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Indrihutami K, Chand K, Fahmia R, Rahardjani M, Wulandari F, Subekti D, Noviyanti R, Soebandrio A, Mallisa NT, Mardika IM, Budiman W, Suriswan I, Ertanto Y, Chen MC, Murshedkar T, Abebe Y, Sim BKL, Hoffman SL, Richie TL, Chen S, Elyazar IRF, Ekawati LL, Baird JK, Nelwan EJ. Implementation of a Randomized, Placebo-Controlled Trial of Live Attenuated Malaria Sporozoite Vaccines in an Indonesian Military Study Population. Am J Trop Med Hyg 2024; 110:892-901. [PMID: 38531102 PMCID: PMC11066349 DOI: 10.4269/ajtmh.23-0597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 11/24/2023] [Indexed: 03/28/2024] Open
Abstract
Malaria eradication efforts prioritize safe and efficient vaccination strategies, although none with high-level efficacy against malaria infection are yet available. Among several vaccine candidates, Sanaria® PfSPZ Vaccine and Sanaria PfSPZ-CVac are, respectively, live radiation- and chemo-attenuated sporozoite vaccines designed to prevent infection with Plasmodium falciparum, the leading cause of malaria-related morbidity and mortality. We are conducting a randomized normal saline placebo-controlled trial called IDSPZV1 that will analyze the safety, tolerability, immunogenicity, and efficacy of PfSPZ Vaccine and PfSPZ-CVac administered pre-deployment to malaria-naive Indonesian soldiers assigned to temporary duties in a high malaria transmission area. We describe the manifold challenges of enrolling and immunizing 345 soldier participants at their home base in western Indonesia before their nearly 6,000-km voyage to eastern Indonesia, where they are being monitored for incident P. falciparum and Plasmodium vivax malaria cases during 9 months of exposure. The unique regulatory, ethical, and operational complexities of this trial demonstrate the importance of thorough planning, frequent communication, and close follow-up with stakeholders. Effective engagement with the military community and the ability to adapt to unanticipated events have proven key to the success of this trial.
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Affiliation(s)
| | - Krisin Chand
- Oxford University Clinical Research Unit Indonesia, Jakarta, Indonesia
| | - Rizka Fahmia
- Oxford University Clinical Research Unit Indonesia, Jakarta, Indonesia
| | - Mutia Rahardjani
- Oxford University Clinical Research Unit Indonesia, Jakarta, Indonesia
| | - Fitria Wulandari
- Oxford University Clinical Research Unit Indonesia, Jakarta, Indonesia
| | - Decy Subekti
- Oxford University Clinical Research Unit Indonesia, Jakarta, Indonesia
| | - Rintis Noviyanti
- Eijkman Research Center for Molecular Biology, National Research & Innovation Agency, Cibinong, West Java, Indonesia
- EXEINS Health Initiative, Jakarta, Indonesia
| | - Amin Soebandrio
- Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Noch T. Mallisa
- Presidential Staff Office, Republic of Indonesia, Jakarta, Indonesia
| | | | - Waras Budiman
- Muhammadiyah University, Surabaya, East Java, Indonesia
| | | | - Yogi Ertanto
- Army Medical Center, Army of the Republic of Indonesia, Jakarta, Indonesia
| | | | | | | | | | | | | | | | | | - Lenny L. Ekawati
- Oxford University Clinical Research Unit Indonesia, Jakarta, Indonesia
- Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - J. Kevin Baird
- Oxford University Clinical Research Unit Indonesia, Jakarta, Indonesia
- Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Erni J. Nelwan
- Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
- Division of Tropical Medicine and Infectious Disease, Department of Internal Medicine, Cipto Mangunkusumo Hospital, Jakarta, Indonesia
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Sutanto I, Soebandrio A, Ekawati LL, Chand K, Noviyanti R, Satyagraha AW, Subekti D, Santy YW, Crenna-Darusallam C, Instiaty I, Budiman W, Prasetya CB, Lardo S, Elyazar I, Duparc S, Cedar E, Rolfe K, Fernando D, Berni A, Jones S, Kleim JP, Fletcher K, Sharma H, Martin A, Taylor M, Goyal N, Green JA, Tan LK, Baird JK. Tafenoquine co-administered with dihydroartemisinin-piperaquine for the radical cure of Plasmodium vivax malaria (INSPECTOR): a randomised, placebo-controlled, efficacy and safety study. Lancet Infect Dis 2023; 23:1153-1163. [PMID: 37236221 PMCID: PMC10533414 DOI: 10.1016/s1473-3099(23)00213-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 03/07/2023] [Accepted: 03/21/2023] [Indexed: 05/28/2023]
Abstract
BACKGROUND Tafenoquine, co-administered with chloroquine, is approved for the radical cure (prevention of relapse) of Plasmodium vivax malaria. In areas of chloroquine resistance, artemisinin-based combination therapies are used to treat malaria. This study aimed to evaluate tafenoquine plus the artemisinin-based combination therapy dihydroartemisinin-piperaquine for the radical cure of P vivax malaria. METHODS In this double-blind, double-dummy, parallel group study, glucose-6-phosphate dehydrogenase-normal Indonesian soldiers with microscopically confirmed P vivax malaria were randomly assigned by means of a computer-generated randomisation schedule (1:1:1) to dihydroartemisinin-piperaquine alone, dihydroartemisinin-piperaquine plus a masked single 300-mg dose of tafenoquine, or dihydroartemisinin-piperaquine plus 14 days of primaquine (15 mg). The primary endpoint was 6-month relapse-free efficacy following tafenoquine plus dihydroartemisinin-piperaquine versus dihydroartemisinin-piperaquine alone in all randomly assigned patients who received at least one dose of masked treatment and had microscopically confirmed P vivax at baseline (microbiological intention-to-treat population). Safety was a secondary outcome and the safety population comprised all patients who received at least one dose of masked medication. This study is registered with ClinicalTrials.gov, NCT02802501 and is completed. FINDINGS Between April 8, 2018, and Feb 4, 2019, of 164 patients screened for eligibility, 150 were randomly assigned (50 per treatment group). 6-month Kaplan-Meier relapse-free efficacy (microbiological intention to treat) was 11% (95% CI 4-22) in patients treated with dihydroartemisinin-piperaquine alone versus 21% (11-34) in patients treated with tafenoquine plus dihydroartemisinin-piperaquine (hazard ratio 0·44; 95% CI [0·29-0·69]) and 52% (37-65) in the primaquine plus dihydroartemisinin-piperaquine group. Adverse events over the first 28 days were reported in 27 (54%) of 50 patients treated with dihydroartemisinin-piperaquine alone, 29 (58%) of 50 patients treated with tafenoquine plus dihydroartemisinin-piperaquine, and 22 (44%) of 50 patients treated with primaquine plus dihydroartemisinin-piperaquine. Serious adverse events were reported in one (2%) of 50, two (4%) of 50, and two (4%) of 50 of patients, respectively. INTERPRETATION Although tafenoquine plus dihydroartemisinin-piperaquine was statistically superior to dihydroartemisinin-piperaquine alone for the radical cure of P vivax malaria, the benefit was not clinically meaningful. This contrasts with previous studies in which tafenoquine plus chloroquine was clinically superior to chloroquine alone for radical cure of P vivax malaria. FUNDING ExxonMobil, Bill & Melinda Gates Foundation, Newcrest Mining, UK Government all through Medicines for Malaria Venture; and GSK. TRANSLATION For the Indonesian translation of the abstract see Supplementary Materials section.
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Affiliation(s)
- Inge Sutanto
- Faculty of Medicine, University of Indonesia, Jakarta, Indonesia
| | | | - Lenny L Ekawati
- Faculty of Medicine, University of Indonesia, Jakarta, Indonesia; University of Oxford Clinical Research Unit-Indonesia, Jakarta, Indonesia
| | - Krisin Chand
- Faculty of Medicine, University of Indonesia, Jakarta, Indonesia; University of Oxford Clinical Research Unit-Indonesia, Jakarta, Indonesia
| | | | | | - Decy Subekti
- Faculty of Medicine, University of Indonesia, Jakarta, Indonesia; University of Oxford Clinical Research Unit-Indonesia, Jakarta, Indonesia
| | - Yulia Widya Santy
- Faculty of Medicine, University of Indonesia, Jakarta, Indonesia; University of Oxford Clinical Research Unit-Indonesia, Jakarta, Indonesia
| | - Chelzie Crenna-Darusallam
- Eijkman Institute for Molecular Biology, Jakarta, Indonesia; Mochtar Riady Institute for Nanotechnology, Banten, Indonesia
| | | | - Waras Budiman
- Health Service, Army of the Republic of Indonesia, Jakarta, Indonesia
| | | | - Soroy Lardo
- Health Service, Army of the Republic of Indonesia, Jakarta, Indonesia
| | - Iqbal Elyazar
- University of Oxford Clinical Research Unit-Indonesia, Jakarta, Indonesia
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - J Kevin Baird
- Faculty of Medicine, University of Indonesia, Jakarta, Indonesia; University of Oxford Clinical Research Unit-Indonesia, Jakarta, Indonesia; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Khairunisa SQ, Megasari NLA, Ueda S, Budiman W, Kotaki T, Nasronudin, Kameoka M. 2018-2019 Update on the Molecular Epidemiology of HIV-1 in Indonesia. AIDS Res Hum Retroviruses 2020; 36:957-963. [PMID: 32799643 DOI: 10.1089/aid.2020.0151] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The HIV type 1 (HIV-1) epidemic has continued to grow in Indonesia; however, continuous updates on the epidemiology of HIV-1 in Indonesia remain challenging because it is the biggest archipelago in the world. Furthermore, the emergence of HIV drug resistance (HIVDR) has had a negative impact on the treatment of infected individuals. In this study, we performed HIV-1 subtyping and the detection of HIVDR in 105 HIV-1-infected individuals residing in various cities in Indonesia during 2018-2019. The results obtained identified CRF01_AE as the major epidemic HIV-1 strain, responsible for 81.9% of infection cases, followed by subtype B (12.4%), CRF02_AG (3.8%), CRF52_01B (1%), and a recombinant between CRF01_AE and CRF02_AG (1.0%). Major drug resistance-associated mutations against reverse transcriptase inhibitors were detected in 20% of samples. These results suggest that CRF01_AE is a major HIV-1 strain in Indonesia, while CRF02_AG is emerging. The prevalence of HIVDR in Indonesia needs to be monitored.
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Affiliation(s)
- Siti Qamariyah Khairunisa
- Indonesian-Japan Collaborative Research Center for Emerging and Re-emerging Infectious Diseases, Institute of Tropical Disease, Universitas Airlangga, Surabaya, Indonesia
| | - Ni Luh Ayu Megasari
- Indonesian-Japan Collaborative Research Center for Emerging and Re-emerging Infectious Diseases, Institute of Tropical Disease, Universitas Airlangga, Surabaya, Indonesia
| | - Shuhei Ueda
- Indonesian-Japan Collaborative Research Center for Emerging and Re-emerging Infectious Diseases, Institute of Tropical Disease, Universitas Airlangga, Surabaya, Indonesia
- Center for Infectious Diseases, Kobe University Graduate School of Medicine, Hyogo, Japan
- Department of Public Health, Kobe University Graduate School of Health Sciences, Hyogo, Japan
| | | | - Tomohiro Kotaki
- Department of Public Health, Kobe University Graduate School of Health Sciences, Hyogo, Japan
| | - Nasronudin
- Indonesian-Japan Collaborative Research Center for Emerging and Re-emerging Infectious Diseases, Institute of Tropical Disease, Universitas Airlangga, Surabaya, Indonesia
- Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia
| | - Masanori Kameoka
- Department of Public Health, Kobe University Graduate School of Health Sciences, Hyogo, Japan
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