Optimising DTwP-containing vaccine infant immunisation schedules (OptImms) - a protocol for two parallel, open-label, randomised controlled trials

BACKGROUND

Universal immunisation is the cornerstone of preventive medicine for children, The World Health Organisation (WHO) recommends diphtheria-tetanus-pertussis (DTP) vaccine administered at 6, 10 and 14 weeks of age as part of routine immunisation. However, globally, more than 17 unique DTP-containing vaccine schedules are in use. New vaccines for other diseases continue to be introduced into the infant immunisation schedule, resulting in an increasingly crowded schedule. The OptImms trial will assess whether antibody titres against pertussis and other antigens in childhood can be maintained whilst adjusting the current Expanded Programme on Immunisation (EPI) schedule to provide space for the introduction of new vaccines.

METHODS

The OptImms studies are two randomised, five-arm, non-inferiority clinical trials in Nepal and Uganda. Infants aged 6 weeks will be randomised to one of five primary vaccination schedules based on age at first DTwP-vaccination (6 versus 8 weeks of age), number of doses in the DTwP priming series (two versus three), and spacing of priming series vaccinations (4 versus 8 weeks). Additionally, participants will be randomised to receive their DTwP booster at 9 or 12 months of age. A further sub-study will compare the co-administration of typhoid vaccine with other routine vaccines at one year of age. The primary outcome is anti-pertussis toxin IgG antibodies measured at the time of the booster dose. Secondary outcomes include antibodies against other vaccine antigens in the primary schedule and their safety.

DISCUSSION

These data will provide key data to inform policy decisions on streamlining vaccination schedules in childhood.

TRIAL REGISTRATIONS

ISRCTN12240140 (Nepa1, 7th January 2021) and ISRCTN6036654 (Uganda, 17th February 2021).

MICROSCOPIC CHANGES OF THE KIDNEY IN EXPERIMENTAL HYPERHOMOCYSTEINEMIA ON THE BACKGROUND OF HYPER- AND HYPOTHYROIDISM

Hyper- and hypothyroidism are two typical clinical conditions that can cause a variety of metabolic changes, including impaired sulfur-containing amino acids metabolism, increased risk of cardiovascular disease, renal dysfunction, and renal failure. Hypothyroidism has been shown to be associated with increased serum creatinine, decreased glomerular filtration rate, and an increased risk of chronic kidney disease. At the same time, the pathophysiological mechanisms of renal dysfunction induced by excessive iodothyronine secretion are poorly understood. The aim of the study was to establish the reorganization of the kidney structural components under the conditions of experimental hyperhomocysteinemia (HHCy), hyper- and hypothyroidism and their combined effects. Thiolactone HHCy was simulated by administering to animals exogenous homocysteine ​​(HC) in the form of thiolactone at a dose of 100 mg/kg body weight once a day for 28 days. Hyperthyroidism was simulated by daily administration of L-thyroxine at a dose of 200 μg/kg on 21st day, hypothyroidism - daily administration of mercazolyl at a dose of 10 mg/kg on 21st day. Separate groups of animals were administered L-thyroxine and mercazolyl in parallel with HC. A significant degree of dystrophic changes in the structural components of the kidneys under conditions of simulated hyperthyroidism and HHCy was established. Signs of vascular insufficiency in the kidneys were detected. Deformation of renal corpuscles, single focal thickenings and destruction of the outer layer of the renal corpuscle capsule were observed, there was a narrowing of the urinary space in the capsule. Microscopic study of the kidneys of animals under the combined effects of hypothyroidism and HHCy revealed the most significant destructive-degenerative changes in the filtration and reabsorption apparatus of the organ on the background of significant vascular disorders. An increase in number of glomeruli and a decrease of the urinary space of the Shumlyansky-Bowman's capsule were observed in the renal corpuscles. Podocytes underwent significant destructive changes. Damage to the epithelium in the system of tubules was manifested by cell hypertrophy. Under the conditions of simulated HHCy, hyper- and hypothyroidism, and especially with their combined effect, there are significant disorders of the vascular bed with remodeling of the vascular wall. On the background of hemodynamic disorders, there are significant destructive and dystrophic changes in the epitheliocytes of the renal corpuscles of the Shumlyansky-Bowman's capsule, the proximal and distal tubules of the nephron, the filtration and reabsorption apparatus of the nephrons of the organ.

Efficacy of typhoid conjugate vaccine in Nepal: final results of a phase 3, randomised, controlled trial

BACKGROUND

Typhoid fever is a major public health problem in low-resource settings. Vaccination can help curb the disease and might reduce transmission. We have previously reported an interim analysis of the efficacy of typhoid conjugate vaccine (TCV) in Nepali children. Here we report the final results after 2 years of follow-up.

METHODS

We did a participant-masked and observer-masked individually randomised trial in Lalitpur, Nepal, in which 20 019 children aged 9 months to younger than 16 years were randomly assigned in a 1:1 ratio to receive a single dose of TCV (Typbar TCV, Bharat Biotech International, India) or capsular group A meningococcal conjugate vaccine (MenA). Participants were followed up until April 9, 2020. The primary outcome was blood culture-confirmed typhoid fever. Cases were captured via passive surveillance and active telephone surveillance followed by medical record review. The trial is registered at ISRCTN registry, ISRCTN43385161 and is ongoing.

FINDINGS

From Nov 20, 2017, to April 9, 2018, of 20 119 children screened, 20 019 participants were randomly assigned to receive TCV or MenA vaccine. There were 75 cases of blood culture-confirmed typhoid fever included in the analysis (13 in the TCV group and 62 in the MenA group) over the 2-year period. The protective efficacy of TCV against blood culture-confirmed typhoid fever at 2 years was 79·0% (95% CI 61·9-88·5; p<0·0001). The incidence of typhoid fever was 72 (95% CI 38-123) cases per 100 000 person-years in the TCV group and 342 (95% CI 262-438) cases per 100 000 person-years in the MenA group. Adverse events occurring within the first 7 days post-vaccination were reported previously.

INTERPRETATION

The final results of this randomised, controlled trial are in keeping with the results of our published interim analysis. There is no evidence of waning protection over a 2-year period. These findings add further support for the WHO recommendations on control of enteric fever.

FUNDING

Bill & Melinda Gates Foundation.

Protection by vaccination of children against typhoid fever with a Vi-tetanus toxoid conjugate vaccine in urban Bangladesh: a cluster-randomised trial

BACKGROUND

Typhoid fever remains a major cause of morbidity and mortality in low-income and middle-income countries. Vi-tetanus toxoid conjugate vaccine (Vi-TT) is recommended by WHO for implementation in high-burden countries, but there is little evidence about its ability to protect against clinical typhoid in such settings.

METHODS

We did a participant-masked and observer-masked cluster-randomised trial preceded by a safety pilot phase in an urban endemic setting in Dhaka, Bangladesh. 150 clusters, each with approximately 1350 residents, were randomly assigned (1:1) to either Vi-TT or SA 14-14-2 Japanese encephalitis (JE) vaccine. Children aged 9 months to less than 16 years were invited via parent or guardian to receive a single, parenteral dose of vaccine according to their cluster of residence. The study population was followed for an average of 17·1 months. Total and overall protection by Vi-TT against blood culture-confirmed typhoid were the primary endpoints assessed in the intention-to-treat population of vaccinees or all residents in the clusters. A subset of approximately 4800 participants was assessed with active surveillance for adverse events. The trial is registered at www.isrctn.com, ISRCTN11643110.

FINDINGS

41 344 children were vaccinated in April-May, 2018, with another 20 412 children vaccinated at catch-up vaccination campaigns between September and December, 2018, and April and May, 2019. The incidence of typhoid fever (cases per 100 000 person-years) was 635 in JE vaccinees and 96 in Vi-TT vaccinees (total Vi-TT protection 85%; 97·5% CI 76 to 91, p<0·0001). Total vaccine protection was consistent in different age groups, including children vaccinated at ages under 2 years (81%; 95% CI 39 to 94, p=0·0052). The incidence was 213 among all residents in the JE clusters and 93 in the Vi-TT clusters (overall Vi-TT protection 57%; 97·5% CI 43 to 68, p<0·0001). We did not observe significant indirect vaccine protection by Vi-TT (19%; 95% CI -12 to 41, p=0·20). The vaccines were well tolerated, and no serious adverse events judged to be vaccine-related were observed.

INTERPRETATION

Vi-TT provided protection against typhoid fever to children vaccinated between 9 months and less than 16 years. Longer-term follow-up will be needed to assess the duration of protection and the need for booster doses.

FUNDING

The study was funded by the Bill & Melinda Gates Foundation.

Logistics of Implementing a Large-scale Typhoid Vaccine Trial in Kathmandu, Nepal

Typhoid fever is estimated to affect over 20 million people per year worldwide, with infants, children, and adolescents in south-central and southeast Asia experiencing the greatest burden of disease. The Typhoid Vaccine Acceleration Consortium (TyVAC) aims to support the introduction of typhoid conjugate vaccines into Gavi-eligible countries in an effort to reduce morbidity and mortality from typhoid. TyVAC-Nepal is a large-scale, participant- and observer-blind, individually randomized, controlled trial evaluating the efficacy of a newly developed typhoid conjugate vaccine in an urban setting in Nepal. In order to effectively deliver the trial, a number of key elements required meticulous planning. Public engagement strategies were considered early, and involved the implementation of a tiered approach. Approximately 300 staff were employed and trained in order to achieve the mass vaccination of 20 000 children aged 9 months to ≤16 years old over a 4-month period. There were 19 vaccination clinics established across the Lalitpur metropolitan city in the Kathmandu valley. Participants will be followed for 2 years post-vaccination to measure the rate reduction of blood culture–confirmed typhoid fever in the vaccination arm as compared to the control arm. The experience of conducting this large-scale vaccine trial suggests that comprehensive planning, continuous monitoring, and an ability to adapt plans in response to feedback are key.

Phase 3 Efficacy Analysis of a Typhoid Conjugate Vaccine Trial in Nepal

BACKGROUND

Salmonella Typhi is a major cause of fever in children in low- and middle-income countries. A typhoid conjugate vaccine (TCV) that was recently prequalified by the World Health Organization was shown to be efficacious in a human challenge model, but data from efficacy trials in areas where typhoid is endemic are lacking.

METHODS

In this phase 3, randomized, controlled trial in Lalitpur, Nepal, in which both the participants and observers were unaware of the trial-group assignments, we randomly assigned children who were between 9 months and 16 years of age, in a 1:1 ratio, to receive either a TCV or a capsular group A meningococcal conjugate vaccine (MenA) as a control. The primary outcome was typhoid fever confirmed by blood culture. We present the prespecified analysis of the primary and main secondary outcomes (including an immunogenicity subgroup); the 2-year trial follow-up is ongoing.

RESULTS

A total of 10,005 participants received the TCV and 10,014 received the MenA vaccine. Blood culture-confirmed typhoid fever occurred in 7 participants who received TCV (79 cases per 100,000 person-years) and in 38 who received MenA vaccine (428 cases per 100,000 person-years) (vaccine efficacy, 81.6%; 95% confidence interval, 58.8 to 91.8; P<0.001). A total of 132 serious adverse events (61 in the TCV group and 71 in the MenA vaccine group) occurred in the first 6 months, and 1 event (pyrexia) was identified as being vaccine-related; the participant remained unaware of the trial-group assignment. Similar rates of adverse events were noted in the two trial groups; fever developed in 5.0% of participants in the TCV group and 5.4% in the MenA vaccine group in the first week after vaccination. In the immunogenicity subgroup, seroconversion (a Vi IgG level that at least quadrupled 28 days after vaccination) was 99% in the TCV group (677 of 683 participants) and 2% in the MenA vaccine group (8 of 380 participants).

CONCLUSIONS

A single dose of TCV was immunogenic and effective in reducing S. Typhi bacteremia in children 9 months to 16 years of age. (Funded by the Bill and Melinda Gates Foundation; Current Controlled Trials number, ISRCTN43385161.).

Enhanced large conductance K+ channel activity contributes to the impaired myogenic response in the cerebral vasculature of Fawn Hooded Hypertensive rats

Recent studies have indicated that the myogenic response (MR) in cerebral arteries is impaired in Fawn Hooded Hypertensive (FHH) rats and that transfer of a 2.4 megabase pair region of chromosome 1 (RNO1) containing 15 genes from the Brown Norway rat into the FHH genetic background restores MR in a FHH.1(BN) congenic strain. However, the mechanisms involved remain to be determined. The present study examined the role of the large conductance calcium-activated potassium (BK) channel in impairing the MR in FHH rats. Whole-cell patch-clamp studies of cerebral vascular smooth muscle cells (VSMCs) revealed that iberiotoxin (IBTX; BK inhibitor)-sensitive outward potassium (K+) channel current densities are four- to fivefold greater in FHH than in FHH.1(BN) congenic strain. Inside-out patches indicated that the BK channel open probability (NPo) is 10-fold higher and IBTX reduced NPo to a greater extent in VSMCs isolated from FHH than in FHH.1(BN) rats. Voltage sensitivity of the BK channel is enhanced in FHH as compared with FHH.1(BN) rats. The frequency and amplitude of spontaneous transient outward currents are significantly greater in VSMCs isolated from FHH than in FHH.1(BN) rats. However, the expression of the BK-α and -β-subunit proteins in cerebral vessels as determined by Western blot is similar between the two groups. Middle cerebral arteries (MCAs) isolated from FHH rats exhibited an impaired MR, and administration of IBTX restored this response. These results indicate that there is a gene on RNO1 that impairs MR in the MCAs of FHH rats by enhancing BK channel activity.

Apo- and cellopentaose-bound structures of the bacterial cellulose synthase subunit BcsZ

Cellulose, a very abundant extracellular polysaccharide, is synthesized in a finely tuned process that involves the activity of glycosyl-transferases and hydrolases. The cellulose microfibril consists of bundles of linear β-1,4-glucan chains that are synthesized inside the cell; however, the mechanism by which these polymers traverse the cell membrane is currently unknown. In Gram-negative bacteria, the cellulose synthase complex forms a trans-envelope complex consisting of at least four subunits. Although three of these subunits account for the synthesis and translocation of the polysaccharide, the fourth subunit, BcsZ, is a periplasmic protein with endo-β-1,4-glucanase activity. BcsZ belongs to family eight of glycosyl-hydrolases, and its activity is required for optimal synthesis and membrane translocation of cellulose. In this study we report two crystal structures of BcsZ from Escherichia coli. One structure shows the wild-type enzyme in its apo form, and the second structure is for a catalytically inactive mutant of BcsZ in complex with the substrate cellopentaose. The structures demonstrate that BcsZ adopts an (α/α)(6)-barrel fold and that it binds four glucan moieties of cellopentaose via highly conserved residues exclusively on the nonreducing side of its catalytic center. Thus, the BcsZ-cellopentaose structure most likely represents a posthydrolysis state in which the newly formed nonreducing end has already left the substrate binding pocket while the enzyme remains attached to the truncated polysaccharide chain. We further show that BcsZ efficiently degrades β-1,4-glucans in in vitro cellulase assays with carboxymethyl-cellulose as substrate.

Characteristics of extracellular DNA containing unmethylated CpG motifs isolated from Bacillus subtilis culture medium filtrate

The application of CpG DNA is one of the most modern and sufficiently perspective trends in immunotherapy of cancer. The AIM of the investigation was to characterize the DNA as a part of nucleoprotein fraction isolated from Bacillus subtilis culture medium filtrate (CMF) and to evaluate the dynamic of accumulation of such DNA and level of its unmethylated CpG motifs enrichment in the process of cultivation of bacterium.

METHODS

Two bacterial strains--B. subtilis 7025 and B. subtilis GP1-807-03--were used. Polyacrylamide and agarose gel electrophoresis, restriction analysis and transmission electron microscopy were used. The RESULTS of the investigations showed that DNA was accumulated in culture medium irregularly. DNA-containing fractions isolated on the 7th-9th day of cultivation have the greatest sensitivity to restriction endonuclease HpaII. The presence of phages in CMF concentrates has been shown.

CONCLUSION

The present findings suggest that 7th-9th day of cultivation are the most optimal to obtain the bacterial extracellular DNA for the following immunotherapy application.

Changes in serum concentration of prolactational hormones in the periparturient cow

The endocrine status around the time of parturition was investigated by radioimmunoassay of the prolactational hormones: prolactin, progesterone, thyroxine, triiodothyronine and insulin, thought to be related to the initiation and intensity of lactation in the cow. A marked drop in progesteronaemia with subsequent high prolactinaemia was found in the period of initiation of milk secretion. There was a drop in the levels of insulin and thyroid hormones during the periparturient period, except for a short rise of their concentrations at the very end of pregnancy. The results suggest that the release of the mammary gland from progesterone inhibition associated with higher utilization of the prolactational hormones is important for lactogenesis.