Safety, tolerability, and immunogenicity of an oral inactivated ETEC vaccine (ETVAX®) with dmLT adjuvant in healthy adults and children in Zambia: An age descending randomised, placebo-controlled trial.

BACKGROUND: Enterotoxigenic Escherichia coli (ETEC) is an important cause of moderate to severe diarrhoea in children for which there is no licensed vaccine. We evaluated ETVAX®, an oral, inactivated ETEC vaccine containing four E. coli strains over-expressing the major colonization factors CFA/I, CS3, CS5, and CS6, a toxoid (LCTBA) and double mutant heat-labile enterotoxin (dmLT) adjuvant for safety, tolerability, and immunogenicity. METHODS: A double-blind, placebo-controlled, age-descending, dose-finding trial was undertaken in 40 adults, 60 children aged 10-23 months, and 146 aged 6-9 months. Adults received one full dose of ETVAX® and children received 3 doses of either 1/4 or 1/8 dose. Safety was evaluated as solicited and unsolicited events for 7 days following vaccination. Immunogenicity was assessed by evaluation of plasma IgA antibody responses to CFA/I, CS3, CS5, CS6, and LTB, and IgG responses to LTB. RESULTS: Solicited adverse events were mostly mild or moderate with only 2 severe fever reports which were unrelated to the vaccine. The most common events were abdominal pain in adults (26.7 % in vaccinees vs 20 % in placebos), and fever in children aged 6-9 months (44 % vs 54  %). Dosage, number of vaccinations and decreasing age had no influence on severity or frequency of adverse events. The vaccine induced plasma IgA and IgG responses against LTB in 100 % of the adults and 80-90 % of the children. In the 6-23 months cohort, IgA responses to more than 3 vaccine antigens after 3 doses determined as ≥2-fold rise was significantly higher for 1/4 dose compared to placebo (56.7 % vs 27.2 %, p = 0.01). In the 6-9 months cohort, responses to the 1/4 dose were significantly higher than 1/8 dose after 3 rather than 2 doses. CONCLUSION: ETVAX® was safe, tolerable, and immunogenic in Zambian adults and children. The 1/4 dose induced significantly stronger IgA responses and is recommended for evaluation of protection in children. CLINICAL TRIALS REGISTRATION: The trial is registered with the Pan African Clinical Trials Registry (PACTR Ref. 201905764389804) and a description of this clinical trial is available on: https://pactr.samrc.ac.za/Trial Design.

Spatiotemporal variation in risk of Shigella infection in childhood: a global risk mapping and prediction model using individual participant data.

BACKGROUND: Diarrhoeal disease is a leading cause of childhood illness and death globally, and Shigella is a major aetiological contributor for which a vaccine might soon be available. The primary objective of this study was to model the spatiotemporal variation in paediatric Shigella infection and map its predicted prevalence across low-income and middle-income countries (LMICs). METHODS: Individual participant data for Shigella positivity in stool samples were sourced from multiple LMIC-based studies of children aged 59 months or younger. Covariates included household-level and participant-level factors ascertained by study investigators and environmental and hydrometeorological variables extracted from various data products at georeferenced child locations. Multivariate models were fitted and prevalence predictions obtained by syndrome and age stratum. FINDINGS: 20 studies from 23 countries (including locations in Central America and South America, sub-Saharan Africa, and south and southeast Asia) contributed 66 563 sample results. Age, symptom status, and study design contributed most to model performance followed by temperature, wind speed, relative humidity, and soil moisture. Probability of Shigella infection exceeded 20% when both precipitation and soil moisture were above average and had a 43% peak in uncomplicated diarrhoea cases at 33°C temperatures, above which it decreased. Compared with unimproved sanitation, improved sanitation decreased the odds of Shigella infection by 19% (odds ratio [OR]=0·81 [95% CI 0·76-0·86]) and open defecation decreased them by 18% (OR=0·82 [0·76-0·88]). INTERPRETATION: The distribution of Shigella is more sensitive to climatological factors, such as temperature, than previously recognised. Conditions in much of sub-Saharan Africa are particularly propitious for Shigella transmission, although hotspots also occur in South America and Central America, the Ganges-Brahmaputra Delta, and the island of New Guinea. These findings can inform prioritisation of populations for future vaccine trials and campaigns. FUNDING: NASA, National Institutes of Health-The National Institute of Allergy and Infectious Diseases, and Bill & Melinda Gates Foundation.

Immunogenicity and waning immunity from the oral cholera vaccine (Shanchol™) in adults residing in Lukanga Swamps of Zambia.

INTRODUCTION: In cholera endemic areas, the periodicity of cholera outbreaks remains unpredictable, making it difficult to organize preventive efforts. Lack of data on duration of protection conferred by oral cholera vaccines further makes it difficult to determine when to deploy preemptive vaccination. We report on the immunogenicity and waning of immunity to Shanchol™ in Lukanga Swamps. METHODS: We enrolled a cohort of 223 participants aged between 18 and 65 years old from whom serum samples were collected at baseline, day 28 before administration of the second dose, and consecutively at 6, 12, 24, 30, 36, and 48 months. Vibriocidal antibody titres were measured and expressed as geometric mean titres. Box plots and 95% CI were computed at each visit for both Inaba and Ogawa. Seroconversion was defined as a four fold or greater increase in antibody titres compared to baseline titres. RESULTS: Overall, seroconversion against V. cholerae Inaba and Ogawa after 1st dose was 35/134 (26%) and 34/134 (25%) respectively. We observed a statistical difference in seroconversion between the two subgroups of baseline titres (low <80 and high ≥80) for both Inaba (p = 0.02) and Ogawa (p<0.0001). From a baseline of 13.58, anti-Ogawa GMT increased to 21.95 after the first dose, but rapidly waned to 14.52, 13.13, and 12.78 at months 6, 12 and 24 respectively, and then increased to 13.21, 18.67 and 23.65 at months 30, 36 and 48 respectively. A similar trend was observed for anti-Inaba GMT across the same time points. CONCLUSION: We found that Shanchol™ was immunogenic in our study population and that vibriocidal antibodies may not be a good marker for long-term immunity. The observed rise in titres after 36 months suggests natural exposure, and this may be a critical time window opening for natural transmission in an endemic areas. We recommend re-vaccination at this time point in high risk areas.

Effect of HIV status and retinol on immunogenicity to oral cholera vaccine in adult population living in an endemic area of Lukanga Swamps, Zambia.

BACKGROUND: We set out to assess the impact of human immunodeficiency virus (HIV) and micronutrient deficiency as indicated by serum retinol levels on the immune responses to Oral Cholera Vaccine (Shanchol™) in a cohort of participants in Lukanga Swamps, Zambia. Cholera remains endemic in Zambia with vaccines being the only effective preventive measures. However, the effect of these vaccines on populations living with HIV has not been widely documented. METHODS: HIV testing and confirmation was done using the Alere Determine™ HIV-1/2 and Uni-Gold™ kits while vibriocidal antibody assay was applied for vaccine immunogenicity. Serum retinol analysis was assessed by Shimadzu Prominence HCT-2010 High Performance Liquid Chromatography (HPLC). The primary outcome was log transformed geometric mean titre. RESULTS: From 47 participants screened for HIV, 51% (24) tested positive. There was a statistically significant reduction in Ogawa geometric mean ratio (GMR) by 67% (GMR = 0.33; 95% CI: -0.15, 0.76; p-value = 0.009) attributable to HIV positivity with a non-significant reduction in Inaba GMR by about 50% due to HIV positivity. When doubling of retinol levels modelled, GMR reduction against Ogawa were non-significant but that against Inaba resulted in a significant reduction in geometric mean titer (GMT) (GMT-0.33, C.I 0.16-0.66, p-value 0.002). At 1000copies/ml viral load cut off and 350 cells/µl CD4 counts, Ogawa GMT was two times higher 11.16 (95%CI: 8.20-15.19) versus 6.06 (95%CI: 4.04-9.10) in low viremia participants, and three times higher in above threshold CD4 count participants; 24.81 (95%CI: 18.94-32.50) versus 7.07 (95%CI: 5.22-9.58). CONCLUSION: Our results show that while Shanchol™ is immunogenic in both HIV+/- individuals, HIV + participants responded poorly. Viral load and CD4 count affected vaccine immunogenicity. More research is required for detailed understanding of this in order to appropriately inform policy and practice.

Comparing growth velocity of HIV exposed and non-exposed infants: An observational study of infants enrolled in a randomized control trial in Zambia.

BACKGROUND: Impaired growth among infants remains one of the leading nutrition problems globally. In this study, we aimed to compare the growth trajectory rate and evaluate growth trajectory characteristics among children, who are HIV exposed uninfected (HEU) and HIV unexposed uninfected (HUU), under two years in Zambia. METHOD: Our study used data from the ROVAS II study (PACTR201804003096919), an open-label randomized control trial of two verses three doses of live, attenuated, oral RotarixTM administered 6 &10 weeks or at 6 &10 weeks plus an additional dose at 9 months of age, conducted at George clinic in Lusaka, Zambia. Anthropometric measurements (height and weight) were collected on all scheduled and unscheduled visits. We defined linear growth velocity as the rate of change in height and estimated linear growth velocity as the first derivative of the mixed effect model with fractional polynomial transformations and, thereafter, used the second derivative test to determine the peak height and age at peak heigh. RESULTS: We included 212 infants in this study with median age 6 (IQR: 6-6) weeks of age. Of these 97 (45.3%) were female, 35 (16.4%) were stunted, and 59 (27.6%) were exposed to HIV at baseline. Growth velocity was consistently below the 3rd percentile of the WHO linear growth standard for HEU and HUU children. The peak height and age at peak height among HEU children were 74.7 cm (95% CI = 73.9-75.5) and 15.5 months (95% CI = 14.7-16.3) respectively and those for HUU were 73 cm (95% CI = 72.1-74.0) and 15.6 months (95% CI = 14.5-16.6) respectively. CONCLUSION: We found no difference in growth trajectories between infants who are HEU and HUU. However, the data suggests that poor linear growth is universal and profound in this cohort and may have already occurred in utero.

Bartonella diversity and zoonotic potential in indigenous Tete Veld rats (Aethomys ineptus) from South Africa.

Bartonellosis is a vector-borne disease that is often misdiagnosed due to a broad range of clinical symptoms, compounded by a lack of awareness regarding the prevalence, diversity and public health impacts of regional strains. Despite recent PCR-based confirmation of Bartonella in 9.7% of non-malarial, acute febrile patients in South Africa, data regarding reservoirs of infection are limited. As the majority of Bartonella species described to date are associated with rodent species globally, including zoonotic species such as B. elizabethae, and as rodent biodiversity is high in southern Africa, we evaluated Bartonella in the Tete Veld rat (Aethomys ineptus), a highly adaptable murid rodent that thrives in both natural and commensal settings. These rodents are infested with a broad range of ectoparasite species, and often occur in sympatry with Micaelamys namaquensis, an indigenous rodent previously shown to host B. elizabethae. DNA extracts from heart samples of 75 A. ineptus trapped over an eight-month period, from the Roodeplaat Nature Reserve (RNR), were evaluated using a multi-locus sequence analysis (MLSA) approach. Nucleotide sequencing and phylogenetic analyses of individual (gltA, ribC, rpoB and nuoG) and concatenated gene datasets confirmed the presence of three discrete Bartonella lineages (I-III). Lineages I and II, are genetically distinct from all currently recognised Bartonella species but cluster with strains present in other indigenous rodents from South and East Africa, whereas lineage III contained B. elizabethae, a zoonotic species associated with Rattus species globally. Records confirming R. tanezumi presence in this nature reserve, which is situated in close proximity to Pretoria, the administrative capital of South Africa, suggests the likelihood of spill-over from invasive to indigenous species. These results together with the high levels of infection (86.7%) and co-infection (33.8%), indicate that A. ineptus is a natural reservoir for multiple Bartonella species in South Africa, including one with zoonotic potential.

Bartonellae of Synanthropic Four-Striped Mice (Rhabdomys pumilio) from the Western Cape Province, South Africa.

Bartonella is a species-rich bacterial genus that infects a wide variety of wild and domestic animals, including rodents. Despite high levels of murid rodent diversity in Africa, associated Bartonella prevalence and diversity remains understudied, particularly within the southern African subregion. To address this, we sampled endemic four-striped mice, Rhabdomys pumilio, from three rural and two urban localities in the Western Cape Province, South Africa. PCR screening and multilocus sequence analysis inclusive of five genome regions (gltA, nuoG, ribC, rpoB, and ITS), were respectively used to evaluate Bartonella status and diversity in these synanthropic rodent populations. An overall infection rate of 15% was recovered, ranging from 0% for an urban locality to 36.4% for a rural locality, consistent with the higher flea abundance recorded at the latter sites. Nucleotide sequencing and phylogenetic analyses confirmed the presence of three distinct Bartonella lineages (I-III), with lineages II and III grouping with bartonellae previously detected in R. pumilio from nature reserves in the Free State Province of South Africa, and lineage I being novel and sister to Bartonella strains identified previously in Micaelamys namaquensis. Our results indicate significant landscape effects on infection rates, highlight differential PCR assay performance, and identify three host-associated Bartonella lineages in Rhabdomys from South Africa.

Molecular assessment of Bartonella in Gerbillus nanus from Saudi Arabia reveals high levels of prevalence, diversity and co-infection.

Bartonellae bacteria are associated with several re-emerging human diseases. These vector-borne pathogens have a global distribution, yet data on Bartonella prevalence and diversity in the Arabian Peninsula are limited. In this study we assessed the Bartonella infection status of the Baluchistan gerbil (Gerbillus nanus), a species associated with pastoral communities throughout the Middle East region, using a multi-gene PCR screening approach. The results demonstrated that 94 (68.1%) of the 138 gerbils trapped on a monthly basis, over a period of one year, were PCR-positive. Sequencing of the gltA gene region confirmed the presence of four discrete Bartonella lineages (I-IV) and high levels of co-infection (33.0%). Each of the four lineages, varied in overall abundance (7.5%-47.9%) and had discernible seasonal peaks. Bartonella status was significantly correlated with ectoparasite presence, but not with sex, nor with season. Statistical analyses further revealed that co-infected individuals had a significantly higher relative body condition. Multi-locus sequence analysis (MLSA) performed with a concatenated dataset of three genetic loci (gltA, nuoG, and rpoB), 1452 nucleotides (nt) in length confirmed that lineage IV, which occurred in 24 PCR-positive animals (25.5%), is most closely related to zoonotic B. elizabethae. The remaining three lineages (I-III) formed a monophyletic clade which, on the basis of gltA was shown to contain bartonellae from diverse Gerbillinae species from the Middle East, suggestive of a gerbil-associated species complex in this region. Lineage I was identical to a Candidatus B. sanaae strain identified previously in Bushy-tailed jirds (Sekeetamys calurus) from Egypt, wherease MLSA indicate that lineages II and III are novel. The high levels of infection and co-infection, together with the presence of multiple Bartonella lineages indicate that Gerbillus nanus is likely a natural reservoir of Bartonella in the Arabian Peninsula.