Evaluation of dengue virus strains for human challenge studies.
Discordance between the measured levels of dengue virus neutralizing antibody and clinical outcomes in the first-ever efficacy study of a dengue tetravalent vaccine (Lancet, Nov 2012) suggests a need to re-evaluate the process of pre-screening dengue vaccine candidates to better predict clinical benefit prior to large-scale vaccine trials. In the absence of a reliable animal model and established correlates of protection for dengue, a human dengue virus challenge model may provide an approach to down-select vaccine candidates based on their ability to reduce risk of illness following dengue virus challenge. We report here the challenge of flavivirus-naïve adults with cell culture-passaged dengue viruses (DENV) in a controlled setting that resulted in uncomplicated dengue fever (DF). This sets the stage for proof-of-concept efficacy studies that allow the evaluation of dengue vaccine candidates in healthy adult volunteers using qualified DENV challenge strains well before they reach field efficacy trials involving children. Fifteen flavivirus-naïve adult volunteers received 1 of 7 DENV challenge strains (n=12) or placebo (n=3). Of the twelve volunteers who received challenge strains, five (two DENV-1 45AZ5 and three DENV-3 CH53489 cl24/28 recipients) developed DF, prospectively defined as ≥2 typical symptoms, ≥48h of sustained fever (>100.4°F) and concurrent viremia. Based on our study and historical data, we conclude that the DENV-1 and DENV-3 strains can be advanced as human challenge strains. Both of the DENV-2 strains and one DENV-4 strain failed to meet the protocol case definition of DF. The other two DENV-4 strains require additional testing as the illness approximated but did not satisfy the case definition of DF. Three volunteers exhibited effusions (1 pleural/ascites, 2 pericardial) and 1 volunteer exhibited features of dengue (rash, lymphadenopathy, neutropenia and thrombocytopenia), though in the absence of fever and symptoms. The occurrence of effusions in milder DENV infections counters the long-held belief that plasma leakage syndromes are restricted to dengue hemorrhagic fever/dengue shock syndromes (DHF/DSS). Hence, the human dengue challenge model may be useful not only for predicting the efficacy of vaccine and therapeutic candidates in small adult cohorts, but also for contributing to our further understanding of the mechanisms behind protection and virulence.
Divisions of Viral Diseases, Regulated Activities, Veterinary Services Program, and Pathology, Walter Reed Army Institute of Research (WRAIR), Silver Spring, MD 20910, United States. Electronic address: mammen.mammen@vical.com.
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MP
Mammen
Divisions of Viral Diseases, Regulated Activities, Veterinary Services Program, and Pathology, Walter Reed Army Institute of Research (WRAIR), Silver Spring, MD 20910, United States. Electronic address: Arthur.g.lyons.mil@health.mil.
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Lyons
Divisions of Viral Diseases, Regulated Activities, Veterinary Services Program, and Pathology, Walter Reed Army Institute of Research (WRAIR), Silver Spring, MD 20910, United States. Electronic address: Bruce.2.Innis@gsk.com.
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Innis
Divisions of Viral Diseases, Regulated Activities, Veterinary Services Program, and Pathology, Walter Reed Army Institute of Research (WRAIR), Silver Spring, MD 20910, United States. Electronic address: Wellington.Sun@fda.hhs.gov.
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Sun
Divisions of Viral Diseases, Regulated Activities, Veterinary Services Program, and Pathology, Walter Reed Army Institute of Research (WRAIR), Silver Spring, MD 20910, United States. Electronic address: dmckinney@clinicalrm.com.
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McKinney
Infectious Disease Service, Walter Reed Army Medical Center (WRAMC), Washington, DC 20307, United States. Electronic address: Raymond.Chung@va.gov.
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RC
Chung
Translational Medicine Branch, WRAIR, Silver Spring, MD 20910, United States. Electronic address: Kenneth.h.eckels.civ@mail.mil.
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Eckels
Divisions of Viral Diseases, Regulated Activities, Veterinary Services Program, and Pathology, Walter Reed Army Institute of Research (WRAIR), Silver Spring, MD 20910, United States. Electronic address: JRPutnak@hotmail.com.
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Putnak
Divisions of Viral Diseases, Regulated Activities, Veterinary Services Program, and Pathology, Walter Reed Army Institute of Research (WRAIR), Silver Spring, MD 20910, United States. Electronic address: Niranjan.kanesa-thasan@novartis.com.
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Kanesa-thasan
Divisions of Viral Diseases, Regulated Activities, Veterinary Services Program, and Pathology, Walter Reed Army Institute of Research (WRAIR), Silver Spring, MD 20910, United States. Electronic address: John.Scherer@us.army.mil.
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JM
Scherer
Radiology Service, Walter Reed Army Medical Center (WRAMC), Washington, DC 20307, United States. Electronic address: jstatrad@aol.com.
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Statler
Translational Medicine Branch, WRAIR, Silver Spring, MD 20910, United States. Electronic address: ludmila.asher@us.army.mil.
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Asher
Divisions of Viral Diseases, Regulated Activities, Veterinary Services Program, and Pathology, Walter Reed Army Institute of Research (WRAIR), Silver Spring, MD 20910, United States. Electronic address: Stephen.thomas1@us.army.mil.
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SJ
Thomas
Divisions of Viral Diseases, Regulated Activities, Veterinary Services Program, and Pathology, Walter Reed Army Institute of Research (WRAIR), Silver Spring, MD 20910, United States. Electronic address: D.W.Vaughn@usa.net.
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Vaughn
D000293:Adolescent; D000328:Adult; D003715:Dengue / Q000175:diagnosis / Q000473:pathology*; D003716:Dengue Virus / Q000145:classification* / Q000472:pathogenicity; D004311:Double-Blind Method; D005334:Fever / Q000821:virology; D064368:Healthy Volunteers; D006801:Humans; D014766:Viremia / Q000473:pathology; D055815:Young Adult
Challenge; Dengue; Vaccine; Virus