Controlled human malaria infection by intramuscular and direct venous inoculation of cryopreserved Plasmodium falciparum sporozoites in malaria-naïve volunteers: effect of injection volume and dose on infectivity rates

Gloria P Gómez-Pérez, Almudena Legarda, Jose Muñoz, B Kim Lee Sim, María Rosa Ballester, Carlota Dobaño, Gemma Moncunill, Joseph J Campo, Pau Cisteró, Alfons Jimenez, Diana Barrios, Benjamin Mordmüller, Josefina Pardos, Mireia Navarro, Cecilia Justino Zita, Carlos Arlindo Nhamuave, Alberto L García-Basteiro, Ariadna Sanz, Marta Aldea, Anita Manoj, Anusha Gunasekera, Peter F Billingsley, John J Aponte, Eric R James, Caterina Guinovart, Rosa M Antonijoan, Peter G Kremsner, Stephen L Hoffman, Pedro L Alonso, Gloria P Gómez-Pérez, Almudena Legarda, Jose Muñoz, B Kim Lee Sim, María Rosa Ballester, Carlota Dobaño, Gemma Moncunill, Joseph J Campo, Pau Cisteró, Alfons Jimenez, Diana Barrios, Benjamin Mordmüller, Josefina Pardos, Mireia Navarro, Cecilia Justino Zita, Carlos Arlindo Nhamuave, Alberto L García-Basteiro, Ariadna Sanz, Marta Aldea, Anita Manoj, Anusha Gunasekera, Peter F Billingsley, John J Aponte, Eric R James, Caterina Guinovart, Rosa M Antonijoan, Peter G Kremsner, Stephen L Hoffman, Pedro L Alonso

Abstract

Background: Controlled human malaria infection (CHMI) by mosquito bite is a powerful tool for evaluation of vaccines and drugs against Plasmodium falciparum malaria. However, only a small number of research centres have the facilities required to perform such studies. CHMI by needle and syringe could help to accelerate the development of anti-malaria interventions by enabling centres worldwide to employ CHMI.

Methods: An open-label CHMI study was performed with aseptic, purified, cryopreserved P. falciparum sporozoites (PfSPZ Challenge) in 36 malaria naïve volunteers. In part A, the effect of the inoculation volume was assessed: 18 participants were injected intramuscularly (IM) with a dose of 2,500 PfSPZ divided into two injections of 10 µL (n = 6), 50 µL (n = 6) or 250 µL (n = 6), respectively. In part B, the injection volume that resulted in highest infectivity rates in part A (10 µL) was used to formulate IM doses of 25,000 PfSPZ (n = 6) and 75,000 PfSPZ (n = 6) divided into two 10-µL injections. Results from a parallel trial led to the decision to add a positive control group (n = 6), each volunteer receiving 3,200 PfSPZ in a single 500-µL injection by direct venous inoculation (DVI).

Results: Four/six participants in the 10-µL group, 1/6 in the 50-µL group and 2/6 in the 250-µL group developed parasitaemia. Geometric mean (GM) pre-patent periods were 13.9, 14.0 and 15.0 days, respectively. Six/six (100%) participants developed parasitaemia in the 25,000 and 75,000 PfSPZ IM and 3,200 PfSPZ DVI groups. GM pre-patent periods were 12.2, 11.4 and 11.4 days, respectively. Injection of PfSPZ Challenge was well tolerated and safe in all groups.

Conclusions: IM injection of 75,000 PfSPZ and DVI injection of 3,200 PfSPZ resulted in infection rates and pre-patent periods comparable to the bite of five PfSPZ-infected mosquitoes. Remarkably, it required 23.4-fold more PfSPZ administered IM than DVI to achieve the same parasite kinetics. These results allow for translation of CHMI from research to routine use, and inoculation of PfSPZ by IM and DVI regimens.

Trial registration: ClinicalTrials.gov NCT01771848.

Figures

Fig. 1
Fig. 1
Flow chart of volunteer recruitment. This trial was divided in two parts. In part A the impact of volume of inoculation on infectivity rate and pre-patent period was tested by injecting the same dose of P. falciparum sporozoites (PfSPZ) in three different injection volumes. In part B, the volume that resulted in the highest infectivity rate was used for the formulation of two increased IM doses. A DVI group was included in part B to independently corroborate the results of the trial in Tübingen [18]. IM intramuscular, DVI direct venous inoculation, back up refers to the extra volunteers who were enrolled in each part of the study. Group 1: 2,500 PfSPZ in 10 μL; group 2: 2,500 PfSPZ in 50 μL; group 3: 2,500 PfSPZ in 250 μL; group 4: 3,200 PfSPZ in 500 μL; group 5: 25,000 PfSPZ in 10 μL; group 6: 75,000 PfSPZ in 10 μL.
Fig. 2
Fig. 2
Kaplan–Meier plot of time to infection. OM optic microscopy; group 1: 2,500 PfSPZ in 10 μL × 2 IM; group 2: 2,500 PfSPZ in 50 μL × 2 IM. Group 3: 2,500 PfSPZ in 250 μL × 2 IM; group 4: 3,200 PfSPZ in 500 μL × 1 DVI; group 5: 25,000 PfSPZ in 10 μL × 2 IM; group 6: 75,000 PfSPZ in 10 μL × 2 IM; PfSPZP. falciparum sporozoites, IM intramuscular injection, DVI direct venous inoculation.
Fig. 3
Fig. 3
Relationship between dose of PfSPZ Challenge and pre-patent period. Geometric means (horizontal bars) and 95% confidence intervals (vertical bars) for pre-patent periods. Individual pre-patent periods are shown.
Fig. 4
Fig. 4
Parasite kinetics measured by qPCR per group. Density units are parasites/mL; Limit of quantification of qPCR was 30 parasites per mL. Group 1: 2,500 PfSPZ in 10 μL × 2 IM; group 2: 2,500 PfSPZ in 50 μL × 2 IM. Group 3: 2,500 PfSPZ in 250 μL × 2 IM; group 4: 3,200 PfSPZ in 500 μL × 1 DVI; group 5: 25,000 PfSPZ in 10 μL × 2 IM; group 6: 75,000 PfSPZ in 10 μL × 2 IM; PfSPZPlasmodium falciparum sporozoites, IM intramuscular injection, DVI direct venous inoculation.

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