Pharmaceuticals 2010, 3, 1122-1138; doi:10.3390/ph3041122 OPEN ACCESS ISSN 1424-8247 Review The Impact of CYP2D6 Genotyping on Tamoxifen Treatment Roberta Ferraldeschi 1,2 and William G. Newman 2,* 1 Department of Medical Oncology, Christie Hospital NHS Trust, Wilmslow Road, Manchester M20
Doi:10.1016/s0140-6736(04)15267-7Malaria vaccine developments Vasee S Moorthy, Michael F Good, Adrian V S Hill Large gains in the reduction of malaria mortality in the early 20th century were lost in subsequent decades. Malaria nowkills 2–3 million people yearly. Implementation of malaria control technologies such as insecticide-treated bednets andchemotherapy could reduce mortality substantially, but an effective malaria vaccine is also needed. Advances invaccine technology and immunology are being used to develop malaria subunit vaccines. Novel approaches that mightyield effective vaccines for other diseases are being evaluated first in malaria. We describe progress in malaria vaccinedevelopment in the past 5 years: reasons for cautious optimism, the type of vaccine that might realistically beexpected, and how the process could be hastened. Although exact predictions are not possible, if sufficient fundingwere mobilised, a deployable, effective malaria vaccine is a realistic medium-term to long-term goal.
In 1955, a book entitled Man's Mastery of Malaria1 We summarise the life cycle of malaria, describe the reflected the generally held views of that time. Half a differences between naturally acquired and vaccine century later, malaria kills 2–3 million people a year.2 Most induced immunity, discuss the relevance of the of these deaths are in children younger than 5 years living elucidation of the Plasmodium falciparum in sub-Saharan Africa; one African child dies from malaria sequence14 to vaccine development, and highlight some every 30 seconds.3 Rarely has scientific optimism been so vaccine candidates that have reached clinical evaluation. misplaced. With the advent of resistance to chloroquineand dichlorodiphenyltrichloroethane (DDT), malaria re- emerged in many parts of the world. In recent years, the Which statement speaks to your instinct: Plutarch's burden of disease and death has increased substantially in "history repeats itself" or Robert Walpole's "anything but malaria-endemic countries,4 and transmission has spread history, for history must be false"? Your answer could to new areas.5 The major causes of this resurgence are the determine your level of optimism in malaria vaccine development of resistance to affordable drugs6 and development. 1973 saw the first report of human deterioration of national control pro- protection from malaria by vaccination.15 However, the grammes,8 increasing human migration,9 and tourism.10 vaccination consisted of the bites of about a thousand The rise in malaria deaths contrasts with falls in all-cause mosquitoes infected with malaria parasites that had been mortality in children in many developing countries.11 Since X irradiated.16 This demonstration was obviously unlikely economic prospects for countries in which malaria is to be a practical means of mass vaccination. For about endemic are closely linked to the disease burden, a strong
20 years, progress occurred mainly in experimental economic and political case can be made for increasing models rather than in human vaccine trials.17,18 Much funding for interventions.12 speculation and excitement was generated by the Spf66 The WHO Roll Back Malaria programme is candidate vaccine, despite uncertainty about how such a coordinating improved case management, insecticide- construct could work. Eventually, phase III trials showed treated bednets, and other control measures for reduction that Spf66 lacked efficacy.19–23 During the past 5 years, of malaria mortality. Malaria drug development is a many candidate vaccine approaches have been tested in research priority. Vaccine development is only one aspect clinical trials (table).24 Many potential candidate vaccines of efforts to control malaria, but an effective vaccine now warrant preclinical assessment.
should transform prospects for reducing the burden of thisdisease. There are three intermediate goals of vaccine The life cycle of P falciparum
research: induction of strong, strain-transcending, durable A female anopheline mosquito requires a blood meal for immune responses;13 identification of protective antigens egg production (figure 1). During such a meal, a mosquito for stage-specific immunity; and successful combination of infected with P falciparum will inject five to candidate immunogens. Worldwide funding for malaria 20 sporozoites,25,26 which invade hepatocytes within vaccines has increased recently from below US$50 million minutes. Sporozoites migrate through several hepatocytes to around $60–70 million, but remains an order of before entering one; this is the start of the liver stage.27,28 magnitude below that for HIV vaccine development.
The sporozoite and liver stages are the pre-erythrocytic Nonetheless, substantial advances have been made in parts of the life cycle. Over an average of 6·5 days, Lancet 2004; 363: 150–56 We searched PubMed using the phrase "malaria and vaccine"with a limit for clinical trials. We also searched for papers that MRC Laboratories, Banjul, The Gambia (V S Moorthy MRCP); Nuffield detailed antigen characterisation or vaccine platform Department of Clinical Medicine, University of Oxford, John evaluation by use of in-vitro assays and animal models. The Radcliffe Hospital, Oxford, UK (V S Moorthy, Prof A V S Hill DM); phrase for the second search was "malaria vaccines[MeSH]".
The Cooperative Research Centre for Vaccine Technology, We reviewed all abstracts and selected relevant articles. We Queensland Institute of Medical Research, Brisbane, Australia (Prof M F Good also identified relevant articles from the reference lists in articles from these two searches. Searches were done in Correspondence to: Dr Vasee S Moorthy, Malaria Vaccine Initiative, November, 2002, and May, 2003. We did not restrict the 6290 Montrose Road, Rockville, MD 20852, USA search by language or date.
THE LANCET • Vol 363 • January 10, 2004 • www.thelancet.com For personal use. Only reproduce with permission from The Lancet.
Group (field collaboration) Apovia, USA; New York University, USA ICC-1132 (protein) GlaxoSmithKline Biologicals, Belgium; and WRAIR, USA (Medical Research Council [MRC] Laboratories, The Gambia; Centro de Investigacao em Saude de Manhica [CISM], Mozambique)Malaria Vaccine Development Unit, National Institutes Of Health, USA Pvs25, AMA-1 (protein) Transmission blocking,blood stage Naval Medical Research Center (NMRC), USA; Vical, USA Pf-CS, Pf-SSP2/TRAP, Pf-LSA-1, Pf-EXP-1, Pf-LSA-3 (DNA vaccines) New York University, USA CS (synthetic polymers, MAPs, polyoximes) Oxford University, UK (MRC Laboratories, The Gambia; Wellcome-Kenya Medical Research DNA ME-TRAP, MVA ME-TRAP, Institute [KEMRI] collaboration, Kilifi, Kenya) FP9 ME-TRAP, MVA-CS (DNA and recombinant viral) Statens Serum Institut (SSI), Copenhagen; Institut Pasteur; Institute of Lausanne, Switzerland GLURP, MSP-3, CS (synthetic Pre-erythrocytic, Walter and Eliza Hall Institute of Medical Research, Melbourne; Queensland Institute of Medical MSP-1, MSP-2, RESA (protein) Research (QIMR), Brisbane; Swiss Tropical Institute; Biotech Australia Pty (Papua New Guinea Institute Of Medical Research)Walter Reed Army Institute of Research (WRAIR), USA (KEMRI, Kisumu, Kenya) EXP=exported protein. LSA=liver stage antigen. MAP=multiple antigen peptide. Pvs=Plasmodium vivax surface protein. AMA-1=apical membrane antigen-1. RESA=ringinfected erythrocyte surface antigen. SSP2 and TRAP are synonyms: sporozoite surface protein 2 and thrombospondin-related adhesion protein. Only vaccines beingtested in clinical trials as of May, 2003, are listed. Field collaborations are only listed if field trials of the candidate had begun as of May, 2003.
Candidate malaria vaccines in clinical trials parasites develop within the liver into schizonts. The erythrocyte, and starts a 48-h cycle of replication.
schizonts rupture, releasing 20 000–30 000 merozoites Replication is followed by schizont rupture and invasion per original sporozoite into the hepatic venous circulation, of new red blood cells—the blood stage of malaria. The from where they disseminate systemically. Each merozoite blood stage culminates either in death of the human host that is not picked up by phagocytic cells invades an or control by the immune system. Some merozoites differentiate into male or femalegametocytes, which can be ingestedby an anopheline mosquito.
Sporozoites are injected when infected Fertilisation occurs within the mosquito takes second blood meal mosquito midgut, leading tocompletion of the life cycle, withsporozoites migrating to the salivaryglands, and becoming infective.
Gametocytes are ingestedwhen mosquito takes Subunit vaccination Sporozoites enter The production of live, attenuated, or killed inactivated vaccines is notpractical for many diseases. In subunitvaccination, part or complete antigensare identified from a pathogen's proteomic complement, which can induce protective immunity to thewhole pathogen on vaccination. Thehepatitis B vaccine is an effectiverecombinant protein subunit vaccine.29This vaccine was designed to induce the maximum antibody (humoral)immune response. Unfortunately, proteins vary greatly in their immunogenicity. Moreover,induced antibodies must have thecorrect avidity (ability to bind), Infected livercell ruptures, specificity, biological activity, and be produced at a high enough titre to block infection. Increased under- standing of antigen processing, adjuvants, and their effects on innateimmunity, genetic engineering tech- niques, and novel delivery systems are gradually increasing antibody immunogenicity. Insufficient duration of induced immune responses remains Figure 1: Vaccines by life-cycle target a difficulty. Also, recombinant protein Targets: 1 (sporozoites)=RTS,S, ICC-1132, NYU CS, Lausanne CS; 2 (liver stage)=DNA and viral subunit vaccines are generally poor vectors (NMRC, Vical, and Oxford), ?RTS,S, ?Lausanne CS; 3 (blood stages)=MSP1, MSP2, RESA, at induction of effector T-cell MSP3, GLURP, FMP1, AMA-1; 4 (sexual stages)=Pvs25. The ? in front of RTS,S and Lausanne CS responses, such as CD8+ cytotoxic indicates that these vaccines might also partly act against the liver stage as well as againstsporozoites. T lymphocytes, that are necessary for THE LANCET • Vol 363 • January 10, 2004 • www.thelancet.com For personal use. Only reproduce with permission from The Lancet.
elimination of intracellular pathogens such as liver-stage malaria parasites. The ideal vaccine for this stage would induce high titres of The newest generation of subunit vaccines are DNA functional antibodies against sporozoites to prevent all based.30,31 DNA sequences from P falciparum parasites parasites entering the liver stage, and induce potent have been inserted into plasmid DNA molecules (DNA cytotoxic T-lymphocyte immunogenicity against the liver vaccines) or various recombinant attenuated DNA stage to kill infected hepatocytes, while not harming the viruses (recombinant viral vaccines) to generate human host. The lead candidate vaccine of this type is candidate vaccines.32,33 DNA vaccines are taken up by RTS,S—a recombinant protein vaccine.46 Hepatitis B host cells, protein is expressed, and T-cell epitopes surface antigen DNA was fused to DNA encoding a large bound to HLA molecules prime naive T cells to form part of the best characterised pre-erythrocytic malaria memory T-cell populations.34 Recombinant viral vaccines antigen, the circumsporozoite (CS) protein.47,48 When work in a similar way, but actively infect cells and express expressed in yeast, the fusion product (RTS) binds the recombinant malaria proteins before aborting hepatitis B surface antigen (S) to form RTS,S particles.
infection.35 DNA and recombinant viral subunit vaccines These particles are mixed with an adjuvant, AS02—a can induce high levels of effector T-cell immune mixture of deacylated monophosphoryl lipid A, QS21, responses, although antibody responses have been poor and an emulsion—and given intramuscularly on two to in clinical trials.34,36 three occasions. RTS,S vaccination induces high titre Assessment of T-cell responses has been revolutionised antibodies to CS and to hepatitis B, and gives 30–60% by the enzyme-linked immunospot (ELISPOT) assay and protection against parasites of the same strain as the the tetramer assay.37–39 ELISPOT is a highly sensitive vaccine in a sporozoite challenge model.49 In this model, means of quantitatively detecting functional antigen- vaccinees from developed countries (USA and Europe) specific T cells. Tetramer assays allow detailed are bitten by five mosquitoes infected with the 3D7 strain characterisation of antigen-specific T cells. These of P falciparum, which is sensitive to chloroquine.
advances in assays, together with those of subunit Volunteers are monitored closely by malaria blood smears vaccination in malaria, raise the possibility of identifying or PCR techniques, and treated promptly once blood robust antibody and T-cell immune correlates of stages are detected by microscopy.50 protection or, in other words, of understanding how partly Proof of the efficacy of RTS,S/AS02 followed years of effective vaccines provide their level of protection. Such iterative development of CS-based vaccines—trials either an understanding should allow tailoring of vaccine design with no challenge component, or resulting in very limited around immune correlates of protection to systematically protection.51–58 Several adjuvants used with the RTS,S improve vaccine efficacy—a process dubbed iterative construct were far less protective than AS02. In a randomised controlled field trial of three-dose RTS,S inGambian adults, vaccine efficacy was 34% (p=0·014) Natural and vaccine induced immunity during the 15-week surveillance period, but with 71% Natural exposure to P falciparum gradually elicits, in efficacy in the first 9 weeks and 0% in the next 6 weeks.59 human hosts, short-lived strain-specific malaria Protection was not strain-specific.60 Although the duration immunity: first to severe disease and death, and then to of efficacy was short, RTS,S is the first pre-erythrocytic mild disease.40 Repeated infections are required to vaccine to show clear protection against natural maintain immunity, which is both antibody and T-cell P falciparum infection. Development of RTS,S has been based, although evidence is most clear for antibody- accelerated by the Malaria Vaccine Initiative, which is mediated immunity to blood-stage malaria.41–43 Exactly funding an efficacy trial of RTS,S in children aged which of the 5300 antigens encoded by the P falciparum 1–4 years in Mozambique. Phase-I trials of varying doses parasite produces the key protective immune responses is of RTS,S in children aged 1–11 years have already been not known, although some evidence implicates about 20.
done in The Gambia and Mozambique.
Immunity acquired in malaria-endemic areas is likely to Several other pre-erythrocytic candidates have reached be mediated by an integration of low to moderate the clinical evaluation stage: ICC-1132 is being tested in responses to many antigens. Immunity to one stage of the different formulations in the USA, Germany, and the UK.
parasite is restricted to that part of the life cycle; this ICC-1132 is a hepatitis B core particle, genetically complicates vaccine development—although sporozoite engineered to include a region of CS for high titre and liver-stage immunity overlap to some extent.
antibody induction. High titres of biologically active CS However, proteomics techniques have detected antigens antibody have been noted in preclinical studies,61 and thought to be specific to one stage of the life cycle to be clinical trials have started. present at other stages.44 Another approach is heterologous prime-boost The aim with most vaccines is to induce antibody and vaccination. Two different vaccine vectors encoding the T-cell responses to one or a few antigens, but for effective same antigen are given sequentially. Viral vectors can be vaccination these will need to be of greater magnitude, given first (priming) or second (boosting); DNA vaccines duration, and strain-transcendence than in naturally are efficient priming vaccines but do not boost acquired immunity. Antigenic variation occurs in some efficiently.62 Three carriers have been clinically tested: important blood-stage malaria antigens, and there is a DNA; modified vaccinia virus Ankara (MVA); and possibility that vaccination could select for escape attenuated poxvirus FP9, once used to vaccinate chickens mutants, but this is less of a concern than with viruses against fowlpox.24 The insert includes thrombospondin- such as HIV-1. T-cell responses have been neglected, in related adhesive protein (TRAP), a well characterised pre- particular for blood-stage vaccine development; which erythrocytic antigen, and a string of T-cell epitopes (called responses are necessary is little known or understood, ME for multiple epitope); these ME-TRAP vaccines are except for the need to produce T-cell help for an antibody given in prime-boost sequence—ie, DNA then MVA, or response. An alternative, ambitious, long-term approach FP9 then MVA.63,64 This approach has induced high is to use a cocktail of many antigens to attempt to mimic T-cell responses and some protection, manifest by a natural immunity, but this could lead to a complex and substantial delay to parasitaemia in sporozoite challenge costly product.45 studies.65 A randomised controlled trial of the efficacy of THE LANCET • Vol 363 • January 10, 2004 • www.thelancet.com For personal use. Only reproduce with permission from The Lancet.
DNA and ME-TRAP followed by MVA and ME-TRAP Another approach to blood-stage vaccine design has has been completed in The Gambia with 372 adult been suggested by the demonstration that vaccine induced volunteers. MVA encoding the CS protein and given before T-cell responses to blood-stage antigens can be protective or after RTS,S is being assessed in phase I and IIa studies in in animal models, and by the finding that human volunteers can be protected against infection by Intense efforts have been made to develop effective immunisation with low doses of blood-stage parasites that DNA-based vaccines to the liver stage and blood stages.
do not induce detectable antibodies.77,78 Development of Various DNA vaccines, each encoding a pre-erythrocytic blood-stage challenge models, and the increasing antigen, have undergone phase-I studies.45,66 A mixture of availability of new antigens, should lead to a growing five pre-erythrocytic DNA vaccines has been administered number of clinical studies of blood-stage candidate in phase-I studies, but no evidence of protection was noted in sporozoite challenge tests. DNA vaccines require viral Sequestration of P falciparum by adherence to vascular boosting to induce strong T-cell immunogenicity in endothelial cells in the brain, kidneys, and placenta is an macaques as well as in human beings; antibody induction in important cause of severe malaria. The PfEMP-1 human beings is generally very low after DNA vaccination, antigen (erythrocyte membrane protein-1), the main by contrast with some animal models.32,65,67,68 ligand for such adherence, is being researched as a Other CS-based candidate vaccines that have been tested vaccine candidate. However, its high degree of in phase-I studies include a multiple antigen peptide, a type variability, rapid rate of antigenic variation, and high of synthetic delivery system, which induced strong antibody copy number within each parasite complicate vaccine responses; a polyoxime construct, containing a universal T- development, although some researchers think that use cell epitope; and a long synthetic peptide in an oil-based of a conserved part of the antigen could be a promising adjuvant, which induced detectable antibody and CD4+ approach. At schizont rupture, inflammatory mediators and CD8+ T-cell responses with a good safety profile.69–71 are released, leading to many severe manifestations ofmalaria disease. The P falciparum glycosyl phosphatidyl Blood-stage vaccines: invasion and inositol (GPI) molecule is a lead candidate for this mediator, the so-called malaria toxin. Immunisation There are two possible classes of blood-stage vaccine: anti- with P falciparum GPI protected mice from severe invasion and anticomplication. A vaccine that could disease manifestations on malaria challenge, although prevent invasion of red blood cells by merozoites would this finding was not reproducible by other investigators, prevent malaria disease. Development of such vaccines has and the pathway from this work to an effective clinical been hampered by the lack of an established human vaccine is unclear.80,81 challenge model, by the limitations of available animalmodels, and by unclear immunological correlates of Sexual-stage vaccines: the altruistic vaccine protection. Merozoite surface protein-1 (MSP-1) is the Induction of antibodies to gametocyte antigens can most well characterised antigen involved in invasion, and is prevent fertilisation in the mosquito; as well as its blood the basis of several candidate vaccines. However, vaccine meal, the mosquito ingests antibodies that block development has been complicated by the discovery of fertilisation. As a result, assessment of the efficacy of parallel pathways for invasion, and by the elegant gametocyte vaccines is possible with a simple ex-vivo demonstration that some antibodies to MSP-1 can block assay. Mosquitoes are fed on gametocytes with or without the activity of malaria-protective antibodies.72 In a small the addition of human serum samples from vaccinated efficacy study in Papua New Guinea, a blood-stage vaccine volunteers. The US National Institute for Allergy and incorporating the antigen MSP-2 and two other blood- Infectious Disease Malaria Vaccine Development Unit stage antigens reduced parasite density in vaccine plans clinical assessment of a P falciparum gametocyte Participants were protected most from candidate vaccine, Pfs25, a recombinant protein. There is infection with the vaccine strain of malaria, suggesting that little commercial funding for sexual-stage vaccine for polymorphic antigens such as MSP2, a vaccine candidates, since they have no market in developed including just one allelic form of the antigen is not likely to countries. Such vaccines could, however, contribute to give sufficient protection.
malaria control, especially if linked with other A recombinant viral vaccine, NYVAC Pf-7 (P falciparum- interventions. A sexual-stage vaccine consisting of an 7), has been developed that encodes seven antigens from antigen not expressed in human beings during natural various life-cycle stages.74 Results of a sporozoite challenge infection would not select for escape mutants. Therefore, study of NYVAC Pf-7 showed encouraging delays in time combination of such a vaccine with a blood-stage or pre- to parasitaemia, and some antibody and cytotoxic erythrocytic vaccine could prevent potential immune T-lymphocyte immunogenicity, but this candidate has not selection. Sexual-stage vaccination would not protect been further developed. An anti-invasion vaccine based on vaccinated individuals from disease but would protect MSP-1 known as falciparum malaria protein (FMP-1) is communities from infection. being clinically assessed and has progressed quickly to anadult phase-I study in western Kenya. Vaccine development in the post-genomic era Two blood-stage candidates, glutamate rich protein Results of whole-genome sequencing indicate that there (GLURP) and MSP3, have been clinically assessed in are probably 5300 P falciparum antigens. Genome Europe.75,76 A key issue with all such protein candidates is databases can be used for identifying hundreds of the identification of a safe, immunogenic adjuvant, since candidates for vaccination. However, the number of the traditional adjuvant, alum, seems to be insufficiently possible antigens is not rate-limiting for malaria vaccine immunogenic for many malaria proteins. Additionally, development. Identification of antigens does not help vaccines with an alum adjuvant induce a Th2 response, solve some key problems in malaria vaccine development: rather than the generally more desirable Th1 response.
how to induce strong, durable immune responses; and Induction of biologically-relevant antibodies is a further how to combine multiple antigens without interference or challenge, and it is uncertain how often this will require a competition. Post-genomic antigen identification should native conformation of the recombinant protein. generate a wealth of information of long-term value to THE LANCET • Vol 363 • January 10, 2004 • www.thelancet.com For personal use. Only reproduce with permission from The Lancet.
Children aged 1–5 years Children aged 2–4 months Combination vaccines phase IIb manufacture Phase I in malaria- Phase IIb in malaria- Repeat may occur, adding 2–3 years Figure 2: A simplified timeline for assessment of a hypothetical candidate malaria vaccineRegulatory and ethics approval must be obtained before the first clinical trial. The first trial has always occurred to date in a non-malaria-endemic country.
With safety data and ethics approval from country of origin and locally, the vaccine can be tested in a malaria-endemic country. Once safety, immunogenicity,and perhaps artificial challenge efficacy data warrant field efficacy testing, the candidate moves to a phase IIb trial. This is a malaria-specific term indicatinga small-scale safety, immunogenicity, and efficacy study usually involving a few hundred participants. At some point the candidate will probably requirecombination with other antigens—the earlier this occurs, the sooner a final combined product can be licensed. *If efficacy in the laboratory challenge modelis sufficient and safety requirements allow, it may be possible to bypass adults entirely in malaria-endemic countries. Safety and efficacy will usually need tobe shown in children aged 1–5 years before progressing to infants. Before efficacy studies in infants, coadministration studies with vaccines routinelyadministered to infants would be done. A safe and efficacious vaccine would move to critical prelicensing safety and efficacy assessment in severalthousand infants. In this timeline, the vaccine candidate enters the clinic in 2003; some current candidate vaccines entered trials earlier and could reachlicensure sooner.
vaccine development, but solving other problems could be a vaccine. Currently, it can take more than a decade a faster means to developing an effective vaccine. Clearly, between first demonstration of high-level efficacy of a new diversion of funding from clinical development of the well vaccine and licensing for use in young children. The characterised antigens already available would be availability of trained, motivated, local investigators to do counterproductive. A distinction can be made here efficacy studies is a further limiting factor. Funds are between vaccine and drug development, in which there needed to train and support developing country are likely to be shorter-term promising applications of investigators to work with sponsors and take a leading role genome sequence information.
in vaccine development. The cost of vaccines should be considered before large- scale efficacy trials are planned. Estimation of cost is Development of an effective and deployable malaria complicated by the unpredictable but anticipated decrease vaccine seems technically feasible in the view of most in price of a vaccine over time. The establishment of a malaria researchers. New vaccine delivery methods and global purchase fund could be essential to spur industrial adjuvants could continue to increase the antibody and interest in late-stage vaccine development. Increasing cellular immunogenicity of subunit vaccination. The rate numbers of trials will result in increasing numbers of of clinical assessment of candidate malaria vaccines is study participants who should be followed up in the long increasing; in the past 5 years, the number of groups doing term. However, funding rarely exists for more than such research has increased from three to 11. Careful 1–2 years per trial; thus, the best way to maintain long- clinical expansion is needed to translate immunogenicity term follow-up is to do sequential trials in the same into efficacy against malaria parasites in people resident in setting, and to include demographic surveillance malaria-endemic countries. Artificial challenge models infrastructures. As occurred in The Gambia in phase-III and improved in-vitro assays should speed up this process.
trials of hepatitis B and Haemophilus influenzae type b However, development of an effective vaccine also vaccines, a plan should be made in conjunction with local requires research into antigenic polymorphism, duration governments for provision of vaccine to the country or of efficacy, and means of antigen combination. A practical region participating in key prelicensing field trials.
limitation is the lack of worldwide Good Manufacturing Increasingly, cessation of vaccinations once such a trial Practice (GMP) manufacturing facilities for some new has ended is seen as unacceptable if the intervention has technologies such as recombinant viral vaccines. been shown to work.
An effective vaccine is urgently needed. Efficacy studies Informed consent is a complex issue in efficacy studies.
often have to progress through adults and children aged In many rural African settings, community consent is as 1–5 years before reaching their target age group of infants important as individual consent, and rates of literacy can (figure 2). There will probably be a need for combination be poor. The American-European-Japanese ICH-GCP vaccines, and therefore vaccine development efforts of (International Committee on Harmonisation-Good several groups will almost certainly have to be combined.
Clinical Practice) guidelines are moving towards the Although one candidate vaccine has moved from first use status of law in much of the developed world. The in human participants to a phase-I trial in developing guidelines were drawn up by regulatory authorities and countries within months, a greater challenge is speeding pharmaceutical companies with little contribution from the progression from demonstrated efficacy to licensing of developing countries. GCP consent forms may be very THE LANCET • Vol 363 • January 10, 2004 • www.thelancet.com For personal use. Only reproduce with permission from The Lancet.
Russell PF. Man's mastery of malaria. London: Oxford University Press, 1955.
WHO. Malaria fact sheet no 94. Geneva: World Health Organization,1996.
WHO. Malaria—a global crisis. Geneva: World Health Organization,2000.
Shanks GD, Biomndo K, Hay SI, Snow RW. Changing patterns of
clinical malaria since 1965 among a tea estate population located in the
Kenyan highlands. Trans R Soc Trop Med Hyg 2000; 94: 253–55.
le Sueur D, Sharp BL, Gouws E, Ngxongo S. Malaria in South Africa.
S Afr Med J 1996; 86: 936–39.
Greenwood B, Mutabingwa T. Malaria in 2002. Nature 2002; 415:
Hemingway J, Field L, Vontas J. An overview of insecticide resistance.
Science 2002; 298: 96–97.
Guerin PJ, Olliaro P, Nosten F, et al. Malaria: current status of control,diagnosis, treatment, and a proposed agenda for research and development. Lancet Infect Dis 2002; 2: 564–73.
Martens P, Hall L. Malaria on the move: human population movement
and malaria transmission. Emerg Infect Dis 2000; 6: 103–09.
Figure 3: Endpoints in malaria vaccine field trials 10 Muentener P, Schlagenhauf P, Steffen R. Imported malaria (1985–95): A trial in adults can detect 40% efficacy against infection but not disease trends and perspectives. Bull World Health Organ 1999; 77: 560–66.
with only 300 participants, even in moderate transmission settings. The 11 Snow RW, Trape JF, Marsh K. The past, present and future of higher the transmission intensity the smaller the necessary sample size.
childhood malaria mortality in Africa. Trends Parasitol 2001; 17: 593–97.
About 1000 children aged 1–5 years are needed to measure efficacy against 12 Sachs JD. A new global effort to control malaria. Science 2002; 298:
mild malaria, whereas 5000 such children would be required to measure efficacy against severe malaria, and about 20 000 against death. The more 13 Beverley PC. Immunology of vaccination. Br Med Bull 2002; 62: 15–28.
clinically relevant the endpoint, the larger and more complex the trial, but the 14 Gardner MJ, Hall N, Fung E, et al. Genome sequence of the human more likely the trial would be to change public-health policy locally.
malaria parasite Plasmodium falciparum. Nature 2002; 419: 498–511.
15 Clyde DF, Most H, McCarthy VC, Vanderberg JP. Immunization of detailed, in part for the legal protection of sponsors. In man against sporozite-induced falciparum malaria. Am J Med Sci 1973;
rural Gambia, for example, the local consensus (of lay 16 Hoffman SL, Goh LM, Luke TC, et al. Protection of humans against Gambian and Gambian Government ethics review board malaria by immunization with radiation-attenuated Plasmodium members) is that ICH-GCP-compliant consent forms are falciparum sporozoites. J Infect Dis 2002; 185: 1155–64.
not always appropriate. Complex trials must be clearly 17 Kwiatkowski D, Marsh K. Vaccine series: development of a malaria explained to participants; Gambian experience is that by vaccine. Lancet 1997; 350: 1696–701.
repeated delivery of complex messages with reinforcement 18 Cochrane AH, Nussenzweig RS, Nardin EH. Immunization against sporozoites. In: Kreier JP, ed. Malaria. New York: New York Academic throughout the study, adequate understanding is possible, Press, 1980.
but this undertaking is far from trivial. In particular, the 19 Patarroyo G, Franco L, Amador R, et al. Study of the safety and fact that the vaccine being tested is not known to protect immunogenicity of the synthetic malaria SPf66 vaccine in children aged against malaria must be stressed throughout the consent 1–14 years. Vaccine 1992; 10: 175–78.
procedure and the study. 20 Alonso PL, Smith T, Schellenberg JR, et al. Randomised trial of efficacy of SPf66 vaccine against Plasmodium falciparum malaria in children in If funding continues to increase in line with recent southern Tanzania. Lancet 1994; 344: 1175–81.
trends, a malaria vaccine candidate could, in the next 21 D'Alessandro U, Leach A, Drakeley CJ, et al. Efficacy trial of malaria decade, be proven to have sustained efficacy in infants, vaccine SPf66 in Gambian infants. Lancet 1995; 346: 462–67.
young children, or both. The next step would be to do 22 Nosten F, Luxemburger C, Kyle DE, et al. Randomised double-blind large trials in various epidemiological settings, perhaps placebo-controlled trial of SPf66 malaria vaccine in children in including other interventions such as insecticide-treated northwestern Thailand. Shoklo SPf66 Malaria Vaccine Trial Group.
Lancet 1996; 348: 701–07.
bednets. These trials should be designed with severe 23 Acosta CJ, Galindo CM, Schellenberg D, et al. Evaluation of the SPf66 disease or death as an endpoint, and with sufficient vaccine for malaria control when delivered through the EPI scheme in sample size to convince local policymakers and Tanzania. Trop Med Int Health 1999; 4: 368–76.
international organisations of its worth (figure 3). If an 24 Moorthy V, Hill AV. Malaria vaccines. Br Med Bull 2002; 62: 59–72.
effective vaccine is licensed, public-sector funding will be 25 Rosenberg R, Wirtz RA, Schneider I, Burge R. An estimation of the number of malaria sporozoites ejected by a feeding mosquito. needed to deliver the product to African infants.
Trans R Soc Trop Med Hyg 1990; 84: 209–12.
Organisations such as the Global Alliance for Vaccines 26 Ponnudurai T, Lensen AH, van Gemert GJ, Bolmer MG, and Immunisation; the Global Fund to Fight AIDS, Meuwissen JH. Feeding behaviour and sporozoite ejection by infected Tuberculosis and Malaria; or a dedicated purchase fund Anopheles stephensi. Trans R Soc Trop Med Hyg 1991; 85: 175–80.
could support widespread vaccination in the medium 27 Mota MM, Pradel G, Vanderberg JP, et al. Migration of Plasmodium sporozoites through cells before infection. Science 2001; 291: 141–44.
28 Mota MM, Hafalla JC, Rodriguez A. Migration through host cells activates Plasmodium sporozoites for infection. Nat Med 2002; 8:
Conflict of interest statement AVSH is a cofounder of, and consultant to, Oxxon Pharmaccines, which 29 Crosnier J, Jungers P, Courouce AM, et al. Randomised placebo- is developing prime-boost vaccines for therapeutic applications using controlled trial of hepatitis B surface antigen vaccine in French MVA. No conflicts declared by VSM or MFG.
haemodialysis units: I, Medical staff. Lancet 1981; 1: 455–59.
30 Ulmer JB, Donnelly JJ, Parker SE, et al. Heterologous protection against influenza by injection of DNA encoding a viral protein. Science 1993; VSM was funded at the time of writing this Review by a Wellcome Trust 31 Li S, Rodrigues M, Rodriguez D, et al. Priming with recombinant Training Fellowship in Clinical Tropical Medicine. AVSH is a Wellcome influenza virus followed by administration of recombinant vaccinia virus Trust Principal Fellow. MFG receives funding support from the National induces CD8+ T-cell-mediated protective immunity against malaria.
Health and Medical Research Council of Australia and WHO Special Proc Natl Acad Sci USA 1993; 90: 5214–18.
Programme for Research and Training in Tropical Diseases. Formative 32 Wang R, Doolan DL, Le TP, et al. Induction of antigen-specific discussions were held with Brian Greenwood. Funding sources had no cytotoxic T lymphocytes in humans by a malaria DNA vaccine. role in the preparation or writing of this review.
Science 1998; 282: 476–80.
THE LANCET • Vol 363 • January 10, 2004 • www.thelancet.com For personal use. Only reproduce with permission from The Lancet.
33 Schneider J, Gilbert SC, Blanchard TJ, et al. Enhanced immunogenicity monophosphoryl lipid A, cell wall skeleton of mycobacteria, and for CD8+ T cell induction and complete protective efficacy of malaria squalane as adjuvant. Am J Trop Med Hyg 1994; 51: 603–12.
DNA vaccination by boosting with modified vaccinia virus Ankara. 59 Bojang KA, Milligan PJ, Pinder M, et al. Efficacy of RTS,S/AS02 malaria Nat Med 1998; 4: 397–402.
vaccine against Plasmodium falciparum infection in semi-immune adult 34 Gurunathan S, Klinman DM, Seder RA. DNA vaccines: immunology, men in The Gambia: a randomised trial. Lancet 2001; 358: 1927–34.
application, and optimization. Annu Rev Immunol 2000; 18: 927–74.
60 Alloueche A, Milligan P, Conway DJ, et al. Protective efficacy of the 35 Miyahira Y, Garcia-Sastre A, Rodriguez D, et al. Recombinant viruses RTS,S/AS02 Plasmodium falciparum malaria vaccine is not strain expressing a human malaria antigen can elicit potentially protective specific. Am J Trop Med Hyg 2003; 68: 97–101.
immune CD8(+) responses in mice. Proc Natl Acad Sci USA 1998; 95:
61 Birkett A, Lyons K, Schmidt A, et al. A modified hepatitis b virus core particle containing multiple epitopes of the Plasmodium falciparum 36 Paoletti E. Applications of pox virus vectors to vaccination: an update.
circumsporozoite protein provides a highly immunogenic malaria Proc Natl Acad Sci USA 1996; 93: 11349–53.
vaccine in preclinical analyses in rodent and primate hosts. 37 Kabilan L, Troye-Blomberg M, Andersson G, et al. Number of cells Infect Immun 2002; 70: 6860–70.
from Plasmodium falciparum-immune donors that produce gamma 62 Schneider J, Gilbert SC, Hannan CM, et al. Induction of CD8+ T cells interferon in vitro in response to Pf155/RESA, a malaria vaccine using heterologous prime-boost immunisation strategies. Immunol Rev candidate antigen. Infect Immun 1990; 58: 2989–94.
1999; 170: 29–38.
38 Lalvani A, Brookes R, Hambleton S, Britton WJ, Hill AV, 63 Moorthy VS, McConkey S, Roberts M, et al. Safety of DNA and McMichael AJ. Rapid effector function in CD8+ memory T cells. modified vaccinia virus Ankara vaccines against liver-stage P falciparum J Exp Med 1997; 186: 859–65.
malaria in non-immune volunteers. Vaccine 2003; 21: 2004–11.
39 Altman JD, Moss PA, Goulder PJ, et al. Phenotypic analysis of antigen- 64 Moorthy VS, Pinder M, Reece WHH, et al. Safety and immunogenicity specific T lymphocytes. Science 1996; 274: 94–96.
of DNA/modified vaccinia virus Ankara malaria vaccination in African 40 McGregor IA. Mechanisms of acquired immunity and epidemiological adults. J Infect Dis (in press).
patterns of antibody responses in malaria in man. Bull World Health 65 McConkey S, Reece WHH, Moorthy VS, et al. Enhanced T-cell Organ 1974; 50: 259–66.
immunogenicity in humans of plasmid DNA vaccines boosted by 41 Cohen S, McGregor IA, Carrington S. Gamma globulin and acquired recombinant modified vaccinia virus Ankara. Nat Med 2003; 9: 729–35.
immunity to malaria. Nature 1961; 192: 733–37.
66 Richie TL, Wang R, Charoenvit Y, et al. Safety, immunogenicity and 42 Marsh K, Howard RJ. Antigens induced on erythrocytes by efficacy of MuStDO5, a five gene sporozoite/hepatic stage Plasmodium P falciparum: expression of diverse and conserved determinants.
falciparum DNA vaccine combined with human GM-CSF DNA Science 1986; 231: 150–53.
(conference abstract). Am J Trop Med Hyg 2001; 65 (suppl): 230.
67 Rogers WO, Weiss WR, Kumar A, et al. Protection of rhesus macaques 43 Bouharoun-Tayoun H, Attanath P, Sabchareon A, Chongsuphajaisiddhi against lethal Plasmodium knowlesi malaria by a heterologous DNA T, Druilhe P. Antibodies that protect humans against Plasmodium priming and poxvirus boosting immunization regimen. falciparum blood stages do not on their own inhibit parasite growth and Infect Immun 2002; 70: 4329–35.
invasion in vitro, but act in cooperation with monocytes. J Exp Med
1990; 172: 1633–41.
68 Wang R, Epstein J, Baraceros FM, et al. Induction of CD4(+) T cell- dependent CD8(+) type 1 responses in humans by a malaria DNA 44 Florens L, Washburn MP, Raine JD, et al. A proteomic view of the vaccine. Proc Natl Acad Sci USA 2001; 98: 10817–22.
Plasmodium falciparum life cycle. Nature 2002; 419: 520–26.
69 Nardin EH, Oliveira GA, Calvo-Calle JM, et al. Synthetic malaria 45 Doolan DL, Hoffman SL. DNA-based vaccines against malaria: status peptide vaccine elicits high levels of antibodies in vaccinees of defined and promise of the Multi-Stage Malaria DNA Vaccine Operation. HLA genotypes. J Infect Dis 2000; 182: 1486–96.
Int J Parasitol 2001; 31: 753–62.
70 Nardin EH, Calvo-Calle JM, Oliveira GA, et al. A totally synthetic 46 Stoute JA, Slaoui M, Heppner DG, et al. A preliminary evaluation of a polyoxime malaria vaccine containing Plasmodium falciparum B cell and recombinant circumsporozoite protein vaccine against Plasmodium universal T cell epitopes elicits immune responses in volunteers of falciparum malaria. RTS,S Malaria Vaccine Evaluation Group. diverse HLA types. J Immunol 2001; 166: 481–89.
N Engl J Med 1997; 336: 86–91.
71 Lopez JA, Weilenman C, Audran R, et al. A synthetic malaria vaccine 47 Potocnjak P, Yoshida N, Nussenzweig RS, Nussenzweig V. Monovalent elicits a potent CD8(+) and CD4(+) T lymphocyte immune response in fragments (Fab) of monoclonal antibodies to a sporozoite surface humans: implications for vaccination strategies. Eur J Immunol 2001; 31:
antigen (Pb44) protect mice against malarial infection. J Exp Med 1980; 151: 1504–13.
72 Holder AA, Guevara Patino JA, Uthaipibull C, et al. Merozoite surface 48 Nardin EH, Nussenzweig V, Nussenzweig RS, et al. Circumsporozoite protein 1, immune evasion, and vaccines against asexual blood stage proteins of human malaria parasites Plasmodium falciparum and malaria. Parassitologia 1999; 41: 409–14.
Plasmodium vivax. J Exp Med 1982; 156: 20–30.
73 Genton B, Betuela I, Felger I, et al. A recombinant blood-stage malaria 49 Kester KE, McKinney DA, Tornieporth N, et al. Efficacy of vaccine reduces Plasmodium falciparum density and exerts selective recombinant circumsporozoite protein vaccine regimens against experi- pressure on parasite populations in a phase 1–2b trial in Papua New mental Plasmodium falciparum malaria. J Infect Dis 2001; 183: 640–47.
Guinea. J Infect Dis 2002; 185: 820–27.
50 Church LW, Le TP, Bryan JP, et al. Clinical manifestations of 74 Ockenhouse CF, Sun PF, Lanar DE, et al. Phase I/IIa safety, Plasmodium falciparum malaria experimentally induced by mosquito immunogenicity, and efficacy trial of NYVAC-Pf7, a pox-vectored, challenge. J Infect Dis 1997; 175: 915–20.
multiantigen, multistage vaccine candidate for Plasmodium falciparum 51 Ballou WR, Hoffman SL, Sherwood JA, et al. Safety and efficacy malaria. J Infect Dis 1998; 177: 1664–73.
of a recombinant DNA Plasmodium falciparum sporozoite vaccine. 75 Oeuvray C, Theisen M, Rogier C, Trape JF, Jepsen S, Druilhe P.
Lancet 1987; 1: 1277–81.
Cytophilic immunoglobulin responses to Plasmodium falciparum 52 Herrington DA, Clyde DF, Losonsky G, et al. Safety and glutamate-rich protein are correlated with protection against clinical immunogenicity in man of a synthetic peptide malaria vaccine against malaria in Dielmo, Senegal. Infect Immun 2000; 68: 2617–20.
Plasmodium falciparum sporozoites. Nature 1987; 328: 257–59.
76 Oeuvray C, Bouharoun-Tayoun H, Gras-Masse H, et al. Merozoite 53 Sherwood JA, Oster CN, Adoyo-Adoyo M, et al. Safety and surface protein-3: a malaria protein inducing antibodies that promote immunogenicity of a Plasmodium falciparum sporozoite vaccine: boosting Plasmodium falciparum killing by cooperation with blood monocytes.
of antibody response in a population with prior natural exposure to Blood 1994; 84: 1594–602.
malaria. Trans R Soc Trop Med Hyg 1991; 85: 336–40.
77 Makobongo MO, Riding G, Xu H, et al. The purine salvage enzyme 54 Vreden SG, Verhave JP, Oettinger T, Sauerwein RW, Meuwissen JH.
hypoxanthine guanine xanthine phosphoribosyl transferase is a major Phase I clinical trial of a recombinant malaria vaccine consisting of the target antigen for cell-mediated immunity to malaria. circumsporozoite repeat region of Plasmodium falciparum coupled to Proc Natl Acad Sci USA 2003; 100: 2628–33.
hepatitis B surface antigen. Am J Trop Med Hyg 1991; 45: 533–38.
78 Pombo DJ, Lawrence G, Hirunpetcharat C, et al. Immunity to malaria 55 Herrington DA, Losonsky GA, Smith G, et al. Safety and after administration of ultra-low doses of red cells infected with immunogenicity in volunteers of a recombinant Plasmodium falciparum Plasmodium falciparum. Lancet 2002; 360: 610–17.
circumsporozoite protein malaria vaccine produced in Lepidopteran 79 Cheng Q, Lawrence G, Reed C, et al. Measurement of Plasmodium cells. Vaccine 1992; 10: 841–46.
falciparum growth rates in vivo: a test of malaria vaccines. 56 Brown AE, Singharaj P, Webster HK, et al. Safety, immunogenicity and Am J Trop Med Hyg 1997; 57: 495–500.
limited efficacy study of a recombinant Plasmodium falciparum 80 Schofield L, Hewitt MC, Evans K, Siomos MA, Seeberger PH.
circumsporozoite vaccine in Thai soldiers. Vaccine 1994; 12: 102–08.
Synthetic GPI as a candidate anti-toxic vaccine in a model of malaria.
57 Gonzalez C, Hone D, Noriega FR, et al. Salmonella typhi vaccine strain Nature 2002; 418: 785–89.
CVD 908 expressing the circumsporozoite protein of Plasmodium 81 Molano A, Park SH, Chiu YH, Nosseir S, Bendelac A, Tsuji M.
falciparum: strain construction and safety and immunogenicity in Cutting edge: the IgG response to the circumsporozoite protein is MHC humans. J Infect Dis 1994; 169: 927–31.
class II-dependent and CD1d-independent: exploring the role of GPIs 58 Hoffman SL, Edelman R, Bryan JP, et al. Safety, immunogenicity, and in NK T cell activation and antimalarial responses. J Immunol 2000; efficacy of a malaria sporozoite vaccine administered with THE LANCET • Vol 363 • January 10, 2004 • www.thelancet.com For personal use. Only reproduce with permission from The Lancet.
Fibromyalgia Frontiers • 2010 (Volume 18, Number 1) Pathophysiology & Treatment A GUIDE FOR PATIENTS & PHYSICIANS By Russell Rothenberg, M.D. Fibromyalgia remains an enigma to many term "fibrositis" in 1904. In 1978, Drs. Smythe and physicians despite its high prevalence in the U.S. Moldofsky published the first scientific research on