Development of a Live Attenuated Rotavirus Vaccine as a Human Infection Challenge Model
Condition: Diarrhoeal Disease
MeSH terms: Infections
Study type: Interventional

Summary: 
      The impact of licensed rotavirus vaccines in LMICs is limited by their lower immunogenicity
      and efficacy in these settings. Improved vaccines and vaccination schedules would result in
      substantially greater reductions in infant diarrhoeal disease and mortality.
      Placebo-controlled trials of new rotavirus vaccines are no longer ethical, leading to
      challenges for traditional routes of licensure for vaccines that are in the development
      pipeline.

      A HIC model of rotavirus would address these challenges, whilst also offering an opportunity
      to study the causes of poor oral vaccine immunogenicity. Rotarix™ is in routine use in Zambia
      administered at 6 and 10 weeks infant age. Shedding of rotavirus vaccine after vaccination
      has recently been explored as a measure of mucosal immunity, analogous to oral poliovirus
      vaccine challenge models.

      We propose to explore methodological development of an attenuated vaccine as a HIC model to
      advance rotavirus immunology and vaccinology in Zambian infants. We will evaluate use of
      minimally invasive procedures including sublingual/submandibular sampling and stool
      collection for viral shedding as measures of vaccine-induced and naturally acquired mucosal
      immunity. This approach holds the potential to develop the first rotavirus HIC model in a
      low-income country and could be used to accelerate licensure of new rotavirus vaccines and
      explore causes of poor oral vaccine efficacy as well as correlates of vaccine protection.

      To do this, we will recruit a cohort of 22 Zambian infants receiving Rotarix™ at 6 and 10
      weeks as part of their routine immunisation. Infants will be followed up actively on the day
      of vaccination, days 1,3,5 and 7 following each vaccine dose for collection of stool and
      saliva samples. Blood samples for IgA and IgG titres will be collected on days 0, 28, 31 and
      56, and standard ELISA methods used to determine vaccine seroconversion.

      The work brings together collaborators at the Centre for Infectious Disease Research in
      Zambia, Imperial College in UK and Christian Medical College, Vellore in India to prepare the
      Zambian centre as a potential HIC model site.
    

Detailed description: 
      Diarrhoeal disease is a leading cause of morbidity and mortality in young children,
      particularly those living in the developing countries of South Asia and sub-Saharan Africa1.
      Rotavirus is the most common causative agent of moderate to severe diarrhoea in children
      under age five, responsible for an estimated 215,000 infant deaths every year, most of which
      occur within lower and middle-income countries (LMICs)2. The widespread introduction of two
      World Health Organisation (WHO)-approved rotavirus vaccines , RotarixTM, (GlaxoSmithKline
      Biologicals, Belgium) and RotaTeq, (Merck and Co, New Jersey), has contributed substantially
      to reducing the number of rotavirus-associated hospitalisations and deaths3-18. However, even
      with these gains, rotavirus vaccines have repeatedly demonstrated lower immunogenicity,
      effectiveness, efficacy and duration of protection in children living in LMICs as compared to
      high-income countries19,20,21. Thus, even after the introduction of rotavirus vaccines (RV),
      rotavirus remains the leading cause of diarrhoeal morbidity and mortality within these
      settings. Improved RV would result in substantially greater reductions in diarrhoeal disease
      morbidity and mortality among infants; there is, therefore, an urgent need to understand the
      reduced performance of currently available live attenuated oral vaccines in LMICs, to inform
      and accelerate the development of maximally effective therapeutics.

      Recent studies have suggested that alternative schedules could also enhance immunogenicity
      and eventual vaccine performance in LMICs22,23. In addition, new RV candidates with
      alternative routes of administration are under development, and show promise for improved
      vaccine performance21,24,25. However, traditional pathways for licensure of new vaccines that
      are in the development pipeline through clinical trials have become challenging, with
      placebo-controlled trials no longer considered ethical, and field efficacy trials requiring
      increasingly larger cohorts to compare new candidates against existing vaccines. Human
      Infection Challenge (HIC) models have historically been employed to accelerate vaccine
      development and offer an opportunity to study both pathogenesis and vaccine immunogenicity
      mechanisms particularly in human-restricted pathogens. HIC models have not been widely used
      and accepted in LMICs even though there are scientific and ethical merits of considering the
      unique opportunity this methodology offers.

      We propose to explore the methodological development of an attenuated vaccine as a HIC model
      to advance rotavirus immunology and vaccinology in Zambian infants. We will also evaluate the
      use of minimally invasive procedures, including collection of saliva for antibody measurement
      and stool samples for vaccine virus shedding as measures of vaccine-induced mucosal immunity.

      Objective 1 To profile rotavirus specific IgA and IgG responses to vaccination and determine
      correlation between serum and saliva.

      Specific Objective 1a: To profile rotavirus specific IgA and IgG responses at baseline (Day
      0), pre-dose 2 (day 28) and 1 month post dose 2 (day 56) in serum and saliva to determine
      seropositivity and vaccine seroconversion.

      Objective 2 To profile cytokine immune responses and determine correlation between serum and
      saliva.

      Specific objective 2a: Determine cytokine profiles in serum and saliva at baseline (Day 0)
      and track their association with vaccine seroconversion (day 56).

      Specific objective 2b: To profile cytokine responses immediately before dose 2 vaccination
      (day 28), and at 3 days after administration of the second vaccine dose (day 31: rotavirus
      vaccine challenge).

      Objective 3: To assess the relationship of antibody levels in serum and saliva at the time of
      vaccination (day 0) and on days 28, 31, and 56, against faecal shedding of RV strain in stool
      collected and on days 3,5,7,14 and 21, and also on day 28 and post dose 2 vaccination days
      31, 33, 35, 42, 49 and 56.

      Objective 4: To profile and characterize the immediate cytokine immune response to the
      vaccine in saliva collected on day 0 and day 31, in order to determine whether saliva could
      serve as a satisfactory proxy for serum in evaluating vaccine-induced mucosal immunity.

      1. Methodology

        1. Study Design An exploratory and observational cohort study following infants receiving
           two standard doses of live, attenuated, oral Rotarix™ administered at 6 & 10 weeks.
           Infants will be enrolled during the routine EPI visit for week 6 immunizations following
           administration and provision of written informed consent by their mothers/legal
           guardians. Each infant will remain in the study for up to 56 days during which they will
           be intensively followed up with study activities and/or scheduled study clinic visits
           (summarized in Table 1 below).

        2. Study site and population The study will be conducted at George Clinic in Lusaka where
           the government maternal child health (MCH) and antiretroviral therapy (ART) clinics as
           well as the CIDRZ George Clinical Study Site are co-located. George Clinic has a
           catchment population of 145,23053 and is located in a typical peri-urban setting in
           Lusaka within a surrounding slum. We plan to recruit participants as they randomly
           attend the health facility. CIDRZ has a good research facility already existing at this
           clinic and below is a schematic image of the site plan.

        3. Selection of participants, sampling methods and sample size Sample size Considerations
           Participants will be randomly selected from mother-infant pairs attending routine
           antenatal care at George Clinic. As this will be an exploratory and methodological
           development study, no formal sample size calculations have been undertaken. We have
           pragmatically decided to enroll 20 infants which is generally acceptable for phase
           I-type studies. In case of an estimated 10% attrition due to loss to follow up, we have
           adjusted the sample to recruit 22 infants.
    

Intervention name(s): Rotavirus vaccine
Intervention type(s): Biological
Intervention description(s): An exploratory and observational cohort study following infants receiving two standard doses of live, attenuated, oral Rotarix™ administered at 6 & 10 weeks.
Intervention model: Single Group Assignment
Masking: None (Open Label)
Primary purpose: Prevention