Malaria Vaccine:

Current Status

Presenter: Dr Pranav Sopory

Department of Pharmacology
All India Institute of Medical Sciences
New Delhi
Mob: 9999-491-690
email: pranav.sopory@gmail.com
 Contents

1 Burden of Malaria

2 Need of Malaria Vaccine

3 Life Cycle of Plasmodium

4 Types of Malaria

5 Principle Targets of Malaria Vaccine

6 Vaccine currently available

7 Challenges in making an Anti-Malarial Vaccine

8 Newer formulations and their status

9 Ethical Issues
 Burden of Malaria

•
Population at risk Worldwide3.2Parameters
billion

New cases in 2015 214 million

Deaths 438,000

Case Fatality Rate 0.2%

Maximum risk in Africa:

• -90% of all malaria deaths.
• -68% of deaths occur in children under 5 years of age.
 Malaria in India
Confirmed cases (2015) 11,26,661

Reported Deaths (2015) 287

Case Fatality rate (2014) 0.2 %

Population at risk of Transmission 2014 %

(using Parasite Prevalence)
High transmission (> 1 case per 1000 population) 27,55,00,000 22
Low transmission (0–1 cases per 1000 population) 83,89,00,000 67
Malaria-free (0 cases) 13,77,00,000 11
Total 1 25,21,00,000 100

Major Vectors Causes

An. Culicifacies (Rural Malaria)
An. Stephensi (Urban Malaria)
 Need of a Malaria Vaccine :
Drug resistance
Drug Mechanism of Action Cause of resistance
Chloroquine Inhibits haem (by-product of Drug Efflux via PFCRT
Hb metabolism) (Plasmodium Falciparum
Chloroquine-Resistance Transporter)
polymerization
Sulfadoxine(S) + Enzyme Inhibition: Specific gene mutations
Pyrimethamine(P) -DHPS(S) encoding for resistance to
(Antifolates) -DHFR(P both DHPS(S) and DHFR(P)
Atovaquone Inhibition of ETC at the Single-point mutations in
Cytochrome complex the cytochrome-b gene
Artemisinin Kill parasites by activation of Mutations in a gene
free radicals. encoded on P. falciparum
chromosome 13
Primaquine Generates free radicals Unknown
or inhibits ETC.

• Vaccines are the most cost-effective component of public health services.

Life Cycle of Plasmodium

PE

ATV
PRG
S+P

BS

CLQ
ART

PRQ
ART

TBV
 Types of Malaria

Plasmodium Fever Prevalence

Species
P. Falciparum Malignant Tertian Malaria (48 hrs) 65 %

P. Vivax Benign Tertian Malaria (48 hrs) 34 %

P. Malariae Quartern Malaria (72 hrs) Rare

P. Ovale Ovale Tertian Malaria Not found in India

 Principle Targets of Malaria Vaccine

Based on Vector

P. Falciparum P. Vivax

Transmission
Pre-erythrocytic Borne Vaccine
Blood Stage (BS)
(PE)
(TBV)
 Pre-erythrocytic (PE) Vaccine Approach
(against P. Falciparum)

Target Antigen Outcome

CSP (Circumsporozoite Protein) Inhibits sporozoite adhesion to
hepatocyte.
(On the hepatocyte surface: protelytic cleavage at
region 1 of the N-terminus exposes the adhesive part
of , thereby priming the parasites for invasion of the
liver.)

Irradiated Sporozoites Retain their immunogenicity but lose their

virulence

CelTOS (Cell-traversal protein for ookinetes Abolishes hepatocyte entry of the parasite
and sporozoites ) (Present in micronemes that are organelles for parasite
invasive motility. )
 Blood Stage (BS) approach
(against P. Falciparum)

Antigens used Outcome

EBA 175 (Erythrocyte Binding Antigen Inhibits merozoite invasion into

175) erythrocytes via Glycophorin A
MSP 1 (Merozoite Surface Protein 1) Inhibits merozoite invasion into
erythrocytes via Band 3 (Anion Exchanger
1 of the RBC)
AMA 1 (Apical Membrane Antigen 1) Inhibits merozoite interaction with RBC
 Transmission Blocking Vaccine
(against P. Falciparum)

Target Antigen Outcome

Pfs 48/45 Ligand in the fertilisation process
(exact locatin of epitope unknown)

Pfs 230 -same-

 Approaches that target P. Vivax

Antigens used Outcome

CSP (Circumsporozoite Protein) Inhibits sporozoite binding to hepatocyte

DBP (Duffy Binding Protein) Prevents Duffy antigen mediated entry of

merozoites into erythrocytes via DARC
(Duffy Antigen/Receptor Complex)
 RTS,SA (Mosquirix)
Only Anti-Malarial Vaccine approved by European Medicines Agency(EMA) in
July 2015 for use in Malaria endemic regions.

It is also the first vaccine licensed for use against any kind of parasitic disease.

Year Development
1984 Early development of RTS,S
2009 Phase 3 trials conducted in seven African countries
2011 Result of Phase 3 trial published
2014 Result of “Extended” Phase 3 trial published
2015+ WHO gives a positive regulatory approval for use in African countries as
per Local Regulations
 TLD GPI
CSP

RTS

CSP is composed of
• an N-terminal region that binds heparin sulfate proteoglycans
• a central region containing a four-amino-acid (NANP) repeat,
• and a GPI-anchored C-terminal region containing a
thrombospondin-like domain (TLD).

HBsAg particle serves as an carrier for RTS,S, which is fused to

the CSP segment.

Immunogenicity is induced primarily via

• One B cell epitope
• Three T cell epitopes.
Cont.
Recombinant vaccine is expressed in Yeast cells and includes adjuvant
(AS01).
Adjuvant is composed of:
• Monophosphoryl lipid (MPL): binds to TLR-4 and induces innate
immunity.
• Quillaja Saponaira: induces Ig G.
• Emulsion oil: mimics Lipo Polysaccharide (LPS).
Nomenclature
• R: central Repeat region
• T: T cell epitopes
• S: Surface antigen of HBV (HBsAg) attached to C-region
• S: Saccharomyces cerevisiae (Yeast)
• A: Adjuvant
 “Extended” Phase 3 trials
Carried out between March 2009 and January 2014.
Site: 11 centers in 7 countries.
Total of 15,459 children.

Participants:
• Children (Aged: 5-17 months)
• Young Infants (Aged: 6-12 weeks)

Divided into three groups.

Randomly assigned to receive 3 doses of vaccine or a

comparator/contrl at months 0, 1 and 2 and a booster dose at
month 20.

Cont.
Control Vaccine: Rabies Vaccine (also endemic in these
countries)
Control Booster: Meningococcal Vaccine (also prevalent)
Primary Objectives
• Measuring Vaccine Efficacy
• Measuring Vaccine Immunogenicity
• Safety (Adverse Events)

Primary Endpoint:
Occurrence of Clinical Malaria i.e.
• Parasitemia > 5,000/ uL
• Axillary Temperature > 37.5 °C
 Vaccine Efficacy
15,459
participants

6537 Young
8,922 Children
Infants
(Age: 5-17 mo.)
(Age: 6-12 wk.)

No. of cases of No. of cases of

Clinical Malaria Clinical Malaria

C3C R3R R3C C3C R3R R3C

9,585 6,616 7,396 6,170 4,993 5,444

Vaccine Efficacy VE VE VE
36.3% 28.3% 25.9% 18.3%
 Vaccine Efficacy (w.r.t. Severe Malaria)

15,459
participants

6,537 Young
8,922 Children
Infants
(Age: 5-17 mo.)
(Age: 6-12 wk.)

No. of cases of No. of cases of

Severe Malaria Severe Malaria

C3C R3R R3C C3C R3R R3C

171 116 169 116 96 104

Vaccine
VE VE VE
Efficacy
1.1% 17.3% 10.3%
32.2%
 R3R
Vaccine Immunogenicity Children
318.2 EU/ml

(Age: 5-17 mo.)

R3C
Measured at 1 34.2
month after
booster dose R3R
169.9
Young Infants
(Age: 6-12 wk.)
R3C
Anti-CSP Antibody 6.2
(Measured via
ELISA) R3R
52.4
Children
(Age: 5-17 mo.)
R3C
19.3
12 Months after
booster dose
R3R
15.9
Young Infants
(Age: 5 -17 mo.)
R3C
3.7
 Safety

Adverse Effects
(within 30 days)

Children Young Infants

(Age: 5-17 mo.) (Age: 6-12 wk.)

R3R+R3C C3C R3R+R3C C3C

86.1% 86.8% 79.4% 89.3%

Adverse Events:
• Local site reactions (Pain, redness and swelling )
• Drowsiness
• Irritability
• Loss of appetite
• Fever (Most common symptom)

Serious Adverse Events:

• Meningitis
• Febrile Convulsions
 Fever

Children Young Infants

(Age: 5-17 mo.) (Age: 6-12 wk)

Fever Grade 3 fever Fever

(>37.5 °C) (>39 °C) (<37.5 °C)

R3R+R3C C3C R3R+R3C C3C R3R+R3C C3C

31.1% 13.4% 2.5% 1.1% 30.6% 21.1%

Challenges in making an Anti-Malarial Vaccine

Applying the Traditional Approach

Animal Models

Waning Effect of Vaccines

 1. Applying the Traditional Approach
• Traditional approaches to vaccine production include
inoculation via:
Live Attenuated Vaccine
Killed Whole organisms

• Traditional Methods have failed. All Plasmodium species have

distinct forms in both human and mosquito stages for their
life cycle.

• Preventing PE stage from initiating is the only method that

wards off sign and symptoms of Malaria.
 2. Animal Models

• Good Model: Pathological and clinical alterations should mimic the

human response.
• Humans have a diverse genetic background that has a profound
influence on the immune response.
• Most animal models: Inbred and homogenous.
• Data resulting from experimental does not automatically
extrapolate to the disease in humans
• Apart from RTS,S, other vaccine attempts have not been successful”
based on mouse models.
• This limitation can be solved by the use of outbreed large animal
models that are more closely related to humans, like dogs and non-
human primates.
• Aotus Gri-sei-membra represents the best current malaria primate
model because of its high susceptibility to infection by blood forms
and sporozoites of both species of Plasmodium
 3. Waning Effect of Vaccines

Vaccine Efficacy

Phase 3 Trials Extended Phase

(1 year after 3 Trials
booster dose) (2009-2014)

Children Young Infants Children Young Infants

(Age: 5-17 mo.) (Age: 6-12 wk.) (Age: 5-17 mo.) (Age: 6-12 wk.)

55.8% 31.3% 28% 18%

Newer Projects in India
and their status

JAIVAC-1

JAIVAC-2

PvDBP II

PfCHMI
 JAIVAC-1
Indication Plasmodium Falciparum Malaria
Target Antigen RECOMBINANT VACCINE
-PfMSP-119
-PfF2 (receptor-binding F2 domain of EBA175)
Route Intramuscular
Adjuvant Montanide (oil emulsion)
Clinical Development Phase 1 complete (April 2015)
Dose Three doses (10 μg, 25 μg and 50 μg of each antigen) on Day 0, Day
28 and Day 180
Study Endpoint -Assessment of safety of the study vaccines
-Check Immunogenicity of the Antigen
Results -No serious side effect noticed.
-All subjects sero-converted for PfF2 but elicited poor immune
response to PfMSP-119.
-The antibodies against PfF2 were predominantly of IgG1 and IgG3
isotype.
Conclusion Antigen PfF2 should be retained as a component of a malaria
vaccine but PfMSP-119 construct needs to be optimised (improve
efficiency) to improve its immunogenicity.
Anti-PfF2 and PfMSP-119 antibody levels measured by ELISA in sera collected
from Day 0 to Day 365
 JAIVAC-2
Indication Plasmodium Falciparum Malaria
Target Antigen RECOMBINANT VACCINE
-PfMSP-Fu24
-PfF2 (receptor-binding F2 domain of
EBA175)
Route Intramuscular

Development Under Manufacture for Phase 1 trials

Biological Rationale PfMSP-Fu24 (Fu: Fusion):

Chimeric fusion between PfMSP-119 and
PfMSP-3 that contains a T-helper epitope
and B-cell epitope
Pre-Clinical Study Increased Efficacy (Unpublished Data)
 PvDBP II
Indication Plasmodium Vivax Malaria
Target Antigen PvDBP II :
39 kDa cysteine rich region on the Duffy
Binding Protein of P. Vivax
Route Intramuscular

Development Under manufacture

Biological Rationale PvDBP II is a critical domain necessary for

interaction between P. Vivax to the RBC.
Thus, blocking this functionally important
component prevents the erythrocytic
stage of Malaria from occuring.
 PF-CHMI (CONTROLLED HUMAN MALARIA INITIATIVE)
CHMI studies: Healthy volunteers are infected with Plasmodium falciparum to assess the efficacy
of novel malaria vaccines.
Have become a vital tool to accelerate vaccine development.
CHMI studies provide a cost-effective way to circumvent the use of large-scale field efficacy
studies.
However, to date few modern CHMI studies have been performed in malaria-endemic countries.

Indication Plasmodium Falciparum Malaria

Study Intervention Sporozites of P. Falciparum NF54 strain
delivered via laboratory reared An.
Stephensi mosquitoes.

Route Anopheles bite on the ventral aspect of

forearm
Objective To standardize the CHMI model in India

Biological Rationale Widely accepted as a safe and informative

initial step in evaluating the efficacy of
pre-erythrocytic stage vaccines
 Plasmodium falciparum NF54

• It is a transgenic
Plasmodium parasite that
expresses a luciferase
transgene throughout the
life cycle.
• Luciferase expression is
robust and measurable at
all life cycle stages,
including midgut oocyst,
salivary gland sporozoites
and liver stages Fluorescent Microscopy
 Ethical Issues

•
1. Controlled infection studies
2. Human landing catches
 1. Controlled infection studies
• Participants often experience significant acute symptoms—including fever, headache, joint
and muscle pains, and even cardiac events—which go beyond many definitions of ‘minimal
harm’ that are commonly employed in the ethical assessment of non-therapeutic research
*
• Further, malaria infection studies often involve exposure to blood products via mosquitoes or
injection, which poses the risk of transmitting other infections and prion diseases. Finally, if
participants are able to leave research centres while still infected, this can pose risks to the
wider community. In all cases, participants must be carefully selected and informed.
*

• Such studies should only occur in contexts with access to affordable quality healthcare, high
standards of research conduct, and robust ethical oversight so that the safety of participants is
ensured
*
 2. Human landing catches

• Using human participants act as mosquito ‘traps’.

• Receiving 50–100 mosquito bites in one nightshift
*
• Potential harms to a few individuals are (voluntarily
consented) balanced against benefits to the wider
community
*

• It would nonetheless be ethically preferable to develop

alternative practices that offer no risk to human beings.
*
Thank You