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Datoo MS, Dicko A, Tinto H, Ouédraogo JB, Hamaluba M, Olotu A, Beaumont E, Ramos Lopez F, Natama HM, Weston S, Chemba M, Compaore YD, Issiaka D, Salou D, Some AM, Omenda S, Lawrie A, Bejon P, Rao H, Chandramohan D, Roberts R, Bharati S, Stockdale L, Gairola S, Greenwood BM, Ewer KJ, Bradley J, Kulkarni PS, Shaligram U, Hill AVS. Safety and efficacy of malaria vaccine candidate R21/Matrix-M in African children: a multicentre, double-blind, randomised, phase 3 trial. Lancet 2024; 403:533-544. [PMID: 38310910 DOI: 10.1016/s0140-6736(23)02511-4] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 10/22/2023] [Accepted: 11/06/2023] [Indexed: 02/06/2024]
Abstract
BACKGROUND Recently, we found that a new malaria vaccine, R21/Matrix-M, had over 75% efficacy against clinical malaria with seasonal administration in a phase 2b trial in Burkina Faso. Here, we report on safety and efficacy of the vaccine in a phase 3 trial enrolling over 4800 children across four countries followed for up to 18 months at seasonal sites and 12 months at standard sites. METHODS We did a double-blind, randomised, phase 3 trial of the R21/Matrix-M malaria vaccine across five sites in four African countries with differing malaria transmission intensities and seasonality. Children (aged 5-36 months) were enrolled and randomly assigned (2:1) to receive 5 μg R21 plus 50 μg Matrix-M or a control vaccine (licensed rabies vaccine [Abhayrab]). Participants, their families, investigators, laboratory teams, and the local study team were masked to treatment. Vaccines were administered as three doses, 4 weeks apart, with a booster administered 12 months after the third dose. Half of the children were recruited at two sites with seasonal malaria transmission and the remainder at standard sites with perennial malaria transmission using age-based immunisation. The primary objective was protective efficacy of R21/Matrix-M from 14 days after third vaccination to 12 months after completion of the primary series at seasonal and standard sites separately as co-primary endpoints. Vaccine efficacy against multiple malaria episodes and severe malaria, as well as safety and immunogenicity, were also assessed. This trial is registered on ClinicalTrials.gov, NCT04704830, and is ongoing. FINDINGS From April 26, 2021, to Jan 12, 2022, 5477 children consented to be screened, of whom 1705 were randomly assigned to control vaccine and 3434 to R21/Matrix-M; 4878 participants received the first dose of vaccine. 3103 participants in the R21/Matrix-M group and 1541 participants in the control group were included in the modified per-protocol analysis (2412 [51·9%] male and 2232 [48·1%] female). R21/Matrix-M vaccine was well tolerated, with injection site pain (301 [18·6%] of 1615 participants) and fever (754 [46·7%] of 1615 participants) as the most frequent adverse events. Number of adverse events of special interest and serious adverse events did not significantly differ between the vaccine groups. There were no treatment-related deaths. 12-month vaccine efficacy was 75% (95% CI 71-79; p<0·0001) at the seasonal sites and 68% (61-74; p<0·0001) at the standard sites for time to first clinical malaria episode. Similarly, vaccine efficacy against multiple clinical malaria episodes was 75% (71-78; p<0·0001) at the seasonal sites and 67% (59-73; p<0·0001) at standard sites. A modest reduction in vaccine efficacy was observed over the first 12 months of follow-up, of similar size at seasonal and standard sites. A rate reduction of 868 (95% CI 762-974) cases per 1000 children-years at seasonal sites and 296 (231-362) at standard sites occurred over 12 months. Vaccine-induced antibodies against the conserved central Asn-Ala-Asn-Pro (NANP) repeat sequence of circumsporozoite protein correlated with vaccine efficacy. Higher NANP-specific antibody titres were observed in the 5-17 month age group compared with 18-36 month age group, and the younger age group had the highest 12-month vaccine efficacy on time to first clinical malaria episode at seasonal (79% [95% CI 73-84]; p<0·001) and standard (75% [65-83]; p<0·001) sites. INTERPRETATION R21/Matrix-M was well tolerated and offered high efficacy against clinical malaria in African children. This low-cost, high-efficacy vaccine is already licensed by several African countries, and recently received a WHO policy recommendation and prequalification, offering large-scale supply to help reduce the great burden of malaria in sub-Saharan Africa. FUNDING The Serum Institute of India, the Wellcome Trust, the UK National Institute for Health Research Oxford Biomedical Research Centre, and Open Philanthropy.
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Affiliation(s)
- Mehreen S Datoo
- Centre for Clinical Vaccinology and Tropical Medicine, The Jenner Institute, University of Oxford and the NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Alassane Dicko
- Clinical Research Unit of Bougouni-Ouelessebougou, Malaria Research and Training Centre, University of Sciences, Techniques, and Technologies of Bamako, Bamako, Mali
| | - Halidou Tinto
- Unité de Recherche Clinique de Nanoro, Institut de Recherche en Sciences de la Santé, Nanoro, Burkina Faso
| | | | - Mainga Hamaluba
- Kenya Medical Research Institute Centre for Geographical Medicine Research-Coast (KEMRI-CGMRC), Kilifi, Kenya; Centre for Tropical Medicine & Global Health, Nuffield Department of Medicine, Oxford, UK
| | - Ally Olotu
- Ifakara Health Institute, Bagamoyo Research and Training Centre, Bagamoyo, Tanzania
| | - Emma Beaumont
- London School of Hygiene and Tropical Medicine, London, UK
| | - Fernando Ramos Lopez
- Centre for Clinical Vaccinology and Tropical Medicine, The Jenner Institute, University of Oxford and the NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Hamtandi Magloire Natama
- Unité de Recherche Clinique de Nanoro, Institut de Recherche en Sciences de la Santé, Nanoro, Burkina Faso
| | - Sophie Weston
- Centre for Clinical Vaccinology and Tropical Medicine, The Jenner Institute, University of Oxford and the NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Mwajuma Chemba
- Ifakara Health Institute, Bagamoyo Research and Training Centre, Bagamoyo, Tanzania
| | | | - Djibrilla Issiaka
- Clinical Research Unit of Bougouni-Ouelessebougou, Malaria Research and Training Centre, University of Sciences, Techniques, and Technologies of Bamako, Bamako, Mali
| | - Diallo Salou
- Unité de Recherche Clinique de Nanoro, Institut de Recherche en Sciences de la Santé, Nanoro, Burkina Faso
| | - Athanase M Some
- Unité de Recherche Clinique de Nanoro, Institut de Recherche en Sciences de la Santé, Nanoro, Burkina Faso
| | - Sharon Omenda
- Kenya Medical Research Institute Centre for Geographical Medicine Research-Coast (KEMRI-CGMRC), Kilifi, Kenya
| | - Alison Lawrie
- Centre for Clinical Vaccinology and Tropical Medicine, The Jenner Institute, University of Oxford and the NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Philip Bejon
- Kenya Medical Research Institute Centre for Geographical Medicine Research-Coast (KEMRI-CGMRC), Kilifi, Kenya
| | | | | | - Rachel Roberts
- Centre for Clinical Vaccinology and Tropical Medicine, The Jenner Institute, University of Oxford and the NIHR Oxford Biomedical Research Centre, Oxford, UK
| | | | - Lisa Stockdale
- The Jenner Institute Laboratories, University of Oxford, Oxford, UK
| | | | | | - Katie J Ewer
- The Jenner Institute Laboratories, University of Oxford, Oxford, UK
| | - John Bradley
- London School of Hygiene and Tropical Medicine, London, UK
| | | | | | - Adrian V S Hill
- Centre for Clinical Vaccinology and Tropical Medicine, The Jenner Institute, University of Oxford and the NIHR Oxford Biomedical Research Centre, Oxford, UK; The Jenner Institute Laboratories, University of Oxford, Oxford, UK.
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Hema-Ouangraoua S, Zongo I, Kabore NF, Frédéric N, Yerbanga RS, Tinto H, Compaore YD, Kuepfer I, Chandramohan D, Greenwood B, Ouedraogo JB. Serotype Profile of Nasopharyngeal Isolates of Streptococcus pneumoniae Obtained from Children in Burkina Faso before and after Mass Administration of Azithromycin. Am J Trop Med Hyg 2020; 103:679-683. [PMID: 32524945 PMCID: PMC7410481 DOI: 10.4269/ajtmh.19-0944] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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] [Indexed: 11/07/2022] Open
Abstract
Mass drug administration (MDA) with azithromycin (AZ) has been used successfully to control trachoma. However, several studies have shown that MDA with AZ has led to the emergence of resistance to AZ in Streptococcus pneumoniae. The emergence of resistance to AZ has also been observed when this antibiotic was combined with the antimalarials used for seasonal malaria chemoprevention (SMC). The development of antibiotic resistance, including resistance to AZ, is sometimes associated with the emergence of a bacterial clone that belongs to a specific serotype. We hypothesize that the increase in resistance of S. pneumoniae observed after 3 years of SMC with AZ might be associated with a change in the distribution of pneumococcal serotypes. Therefore, 698 randomly selected isolates from among the 1,468 isolates of S. pneumoniae obtained during carriage studies undertaken during an SMC plus AZ trial were serotyped. A polymerase chain reaction (PCR) multiplex assay using an algorithm adapted to the detection of the pneumococcal serotypes most prevalent in African countries was used for initial serotyping, and the Quellung technique was used to complement the PCR technique when necessary. Fifty-six serotypes were detected among the 698 isolates of S. pneumoniae. A swift appearance and disappearance of many serotypes was observed, but some serotypes including 6A, 19F, 19A, 23F, and 35B were persistent. The distribution of serotypes between isolates obtained from children who had received AZ or placebo was similar. An increase in AZ resistance was seen in several serotypes following exposure to AZ. Mass drug administration with AZ led to the emergence of resistance in pneumococci of several different serotypes and did not appear to be linked to the emergence of a single serotype.
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Affiliation(s)
| | - Issaka Zongo
- Institut de Recherche en Sciences de la Santé (IRSS), Bobo-Dioulasso, Burkina Faso
| | | | - Nikiema Frédéric
- Institut de Recherche en Sciences de la Santé (IRSS), Bobo-Dioulasso, Burkina Faso
| | | | - Halidou Tinto
- Institut de Recherche en Sciences de la Santé (IRSS), Bobo-Dioulasso, Burkina Faso
| | - Yves Daniel Compaore
- Institut de Recherche en Sciences de la Santé (IRSS), Bobo-Dioulasso, Burkina Faso
| | - Irene Kuepfer
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | | | - Brian Greenwood
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Jean Bosco Ouedraogo
- Institut de Recherche en Sciences de la Santé (IRSS), Bobo-Dioulasso, Burkina Faso
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Chotsiri P, Zongo I, Milligan P, Compaore YD, Somé AF, Chandramohan D, Hanpithakpong W, Nosten F, Greenwood B, Rosenthal PJ, White NJ, Ouédraogo JB, Tarning J. Optimal dosing of dihydroartemisinin-piperaquine for seasonal malaria chemoprevention in young children. Nat Commun 2019; 10:480. [PMID: 30696903 PMCID: PMC6351525 DOI: 10.1038/s41467-019-08297-9] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Accepted: 12/24/2018] [Indexed: 12/31/2022] Open
Abstract
Young children are the population most severely affected by Plasmodium falciparum malaria. Seasonal malaria chemoprevention (SMC) with amodiaquine and sulfadoxine-pyrimethamine provides substantial benefit to this vulnerable population, but resistance to the drugs will develop. Here, we evaluate the use of dihydroartemisinin-piperaquine as an alternative regimen in 179 children (aged 2.33–58.1 months). Allometrically scaled body weight on pharmacokinetic parameters of piperaquine result in lower drug exposures in small children after a standard mg per kg dosage. A covariate-free sigmoidal EMAX-model describes the interval to malaria re-infections satisfactorily. Population-based simulations suggest that small children would benefit from a higher dosage according to the WHO 2015 guideline. Increasing the dihydroartemisinin-piperaquine dosage and extending the dose schedule to four monthly doses result in a predicted relative reduction in malaria incidence of up to 58% during the high transmission season. The higher and extended dosing schedule to cover the high transmission period for SMC could improve the preventive efficacy substantially. Seasonal malaria chemoprevention provides substantial benefit for young children, but resistance to used drugs will likely develop. Here, Chotsiri et al. evaluate the use of dihydroartemisinin-piperaquine as a regimen in 179 children, and population-based simulations suggest that small children would benefit from a higher and extended dosage.
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Affiliation(s)
- Palang Chotsiri
- Faculty of Tropical Medicine, Department of Clinical Pharmacology, Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, 10400, Thailand
| | - Issaka Zongo
- Institut de Recherche en Sciences de la Santé, Bobo-Dioulasso, Burkina Faso
| | - Paul Milligan
- Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, United Kingdom
| | | | | | - Daniel Chandramohan
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, United Kingdom
| | - Warunee Hanpithakpong
- Faculty of Tropical Medicine, Department of Clinical Pharmacology, Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, 10400, Thailand
| | - François Nosten
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, London, OX3 7LJ, United Kingdom.,Faculty of Tropical Medicine, Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Mae Sot, 63110, Thailand
| | - Brian Greenwood
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, United Kingdom
| | - Philip J Rosenthal
- Department of Medicine, University of California, Box 0811, San Francisco, CA 94143, CA, USA
| | - Nicholas J White
- Faculty of Tropical Medicine, Department of Clinical Pharmacology, Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, 10400, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, London, OX3 7LJ, United Kingdom
| | | | - Joel Tarning
- Faculty of Tropical Medicine, Department of Clinical Pharmacology, Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, 10400, Thailand. .,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, London, OX3 7LJ, United Kingdom.
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