Abstract Background The rVSVΔG-ZEBOV-GP vaccine prevented Ebola virus disease when used at 2 × 107 plaque-forming units (PFU) in a trial in Guinea. This study provides further safety and immunogenicity data. Methods and findings A randomised, open-label phase I trial in Lambaréné, Gabon, studied 5 single intramuscular vaccine doses of 3 × 103, 3 × 104, 3 × 105, 3 × 106, or 2 × 107 PFU in 115 adults and a dose of 2 × 107 PFU in 20 adolescents and 20 children. The primary objective was safety and tolerability 28 days post-injection. Immunogenicity, viraemia, and shedding post-vaccination were evaluated as secondary objectives. In adults, mild-to-moderate adverse events were frequent, but there were no serious or severe adverse events related to vaccination. Before vaccination, Zaire Ebola virus (ZEBOV)–glycoprotein (GP)–specific and ZEBOV antibodies were detected in 11% and 27% of adults, respectively. In adults, 74%–100% of individuals who received a dose 3 × 104, 3 × 105, 3 × 106, or 2 × 107 PFU had a ≥4.0-fold increase in geometric mean titres (GMTs) of ZEBOV-GP-specific antibodies at day 28, reaching GMTs of 489 (95% CI: 264–908), 556 (95% CI: 280–1,101), 1,245 (95% CI: 899–1,724), and 1,503 (95% CI: 931–2,426), respectively. Twenty-two percent of adults had a ≥4-fold increase of ZEBOV antibodies, with GMTs at day 28 of 1,015 (647–1,591), 1,887 (1,154–3,085), 1,445 (1,013–2,062), and 3,958 (2,249–6,967) for the same doses, respectively. These antibodies persisted up to day 180 for doses ≥3 × 105 PFU. Adults with antibodies before vaccination had higher GMTs throughout. Neutralising antibodies were detected in more than 50% of participants at doses ≥3 × 105 PFU. As in adults, no serious or severe adverse events related to vaccine occurred in adolescents or children. At day 2, vaccine RNA titres were higher for adolescents and children than adults. At day 7, 78% of adolescents and 35% of children had recombinant vesicular stomatitis virus RNA detectable in saliva. The vaccine induced high GMTs of ZEBOV-GP-specific antibodies at day 28 in adolescents, 1,428 (95% CI: 1,025–1,989), and children, 1,620 (95% CI: 806–3,259), and in both groups antibody titres increased up to day 180. The absence of a control group, lack of stratification for baseline antibody status, and imbalances in male/female ratio are the main limitations of this study. Conclusions Our data confirm the acceptable safety and immunogenicity profile of the 2 × 107 PFU dose in adults and support consideration of lower doses for paediatric populations and those who request boosting. Trial registration Pan African Clinical Trials Registry PACTR201411000919191

Author summary Why was this study done? The worst Ebola outbreak in history ended in 2016 after killing about 11,323 individuals and infecting 28,650 individuals worldwide.

This public health emergency accelerated efforts to develop a vaccine as part of the strategy to contain the outbreak.

Two vaccine candidates with preclinical safety and efficacy data obtained from non-human primates entered human trials.

The one used in our study is the rVSV Δ G-ZEBOV-GP vaccine, containing a non-infectious portion of a gene from the Zaire Ebola virus introduced into a recombinant vesicular stomatitis virus (rVSV), which itself is unlikely to cause disease in humans.

G-ZEBOV-GP vaccine, containing a non-infectious portion of a gene from the Zaire Ebola virus introduced into a recombinant vesicular stomatitis virus (rVSV), which itself is unlikely to cause disease in humans. To generate data for deployment of the vaccine, several dose-ranging phase I trials were initiated across centres in the United States, Europe, and Africa. What did the researchers do and find? We allocated 115 adults aged 18–50 years to receive 1 of the 5 doses used in the trial. A single intramuscular dose ranging from 3 × 10 3 to 2 × 10 7 plaque-forming units (PFU) was given, and participants were followed up until 6 months post-injection for safety and immunogenicity.

to 2 × 10 plaque-forming units (PFU) was given, and participants were followed up until 6 months post-injection for safety and immunogenicity. Preliminary results led to the selection of the 2 × 10 7 PFU dose for further development.

PFU dose for further development. We also included 20 adolescents (13–17 years) and 20 children (6–12 years), who received the 2 × 10 7 PFU dose and were followed-up in a similar way as the adults.

PFU dose and were followed-up in a similar way as the adults. No vaccine-related serious or severe adverse event was reported by any participant.

A high proportion of our population—even though residing in an area with no history of Ebola outbreak—had pre-vaccination antibodies specific to the Zaire Ebola virus.

In adults, antibodies persisted up to 6 months post-injection at doses of 3 × 10 5 to 2 × 10 7 PFU.

to 2 × 10 PFU. In participants with baseline antibodies, a dose as low as 3 × 10 4 PFU could induce high antibody titres up to day 56 post-injection.

PFU could induce high antibody titres up to day 56 post-injection. Higher vaccine replication, leading to shedding of the vaccine in saliva and urine, occurred in children and adolescents. What do these findings mean? Our results and other findings show that this vaccine is safe and immunogenic.

Lower vaccine doses may be needed in paediatric populations as well as for boosting after primary vaccination or naturally acquired immunity.

Citation: Agnandji ST, Fernandes JF, Bache EB, Obiang Mba RM, Brosnahan JS, Kabwende L, et al. (2017) Safety and immunogenicity of rVSVΔG-ZEBOV-GP Ebola vaccine in adults and children in Lambaréné, Gabon: A phase I randomised trial. PLoS Med 14(10): e1002402. https://doi.org/10.1371/journal.pmed.1002402 Academic Editor: Lorenz von Seidlein, Mahidol-Oxford Tropical Medicine Research Unit, THAILAND Received: March 21, 2017; Accepted: September 7, 2017; Published: October 6, 2017 This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication. Data Availability: Metadata used to generate the results of this manuscript have been submitted to the Dryad Digital Repository: https://datadryad.org/resource/doi:10.5061/dryad.n515p. http://dx.doi.org/10.5061/dryad.n515p. Funding: The Universitätsklinikum Tübingen in Germany was the clinical sponsor of the trial. Funds for conduct of the trial and for sponsorship costs were provided by the Wellcome Trust (UK), SPHQ14-LOA-255, SPHQ15-LOA-007 (44%), the Bill & Melinda Gates Foundation (US), SPHQ14-LOA-327-REV1, SPHQ14-LOA-327 (30%), Bundesministerium für Gesundheit (BMG, Germany), ZMV I 5-25 14 NIK (11%), the German Center for Infection Research (DZIF), 402-3-04-25 (11%), and the Land Baden-Württemberg (4%). VM and MK, representing the WHO, declare partial support for the study from the Wellcome Trust and the Bill and Melinda Gates Foundation. Funding for work at USAMRIID was also provided by the US Department of Defense (DoD) Medical Countermeasure Systems' Joint Vaccine Acquisition Program (MCS-JVAP). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing interests: The authors of this manuscript have the following competing interests: VM and MK, representing the WHO, declare partial support for the study from the Wellcome Trust and the Bill and Melinda Gates Foundation. Declare no further conflict of interest. SK is a member of the Editorial Board of PLOS Medicine. There are no further potential conflicts of interests to declare. Abbreviations: AEU, arbitrary enzyme-linked immunosorbent assay units; CERMEL, Centre de Recherches Médicales de Lambaréné; ELISA, enzyme-linked immunosorbent assay; EVD, Ebola virus disease; GMT, geometric mean titre; GP, glycoprotein; IQR, interquartile range; Nab, neutralising antibody; PFU, plaque-forming units; PsVNA50, pseudovirion neutralisation assay 50%; rVSV, recombinant vesicular stomatitis virus; USAMRIID, US Army Medical Research Institute of Infectious Diseases; VSV, vesicular stomatitis virus; WHO, World Health Organization; ZEBOV, Zaire Ebola virus

Introduction The western African Ebola virus disease (EVD) public health emergency of international concern ended in June 2016 [1], after infecting approximately 28,650 individuals, of whom 11,323 died [2,3]. Global commitment led to landmarks in vaccine development against EVD, with 8 candidates out of 15 undergoing evaluation in phase I–III clinical trials worldwide by the end of 2015 [4–6]. A live-attenuated recombinant vaccine consisting of the vesicular stomatitis virus (VSV), strain Indiana, with the gene for the Kikwit-95 Zaire Ebola virus (ZEBOV) glycoprotein (GP) replacing the VSV glycoprotein (G) had given acceptable results in non-human primate challenge models and was selected for accelerated clinical development. In European and African populations, the VEBCON Consortium (VSV-EBola CONsortium) carried out parallel dose-escalation phase I trials of the recombinant VSV (rVSV)–ZEBOV candidate vaccine in Germany (NCT02283099), Kenya (NCT02296983), and Gabon (PACTR2014000089322) and a double-blind phase I/II randomised controlled trial in Switzerland (NCT02287480). Three further phase II/III trials were later launched in Guinea, Sierra Leone, and Liberia. Results from phase I trials in the US [7] and preclinical data supported selection of the 2 × 107 plaque-forming units (PFU) dose as the most immunogenic for phase IIb/III trials in Guinea, Sierra Leone, and Liberia. A final analysis of the Guinea trial showed that a single dose of 2 × 107 PFU given immediately after contact with an index case was 100% (95% CI: 70%–100%, P = 0.0045) efficacious in preventing EVD in individuals, and protected the population through a ring vaccination strategy 10 days or more post-vaccination [8]. Detailed dose-ranging studies (3 × 105, 3 × 106, 1 × 107, 2 × 107, and 5 × 107 PFU) at the 4 VEBCON sites showed acceptable safety, dose-dependent reactogenicity [9], and high seroconversion rates among all participants on day 28 after vaccination [9,10]. In Gabon, 2 seroprevalence studies in epidemic and non-epidemic regions showed varying proportions of participants with pre-vaccination ZEBOV-specific IgG antibodies [11,12]. In Lambaréné, with no reported EVD outbreak, ZEBOV-GP-specific antibody responses after vaccination were similar at 2 tested doses (3 × 105 and 3 × 106 PFU) [9]. This finding contrasted with that in vaccinees in Geneva, where antibody titres at 3 × 105 PFU were significantly lower than responses to higher vaccine doses, including 1 × 107 PFU and 5 × 107 PFU [10]. Additionally, irrespective of vaccine dose, delayed oligoarthritis and skin and mucous membrane lesions emerged as vaccine-related adverse events in a proportion of recipients more than 1 week after vaccination in Geneva [10]. These delayed complications were not observed in Gabon, despite the fact that the same vaccine batch and similar doses were used [9]. Because of these divergent site-specific observations, we need further assessments of the vaccine in Ebola virus endemic areas as well as in children. We present a comparison of safety and immunogenicity outcomes in participants vaccinated with (1) 2 × 107 PFU, the dose used in the efficacy trial; (2) 2 previously reported doses, 3 × 106 and 3 × 105 PFU [9]; and (3) 2 lower doses, 3 × 104 PFU and 3 × 103 PFU, in African adults. Furthermore, we report, to our knowledge for the first time, on children and adolescents aged 6 to 17 years vaccinated with 2 × 107 PFU.

Methods Study design and participants The trial protocol was approved by the Scientific Review Committee of Centre de Recherches Médicales de Lambaréné (CERMEL), the Institutional Ethics Committee of CERMEL, the National Ethics Committee of Gabon, the World Health Organization (WHO) Ethics Committee, and the Institutional Ethics Committee of the Universitätsklinikum Tübingen. The trial was registered with the Pan African Clinical Trials Registry (PACTR201411000919191). The study was a randomised, open-label, dose-escalation phase I trial at CERMEL in Gabon. The trial was initially designed to escalate doses to 3 × 105, 3 × 106, and 2 × 107 PFU in 60 adults. After successive protocol amendments, a total of 115 adults (18–50 years), 20 adolescents (13–17 years), and 20 children (6–12 years) were enrolled, between 17 November 2014 and 7 July 2015. Written informed consent was obtained from adults and parents/guardians of adolescents/children, and written assent from minors aged 11–17 years, prior to study-related procedures (details are in S3 Text). Healthy consenting volunteers who were aged 6–50 years and resident in the study area—which had no history of an Ebola outbreak—and willing to minimise blood/body fluid exposure to their relatives for 5 days post-vaccination were included. Field workers used the door-to-door approach to invite individuals from the Lambaréné community to screen for the study. After screening, individuals with a history of severe local or systemic allergic reaction to vaccination, known allergy to constituents of the rVSVΔG-ZEBOV-GP vaccine, or any acute or chronic clinically significant medical or psychiatric condition were excluded. All pregnant and lactating women were excluded. Volunteers who received a licensed vaccine within 14 days (or 30 days for a live vaccine), had a history of blood donation within 60 days prior to vaccination, were positive for HIV and/or hepatitis B or C virus infection, or had an immunocompromised member in the family were also excluded from the study. Randomisation and treatment allocation Randomisation and allocation was performed by an independent investigator from 17 November 2014 until 13 April 2015 using a web-generated sequence. Randomisation in permuted blocks was performed in 2 stages. In the first, participants were assigned in a ratio of 1:1:1 to 3 × 105, 3 × 106, and 2 × 107 PFU, and in the second stage, in a ratio of 1:1 to 3 × 103 and 3 × 104 PFU. On 9 December 2014, a temporary consortium-wide safety hold was placed on doses above 1 × 107 PFU due to adverse events reported at the Swiss site with doses of 1 × 107 and 5 × 107 PFU. In Gabon, only 1 participant had been allocated to the 2 × 107 PFU dose. In all, 20, 20, 1, 20, and 20 adults were randomised to a vaccine dose of 3 × 105, 3 × 106, 2 × 107, 3 × 103, and 3 × 104 PFU, respectively. Preliminary data from the 20 participants vaccinated with 3 × 105 PFU and the initial 19 vaccinated with 3 × 106 PFU were previously reported [9]. An unblinded safety review of VEBCON Consortium trials by the data and safety monitoring board lifted the safety hold on 5 January 2015. After this and during the third stage of the study, 19 adults were vaccinated with 3 × 106 PFU without randomisation. In addition, Merck Sharp & Dohme selected the 2 × 107 PFU dose for further development, as being the most immunogenic dose with an acceptable safety profile (S. Gupta, oral presentation at the WHO Ebola Research and Development Summit, 11–12 May 2015, Geneva) [13,14]. A subsequent amendment included 20 adolescents and 20 children aged 13 to 17 years and 6 to 12 years, respectively, to be vaccinated with 2 × 107 PFU. The National Ethics Committee of Gabon recommended that adults from this population should be vaccinated with the intended dose before administration to the paediatric cohorts, so an additional 15 adults were included in the study (S3 Text). Vaccine and vaccination procedures The rVSVΔG-ZEBOV-GP vaccine, developed by the Canadian National Laboratory under the patent number WO2004011488 A2 and licensed to BioProtection Systems (NewLink Genetics), was the unique intervention in this trial. The vaccine was subsequently sublicensed to Merck and was manufactured at IDT Biologika (Dessau-Rosslau, Germany). WHO supplied single-dose vials of 1 × 108 PFU (lot no 0030513) to conduct the trial at CERMEL, from a donation of rVSVΔG-ZEBOV-GP by the Canadian government to WHO. The dispensed vials were reconstituted in serial dilutions for vaccination. A single injection of 1 ml of the reconstituted vaccine for the required dose was administered intramuscularly into the deltoid muscle of volunteers at vaccination (S1 Fig). Safety assessments The nature, frequency, and severity of adverse events constituted the primary safety endpoint of the trial. Local and systemic reactogenicity symptoms and signs (solicited adverse events) were recorded for 14 days post-injection. Unsolicited adverse events, including laboratory anomalies, were recorded up to 28 days post-injection. Detailed descriptions of all serious adverse events were recorded throughout the study follow-up visits, as a secondary safety endpoint. Solicited adverse events (pain, swelling, redness) were obtained by direct examination of the injection site, or direct questioning when follow-up occurred by telephone. Arthralgia and arthritic symptoms were later added as a solicited adverse event upon the request of the data and safety monitoring board. Participants were asked specifically if they were experiencing these symptoms. rVSVΔG-ZEBOV-GP viraemia and shedding Plasma, saliva, and urine samples (at screening and days 1, 2, and 7 post-vaccination) were processed and stored in Trizol LS at the study site, until rVSVΔG-ZEBOV-GP viral load determinations were performed by reverse transcriptase quantitative PCR as a secondary outcome. The lower limit of detection for rVSVΔG-ZEBOV-GP RNA was 30 copies/ml, and the lower level of quantification was 100 copies/ml [9]. Immunological assessments As a secondary objective, enzyme-linked immunosorbent assays (ELISAs) were performed on days 0, 28, 56, 84, and 180 after injection. ZEBOV-specific antibody assays were conducted at the Institute for Virology, Marburg. Antibodies were detected using an antibody capture ELISA based on inactivated Ebola Zaire Makona virus particles [15]. ELISA for ZEBOV-GP-specific antibodies was performed at the US Army Medical Research Institute of Infectious Diseases (USAMRIID) using the Kikwit-95 ZEBOV strain GP (standard operating procedure AP-03-35-00). Antibodies were reported as geometric mean titres (GMTs), or geometric mean concentrations, of arbitrary ELISA units (AEU) per millilitre with 95% confidence intervals, as indicated. Neutralising antibodies (Nabs) were detected using either particles of Ebola virus (Zaire isolate Mayinga, AF086833), with the assays being performed in a BSL4 laboratory (Institute for Virology, Marburg), or VSV pseudovirions expressing the luciferase reporter gene complemented by GP from the Kikwit-95 ZEBOV strain, with assays being performed at USAMRIID. All 4 assays were previously reported by our team [9,15] and other researchers working on this candidate vaccine in the US [7]. Statistical analysis WHO estimated that a sample size of 74–124 participants would be needed across the VEBCON Consortium sites to show a 2-fold change in ZEBOV-specific antibody titres between vaccine doses and proposed a target sample size of approximately 250 participants for all sites [10]. We described the frequency and intensity of adverse events using counts and percentages, means and standard deviations, or medians and interquartile ranges (IQRs), for skewed continuous variables. Chi-squared test or Fisher’s exact test was used to compare pairwise proportions. Seropositivity rates were defined as the percentage of participants having AEU above a cutoff per vaccine group. Seroconversion rates were defined as the percentage of converted participants in each group. McNemar’s test was used to compare the seropositivity between day 0 and other days. We used Fisher’s test to perform inter-group comparisons and to determine the association between the seroconversion rate and seropositivity rate at each time point. Antibody concentrations or units were normalised using log transformations, and responses are reported as GMTs with 95% confidence intervals or geometric mean of AEU per millilitre with 95% confidence intervals. Student’s test or Wilcoxon’s paired test was used to compare magnitudes of antibody induced between day 0 and other days. All statistical analyses were conducted in R statistical software version 3.1.2 [16], except for viraemias (copies/millilitre of plasma), which were analysed with a Kruskal–Wallis test combined with Dunn’s multiple comparison test using GraphPad Prism version 6.

Discussion Although the 2014–2016 EVD emergency in western Africa has ended, the increasing mobility of people between remote and urban areas and the weak health systems in Ebolavirus endemic countries suggest that a future outbreak could reassert itself as a major international threat [17,18]. Risks include increased human-to-human secondary transmission as in the recent epidemic [19] as well as continuing transmission after recovery. Halting transmission by vaccination will be key in curbing future outbreaks [20]. The rVSVΔG-ZEBOV-GP and ChAd3-ZEBOV vaccine candidates were selected by WHO in August 2014 for fast track clinical evaluation [6]. As part of these efforts, we examined a range of doses for rVSVΔG-ZEBOV-GP in adults as well as safety and immunogenicity in children. As reported earlier, rVSVΔG-ZEBOV-GP doses of 3 × 105 and 3 × 106 PFU were well tolerated by 39 Lambaréné participants until day 28 and were safe up to 6 months [9]. Comparable to studies in Guinea [21] and US adults [7], transient cases of arthralgia were reported after vaccination [9,21,22], but no case of arthritis. In Kilifi, Kenya, there were 2 self-limiting, low-severity, and short-duration cases of arthritis [9,23]. This contrasts with a higher frequency of vaccine-induced arthritis (24%), dermatitis (9.8%), and vasculitis (2%) in Geneva [9,10,24] and more recently in Canada, the US, and Spain [25]. There may be similarities between rVSVΔG-ZEBOV-GP vaccine and rubella vaccine, which also causes transient arthritides in some populations [26–28]. Ongoing studies are investigating the potential mechanisms by which rVSVΔG-ZEBOV-GP vaccine might disseminate into peripheral tissues and induce arthritides in specific hosts. The magnitude of innate immune responses to rVSVΔG-ZEBOV-GP vaccine correlated with the peak of rVSV RNA at day 1 in vaccinees of both Geneva and Lambaréné cohorts [29]. Importantly, high-dose vaccinees who experienced arthritis in Geneva had a significantly lower magnitude of early immune response compared to high-dose vaccinees who did not experience arthritis. These findings suggest that early and appropriate (in nature and magnitude) innate immune responses play a key role in limiting viral replication and dissemination to tissues and thus prevent the risk of arthritis. With lower vaccine dose (3 × 105 PFU), the strength of early innate immune responses was similar in cases both with and without arthritis. Thus, rVSV-ZEBOV-induced arthritis may occur through mechanisms related to either vaccine dose or underlying factors that influence immune responses in vaccinees [29]. We observed higher and persistent viraemia in children and adolescents as well as shedding in saliva and urine, in contrast to the very low proportions or no shedding previously reported in the saliva of American and European adults vaccinated with 3 × 106 to 5 × 107 PFU [7,9,10]. The shedding in saliva did not correlate with oral symptoms. Although no alarming symptoms have been detected so far, our finding suggests that a vaccine dose of 2 × 107 PFU exposed the paediatric population to prolonged or uncontrolled viraemia, with potential to disseminate to peripheral tissues. Specific studies are needed to elucidate the underlying mechanisms prolonging viraemia and causing shedding, such as differences in innate responses to vaccine between adults and younger participants. It is also necessary to assess any potential dissemination of rVSV-ZEBOV among household members of vaccinated children. We observed dose-dependent antibody responses to the rVSVΔG-ZEBOV-GP vaccine. A very low dose (≤3 × 103 PFU) did not generate antibodies measured with either whole-virion or ZEBOV-GP-specific ELISA. In all individuals vaccinated with 3 × 104, 3 × 105, 3 × 106, and 2 × 107 PFU, the vaccine induced significant increases in ZEBOV-GP-specific antibodies measured by ZEBOV-GP ELISA alone for 3 × 104 PFU and by both whole-virion and GP ELISAs for the other vaccine doses. The highest GMTs were observed with 2 × 107 PFU irrespective of the ELISA method used. As previously reported [9,11,12], our participants harboured naturally acquired antibodies against ZEBOV, or possibly related viruses. Western blot analysis of sub-samples showed that these antibodies were directed more often against nucleocapsid and matrix proteins of ZEBOV and not against GP. Nonetheless, 11% of our adults had ZEBOV-GP-specific antibodies before vaccination using the GP-specific ELISA. Individuals with baseline antibodies developed higher antibody titres with a dose as low as 3 × 104 PFU compared to those without. The vaccine may have elicited higher titres of antibodies in the presence of natural GP-specific antibodies but also in the presence of antibodies directed against other viral components including nucleocapsid and matrix proteins (detected in baseline sera of some study participants) [9]. In adults, vaccine-induced antibodies peaked at day 56 and declined slowly by day 180. In children and adolescents, who showed high viraemia at day 2 and shed the vaccine until day 7, antibody titres increased until day 180. The kinetics of antibodies after vaccination may be affected by the specificity of pre-existing antibodies, and persistent vaccine replication may enhance immunogenicity. Also, the highest titres of Nabs against Ebola virus, which paralleled those against VSV pseudovirions, were generated at day 28 post-injection, regardless of baseline seropositivity. The relative roles of neutralising, GP, and non-GP antibodies in protection against EVD remain undefined, so it is difficult to draw conclusions on the clinical significance of correlations between GP-binding and neutralising antibodies produced after vaccinations. The vaccine dose of 2 × 107 PFU showed the optimal safety versus immunogenicity balance in our adult cohorts as well as in the Geneva and Hamburg cohorts [29,30]. These findings support the choice to use this dose in the context of outbreaks [8]. However, our data cannot explain the protection induced by the vaccine within 10 days observed in a phase III trial in Guinea [8] as the seroconversion rates and antibody titres were very weak before day 28 irrespective of the vaccine dose. Innate immune components induced immediately after vaccination may have played an important role in early protection. A recent study demonstrated the direct influence of innate immune responses on this vaccine’s safety and immunogenicity [29], a finding which supports the interest in assessing the efficacy of this vaccine beyond Zaire ebolavirus spp. as innate mechanisms can be cross-reactive. Lower doses could be considered in vaccination strategies for children and individuals with impaired innate immune responses to control early rVSV replication. The dose of 3 × 105 PFU generated significantly fewer rVSV RNA copies and shorter rVSV replication cycles but high antibody titres, so is of interest. As an incidental finding in our area, where Ebola virus transmission is endemic, a proportion of participants had antibodies directed against the whole-virus or GP-specific antigen before vaccination [11,12,31]. In those participants, a vaccine dose as low as 3 × 104 PFU induced high antibody titres, suggesting lower vaccine doses should be considered in boosting strategies. There are some limitations of our observations. For example, we cannot relate viral shedding in saliva with the oral symptoms reported by adolescents and children, suggesting that further studies are needed to evaluate this finding. We did not stratify participants based on antibody status at enrolment; future studies in Ebola virus endemic areas where such stratification is inherent in the design will provide insights into the relationships between naturally acquired antibodies and vaccine-induced immune responses and safety. We enrolled very few women across cohorts, leading to imbalances in the male/female ratio in our trial, which may reflect the general reluctance of women to enrol in phase I studies. Our study confirms the acceptable safety and immunogenicity profile of the 2 × 107 PFU dose in adults. However, considering the persistent replication of the rVSVΔGP-ZEBOV-GP vaccine in children and adolescents, further studies investigating lower doses in this population are warranted. In addition, lower vaccine doses should be considered when boosting individuals with pre-existing antibodies.

Acknowledgments We would like to thank all participants of the study, their parents and family members, clinical staff at CERMEL, members of laboratory teams involved in the analysis, and field workers at CERMEL. We thank Pamela Angoissa Minsoko for coordinating the field team. We would also like to acknowledge the contribution by the Canadian government and WHO of the vaccine, and the coordination provided by WHO, as well as the cooperation and support of BioProtection Systems (NewLink Genetics) and Merck during the conduct of this trial. We would also like to thank the members of the data and safety monitoring board and especially its chairman, Prof. Markus Müller, Vienna, Austria, for their support. The VEBCON consortium collaborators are listed as follows: Claire‐Anne Siegrist and Angela Huttner (Geneva University Hospitals, Geneva, Switzerland), Philip Bejon and Patricia Njuguna (Kenya Medical Research Institute, Kilifi, Kenya); Marylyn M. Addo (University Medical Center Hamburg–Eppendorf, Hamburg, Germany); Patricia Fast, Barbara Savarese, and Olivier Lapujade (World Health Organization, Geneva, Switzerland). The opinions, interpretations, conclusions, and recommendations contained herein are those of the authors and are not necessarily endorsed by the US Department of Defense.