Efficacy and safety of the RTS,S/AS01 malaria vaccine during 18 months after vaccination: a phase 3 randomized, controlled trial in children and young infants at 11 African sites
RTS,S Clinical Trials Partnership, Selidji Todagbe Agnandji, Bertrand Lell, José Francisco Fernandes, Béatrice Peggy Abossolo, Anita Lumeka Kabwende, Ayola Akim Adegnika, Benjamin Mordmüller, Saadou Issifou, Peter Gottfried Kremsner, Marguerite Massinga Loembe, Jahit Sacarlal, Pedro Aide, Lola Madrid, Miguel Lanaspa, Sofia Mandjate, John J Aponte, Helder Bulo, Abel Nhama, Eusébio Macete, Pedro Alonso, Salim Abdulla, Nahya Salim, Ali Takadir Mtoro, Paul Mutani, Marcel Tanner, Caroline Mavere, Grace Mwangoka, Omar Lweno, Omar Ali Juma, Seif Shekalaghe, Halidou Tinto, Umberto D'Alessandro, Hermann Sorgho, Innocent Valea, Jean Bosco Ouédraogo, Palpouguini Lompo, Salou Diallo, Ousmane Traore, Armand Bassole, Edgard Dao, Mary J Hamel, Simon Kariuki, Martina Oneko, Chris Odero, Kephas Otieno, Norbert Awino, Vincent Muturi-Kioi, Jackton Omoto, Kayla F Laserson, Laurence Slutsker, Walter Otieno, Lucas Otieno, Nekoye Otsyula, Stacey Gondi, Allan Otieno, Bernhards Ogutu, Jew Ochola, Irene Onyango, Janet Oyieko, Patricia Njuguna, Roma Chilengi, Pauline Akoo, Christine Kerubo, Charity Maingi, Ally Olotu, Philip Bejon, Kevin Marsh, Gabriel Mwabingu, Jesse Gitaka, Seth Owusu-Agyei, Kwaku Poku Asante, Owusu Boahen, David Dosoo, George Adjei, Elisha Adeniji, Abena Kunadu Yawson, Kingsley Kayan, Daniel Chandramohan, Brian Greenwood, John Lusingu, Samwel Gesase, Anangisye Malabeja, Omari Abdul, Coline Mahende, Edwin Liheluka, Martha Lemnge, Thor G Theander, Chris Drakeley, Joyce Mbwana, Daniel Ansong, Tsiri Agbenyega, Samuel Adjei, Harry Owusu Boateng, Theresa Rettig, John Bawa, Justice Sylverken, David Sambian, Anima Sarfo, Alex Agyekum, Francis Martinson, Irving Hoffman, Tisungane Mvalo, Portia Kamthunzi, Rutendo Nkomo, Tapiwa Tembo, Gerald Tegha Mercy Tsidya, Jane Kilembe, Chimwemwe Chawinga, W Ripley Ballou, Joe Cohen, Yolanda Guerra, Erik Jongert, Didier Lapierre, Amanda Leach, Marc Lievens, Opokua Ofori-Anyinam, Aurélie Olivier, Johan Vekemans, David Kaslow, Didier Leboulleux, Barbara Savarese, David Schellenberg, RTS,S Clinical Trials Partnership, Selidji Todagbe Agnandji, Bertrand Lell, José Francisco Fernandes, Béatrice Peggy Abossolo, Anita Lumeka Kabwende, Ayola Akim Adegnika, Benjamin Mordmüller, Saadou Issifou, Peter Gottfried Kremsner, Marguerite Massinga Loembe, Jahit Sacarlal, Pedro Aide, Lola Madrid, Miguel Lanaspa, Sofia Mandjate, John J Aponte, Helder Bulo, Abel Nhama, Eusébio Macete, Pedro Alonso, Salim Abdulla, Nahya Salim, Ali Takadir Mtoro, Paul Mutani, Marcel Tanner, Caroline Mavere, Grace Mwangoka, Omar Lweno, Omar Ali Juma, Seif Shekalaghe, Halidou Tinto, Umberto D'Alessandro, Hermann Sorgho, Innocent Valea, Jean Bosco Ouédraogo, Palpouguini Lompo, Salou Diallo, Ousmane Traore, Armand Bassole, Edgard Dao, Mary J Hamel, Simon Kariuki, Martina Oneko, Chris Odero, Kephas Otieno, Norbert Awino, Vincent Muturi-Kioi, Jackton Omoto, Kayla F Laserson, Laurence Slutsker, Walter Otieno, Lucas Otieno, Nekoye Otsyula, Stacey Gondi, Allan Otieno, Bernhards Ogutu, Jew Ochola, Irene Onyango, Janet Oyieko, Patricia Njuguna, Roma Chilengi, Pauline Akoo, Christine Kerubo, Charity Maingi, Ally Olotu, Philip Bejon, Kevin Marsh, Gabriel Mwabingu, Jesse Gitaka, Seth Owusu-Agyei, Kwaku Poku Asante, Owusu Boahen, David Dosoo, George Adjei, Elisha Adeniji, Abena Kunadu Yawson, Kingsley Kayan, Daniel Chandramohan, Brian Greenwood, John Lusingu, Samwel Gesase, Anangisye Malabeja, Omari Abdul, Coline Mahende, Edwin Liheluka, Martha Lemnge, Thor G Theander, Chris Drakeley, Joyce Mbwana, Daniel Ansong, Tsiri Agbenyega, Samuel Adjei, Harry Owusu Boateng, Theresa Rettig, John Bawa, Justice Sylverken, David Sambian, Anima Sarfo, Alex Agyekum, Francis Martinson, Irving Hoffman, Tisungane Mvalo, Portia Kamthunzi, Rutendo Nkomo, Tapiwa Tembo, Gerald Tegha Mercy Tsidya, Jane Kilembe, Chimwemwe Chawinga, W Ripley Ballou, Joe Cohen, Yolanda Guerra, Erik Jongert, Didier Lapierre, Amanda Leach, Marc Lievens, Opokua Ofori-Anyinam, Aurélie Olivier, Johan Vekemans, David Kaslow, Didier Leboulleux, Barbara Savarese, David Schellenberg
Abstract
Background: A malaria vaccine could be an important addition to current control strategies. We report the safety and vaccine efficacy (VE) of the RTS,S/AS01 vaccine during 18 mo following vaccination at 11 African sites with varying malaria transmission.
Methods and findings: 6,537 infants aged 6-12 wk and 8,923 children aged 5-17 mo were randomized to receive three doses of RTS,S/AS01 or comparator vaccine. VE against clinical malaria in children during the 18 mo after vaccine dose 3 (per protocol) was 46% (95% CI 42% to 50%) (range 40% to 77%; VE, p<0.01 across all sites). VE during the 20 mo after vaccine dose 1 (intention to treat [ITT]) was 45% (95% CI 41% to 49%). VE against severe malaria, malaria hospitalization, and all-cause hospitalization was 34% (95% CI 15% to 48%), 41% (95% CI 30% to 50%), and 19% (95% CI 11% to 27%), respectively (ITT). VE against clinical malaria in infants was 27% (95% CI 20% to 32%, per protocol; 27% [95% CI 21% to 33%], ITT), with no significant protection against severe malaria, malaria hospitalization, or all-cause hospitalization. Post-vaccination anti-circumsporozoite antibody geometric mean titer varied from 348 to 787 EU/ml across sites in children and from 117 to 335 EU/ml in infants (per protocol). VE waned over time in both age categories (Schoenfeld residuals p<0.001). The number of clinical and severe malaria cases averted per 1,000 children vaccinated ranged across sites from 37 to 2,365 and from -1 to 49, respectively; corresponding ranges among infants were -10 to 1,402 and -13 to 37, respectively (ITT). Meningitis was reported as a serious adverse event in 16/5,949 and 1/2,974 children and in 9/4,358 and 3/2,179 infants in the RTS,S/AS01 and control groups, respectively.
Conclusions: RTS,S/AS01 prevented many cases of clinical and severe malaria over the 18 mo after vaccine dose 3, with the highest impact in areas with the greatest malaria incidence. VE was higher in children than in infants, but even at modest levels of VE, the number of malaria cases averted was substantial. RTS,S/AS01 could be an important addition to current malaria control in Africa.
Trial registration: www.ClinicalTrials.gov NCT00866619 Please see later in the article for the Editors' Summary.
Conflict of interest statement
The trial was sponsored by GlaxoSmithKline Biologicals SA (GSK), the vaccine developer and manufacturer, and funded by both GSK Biologicals SA and the PATH Malaria Vaccine Initiative (MVI). All centers declare receiving a grant from MVI for running the trial. Author travel and accommodation related to this trial were financed by MVI. GlaxoSmithKline Biologicals SA received a grant from MVI to run the trial. MVI received a grant from the Bill & Melinda Gates Foundation to run this trial and to compensate MVI authors for trial-related travel. Additional conflicts of interest are as follows: JJA and PAl declare that their institutions received grant from the Catalan government and from the International Agency for Development and Cooperation. NA, CO, and KO declare that their institutions received a grant from the Malaria Clinical Trial Alliance. PB, SD, BG, CK, PL, CMai, GMwam, BO, and LO declare that their institution has received grants from MVI for other malaria studies. KM declares that his institution received a grant from the Wellcome Trust and that he received support from USAID and the Bill & Melinda Gates Foundation to participate in a scientific advisory group on malaria. MML declares that she received non-financial support from the WHO and the Biomérieux Foundation. PN declares that she received financial support from GSK to present the results of the study at ASTMH congress in 2012. LO declares that he received support from GSK to carry out clinical and epidemiological studies. JSa has received (for the Center) some GlaxoSmithKline group of companies' consultancy fees for other studies. MTa is a board member of the Optimus Foundation, and his institution is reimbursed for his activities on the scientific advisory board of the Novartis Institute for Tropical Diseases. He also has received for his institution other grants from MVI and from the Bill & Melinda Gates Foundation, and travel reimbursements from MVI and Sanaria corp. All GSK Vaccines authors are, or were at the time of the study, employed by the GlaxoSmithKline group of companies. JC now works as an independent consultant for GSK Vaccines. WRB, JC, EJ, DLa, OOA, JV, AL, and MLi have shares/stock options in the GlaxoSmithKline group of companies. JC and WRB declare that they are named inventors on patents for which the rights have been assigned to GlaxoSmithKline group of companies. DK, DLe, and BS are employees at PATH-MVI. DSc is employed by the London School of Hygiene & Tropical Medicine, and his consultancy activities for MVI are funded as a grant to the LSHTM by MVI. DK holds stock or stock options from Merck, Sharpe & Dome.
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