Effects of Nasal-spraying LiveSpo Navax in Treatment of Acute Respiratory Infections in Children
Condition: Acute Respiratory Tract Infections
MeSH terms: Infections; Communicable Diseases; Respiratory Tract Infections
Study type: Interventional

Summary: 
      Rationals: Infection with the Respiratory Syncytial Virus (RSV) is one of the most common
      causes of respiratory tract diseases. However, treatment for pediatric RSV infection remains
      supportive to prevent co-infection bacteria and respiratory failure. In recent years,
      preventive and supportive probiotic therapies for respiratory tract infections (RTIs) have
      been increasingly strengthened, however, the use of oral administrative probiotics as
      functional foods is effective only for mild symptoms and not applicable for Acute RTIs
      (ARTIs). Here, we propose that direct spraying of probiotics into the nose can be a fast and
      effective symptomatic treatment for ARTIs.

      Objectives: Investigate symptomatic treatment effects of probiotic product LiveSpo Navax, as
      liquid-suspension form containing Bacillus spores of safe B. subtilis ANA4 and B. clausii
      ANA39 strains, in children having acute respiratory diseases caused by RSV:

        -  Primary Objective: Evaluation of improved efficacy and reduced treatment time of LiveSpo
           Navax in children infected with RSV.

        -  Secondary Objectives: Measurement of changes in RSV viral load, co-infectious bacterial
           concentrations, and major cytokine indicators in the nasopharyngeal mucosa before and
           after 3 days using LiveSpo Navax.

      Endpoints:

      Primary endpoint: LiveSpo Navax alleviates RSV-infection symptoms about 25% more effectively,
      as indicated by 90% of patients using LiveSpo Navax (Navax group) are symptom-free at day 3-6
      of intervention depending on symptoms, compared to 65% of patients in Control group.

      Secondary endpoint: Patients in Navax group had more significant reductions in RSV load (>10
      fold) than patients in Control group at day 3 of intervention.

      Study Population: Sample size is 100. Description of Sites: The study is carried out at
      Vietnam National Children's Hospital.

      Description of Study Intervention: Totally 100 eligible patients are divided randomly into 2
      groups (n = 50/group each): Patients in Control group received the routine treatment and
      three times per day 0.9% NaCl physiological saline while the and patients in Navax group
      received three times per day LiveSpo Navax in addition to the same standard of care
      treatment. The standard treatment regimen is 3-6 days but can be extended further depending
      on the severity of the patients' respiratory failure.

      Study Duration: 12 months
    

Detailed description: 
      Respiratory syncytial virus (RSV) is the most common virus that causes Acute Respiratory
      Tract Infections (ARTIs) in young children, with a high risk of serious bronchiolitis. RSV
      infection symptoms range from mild fever, cough, runny nose, and wheezing to severe symptoms
      such as difficulty breathing and respiratory failure. Cytokines in the airways of children
      with bronchiolitis, such as tumor necrosis factor (TNF-alpha), Interleukin-6 (IL-6) and IL-8,
      have been shown to increase at a very high level in primary RSV infection, and extreme
      elevation of IL-6 is associated with sudden death in children with RSV infection. The World
      Health Organization (WHO) estimates that 160,000-600,000 children under the age of five die
      or hospitalize each year as a result of RSV infection. There is currently no vaccine or
      specific treatment for RSV-infected children because monoclonal antibody palivizumab therapy
      and antiviral nucleotide drug ribavirin are either too expensive or too dangerous for
      children and are only recommended for high-risk patients.

      In recent years, preventive and supportive therapies for respiratory tract infection have
      grown in popularity, with probiotics emerging as promising safe candidates for therapeutic
      support and antibiotic reduction. It is suggested that probiotics can capture viruses through
      direct interactions, or produce secondary growths that inhibit virus growth or stimulate the
      immune system to capture virus intrusion. However, the efficacy of oral digested probiotics
      on children's respiratory tracts has been slow to develop (normally it takes about 3-12
      months) and is primarily used for prevention rather than supportive treatment of ARITs. As a
      result, alternative delivery routes for probiotics in the treatment of ARTIs are required.

      The aim of the study about to evaluate the effectiveness of nasal-spraying probiotics
      containing two bacterial strains, Bacillus subtilis and Bacillus clausii in preventing and in
      supporting the treatment of children having acute respiratory symptoms due to RSV infection.

      Methods: A randomized, blind, and controlled clinical trial are conducted. The patient's
      parents are required to provide the following information of their children: full name, sex,
      age, obstetric history, vaccination history, antibiotic use history… After informed consent,
      100 patients with ARTIs due to RSV will be randomized into 2 groups (n = 50/group): the
      control group (named "Control" group) use 0.9% NaCl physiological saline and an experimental
      group (named the "Navax" group) use the probiotics LiveSpo Navax. The patient is given a
      coded spray in the form of a blind sample to ensure the objectivity of the study. The
      clinical follow-up will be 6 days, nasopharyngeal samples will be collected at day 0 and day
      3 to evaluate potential reductions in viral load and co-infection bacteria, as well as
      modulation of overreacted cytokine release and the presence of probiotic spores in the
      patient's nasal mucosa.

      Real-time PCR for detection of microorganism in nasopharyngeal samples: semi-quantitative
      assays for measuring changes in RSV load and co-infection bacterial concentrations is
      conducted by the real-time RT-PCR/PCR routine protocol which has been standardized under ISO
      15189:2012 criteria and used in Vietnam National Children's Hospital. Detection of B.
      subtilis ANA4 and B. clausii ANA39 are also conducted by real-time PCR SYBR Green that has
      been standardized under ISO 17025: 2017 standard and routinely in the Key Laboratory of
      Enzyme and Protein Technology, VNU University of Science.

      ELISA assays for cytokine levels: pro-inflammatory cytokines levels (pg/mL) including
      interleukin (IL-6, IL-8) and TNF-alpha are quantified using an enzyme-linked immunosorbent
      assay kit (ELISA) according to the manufacturer's instructions.

      During treatment, patients are monitored daily for typical clinical symptoms of RSV-induced
      respiratory tract infections, including runny nose, chest depression, difficulty breathing,
      dry rales, moist rales, body temperature (oC), oxymetry (SpO2) (%), pulse (beats/min), and
      breath (beats/min) until discharged. The patients' health conditions are observed by doctors
      and nurses, and their pieces of information are filled in medical records. During this study,
      parents' patients are asked to abstain from consumption for their children of other
      probiotics, either via nasal spray or oral administration and refrain from cleaning nose for
      their children with other 0.9% NaCl physiological saline sprayers.

      Data collection and statistical analysis: individual medical records are collected, and the
      patient's information is then gathered and systematized in a data set. The efficacy of
      LiveSpo Navax is evaluated and compared to 0.9% NaCl physiological saline based on the
      following clinical and sub-clinical criteria obtained in Navax and Control groups: (i) the
      symptomatic-relieving day; (ii) the reduction levels (2^△Ct) of RSV load and co-infection
      bacteria concentrations. △Ct for target genes is calculated as Ct (threshold cycle) at day 3
      - Ct at day 0 while Ct of internal control is adjusted to be equal among all samples; (iii)
      the reduction levels of IL-6, IL-8, and TNF-alpha cytokines. The tabular analysis is
      performed on dichotomous variables using the χ2 test or Fisher's exact test when the expected
      value of any cell is below five. Continuous variables are compared using either the Wilcoxon
      test, t-test, or the Mann-Whitney test when data are not normally distributed. The
      correlations among the variables are assessed by Spearman's correlation analysis. Statistical
      and graphical analyses are performed on GraphPad Prism v8.4.3 software (GraphPad Software,
      CA, USA). The significance level of all analyzes is set at p < 0.05. P-values.

      Expected outcomes: (i) LiveSpo Navax alleviates RSV-infection symptoms about 25% more
      effectively, as indicated by 90% of patients using LiveSpo Navax (Navax group) are
      symptom-free at day 3-6 of intervention depending on symptoms, compared to 65% of patients in
      Control group; (ii) Patients in Navax group has more significant reductions in RSV load (>10
      fold) than patients in Control group at day 3 of intervention.
    

Intervention name(s): LiveSpo Navax; 0.9% NaCl physiological saline
Intervention type(s): Combination Product; Drug
Intervention description(s): In Vietnam, LiveSpo Navax is manufactured as a Class-A medical device product (Product declaration No.210001337/PCBA-HN) under manufacturing standards approved by Hanoi Health Department, Ministry of Health, Vietnam (Certificate No YT117-19) and ISO 13485:2016.; Nasal-spraying 0.9% NaCl physiological saline is prepared by extracting 5 mL from 0.9% NaCl intravenous infusion 500 mL PP bottle (B.Braun, Germany, product declaration No. VD-32732-19), and then pouring it into the same opaque plastic spraying 10 mL-bottle that is used for LiveSpo Navax.
Other intervention name(s): Registration number: No.210001337/PCBA-HN; Registration number: VD-32723-19
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: Blind, randomized, and controlled clinical trial
Masking: Triple (Participant, Care Provider, Investigator)
Primary purpose: Treatment
Keywords: Respiratory Syncytial Virus (RSV); Acute Respiratory Tract Infections (ARTIs); Children; Nasal-spraying probiotics; Viral load; Co-infection bacteria; Cytokines; Bacillus spores