Using BCG to Protect Senior Citizens During the COVID-19 Pandemic
Condition: Covid19; Non-specific Effects of Vaccines; Heterologous Immunity; Morbidity; Immunosenescence; Vaccine Preventable Disease
MeSH terms: COVID-19; Vaccine-Preventable Diseases
Study type: Interventional
Phase: Phase 3

Summary: 
      Background: The virus SARS-CoV-2 has spread rapidly throughout the world. Seniors are at high
      risk of severe COVID-19 when infected. Bacille Calmette-Guérin (BCG) is a vaccine against
      tuberculosis, with protective non-specific effects against other infections; significant
      reductions in morbidity and mortality have been reported, and a plausible immunological
      mechanism has been identified: "trained innate immunity". The investigators hypothesize that
      BCG vaccination can reduce the risk of COVID-19 and other infections among senior citizens
      during the COVID-19 pandemic.

      Objectives: Primary objective: To reduce senior citizens' risk of acute infection during the
      COVID-19 pandemic. Secondary objectives: To reduce senior citizens' risk of SARS-CoV-2
      infection during the COVID-19 pandemic. To reduce senior citizens' risk of self-reported
      respiratory illness during the COVID-19 pandemic.

      Study design: A placebo-controlled randomized trial. Study population: 1900 seniors 65 years
      of age or above. Intervention: Participants will be randomized 1:1 to intradermal
      administration of a standard dose of BCG vaccine or placebo (saline).

      Outcomes: Primary outcome: "Acute infection" identified either by a doctor, antibiotics use,
      hospitalization, or death due to infection. Secondary outcomes: Verified SARS-CoV-2 infection
      and self-reported respiratory illness.

      With an expected incidence of "acute infection" of 20%, the trial can show a 25% risk
      reduction in the the intervention group versus the placebo group by including a total of 1900
      individuals, 950 individuals in each group.

      Risk for participants and impact: Based on previous experience and randomized controlled
      trials in adult and elderly individuals, the risks of BCG vaccination are considered low. If
      BCG can reduce the risk of acute infection in seniors by 25% it has tremendous public health
      importance, both during the COVID-19 pandemic and overall.
    

Detailed description: 
      INTRODUCTION One of the most recognized consequences of aging is a decline in immune
      function, so-called "immunosenescence". Vaccination is the most effective prophylactic
      intervention for infectious diseases, but due to immunosenescence, the efficacy of vaccines
      decreases with increasing age.

      Due to immunosenescence, severe infections are more common in the elderly. Not least during
      the COVID-19 pandemic, it has become clear that elderly people are particularly susceptible
      to severe COVID-19. Strategies to strengthen senior citizens' immune system are urgently
      warranted.

      Bacillus Calmette-Guérin (BCG) was developed as a childhood vaccine against tuberculosis, but
      our group has shown that it can protect against death from other infections, i.e. it has what
      the investigators have called non-specific effects (NSEs). In clinical studies, BCG
      vaccination was associated with decreased child mortality, mainly as a result of reduced
      neonatal sepsis and respiratory infections. In a meta-analysis commissioned by the World
      Health Organization (WHO), BCG was associated with a 42% (95%CI: 24-55%) reduction in child
      mortality.

      NSEs of BCG are not limited to children. An Indonesian trial with 34 subjects aged 60-75
      years reported that compared with placebo, consecutive BCG vaccination for 3 months reduced
      the incidence of acute upper respiratory tract infections by 80% (95% confidence interval
      (CI)=22-95%). In a very recent clinical trial in Greece, BCG vs. placebo to senior citizens
      at discharge from the hospital was associated with a significant decrease in time to first
      infection (p: 0.035). The incidence of new infections was 42.3% (99% CIs 31.9 53.4%) in the
      placebo group and 25.0% (95% CIs (16.4-36.16%) in the BCG group; most of the protection was
      against respiratory tract infections (odds ratio 0.20; p: 0.001). No difference in the
      frequency of adverse effects was found between groups. These data show that BCG vaccination
      is safe and can protect the elderly against infections.

      Immunological studies have now provided an explanation for the observed NSEs of BCG: BCG
      induces epigenetic and metabolic reprogramming of innate immune cells such as myeloid cells
      and Natural Killer cells, leading to an increased antimicrobial activity, a process termed
      'trained immunity'.

      In a pilot study the investigators recently investigated whether BCG could induce innate
      immune training in seniors above 50 years of age in Guinea-Bissau. Two months after
      vaccination, BCG recipients had increased release of the pro-inflammatory innate cytokines
      interleukin (IL)-1β, IL-6 and TNF-α to non-specific stimuli. These effects were more
      pronounced among those with a positive Quantiferon test at baseline. Thus, BCG vaccination
      can induce a 'trained immunity' phenotype in older adults. including previously Mycobacterium
      tuberculosis exposed individuals.

      Currently, numerous clinical trials are investigating the effect of BCG as a prophylactic
      treatment for health care workers of all ages. No results of these trials are available yet,
      but ecological analyses have suggested that countries with a functioning BCG vaccination
      program have lower COVID-19 mortality. Furthermore, in a very recent follow-up study of three
      cohorts of healthy volunteers who either received BCG in the last five years or not, BCG
      vaccination was safe and not associated with increased incidence of symptoms during the
      COVID-19 outbreak in the Netherlands. In fact, BCG vaccination was associated with a decrease
      in the incidence of sickness during the COVID-19 pandemic (adjusted odds ratio 0.58, P <
      0.05).

      The investigators hypothesize that BCG vaccination may strengthen the immune system of the
      senior citizens and may (partially) protect against getting infected and/or experiencing
      severe morbidity due to infections with SARS-CoV-2 and other infectious pathogens.

      OBJECTIVES Primary objective: To reduce senior citizens' risk of acute infection during the
      COVID-19 pandemic. Secondary objectives: To reduce senior citizens' risk of SARS-CoV-2
      infection during the COVID-19 pandemic. To reduce senior citizens' risk of self-reported
      respiratory illness during the COVID-19 pandemic.

      HYPOTHESIS BCG vaccination of seniors will reduce the risk of acute infection by 25% over a
      period of 12 months.

      PROJECT GROUP Christine Stabell Benn (MD, DMSc), Peter Aaby (DMSc), Anne Marie Rosendahl
      Madsen (MD, PhD student), Mette Bliddal (PhD), Sebastian Nielsen (MSc, statistician), and
      Frederik Schaltz-Buchholzer (MD, PhD), all from University of Southern Denmark. Lene Annette
      Norberg (MD, PhD) and Anne Grete Pilgaard from Municipality of Odense. Mihai Netea (MD,
      DMSc), Radboud Medical Centre, Nijmegen, The Netherlands. Tyra Grove Krause (MD, PhD),
      Statens Serum Institut.

      METHODS Study design and follow-up A randomized placebo-controlled clinical trial.
      Participants will be followed for 12 months post-randomization with respect to illness,
      medical contacts, use of antibiotics, hospitalization and death. The follow-up will take
      place both through self-reporting, and through the Danish National Registers. Information on
      hospitalizations for infections and other medical conditions will be obtained through
      Denmark's National Patient Register and information on use of antibiotics from the Danish
      Prescription Register. Vaccination history will be acquired from the Danish Vaccination
      Registry at Statens Serum Institut. Furthermore, data on testing for SARS-CoV-2 and results
      will be obtained via the local department of clinical microbiology.

      Since the Investigational Medicinal Product (IMP), the BCG vaccine, is used in this study on
      another indication than the one it has been approved for, this is classified as a phase III
      study.

      Participants will be randomized 1:1 to receiving an intradermal BCG vaccine or placebo.
      Participants who are randomized in the active arm will receive a BCG vaccine (BCG-Denmark, AJ
      Vaccines, http://www.produktresume.dk/AppBuilder/login.html). The BCG vaccines will be
      handled in full compliance with the requirements of the Summary of Product Characteristics
      (SPC). Placebo will be 0.1 ml sterile 0.9 % NaCl, which has a similar color as the
      resuspended BCG vaccine.

      All participants will receive one injection at inclusion. No further treatment of study
      participants will take place. BCG will be administered in the upper arm, intradermally, 0.1
      ml of the suspended vaccine. Placebo will be administered in the upper arm, intradermally,
      0.1 ml of sterile 0.9 % NaCl solution.

      STUDY PROCEDURES The trial will be presented at information meetings and in relevant media,
      local newspapers and homepages and newsletters of the activity houses.

      Citizens wishing to participate will be given written information and will be booked for an
      interview.

      Day of inclusion (day 0) Study physicians, who are trained in good clinical practice and in
      providing intradermal vaccines, will be responsible for the inclusion of study participants.
      Informed consent will be obtained from all participants. Background information on
      participants will be collected in an electronic case report form system (REDCap). A blood
      sample of 5 ml will be drawn for subsequent testing for SARS-CoV-2 antibodies.

      Randomization and blinding The study will be individually randomized, and placebo controlled.
      Randomization will be done using the REDCap tool with stratification per sex and age groups
      (65-74/75+ years of age) in randomly selected block sizes of 4 and 6.

      The participant will be blinded to the treatment.

      Day of inclusion till end of trial A short electronic questionnaire regarding health,
      symptoms and potential side effects will be sent to the participants biweekly.

      End of trial Participants are asked to fill in a final questionnaire. A blood sample of 5 ml
      will be drawn for subsequent testing for SARS-CoV-2 antibodies.

      The end of the trial is defined as whichever comes latest: The last participants last
      registration in the online data collection, or 365 days. When the study is ended, all
      participants receive an email with information about the intervention that they have received
      (BCG/placebo).

      STATISTICAL ANALYSIS The primary endpoint "acute infection" will be analyzed as a recurrent
      time-to-event using an Andersen-Gill Cox proportional hazards regression model with time
      since inclusion as underlying time scale. Analyses will be done stratified by the block
      randomization variables sex and age group.

      The secondary endpoint self-reported respiratory illness will be analyzed the same way as the
      primary endpoint. The other secondary outcome verified SARS-CoV-2 infection will be analyzed
      in a standard Cox proportional hazards model, but otherwise as described above.

      When applicable (i.e. in the event that one or more participants have died during the
      follow-up period) a competing events analysis will be performed in addition (Fine-Gray
      model).

      SAMPLE SIZE CALCULATION With an expected incidence of "acute infection" of 20% the trial can
      show a 25% reduction in the risk of acute infection in the intervention group versus the
      placebo group by including a total of 1890 individuals, 945 individuals in each group.
    

Intervention name(s): BCG-Denmark; Saline
Intervention type(s): Biological; Biological
Intervention description(s): Mycobacterium bovis BCG live attenuated BCG-Denmark vaccine (AJ Vaccines, Copenhagen, Denmark) administered by intradermal injection in the left deltoid region.; Participants randomized to the control group will receive one 0.1 ml dose sterile 0.9 % NaCl by intradermal injection in the left deltoid region.
Other intervention name(s): BCG-1331; BCG-AJ; BCG-SSI; NaCl
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: Placebo-controlled randomized trial.
Masking: Double (Participant, Outcomes Assessor)
Primary purpose: Prevention