Vaccine 32 (2014) 6556–6562

Contents lists available at ScienceDirect

Vaccine
journal homepage: www.elsevier.com/locate/vaccine

Immunogenicity and safety of the candidate RTS,S/AS01 vaccine

in young Nigerian children: A randomized, double-blind, lot-to-lot
consistency trial
Rich Umeh a,1 , Stephen Oguche b,1 , Tagbo Oguonu a , Simon Pitmang b , Elvis Shu a ,
Jude-Tony Onyia a , Comfort A. Daniyam b , David Shwe b , Abdullahi Ahmad c , Erik Jongert c ,
Grégory Catteau c , Marc Lievens c , Opokua Ofori-Anyinam c , Amanda Leach c,∗
a
University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu, Enugu State, Nigeria
b
Jos University Teaching Hospital, University of Jos, Jos, Plateau State, Nigeria
c
GlaxoSmithKline Vaccines, Rixensart, Belgium

a r t i c l e i n f o a b s t r a c t

Article history: Background: For regulatory approval, consistency in manufacturing of vaccine lots is expected to be
Received 30 April 2014 demonstrated in confirmatory immunogenicity studies using two-sided equivalence trials. This ran-
Received in revised form 3 July 2014 domized, double-blind study (NCT01323972) assessed consistency of three RTS,S/AS01 malaria vaccine
Accepted 17 July 2014
batches formulated from commercial-scale purified antigen bulk lots in terms of anti-CS-responses
Available online 28 July 2014
induced.
Methods: Healthy children aged 5–17 months were randomized (1:1:1:1) to receive RTS,S/AS01 at 0-
Keywords:
1-2 months from one of three commercial-scale purified antigen bulk lots (1600 litres-fermentation
Children
Consistency
scale; commercial-scale lots), or a comparator vaccine batch made from pilot-scale purified antigen bulk
Immunogenicity lot (20 litres-fermentation scale; pilot-scale lot). The co-primary objectives were to first demonstrate
Malaria consistency of antibody responses against circumsporozoite (CS) protein at one month post-dose 3 for the
RTS,S/AS01 three commercial-scale lots and second demonstrate non-inferiority of anti-CS antibody responses at one
Safety month post-dose 3 for the commercial-scale lots compared to the pilot-scale lot. Safety and reactogenicity
were evaluated as secondary endpoints.
Results: One month post-dose-3, anti-CS antibody geometric mean titres (GMT) for the 3 commercial
scale lots were 319.6 EU/ml (95% confidence interval (CI): 268.9–379.8), 241.4 EU/ml (207.6–280.7), and
302.3 EU/ml (259.4–352.3). Consistency for the RTS,S/AS01 commercial-scale lots was demonstrated as
the two-sided 95% CI of the anti-CS antibody GMT ratio between each pair of lots was within the range
of 0.5–2.0. GMT of the pooled commercial-scale lots (285.8 EU/ml (260.7–313.3)) was non-inferior to the
pilot-scale lot (271.7 EU/ml (228.5–323.1)). Each RTS,S/AS01 lot had an acceptable tolerability profile,
with infrequent reports of grade 3 solicited symptoms. No safety signals were identified and no serious
adverse events were considered related to vaccination.
Conclusions: RTS,S/AS01 lots formulated from commercial-scale purified antigen bulk batches induced
a consistent anti-CS antibody response, and the anti-CS GMT of pooled commercial-scale lots was non-
inferior to that of a lot formulated from a pilot-scale antigen bulk batch.
© 2014 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license
(http://creativecommons.org/licenses/by/3.0/).

1. Introduction

The RTS,S/AS01 candidate malaria vaccine targets the Plasmo-

Abbreviations: AE, adverse event; ATP, according-to-protocol; CI, confidence
interval; CS, circumsporozoite; ELISA, enzyme-linked immunosorbent assay; GMT,
dium falciparum circumsporozoite (CS) protein, therefore acting at
geometric mean titre; HBs, hepatitis B surface antigen; Ig, immunoglobulin; MPL, the pre-erythrocytic stage of the parasite life cycle [1]. This is a
monophosphoryl lipid A; QS21, Quillaja saponaria Molina, fraction 21; SAE, serious partially efficacious vaccine, which has shown protection against
adverse event; SAS, Statistical Analysis System. both clinical and severe malaria in young children and infants in a
∗ Corresponding author at: GlaxoSmithKline Vaccines, 1300 Wavre, Belgium.
large phase 3 trial in Africa [2,3], and has an acceptable safety pro-
Tel.: +32 10 85 3263.
file when co-administered with vaccines included in the routine
E-mail address: [email protected] (A. Leach).
1
These authors contributed equally to this work. Expanded Programme on Immunization [2–4].

http://dx.doi.org/10.1016/j.vaccine.2014.07.067
0264-410X/© 2014 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/3.0/).
 R. Umeh et al. / Vaccine 32 (2014) 6556–6562 6557

For regulatory approval of a new vaccine, it is necessary to Written informed consent was obtained from the children’s parents
demonstrate the quality of the manufacturing process, including or guardians. Illiterate parents indicated consent with a thumbprint
consistency in the manufacturing of vaccine lots [5–7]. The assess- and a signature was obtained from an independent literate witness.
ment is expected to be performed in confirmatory immunogenicity
studies using two-sided equivalence trials [8,9]. This study eval- 2.3. Study vaccine
uated the consistency and safety of three different RTS,S/AS01
vaccine lots formulated from commercial-scale purified antigen Each vaccine dose contained lyophilized RTS,S (25 ␮g) reconsti-
bulk lots. The co-primary objectives were to demonstrate lot-to-lot tuted with 500 ␮l of AS01E (referred to elsewhere in this paper as
consistency in terms of anti-CS antibody responses and, if reached, AS01), a liposome-based Adjuvant System containing monophos-
subsequently to demonstrate non-inferiority of the commercial- phoryl lipid A (MPL) and Quillaja saponaria Molina, fraction 21
scale lots to a RTS,S/AS01 vaccine lot derived from pilot-scale (QS21, Antigenics Inc., a wholly owned subsidiary of Agenus Inc.,
purified antigen bulk material. Lexington, Massachusetts, USA). The vaccines were administered
intramuscularly to the deltoid muscle of the left arm and vaccine
recipients were observed for at least 60 min following each vac-
2. Methods
cination with appropriate medical treatment available in case of
anaphylactic shock.
2.1. Study design and ethics
2.4. Study objectives
This was a phase III, randomized, double-blind study (Clinical-
Trials.gov, NCT01323972) conducted at two sites between May
The co-primary objectives of the study were to first demon-
2011 and May 2012: University of Nigeria Teaching Hospital in
strate consistency of anti-CS antibody responses at one month
Enugu, which is located in south-east Nigeria, and Jos University
post-dose 3 for three commercial-scale RTS,S/AS01 lots. If the first
Teaching Hospital in Jos, which is in north-central Nigeria.
primary objective was met, then the second primary objective was
The production scale of the RTS,S purified bulk antigen was
to demonstrate non-inferiority of anti-CS antibody responses at one
increased from 20 litres-fermentation (pilot-plant scale, produced
month post-dose 3 of the RTS,S/AS01 commercial-scale lots com-
in January 2010; hereafter referred to as pilot-scale lot) to 1600
pared to the pilot-scale lot. The safety and reactogenicity of the
litres-fermentation (commercial-scale scale in commercial facili-
vaccine lots were evaluated as secondary endpoints.
ties, produced in October/November 2010; hereafter referred to
as commercial-scale lots). The same starting material was used at
2.5. Immunogenicity assessment
both manufacturing scales, and the components of the final vac-
cine, including the adjuvant system, remained identical. Eligible
Assessment of anti-CS and anti-hepatitis B surface antigen (anti-
children were randomized (1:1:1:1) to receive one of three dif-
HBs) antibody titres were performed at the Centre for Vaccinology,
ferent commercial-scale lots (lot 1, 2 or 3) or the pilot-scale lot
Ghent University, Belgium, on serum samples taken before dose 1
(comparator) of RTS,S/AS01 vaccine according to a 0, 1 and 2 month
and one month after dose 3. Antibodies against CS were measured
schedule.
by evaluating immunoglobulin (Ig) G responses to the CS-repeat
A randomization list was generated by the study sponsor via
region, using a validated enzyme-linked immunosorbent assay
an internet-based system, and treatment allocation at each site
(ELISA) with R32LR as the capture antigen and a threshold for a
was performed using MATEX, a program developed for Statistical
positive titre of 0.5 EU/ml [11]. Anti-HBs antibodies were measured
Analysis System (SAS® ; Cary, NC, USA).
using an in-house sandwich ELISA. The cut-off for seroprotection
The study protocol was approved by the ethics review commit-
was 10 mIU/ml [12].
tee of each study site and by the National Agency for Food and
Drug Administration and Control in Nigeria and Western Institu-
2.6. Safety and reactogenicity assessments
tional Review Board in the USA. Overall, this study was conducted in
accordance with Good Clinical Practice guidelines and all applicable
Solicited local (injection site pain, redness and swelling) and
regulatory requirements, including the Declaration of Helsinki. The
general (drowsiness, irritability, loss of appetite and fever) adverse
trial was conducted in partnership with the PATH Malaria Vaccine
events (AEs) were recorded during the 7-day follow-up, and unso-
Initiative. An Independent Data Monitoring Committee oversaw
licited AEs during the 30-day follow-up, after each vaccine dose.
the study’s progress and safety of the children, assisted by a local
Serious AEs (SAEs) were reported throughout the study. Grade 3
safety monitor (an experienced physician) at each site.
(severe) solicited AEs were defined as follows: pain causing cry-
ing when limb is moved/spontaneously painful, swelling or redness
2.2. Study population >20 mm in diameter, drowsiness that prevented normal daily activ-
ity, irritability (crying that could not be comforted) that prevented
Healthy children aged 5–17 months at the time of first vac- normal activity, loss of appetite (not eating at all), fever with axil-
cination were eligible for enrolment. As phase II evaluation of lary temperature >39.0 ◦ C, or any other AE that prevented normal
RTS,S/AS01 indicated that previous hepatitis B immunization may daily activity. All solicited local reactions were considered causally
influence RTS,S-induced antibody responses in children [10], to be related to vaccination; the relationship of other AEs was classified
eligible for participation, all participants must have received three as possible or not causally related. Fever (temperature >37.5 ◦ C)
doses of hepatitis B vaccine before the study start. Exclusion criteria was evaluated for cause by study investigators.
included a history of an immunodeficient or neurological condi-
tion, acute disease or fever (axillary temperature ≥37.5 ◦ C) at the 2.7. Statistical analyses
time of enrolment, and an acute or chronic, clinically significant
pulmonary, cardiovascular, hepatic or renal functional abnormal- Statistical analyses were performed using SAS version 9.2 on
ity. Chronic administration of immune-modifying drugs was not Windows and StatXact-8.1 procedure on SAS.
permitted. Unapproved use of a drug or vaccine within 30 days A sample size of 80 children per group was planned to have at
before the first study vaccine dose and administration of a licensed least 70 evaluable children in each group (3 lots of commercial-
vaccine within 7 days of the first dose were also exclusion criteria. scale and 1 pilot-scale lot). This sample size had >90% power to
6558 R. Umeh et al. / Vaccine 32 (2014) 6556–6562

Fig. 1. Study profile. Footnote on the exclusion from ATP analyses: 7 subjects were excluded from the ATP analysis due to randomization failure: 5 subjects received 3
injections and were found at unblinding to have received vaccines from the wrong lot, and for 2 subjects one dose of the vaccine was switched due to an error in labelling at
the investigator sites; 9 subjects received concomitant Hepatitis B vaccination in violation of protocol; 8 subjects were excluded for not meeting inclusion criteria: 7 subjects
violated the weight-for-age Z-score criteria after recalculation by the GSK-statistician, and 1 subject was too old for inclusion after comparing the date-of-birth provided by
parents with the date-of-birth provided on the vaccination card; 3 subjects were vaccinated outside the protocol-defined interval for vaccination.

reach the primary endpoint of equivalence of anti-CS antibody non-inferiority criteria were reached, so no type 1 error rate adjust-
responses one month post-dose 3 between the three commercial- ment was proposed; instead the type 2 error rate was adjusted to
scale lots and, if reached, demonstrating non-inferiority of the have sufficient overall power.
pooled commercial-scale lots versus the pilot-scale lot in terms of Safety analysis was conducted on the total vaccinated cohort.
anti-CS antibody response one month post-dose 3, using an alpha The percentage of doses followed by at least one solicited AE and
level of 5% (2-sided). percentage of children with an unsolicited AE were calculated with
Immunogenicity analysis was performed on the according- exact 95% CI.
to-protocol (ATP) cohort for immunogenicity, i.e. those meeting
all eligibility criteria, complying with the procedures defined 3. Results
in the protocol. Anti-CS and anti-HBs antibody geometric mean
titres (GMTs) were calculated with 95% confidence intervals (CIs). 3.1. Study population
Percentages of subjects with seropositive levels of anti-CS antibod-
ies (≥0.5 EU/ml) and seroprotective levels of anti-HBs antibodies A total of 320 children (80 per group) were randomized 1:1:1:1
(≥10 mIU/ml) were determined. Pairwise anti-CS antibody GMT to 3 treatment groups receiving three doses of RTS,S/AS01 vaccine
ratios between the groups and their two-sided 95% CIs were com- from one of three commercial-scale (1600L) lots or a comparator
puted using an ANOVA model on the log10 -transformed titre with group, which received the RTS,S/AS01 vaccine pilot-scale (20L) lot.
the vaccine group as fixed effect. Lot-to-lot equivalence was con- Despite best efforts to monitor the study as frequently as possible
cluded if all three 95% CIs on the GMT ratios were within the during a period of civil unrest in Nigeria, there were deviations
range 0.5–2, ruling out a 2-fold increase/decrease between each which led to the exclusion of 27 of 316 subjects who received all
pair of lots. Non-inferiority of the pooled commercial-scale lots was 3 injections from the ATP analyses. Reasons for not receiving three
demonstrated by evaluating the upper limit of the two-sided 95% vaccine doses and reasons for exclusion from the ATP cohort for
CI of the GMT ratio of comparator pilot-scale lot and the pooled immunogenicity are shown in Fig. 1.
commercial-scale lots. If the upper limit of the two-sided 95% Three children were withdrawn from the study because of
CI was below 2, non-inferiority was concluded. The co-primary migration from the study area, two because of consent withdrawal
endpoints were reached if the three equivalence criteria and the not due to an AE and three were lost to follow-up (Fig. 1). The
 R. Umeh et al. / Vaccine 32 (2014) 6556–6562 6559

Table 1
Demographic characteristics (ATP cohort for immunogenicity).

Commercial-scale Commercial-scale Commercial-scale Pilot-scale lot

lot 1 (N = 72) lot 2 (N = 72) lot 3 (N = 73) (comparator) (N = 72)

Mean age ± SD (months) 9.7 ± 3.2 10.2 ± 3.6 10.1 ± 3.2 10.2 ± 3.0
Mean weight-for-age Z-score ± SD −0.7 ± 1.1 −0.8 ± 1.0 −0.6 ± 1.0 −0.8 ± 0.9
Gender (%), female/male 55.6/44.4 54.2/45.8 42.5/57.5 36.1/63.9

SD, standard deviation; N, number of children.

Table 2 vaccine dose, all children in each group had seroprotective anti-HBs
Assessment of consistency among three commercial-scale vaccine lots in terms
antibody titres (Fig. 2b) and GMTs ranged from 46,384.7 to 74,105
of anti-CS antibody geometric mean titre (GMT) ratios one month after the third
RTS,S/AS01 vaccine dose (ATP cohort for immunogenicity). (Table 3).

Ratio order N Anti-CS antibody GMT ratio

3.3. Reactogenicity and safety
Value 95% CIa

Commercial-scale Lot 1:Lot 2 72:72 1.32 1.06, 1.65 Overall per dose incidences of each solicited local and gen-
Commercial-scale Lot 1:Lot 3 72:73 1.06 0.85, 1.32 eral AE during the 7-day period after vaccination were comparable
Commercial-scale Lot 2:Lot 3 72:73 0.80 0.64, 1.00 among groups (Fig. 3). In each group, pain was the most common
N, number of children with available results. solicited local AE and fever was the most common solicited gen-
a
Equivalence was concluded if all three 95% CIs on GMT ratios were within the eral AE (Fig. 3). There were five reports of grade 3 fever (>39.0 ◦ C);
range 0.5–2, ruling out a 2-fold increase/decrease between each pair of lots.
one following a commercial-scale lot 1 dose (incidence 0.4%; 95%
CI: 0.0–2.3) and four following commercial-scale lot 3 doses (1.7%;
demographic characteristics of the participants were consistent 95% CI: 0.5–4.3). There were no other reports of grade 3 solicited
among groups in terms of mean age and mean weight-for-age Z- local or general AEs.
score; some variability in gender ratios was observed (Table 1). During the 30-day period after vaccination, at least one unso-
licited AE was reported in a similar proportion of children
3.2. Immunogenicity in each group (77.8%, 75.9%, 87.5% and 72.5% of children in
commercial-scale lots 1, 2, 3 and the pilot-scale lot, respectively –
Consistent immune responses were demonstrated for the three Supplementary Table 1); none were of grade 3 intensity and none
commercial-scale lots of RTS,S/AS01: one month after the third vac- were considered causally related to vaccination. The most com-
cine dose, the two-sided 95% CI of the anti-CS antibody GMT ratio monly reported unsolicited AEs were malaria (reported in 36, 35,
between each pair of lots was within the range 0.5–2 (Table 2). Non- 41 and 33 children in commercial-scale lots 1, 2, 3 and pilot-scale
inferiority of the pooled commercial-scale lots to the pilot-scale lot lot, respectively) and respiratory tract infection (27, 23, 27 and 23,
was also demonstrated; the anti-CS antibody GMT ratio, pilot-scale respectively).
lot: pooled commercial-scale lot, was 0.95 (95% CI: 0.79, 1.15). The Thirteen SAEs were reported during the study in eight children
anti-CS antibody GMT was 271.7 EU/ml (95% CI: 228.5, 323.1) for (three children in commercial-scale lot 1, two in lot 2, one in lot
the pilot-scale lot and 285.8 EU/ml (95% CI: 260.7, 313.3) for the 3 group and two in the pilot-scale lot), including four reports of
pooled commercial-scale lot (Table 3). severe/complicated malaria and three sepsis reports. None of the
Before vaccination, anti-CS prevalence was below 3% in all SAEs were considered related to vaccination and all events resolved
groups, with low titres in those who were positive (Table 3). One during the study.
month after the third vaccine dose, all vaccine recipients in each
group were seropositive for anti-CS antibodies (Fig. 2a), with anti- 4. Discussion
CS antibody GMTs ranging from 241.4 EU/ml (95% CI: 207.6, 280.7)
to 319.6 EU/ml (95% CI: 268.9, 379.8) (Table 3). In this phase III, randomized, double-blind study in young
The majority of children in each group (≥91.8%) had sero- Nigerian children, consistency of anti-CS antibody responses
protective anti-HBs antibody titres before vaccination reflecting was demonstrated for the three RTS,S/AS01 vaccine commercial-
prior hepatitis B vaccination (Table 3). One month after the third scale lots. Furthermore, the anti-CS antibody response to

Table 3
Anti-CS antibody seropositivity and anti-HBs antibody seroprotective rates, and geometric mean titres (GMTs) for commercial-scale lots 1, 2 and 3, and the comparator
pilot-scale lot (ATP cohort for immunogenicity).

Group Timing N Anti-CS titre, EU/ml (95% CI) Anti-HBs titre, mIU/ml (95% CI)

≥0.5, % children GMT ≥10, % children GMT

Commercial-scale Lot 1 PRE 72 2.8 (0.3–9.7) 0.3 (0.2–0.3) 95.8 (88.3–99.1) 352.8 (217.1–573.4)
Month 3 72 100 (95.0–100) 319.6 (268.9–379.8) 100 (95.0–100) 54,250.2 (43,293.6–67,979.7)

Commercial-scale Lot 2 PRE 72 0.0 (0.0–5.0) 0.3 (0.3–0.3) 94.4 (86.4–98.5) 202.3 (131.1–312.3)
Month 3 72 100 (95.0–100) 241.4 (207.6–280.7) 100 (95.0–100) 46,067.3 (33,919.2–62,566.2)

Commercial-scale Lot 3 PRE 73 2.7 (0.3–9.5) 0.3 (0.2–0.3) 91.8 (83.0–96.9) 293.7 (170.5–506.1)
Month 3 73 100 (95.1–100) 302.3 (259.4–352.3) 100 (95.1–100) 67,384.7 (52,271.4–86,867.7)

Pooled commercial-scale Lots 1, 2, 3 PRE 217 1.8 (0.5–4.7) 0.3 (0.2–0.3) 94.0 (90.0–96.8) 275.8 (208.4–365.1)
Month 3 217 100 (98.3–100) 285.8 (260.7–313.3) 100 (98.3–100) 55,273.5 (47,508.3–64,308.0)

Pilot-scale (Comparator) Lot PRE 72 1.4 (0.0–7.5) 0.3 (0.2–0.3) 95.8 (88.3–99.1) 313.7 (201.7–487.6)
Month 3 72 100 (95.0–100) 271.7 (228.5–323.1) 100 (95.0–100) 74,105.0 (58,613.6–93,690.7)

N, number of children with available results; PRE, pre-vaccination; Month 3, one month after third vaccine dose.
6560 R. Umeh et al. / Vaccine 32 (2014) 6556–6562

Fig. 2. Reverse cumulative distribution curve for anti-CS and anti-HBs antibody titres one month after the third vaccine dose (ATP cohort for immunogenicity). (A) Anti-CS
antibody titres. (B) Anti-HBs antibody titres.

commercial-scale lots was non-inferior to the response to a 3 multicentre RTS,S/AS01 efficacy trial that is ongoing [15]. Vari-
RTS,S/AS01 pilot-scale lot. ation in immune responses has been described for other vaccines
The anti-CS antibody GMTs observed in this trial one month antigens [16] and is believed to have both host and environmental
after the third dose were 286 EU/ml for the pooled commercial- origins [17,18]. Because we did not assess vaccine efficacy, and in
scale lots and 272 EU/ml for the pilot-scale lot. This was lower than the absence of a control (placebo or non-RTS,S vaccine), the clinical
observed in other RTS,S/AS01 studies of children of the same age, relevance of this finding cannot be directly assessed in the current
using the same validated anti-CS assay [2,13]. The anti-CS antibody trial.
GMT in the phase 3 multicentre efficacy trial was 621 EU/ml (95% Each RTS,S/AS01 lot had an acceptable tolerability profile, which
CI: 592–652) in 5–17 month old children, but this pooled value was in line with observations in the large RTS,S/AS01 phase III trial
masked the substantial variation in anti-CS antibody GMTs by site among children of a similar age [2]. In both studies, the most fre-
which ranged from 348 to 787 EU/ml [14]. Despite this variation, quently reported solicited symptoms were pain and fever and grade
vaccine efficacy was at least 40% for all sites in the phase 3 effi- 3 symptoms occurred infrequently. No safety signals were identi-
cacy trial, and no association was seen at site-level between GMTs fied in the present study and none of the SAEs were considered
and vaccine efficacy. Further understanding of immunological cor- related to vaccination. The most frequently reported unsolicited
relates of protection is expected to be generated from the phase AEs were malaria, respiratory tract infections, diarrhoea, and
 R. Umeh et al. / Vaccine 32 (2014) 6556–6562 6561

100
Commercial-scale lot 1

90 Commercial-scale lot 2

Commercial-scale lot 3
80
Pilot-scale lot (comparator)

70
Percentage of doses

60

50

40

30

20

10

0
Pain Redness Swelling Drowsiness Irritability Loss of appetite Fever
Solicited local AEs Solicited general
AEs
Fig. 3. Frequency of solicited local and general adverse events (overall per dose with 95% CIs) occurring within 7 days of vaccination (total vaccinated cohort).

gastroenteritis in all groups. These are common in children of the of subjects, collection and assembly of data, and provided interpre-
study age group (Malaria-055). tation of the results. M.L. and G.C. were responsible for the statistical
In conclusion, these results confirm that RTS,S/AS01 vaccines analyses. E.J. was responsible for lab analysis. M.L. and A.L. designed
formulated from commercial-scale purified antigen bulk lots are the study. A.A., E.J. M.L., G.C., O.O.A. and A.L. interpreted the results.
produced consistently. Anti-CS antibody responses induced were All authors critically reviewed the manuscript drafts and approved
non-inferior to those induced by the batch made from pilot-scale the final manuscript. Conflict of interest: Tagbo Oguonu reports
purified antigen bulk lot. receiving a salary from PATH-MVI as an investigator on the study
and speaker fees from GlaxoSmithKline outside the work sub-
Acknowledgements mitted. At the time of study conduct, Abdullahi Ahmad was a
WHO/TDR fellow at GlaxoSmithKline vaccines. Erik Jongert, Gré-
The authors would like to thank the children and their families gory Catteau, Marc Lievens, Opokua Ofori-Anyinam and Amanda
for participating in this trial and the investigators, study nurses and Leach are employed by the GlaxoSmithKline group of companies.
other staff members at the study sites. In particular, we thank Dr. E.J., M.L., O.O.A. and A.L, own GlaxoSmithKline stocks/stock options.
Onyema, Mr. L.O. Otiji, Matron Asiegbu, Matron Ofodile, and Matron Funding: This study was funded by GlaxoSmithKline Biologicals SA.
Onwubere, Henrietta Nwankwo, Chizoba Eneagu and Helen Ota,
Abba Joseph, Julie Yusuf, Patience Kadung, Jimmy Dakie, Jericho
Bulus, Ruth Gomper and Samuel Pate, for their contributions to the Appendix A. Supplementary data
study at both study sites.
The authors thank the PATH Malaria Vaccine Initiative, and Supplementary data associated with this article can be
Karen Ivinson in particular, for their support of the local study found, in the online version, at http://dx.doi.org/10.1016/j.vaccine.
sites. The authors also thank, from GlaxoSmithKline Vaccines, Lode 2014.07.067.
Schuerman, Pascale Vandoolaeghe, and Marie-Chantal Uwamwezi
for reviewing drafts of this manuscript, Didier Lapierre for his con-
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