REGA 505: BIOTECHNOLOGY

Malaria Vaccine

Deluxini Sundralingam Saifuddin Syed

1. Importance of Malaria Vaccine

It is estimated that over 3 billion people are at risk of infection [1], with a range of 225 [2] to 300 million cases of malaria occurring annually. The toll on human life is dire; ranging from 780,000 [2] to a million deaths worldwide [1]. Plasmodium falciparum is the most deadly of the malarial species accounting to over 90% of malaria related deaths [3] and it is the most common cause of morbidity [1]. The deaths occur primarily in young children and pregnant women in developing countries [1]. For children who survive malaria, their mental and physical development is impacted by constant fever and anemia [4]. The threat to pregnant women and their unborn children range from anemia, low birth weight, premature birth and death [4]. At this point there is a great need for a breakthrough in malaria vaccine. There is an extraordinary cost associated with Malaria in terms of human morbidity, mortality and economic burden [1]. Malaria is prevalent in tropical and subtropical regions of the world which are usually the poorest. It is clear to see that malaria is a significant threat in underdeveloped nations and until a cure is found the threat will continue to hamper development in these nations. The international community has taken different approaches to malaria: one is to reduce and control malaria and the other is to completely eradicate malaria. Progress has been made in reducing and control the incidence of malaria by implementing control measures over the last 5-6 years [5]. One of the three major control measures is artimisinin based combination therapy (ACT) which provides the best antimalarial drugs available and recommended by WHO [6]. The artimisinin in these drugs enhances efficacy and reduces malaria transmission [6]. WHO estimates that in 2010 181 million courses of ACTs was delivered to sub-Saharan Africa up from 158 million courses in 2009 and is recommended as the first-line treatment for malaria from P. falciparum [6]. Another control measure is to distribute long-lasting insecticidal nets (LLIN), which are covered in insecticides
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and are designed to kill mosquitos. According to WHO, in 2010 145 million nets were delivered to sub-Saharan Africa up from 88.5 million nets in 2009 [6]. This is a huge improvement because it insures that there is preventative access available to poor communities and individuals. It is estimated that 96% of individuals with access to LLIN use the and around 50% of household in sub-Saharan Africa have them [6]. Lastly, the invention and improvement of diagnostic tests has helped immensely; 88 million rapid diagnostic tests were delivered in 2010 up from 45 million in 2008 [6]. Malaria interventions are cost effective as well, ACT costs between $.30- $1.40, LLIN costs $1.39 and lasts three years and rapid diagnostic tests cost $.40 [6]. Given all the success to these control measures, the downside associated with them has left a gap that needs to be filled. For ACT, the limiting factors are: adopting policies, limited knowledge on safety in pregnancy, and the imbalance between demand and supply [6]. Recently WHO has recommended that a ban be placed on oral artimisinin bases monotherapies due to emergence and spread of drug resistance [6]. There is also growing resistance to the insecticide used on nets; 45 countries have identified resistance to one of the four classes of insecticides used [6]. Due to the shortfalls of control measures and continuing prevalence of malaria, the focus has shifted to vaccines as the next major intervention. In a report WHO identified vaccines as a cost effective method to reduce the burden of this disease [7]. The report also identified through cost-effective analysis of existing antimalarial interventions that the economic benefit of reducing or eliminating malaria is enormous [7]. The cost effectiveness of vaccines in public health indicated an economical return in improved health per dollar spent [7].

2. Technical Aspects The malaria parasite has a complex lifecycle; and it is this complexity that contributes to the difficulty in engineering an effective vaccine [1]. There are 3 areas of lifecycle development that
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are the focus of vaccine development research: pre-erythrocytic stage, asexual erythrocytic stage (blood stage), and sporogonic cycle (sexual stage) [1]. In theory a blood-stage vaccine would control parasitic infection but not prevent malaria while the transmission blocking vaccines (TBV) or sexual stage vaccine impact the pathogen thus preventing malaria development in mosquitoes but no humans [1]. The most prominent area of research lies in pre-erythrocytic vaccines because there is potential for complete sterilization and immunity [1]. In theory the vaccine would stop parasitic development at the sporozoite stage thus preventing infection in mosquitos and disease in humans [1]. Also, during the pre-erythrocytic stage there is a high-level of sterilizing immunity against heterologous strains of P. falciparum [1]. 2.1 Development of the RTS,S antigen The surface of the sporozoite contains a surface antigen known as circumsporozoite protein (CS), which was first discovered in the rodent malarial parasite, Plasmodium berghei [1]. This protein is important because it established that the antibodies provided protection from malaria [1]. Further research led to the discovery of primate malarial parasite CS protein and of the P. falciparum CS protein [1]. A hybrid vaccine was created which combined an independent T-cell epitope along with the P. falciparum CS protein and hepatitis B surface antigen [1]. This hybrid was called R16HBsAg and it included 16 tandem repeats of the epitope of the P. falciparum CS protein fused with the pre-S2 region of HBsAg [1]. When transformed via Saccharomyces cerevisiae, R16HBsAg assembled into a virus like particle with the CS epitope being exposed to the exterior [1]. When adjuvanted with aluminum salts, R16HBsAg increased antibody response to the CS epitome in mice and rabbits and in clinical trials of R16HBsAg showed that R16HBsAg was safe and immunogenic [1]. All the participants of the trial were given doses at monthly intervals; 20 displayed anti-CS antibody response, 17 displayed antibody titer of
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1200, and 13 with anti- CS antibody response 10 months after vaccination [1]. R16HBsAg was later redesigned to include T- and B-cell epitopes from the C-terminus of the CS protein and was renamed to RTS,S [1]. 2.2 RTS,S adjuvants There are 5 different types of adjuvants used in the formulation RTS,S vaccine; GSK developed and own the proprietary rights on the adjuvant systems (AS); AS01, AS02, AS03, AS04 and Alum [1]. Alum and AS04 contain aluminum salts; which are safe and prolong immune stimulation via recruitment of antigenpresenting cells (APCs) [1]. AS04, AS02 and AS01 also contain 3-deacylated monophosphoryl lipid A (MPL) [1]. MPL triggers immunity, humoral and cellular immune response by promoting the maturation of APCs by acting upon TLR-4 [1]. AS03 and AS02 uses oil (squalene)-in-water-based emulsion; the oil phase contains a unique substance DL-a-tocopherol [1]. DL-a-tocopherol enhances antigen-specific response, early

eosinophil and neutrophil migration, antigen loading in monocytes, and affect cytokine production [1]. AS02 and AS01 contain the saponin QS21; QS21 stimulates antibody and CTL responses to antigens [1]. Also AS01replaces squalene with a liposome formulation; liposomes are safe, efficacious, and have been utilized for commercial vaccines [1]. 2.3 Field trials of RTS,S in semi-immune adults During the late 1990s the first RTS,S field trials were conducted in adults in Gambia and Kenya. RTS, S/AS02A, was found to be safe, well tolerated and immunogenic [1]. In the phase II trials RTS, S was combined with AS02A. Before the third vaccination, this group of men had an increase of twenty fold concentration of antibodies against the CS protein and maintained an increase of tenfold during the following year [1]. This combination provided heterogeneous
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protection against strains other than its original strain and investigators found an overall 34% vaccine efficacy versus parasitic infection [1]. During peak malaria transmission season, a fourth of RTS, S/AS02A was administered; the result was higher antibody concentrations and a vaccine efficacy of 47% [1]. The combination of RTS, S/AS01B was found to be superior to RTS, S/AS02A in humans, so a phase 2 study was conducted [1]. The results found a higher level of antibodies against the CS protein in patients with RTS, S/AS01B when compared to patients with RTS, S/AS02A [1]. It was also demonstrated that those participants administered with the vaccine had a higher blood concentration of antibodies then the participants in the control group with and efficacy rate of 30% [1]. This gave further support for the superiority of the RTS, S/AS01B formulation and led a decision to evaluate in a paediatric population [1]. 2.4 Paediatric trials with RTS, S Starting in 2001, 2 separate phase I trials began in paediatric population at risk for sever malaria; with different vaccine doses tested for RTS, S/AS02A. The trials showed safety, immunogenicity, and the doses were well tolerated in all population [1]. In 2003 phase II trials began in paediatric populations, at the 6 month interval efficacy for first episode of disease was 30% and efficacy against sever malaria was 57.7% [1]. At 45 months the population was tested again to reveal efficacy for first episode of disease was 30.5% and efficacy against sever malaria was 38.3% while also revealing 25% reduction in malarial disease [1]. Another 2 trials were setup afterwards to examine RTS, S/AS02D in infants [1]. After 3 months trial 1 showed vaccine efficacy of 65.9% and an overall efficacy against infection at 35.5% [1]. After 3 months trial 2 showed vaccine efficacy of 65.2% and an overall efficacy against infection at 41.8% [1]. Another paediatric formulation was developed and tested for paediatric population due to its success in adults; RTS, S/AS01E [1]. In 2007, clinical trials conducted showed improved safety
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and immunogenicity when compares to RTS, S/AS02D [1]. Over an 8 month period vaccine efficacy for first episode was reported at 53% and at 15months was reported to be at 45.8% [1]. These successes have led to the initiation of phase 3 trials in 2009 which are set to be completed in 2013. 2.5 Phase 3 Trials in Pediatric Population Phase 3 trials were conducted in children of two age categories among which one group was infants who were 6-12 weeks of age and the other group was children who were 5-17 months of age. These two age categories were separated into three study groups. The first group consisted of kids who received all three doses administered at 1 month intervals and they were scheduled to receive a booster dose after 18 months. The second group consisted of kids who received only the 3 doses without the booster dose. Third group was the control group with kids who received non-malaria vaccine such as rabies vaccine. As a result of the phase 3 trials, it was found that the RTS, S/AS01 reduced clinical malaria and severe malaria by half during the 12 month follow period. For 6-12 weeks age group, efficacy rate for clinical malaria was found to be 31.3% and for severe malaria, it was 36.6%. For 5-17 months age group, efficacy rate for clinical malaria was 55.8% and for severe malaria, it was 47.3%. Serious adverse events were detected among the study groups. Among the 4358 kids who received RTS, S/AS01 vaccine in the 6-12 weeks age group, 569 suffered a serious adverse event and among them 49 died. For 5-17 months age group 1048/5949 kids suffered serious adverse events and 56 of them died. But only 10 of these deaths were due to the diagnosis of malaria. Phase 3 trial is scheduled to be completed in 20132014 but so far the results have shown that 99.9% of the 5-17 months children and 99.7% of the 6-12 weeks infants have shown to be positive for anti-circumsporozoite antibodies [2].

3. World Health Organization Policy Recommendation National policy makers would face numerous challenges when it comes to making decisions about the introduction of malaria vaccine if it gets licensed. They would want to compare the advantages and disadvantages of current malaria control measures to the new vaccine. For example, some of the most important factors they would consider would be the cost effectiveness of the vaccine, interventions, burden of the disease, and delivery system infrastructure. They can use epidemiologic and economic analyses to help facilitate their decision-making [10]. The PATH Malaria Vaccine Initiative (MVI-PATH) and World Health Organization (WHO) collaboratively would determine the role of malaria vaccine in endemic countries. Recommendation by WHO makes a major impact on whether the new malaria vaccine would be used or not used by developing countries. WHOs role is to advice and guide the malaria development activities and it also assess the safety and effectiveness of the vaccine. Based on the assessment, WHO would consider a policy recommendation and pre-qualification. Many countries depend on WHO policy recommendation process to decide which vaccines they want to include in their national immunization programmes. For RTS, S/AS01, information required by WHO to make its policy recommendation would not be available until 2015 [11].

4. Pros and Cons People living in the poorest countries are suffering from malaria every day. Every year, 3.3 billion people are at risk of malaria. Malaria related deaths in these regions are estimated to be 655,000 every year among which 600,000 were children who are under five years of age [12]. Current control measures against malaria are not effective in protecting children and also the parasite has been shown to grow resistance over some of the Artemesinen based drugs and
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insecticides used on the long lasting nets. A vaccine would protect not only the population who resides in endemic areas but also, travellers who travel to these endemic areas. Current antimalarial medications that are prescribed to travellers cause a wide range of side effects such as emotional disturbance, difficulty sleeping and head ache. Also most of the drugs are not safe for pregnant women and people with kidney problems. Another reason why a vaccine would be better treatment for malaria is that current anti-malarial drugs are very expensive and most are not funded by provincial formularies. Therefore, an effective vaccine against malaria is required to protect children and pregnant women from this killer disease. Although malaria vaccine development has its advantages, it also has some disadvantages. Preventing the entry of sporozoites into the liver cells is difficult since the parasites mechanism of entering different cells in the body is very complex which makes it very challenging to make an effective vaccine [13]. This is one reason why the efficacy rate from phase 3 clinical trials is only moderate. Another disadvantage would be the difficulty in delivering the vaccines to the developing countries. Developing countries are slow in adopting the vaccine as a control measure against malaria due to the fact that most people in developing countries cannot afford to pay for the vaccine. But these disadvantages can be conquered if national and international funding is available to pay for the vaccine. Also, more research into the life cycle of the plasmodium parasite and the stages of the parasite in the human body would lead to the development of a highly effective malaria vaccine. So, in our opinion, vaccine against malaria would be an ideal solution to eradicate malaria and protect vulnerable population in endemic areas as well as travellers.

5. Improvements for Malaria Vaccine One area of improvement for malaria vaccines is the development of second generation vaccines with greater efficacy [8]. One of the ways this can be achieved is by having a greater role for IgG against the CS repeat sequence in the protection against infection [9]. For RTS,S any future improvements should incorporate matching the IgG response observed during trials [9]. Studies should be conducted to discover the mechanism of IgG protection; to show correlation of protection along with reduction in risk of malaria [9]. Another approach to the development of second generation vaccines should study cell mediated immunity (CMI). This refers to CD4+ Tcell responses; which have been observed with protection against infection by complementing the antibody concentration [9]. If the CMI aspect can be improved by increasing CD4+ T-cell responses then this would provide greater efficacy CD4+ T-cell responses [9]. If both of these can be combined in RTS, S then it is believed that the protection provided will increase [9].

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Bibliography: 1. Regules, J., Cummings, J., & Ockenhouse, C. (2011). The RTS,S Vaccine Candidate for Malaria. Expert Reviews, 10(5). 2. Agnandji, S., & Lell, B. (2011). First Results of Phase 3 Trial of RTS,S/AS01 Malaria Vaccine in African Children. The New England Journal of Medicine, 365. 3. L, Schwartz and B, Graham.(2012). A Review of Malaria Vaccine Clinical Projects Based on the WHO Rainbow Table. Malaria Journal 11.11. 4. "PATH Malaria Vaccine Initiative: The need for a vaccine." PATH Malaria Vaccine Initiative. N.p., n.d. Web. 28 Nov. 2012. 5. Geoffrey, T., & Greenwood, B. (2008). Malaria vaccines and their potential role in the elimination of malaria. Malaria Journal, 7. 6. Mutabingwa , T. (2005). Artemisinin-based combination therapies (ACTs): best hope for malaria treatment but inaccessible to the needy! Acta Trop, 95(3). 7. WHO (n.d.). Malaria Transmission Blocking Vaccine: an ideal public good. Special Programme for Research & Training in Tropical Disease. 8. PATH Malaria Vaccine Initiative. (n.d.). Retrieved from

http://www.malariavaccine.org/files/MVI-brief-RandD-strategy-FINAL-web.pdf 9. Moorthy, V., & Ballou, R. (2009). Immunological Mechanisms Underlying Protection Mediated by RTS,S: a review of the available data. Malaria Journal, 8(312). 10. Milstein, J., & Crdenas, V. (2010). WHO policy development processes for a new vaccine: case study of malaria vaccines. Malaria Journal, 9. 11. PATH Malaria Vaccine Initiative: Advocacy fellowship. (n.d.). PATH Malaria Vaccine Initiative. Retrieved from http://www.malariavaccine.org/preparing-mvaf.php 12. WHO | Malaria. (n.d.). Retrieved from http://www.who.int/mediacentre/factsheets/fs094/en/ 13. The role of vaccine in the prevention of malaria HCDCP. (n.d.). . Retrieved from http://www2.keelpno.gr/blog/?p=2178&lang=en

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