Using a human challenge model of infection to measure vaccine efficacy: a randomised, controlled trial comparing the Typhoid vaccines M01ZH09 with placebo and Ty21a

Research output: Contribution to journalArticlepeer-review


  • Thomas C Darton
  • Claire Jones
  • Christoph J Blohmke
  • Claire S Waddington
  • Liqing Zhou
  • Anna Peters
  • Kathryn Haworth
  • Rebecca Sie
  • Catherine A Jeppesen
  • Maria Moore
  • Ben A V Thompson
  • Tessa John
  • Robert A Kingsley
  • Ly-Mee Yu
  • Merryn Voysey
  • Zoe Hindle
  • Stephen Lockhart
  • Marcelo B Sztein
  • Gordon Dougan
  • Brian Angus
  • Myron M Levine
  • Andrew J Pollard

Colleges, School and Institutes

External organisations

  • Oxford Vaccine Group, Department of Paediatrics, University of Oxford and the NIHR Oxford Biomedical Research Centre, Oxford, United Kingdom.
  • Microbial Pathogenesis Group, Wellcome Trust Sanger Institute, Hinxton, United Kingdom.
  • Emergent Product Development UK Ltd, Emergent BioSolutions, Wokingham, United Kingdom.
  • Center for Vaccine Development, University of Maryland School of Medicine, Baltimore, Maryland, United States of America.
  • University of Oxford, Nuffield Department of Medicine, Oxford, United Kingdom of Great Britain and Northern Ireland ;
  • Nuffield Department of Primary Care Health Sciences


BACKGROUND: Typhoid persists as a major cause of global morbidity. While several licensed vaccines to prevent typhoid are available, they are of only moderate efficacy and unsuitable for use in children less than two years of age. Development of new efficacious vaccines is complicated by the human host-restriction of Salmonella enterica serovar Typhi (S. Typhi) and lack of clear correlates of protection. In this study, we aimed to evaluate the protective efficacy of a single dose of the oral vaccine candidate, M01ZH09, in susceptible volunteers by direct typhoid challenge.

METHODS AND FINDINGS: We performed a randomised, double-blind, placebo-controlled trial in healthy adult participants at a single centre in Oxford (UK). Participants were allocated to receive one dose of double-blinded M01ZH09 or placebo or 3-doses of open-label Ty21a. Twenty-eight days after vaccination, participants were challenged with 104CFU S. Typhi Quailes strain. The efficacy of M01ZH09 compared with placebo (primary outcome) was assessed as the percentage of participants reaching pre-defined endpoints constituting typhoid diagnosis (fever and/or bacteraemia) during the 14 days after challenge. Ninety-nine participants were randomised to receive M01ZH09 (n = 33), placebo (n = 33) or 3-doses of Ty21a (n = 33). After challenge, typhoid was diagnosed in 18/31 (58.1% [95% CI 39.1 to 75.5]) M01ZH09, 20/30 (66.7% [47.2 to 87.2]) placebo, and 13/30 (43.3% [25.5 to 62.6]) Ty21a vaccine recipients. Vaccine efficacy (VE) for one dose of M01ZH09 was 13% [95% CI -29 to 41] and 35% [-5 to 60] for 3-doses of Ty21a. Retrospective multivariable analyses demonstrated that pre-existing anti-Vi antibody significantly reduced susceptibility to infection after challenge; a 1 log increase in anti-Vi IgG resulting in a 71% decrease in the hazard ratio of typhoid diagnosis ([95% CI 30 to 88%], p = 0.006) during the 14 day challenge period. Limitations to the study included the requirement to limit the challenge period prior to treatment to 2 weeks, the intensity of the study procedures and the high challenge dose used resulting in a stringent model.

CONCLUSIONS: Despite successfully demonstrating the use of a human challenge study to directly evaluate vaccine efficacy, a single-dose M01ZH09 failed to demonstrate significant protection after challenge with virulent Salmonella Typhi in this model. Anti-Vi antibody detected prior to vaccination played a major role in outcome after challenge.

TRIAL REGISTRATION: (NCT01405521) and EudraCT (number 2011-000381-35).


Original languageEnglish
Pages (from-to)e0004926
JournalPLoS Neglected Tropical Diseases
Issue number8
Publication statusPublished - 17 Aug 2016


  • Adult, Antibodies, Bacterial/blood, Double-Blind Method, Female, Healthy Volunteers, Human Experimentation, Humans, Immunoglobulin G/blood, Male, Placebos, Polysaccharides, Bacterial/administration & dosage, Salmonella typhi/immunology, Typhoid Fever/diagnosis, Typhoid-Paratyphoid Vaccines/administration & dosage, Vaccines, Attenuated/administration & dosage, Young Adult