger Institute, Hinxton, United Kingdom
| | - Brian Angus
- Nuffield Department of Medicine, University of Oxford, United Kingdom
| | - Myron M. Levine
- Center for Vaccine Development, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Andrew J. Pollard
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford and the National Institute for Health Research Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Marcelo B. Sztein
- Center for Vaccine Development, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
- * E-mail:
| |
Collapse
|
28
|
|
29
|
Waddington CS, Darton TC, Angus B, Pollard AJ. Reply to Farmakiotis et al. Clin Infect Dis 2014; 59:1198-9. [PMID: 25077788 PMCID: PMC4176429 DOI: 10.1093/cid/ciu561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- Claire S Waddington
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford National Institute for Health Research Oxford Biomedical Research Centre
| | - Thomas C Darton
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford National Institute for Health Research Oxford Biomedical Research Centre
| | - Brian Angus
- Nuffield Department of Medicine, University of Oxford, United Kingdom
| | - Andrew J Pollard
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford National Institute for Health Research Oxford Biomedical Research Centre
| |
Collapse
|
30
|
Abstract
Invasive group A streptococcal (GAS) disease in children includes deep soft tissue infection, bacteraemia, bacteraemic pneumonia, meningitis and osteomyelitis. The expression of toxins and super antigens by GAS can complicate infection by triggering an overwhelming systemic inflammatory response, referred to as streptococcal toxic shock syndrome (STSS). The onset and progression of GAS disease can be rapid, and the associated mortality high. Prompt antibiotics therapy and early surgical debridement of infected tissue are essential. Adjunctive therapy with intravenous immunoglobulin and hyperbaric therapy may improve outcomes in severe disease. Nosocomial outbreaks and secondary cases in close personal contacts are not uncommon; infection control measures and consideration of prophylactic antibiotics to those at high risk are important aspects of disease control. To reduce a substantial part of the global burden of GAS disease, an affordable GAS vaccine with efficacy against a broad number of strains is needed.
Collapse
Affiliation(s)
- Claire S Waddington
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, PO Box West Perth, WA 6872, Australia; Princess Margaret Hospital, 100 Roberts Road, Subiaco, Perth 6008, Western Australia, Australia.
| | - Thomas L Snelling
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, PO Box West Perth, WA 6872, Australia; Princess Margaret Hospital, 100 Roberts Road, Subiaco, Perth 6008, Western Australia, Australia.
| | - Jonathan R Carapetis
- Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, University of Western Australia, PO Box West Perth, WA 6872, Australia; Princess Margaret Hospital, 100 Roberts Road, Subiaco, Perth 6008, Western Australia, Australia.
| |
Collapse
|
31
|
Moreland NJ, Waddington CS, Williamson DA, Sriskandan S, Smeesters PR, Proft T, Steer AC, Walker MJ, Baker EN, Baker MG, Lennon D, Dunbar R, Carapetis J, Fraser JD. Working towards a Group A Streptococcal vaccine: Report of a collaborative Trans-Tasman workshop. Vaccine 2014; 32:3713-20. [DOI: 10.1016/j.vaccine.2014.05.017] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2014] [Accepted: 05/01/2014] [Indexed: 11/25/2022]
|
32
|
Waddington CS, Darton TC, Jones C, Haworth K, Peters A, John T, Thompson BAV, Kerridge SA, Kingsley RA, Zhou L, Holt KE, Yu LM, Lockhart S, Farrar JJ, Sztein MB, Dougan G, Angus B, Levine MM, Pollard AJ. An outpatient, ambulant-design, controlled human infection model using escalating doses of Salmonella Typhi challenge delivered in sodium bicarbonate solution. Clin Infect Dis 2014; 58:1230-40. [PMID: 24519873 PMCID: PMC3982839 DOI: 10.1093/cid/ciu078] [Citation(s) in RCA: 107] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Oral delivery of escalating-dose Salmonella Typhi (Quailes strain) using sodium bicarbonate buffer solution in an outpatient, ambulant-design human infection study demonstrates safety, requires a lower challenge inoculum than that used in historical studies, and offers a unique insight into host–pathogen interactions. Background. Typhoid fever is a major global health problem, the control of which is hindered by lack of a suitable animal model in which to study Salmonella Typhi infection. Until 1974, a human challenge model advanced understanding of typhoid and was used in vaccine development. We set out to establish a new human challenge model and ascertain the S. Typhi (Quailes strain) inoculum required for an attack rate of 60%–75% in typhoid-naive volunteers when ingested with sodium bicarbonate solution. Methods. Groups of healthy consenting adults ingested escalating dose levels of S. Typhi and were closely monitored in an outpatient setting for 2 weeks. Antibiotic treatment was initiated if typhoid diagnosis occurred (temperature ≥38°C sustained ≥12 hours or bacteremia) or at day 14 in those remaining untreated. Results. Two dose levels (103 or 104 colony-forming units) were required to achieve the primary objective, resulting in attack rates of 55% (11/20) or 65% (13/20), respectively. Challenge was well tolerated; 4 of 40 participants fulfilled prespecified criteria for severe infection. Most diagnoses (87.5%) were confirmed by blood culture, and asymptomatic bacteremia and stool shedding of S. Typhi was also observed. Participants who developed typhoid infection demonstrated serological responses to flagellin and lipopolysaccharide antigens by day 14; however, no anti-Vi antibody responses were detected. Conclusions. Human challenge with a small inoculum of virulent S. Typhi administered in bicarbonate solution can be performed safely using an ambulant-model design to advance understanding of host–pathogen interactions and immunity. This model should expedite development of diagnostics, vaccines, and therapeutics for typhoid control.
Collapse
|
33
|
|
34
|
Waddington CS, Walker WT, Oeser C, Reiner A, John T, Wilkins S, Casey M, Eccleston PE, Allen RJ, Okike I, Ladhani S, Sheasby E, Hoschler K, Andrews N, Waight P, Collinson AC, Heath PT, Finn A, Faust SN, Snape MD, Miller E, Pollard AJ. Safety and immunogenicity of AS03B adjuvanted split virion versus non-adjuvanted whole virion H1N1 influenza vaccine in UK children aged 6 months-12 years: open label, randomised, parallel group, multicentre study. BMJ 2010; 340:c2649. [PMID: 20508026 PMCID: PMC2877808 DOI: 10.1136/bmj.c2649] [Citation(s) in RCA: 141] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVES To compare the safety, reactogenicity, and immunogenicity of an adjuvanted split virion H1N1 vaccine and a non-adjuvanted whole virion vaccine used in the pandemic immunisation programme in the United Kingdom. DESIGN Open label, randomised, parallel group, phase II study. SETTING Five UK centres (Oxford, Southampton, Bristol, Exeter, and London). PARTICIPANTS Children aged 6 months to less than 13 years for whom a parent or guardian had provided written informed consent and who were able to comply with study procedures were eligible. Those with laboratory confirmed pandemic H1N1 influenza or clinically diagnosed disease meriting antiviral treatment, allergy to egg or any other vaccine components, or coagulation defects, or who were severely immunocompromised or had recently received blood products were excluded. Children were grouped by age: 6 months-<3 years (younger group) and 3-<13 years (older group). Recruitment was by media advertising and direct mailing. Recruitment visits were attended by 949 participants, of whom 943 were enrolled and 937 included in the per protocol analysis. INTERVENTIONS Participants were randomised 1:1 to receive AS03(B) (tocopherol based oil in water emulsion) adjuvanted split virion vaccine derived from egg culture or non-adjuvanted whole virion vaccine derived from cell culture. Both were given as two doses 21 days apart. Reactogenicity data were collected for one week after immunisation by diary card. Serum samples were collected at baseline and after the second dose. MAIN OUTCOME MEASURES Primary reactogenicity end points were frequency and severity of fever, tenderness, swelling, and erythema after vaccination. Immunogenicity was measured by microneutralisation and haemagglutination inhibition assays. The primary immunogenicity objective was a comparison between vaccines of the percentage of participants showing seroconversion by the microneutralisation assay (fourfold rise to a titre of >or=1:40 from before vaccination to three weeks after the second dose). RESULTS Seroconversion rates were higher after the adjuvanted split virion vaccine than after the whole virion vaccine, most notably in the youngest children (163 of 166 participants with paired serum samples (98.2%, 95% confidence interval 94.8% to 99.6%) v 157 of 196 (80.1%, 73.8% to 85.5%), P<0.001) in children under 3 years and 226 of 228 (99.1%, 96.9% to 99.9%) v 95.9%, 92.4% to 98.1%, P=0.03) in those over 3 years). The adjuvanted split virion vaccine was more reactogenic than the whole virion vaccine, with more frequent systemic reactions and severe local reactions in children aged over 5 years after dose one (13 (7.2%, 3.9% to 12%) v 2 (1.1%, 0.1% to 3.9%), P<0.001) and dose two (15 (8.5%, 4.8% to 13.7%) v 2 (1.1%, 0.1% to 4.1%), P<0.002) and after dose two in those under 5 years (15 (5.9%, 3.3% to 9.6%) v 0 (0.0%, 0% to 1.4%), P<0.001). Dose two of the adjuvanted split virion vaccine was more reactogenic than dose one, especially for fever >or=38 masculineC in those aged under 5 (24 (8.9%, 5.8% to 12.9%) v 57 (22.4%, 17.5% to 28.1%), P<0.001). CONCLUSIONS In this first direct comparison of an AS03(B) adjuvanted split virion versus whole virion non-adjuvanted H1N1 vaccine, the adjuvanted vaccine, while more reactogenic, was more immunogenic and, importantly, achieved high seroconversion rates in children aged less than 3 years. This indicates the potential for improved immunogenicity of influenza vaccines in this age group. TRIAL REGISTRATION Clinical trials.gov NCT00980850; ISRCTN89141709.
Collapse
Affiliation(s)
- Claire S Waddington
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, Oxford OX3 7LJ.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|