Study Protocol Title: Does Neonatal BCG Immunisation Provide Protection Against Heterologous Invasive Infectious Disease by Stimulating the Innate Immune System? ISRCTN: 59683017 Names of applicants: 1) Dr Sarah Prentice 2) Dr Stephen Cose Position of applicants: 1) Wellcome Trust Clinical Fellow, London School of Hygiene and Tropical Medicine, UK 2) Senior Immunologist, MRC/UVRI Uganda Research Unit on AIDS, Entebbe, UG Lecturer in Immunology, London School of Hygiene & Tropical Medicine, London, UK Hon. Senior Lecturer, Makerere University College of Health Sciences, Kampala, UG Sponsor Professor Alison M. Elliott, Programme Head, MRC/UVRI Uganda Research Unit on AIDS, Entebbe, UG Professor of Tropical Medicine, London School of Hygiene & Tropical Medicine, London, Primary Supervisor Dr Stephen Cose Senior Immunologist, MRC/UVRI Uganda Research Unit on AIDS P.O Box 49, Entebbe, Uganda Lecturer in Immunology, London School of Hygiene & Tropical Medicine, London, UK Hon. Senior Lecturer, Makerere University College of Health Sciences, Kampala, UG Secondary Supervisor Professor Hazel Dockrell Professor of Immunology London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT, UK. Clinical Trial Sponsor London School of Hygiene and Tropical Medicine Collaborating Institutions Dr Moses Muwanga, Medical Superintendent, Entebbe General Hospital, Entebbe, UG Dr Robert Asaba, Medical Superintendent, Kisubi Hospital, Kisubi, UG London School of Hygiene & Tropical Medicine, UK Dr Alexander Drakesmith, Weatherall Institute for Molecular Medicine, Oxford University, Oxford, UK Professor Mihai Netea, University Radboud, Nijmegen, The Netherlands Version 2.4 01/12/14 Page 1 of 49 Study Protocol Table of Contents Summary of proposed work .............................................................................................. 3 Background .......................................................................................................................... 4 Evidence for the non-specific effects of BCG immunisation .................................................... 4 Potential innate immunological mechanisms for the non-specific effects of BCG immunisation ........................................................................................................................................ 5 Rationale for the study ........................................................................................................ 7 Aims/Objectives/Hypotheses ............................................................................................. 7 Methodology ....................................................................................................................... 10 Study design and sampling strategies ................................................................................... 10 Study populations .................................................................................................................. 12 Inclusion criteria ..................................................................................................................... 12 Exclusion criteria .................................................................................................................... 12 Consent and recruitment ........................................................................................................ 13 Randomisation ....................................................................................................................... 14 Blinding .................................................................................................................................. 14 Main outcome measures ........................................................................................................ 15 Data collection methods ......................................................................................................... 16 Study procedures ................................................................................................................... 16 Laboratory methods ............................................................................................................... 18 Sample size determination ..................................................................................................... 19 Ethical considerations ............................................................................................................ 20 Risk-benefit analysis .................................................................................................. 20 Evaluation of alternative study designs ...................................................................... 29 Other ethical considerations ....................................................................................... 30 Clinical Trial oversight and monitoring ................................................................................... 32 Data management .............................................................................................................. 33 Data entry .............................................................................................................................. 33 Analysis plan .......................................................................................................................... 34 Potential limitations; anticipated problems .................................................................... 34 Potential logistical problems .................................................................................................. 34 Potential study design limitations ........................................................................................... 35 Significance of the proposed work .................................................................................. 36 Plans for dissemination .................................................................................................... 37 Time frame .......................................................................................................................... 38 Budget ................................................................................................................................. 38 References ......................................................................................................................... 38 Appendix 1…………………………………………………………………………………………44 Safety reporting procedures………………..……………………………………………...………44 Safety reporting flow chart…………………………………………………………………………47 Version 2.4 01/12/14 Page 2 of 49 Study Protocol Summary of proposed work Studies in Guinea-Bissau suggest that BCG immunisation of low birth-weight infants may protect them against a range of non-mycobacterial infectious disease. This heterologous protection appears to be most within the first few weeks of life, but may also persist longer-term. This finding has yet to be replicated in normal birth-weight infants and in different settings. In addition, the biological mechanism for such effects has not been elucidated. We aim to investigate whether BCG immunisation non-specifically enhances the innate immune system, providing short-term protection against heterologous infection, and that ‘training’ of this response occurs, leading to persistently enhanced innate immune responses to heterologous pathogens. To investigate this we propose a randomised controlled trial of neonates born at Entebbe Grade B and Kisubi Hospitals, comparing infants that are BCG vaccinated at birth with those vaccinated at 6 weeks of age. This delay is within the longest acceptable delay (up to 8 weeks) defined by WHO. Comparison of intervention groups shortly after immunisation and at distant time-points will be carried out to assess: 1) innate cytokine levels following in vitro stimulation with various pathogens and 2) inflammatory alterations in the hepcidin-iron axis. The potential for BCG-induced epigenetic modification of monocytes to produce long-term up-regulation of the innate immune response against heterologous pathogens will also be investigated. Clinical follow-up of all infants will occur until 10 weeks of age. Discovery of a broadly protective effect of neonatal BCG immunisation would have profound implications for public healthcare policy both in Uganda and worldwide. This project could provide evidence to prioritise BCG immunisation for all infants on the first day of life, an EPI goal that is yet to be met. Evidence of protection against heterologous pathogens would also provide important advocacy against the termination of BCG’s use in favour of other anti-tuberculous immunisations. Version 2.4 01/12/14 Page 3 of 49 Study Protocol 1. Background Bacillus Calmette-Guerin (BCG) immunisation, the only currently available tuberculosis (TB) vaccine, is one of the most frequently administered immunisations worldwide with more than 100 million children receiving it per year.1 Although it provides protection against severe forms of TB in children, it has variable efficacy against adult pulmonary disease, with protection generally poor in high-risk areas such as sub-Saharan Africa and Asia.2 There are currently concerted efforts in the scientific community to improve anti-TB protection by either enhancing existing BCG immunisation strategies (e.g. altering strain3 or delaying administration past the neonatal period to allow maturation of immune responses4-7) or by developing an alternative vaccine.8 However, BCG may have other beneficial effects beyond protection against TB. There