<clinical_study>
  <!-- This xml conforms to an XML Schema at:
    https://clinicaltrials.gov/ct2/html/images/info/public.xsd -->
  <required_header>
    <download_date>ClinicalTrials.gov processed this data on September 20, 2023</download_date>
    <link_text>Link to the current ClinicalTrials.gov record.</link_text>
    <url>https://clinicaltrials.gov/ct2/show/NCT01661933</url>
  </required_header>
  <id_info>
    <org_study_id>AU/3/BOBD012</org_study_id>
    <nct_id>NCT01661933</nct_id>
  </id_info>
  <brief_title>Desensitising Celiac Disease Patients With the Human Hookworm</brief_title>
  <acronym>NaCeD</acronym>
  <official_title>Combining Necator Americanus With Trace Gluten to Restore Tolerance in Coeliac Disease: a Pilot Clinical and a Detailed in Vitro Immunological Study.</official_title>
  <sponsors>
    <lead_sponsor>
      <agency>The Prince Charles Hospital</agency>
      <agency_class>Other</agency_class>
    </lead_sponsor>
    <collaborator>
      <agency>National Health and Medical Research Council, Australia</agency>
      <agency_class>Other</agency_class>
    </collaborator>
  </sponsors>
  <source>The Prince Charles Hospital</source>
  <oversight_info>
    <has_dmc>Yes</has_dmc>
  </oversight_info>
  <brief_summary>
    <textblock>
      We have established that the hookworm Necator americanus (Na) dramatically alters the local&#xD;
      and systemic immune landscape of the infected human host. Consistent with the principle of&#xD;
      desensitisation, diet managed celiac disease subjects previously infected by us with Na will&#xD;
      be invited to receive small incremental doses of gluten as pasta (3-25 mm straw of spaghetti)&#xD;
      over 16 weeks. Each participant will then be carefully re-assessed to determine if it is&#xD;
      appropriate to undertake a 12-week gluten challenge.&#xD;
    </textblock>
  </brief_summary>
  <detailed_description>
    <textblock>
      Hypothesis The adaptive Th2/regulatory profile imposed by Na will promote gluten tolerance&#xD;
      following a micro-dose desensitising programme.&#xD;
&#xD;
      Primary Aim: To determine the safety and efficacy of Na as a tolerising agent in celiac&#xD;
      subjects&#xD;
&#xD;
      Specific Aim 1. Undertake a therapeutic pilot study comparing mucosal histopathology before&#xD;
      and after a gluten challenge, to be preceded by a programmed desensitising micro-challenge&#xD;
      using Na as a tolerising agent.&#xD;
&#xD;
      Specific Aim 2. Assess systemic and mucosal immune responses to gluten micro-challenge, Na&#xD;
      infection, and gluten re-challenge throughout the pilot study, to be referenced against&#xD;
      hookworm-naive people with treated and untreated celiac disease.&#xD;
&#xD;
      Specific Aim 3. Utilising blood and tissue from hookworm-naive celiac disease volunteers,&#xD;
      undertake in vitro studies focusing on the effects of Na-derived excretory/secretory (ES)&#xD;
      products on gluten-stimulated gut mucosal cell apoptosis, cytokine and gene profiles.&#xD;
    </textblock>
  </detailed_description>
  <overall_status>Completed</overall_status>
  <start_date>August 2012</start_date>
  <completion_date type="Actual">March 2014</completion_date>
  <primary_completion_date type="Actual">March 2014</primary_completion_date>
  <phase>Phase 1/Phase 2</phase>
  <study_type>Interventional</study_type>
  <has_expanded_access>No</has_expanded_access>
  <study_design_info>
    <allocation>N/A</allocation>
    <intervention_model>Single Group Assignment</intervention_model>
    <primary_purpose>Prevention</primary_purpose>
    <masking>Single (Outcomes Assessor)</masking>
  </study_design_info>
  <primary_outcome>
    <measure>Duodenal Villus Height:Crypt Depth</measure>
    <time_frame>Week -24 to -36</time_frame>
    <description>Biopsies were fixed in neutral buffered formalin, processed and carefully orientated and embedded in paraffin wax. Sections (3 µm) were stained with H&amp;E. Slides from both time-points were de-identified, shuffled and graded by Dr John Croese after which results from poorly orientated slides were verified by Dr Andrew Clouston. The Vh:Cd ratios were measured on 5 randomly selected well-orientated sites. The null hypothesis is that hookworm infection will not protect against mucosal damage following 12-week exposure to gluten in celiac disease.</description>
  </primary_outcome>
  <secondary_outcome>
    <measure>Intraepithelial Lymphocyte Count</measure>
    <time_frame>Week-24 and -36</time_frame>
    <description>Biopsies were fixed in neutral buffered formalin, processed and carefully orientated and embedded in paraffin wax. Sections (3 µm) were stained with anti-CD3. All slides were de-identified and graded by Dr John Croese. The IEL percentages were measured on 2 or more randomly selected well-orientated villi. The null hypothesis is that hookworm infection will not protect against mucosal IEL influx following 12-week exposure to gluten in celiac disease.</description>
  </secondary_outcome>
  <secondary_outcome>
    <measure>Number of Participants With 2 Points Increase in Marsh Score Post GC-1g</measure>
    <time_frame>Longitudinal change between week-24 and week-36</time_frame>
    <description>The Marsh score is a defined but qualitative assessment assigned a value to allow for comparison. The scores were evaluated by consensus between the primary (chief) investigator and the study pathologist. The Marsh score was graded 0, 1, 2, 3A (assigned-4), 3B (-5) and 3C (-6); rage 1-6 with normal=0 and severe inflammation=6. Because the scoring is vulnerable to artefact, only a 2-point shift was regarded as a significant intra-individual change. The scores were graded after week-36 on biopsies de-identified shuffled. An upward shift was interpreted to reflect a significant worsening of gluten-associated inflammation. The comparison reported evaluated changes from baseline (week-24) to post-low-dose gluten challenge (week-24; GC-1g). The objective for using the Marsh score was to identify individuals who might have experienced a severe worsening in pathology due to GC-1g that might not be reflected in the Vh:Cd group analysis.</description>
  </secondary_outcome>
  <secondary_outcome>
    <measure>Serum Anti-tissue Transglutaminase Antibodies Measured as International Units/mL (IU/mL)</measure>
    <time_frame>Anti-tTG IU/mL levels pre-trial, mid-trial and after 3 gram/day gluten challenge</time_frame>
    <description>The trial was extended with pre-trial and mid-trial anti-tTG antibody levels used to compare with the post-trial levels. Anti-tTG is a serological measure of tissue transglutaminase-2 antibodies. In active celiac disease, levels are increased. In treated disease, levels are low (normal cut-off was &lt;15 IU/mL). A significant increase compared to baseline in tTG can be expected 2 weeks after consuming 3g of gluten daily for 2 weeks in people with celiac disease who have been maintaining a gluten-free diet, but who are not taking other treatment.</description>
  </secondary_outcome>
  <number_of_arms>1</number_of_arms>
  <enrollment type="Actual">12</enrollment>
  <condition>Celiac Disease</condition>
  <arm_group>
    <arm_group_label>Necator americanus, gluten challenge</arm_group_label>
    <arm_group_type>Experimental</arm_group_type>
    <description>Single arm, vertical.</description>
  </arm_group>
  <intervention>
    <intervention_type>Biological</intervention_type>
    <intervention_name>Necator americanus</intervention_name>
    <description>Previously inoculated subjects will be further inoculated as previously undertaken with 20 3rd stage infective Na larvae (10 + 10 over 4 weeks). Four weeks after the 2nd inoculation, each participant will receive a micro-dose of gluten (10 mg daily) as pasta for 8 weeks, to be followed by a low-dose of gluten (50 mg daily) for 8 weeks. After this, a detailed assessment involving upper endoscopy and duodenal biopsy will be performed before deciding on an individual case basis that it is safe for the participant to proceed to challenge. A gluten challenge of 1 G (15-20 G of pasta or a ½ slice of standard white bread) twice weekly for 12 weeks will commence.</description>
    <arm_group_label>Necator americanus, gluten challenge</arm_group_label>
    <other_name>Hookworm</other_name>
  </intervention>
  <intervention>
    <intervention_type>Biological</intervention_type>
    <intervention_name>Necator americanus</intervention_name>
    <description>After completion of the previously planned challenge, volunteers will be invited to extend the gluten challenge. The extension is for 4 weeks total. The gluten challenge is stepwise: gluten 10 mg daily for one week, 50 mg daily for one week and finally 3 grams daily for 2 weeks. The outcome measure is serum tissue transglutaminase to be compared before and after the intervention.</description>
    <arm_group_label>Necator americanus, gluten challenge</arm_group_label>
    <other_name>Hookworm</other_name>
  </intervention>
  <eligibility>
    <criteria>
      <textblock>
        Inclusion Criteria:&#xD;
&#xD;
          -  Previously enrolled adults who received an experimental hookworm infection with diet&#xD;
             treated celiac disease.&#xD;
&#xD;
        Exclusion Criteria:&#xD;
&#xD;
          -  Immune suppressive therapies&#xD;
      </textblock>
    </criteria>
    <gender>All</gender>
    <minimum_age>18 Years</minimum_age>
    <maximum_age>N/A</maximum_age>
    <healthy_volunteers>No</healthy_volunteers>
  </eligibility>
  <overall_official>
    <last_name>John Croese, MD</last_name>
    <role>Study Director</role>
    <affiliation>The Prince Charles Hospital, Centre for Biodiscovery and Molecular Development of Therapeutics</affiliation>
  </overall_official>
  <overall_official>
    <last_name>Dianne Jones, BAppSc</last_name>
    <role>Principal Investigator</role>
    <affiliation>Logan Hospital</affiliation>
  </overall_official>
  <overall_official>
    <last_name>Alexander Loukas, PhD</last_name>
    <role>Principal Investigator</role>
    <affiliation>Centre for Biodiscovery and Molecular Development of Therapeutics, James Cook University</affiliation>
  </overall_official>
  <location>
    <facility>
      <name>Prince Charles Hospital</name>
      <address>
        <city>Chermside</city>
        <state>Queensland</state>
        <zip>4032</zip>
        <country>Australia</country>
      </address>
    </facility>
  </location>
  <location_countries>
    <country>Australia</country>
  </location_countries>
  <reference>
    <citation>Daveson AJ, Jones DM, Gaze S, McSorley H, Clouston A, Pascoe A, Cooke S, Speare R, Macdonald GA, Anderson R, McCarthy JS, Loukas A, Croese J. Effect of hookworm infection on wheat challenge in celiac disease--a randomised double-blinded placebo controlled trial. PLoS One. 2011 Mar 8;6(3):e17366. doi: 10.1371/journal.pone.0017366.</citation>
    <PMID>21408161</PMID>
  </reference>
  <verification_date>October 2014</verification_date>
  <study_first_submitted>August 6, 2012</study_first_submitted>
  <study_first_submitted_qc>August 9, 2012</study_first_submitted_qc>
  <study_first_posted type="Estimate">August 10, 2012</study_first_posted>
  <results_first_submitted>September 21, 2014</results_first_submitted>
  <results_first_submitted_qc>October 9, 2014</results_first_submitted_qc>
  <results_first_posted type="Estimate">October 13, 2014</results_first_posted>
  <last_update_submitted>October 10, 2014</last_update_submitted>
  <last_update_submitted_qc>October 10, 2014</last_update_submitted_qc>
  <last_update_posted type="Estimate">October 20, 2014</last_update_posted>
  <responsible_party>
    <responsible_party_type>Principal Investigator</responsible_party_type>
    <investigator_affiliation>The Prince Charles Hospital</investigator_affiliation>
    <investigator_full_name>Dr John Croese</investigator_full_name>
    <investigator_title>Chief Investigator</investigator_title>
  </responsible_party>
  <keyword>celiac disease</keyword>
  <keyword>hookworm</keyword>
  <keyword>probiotic</keyword>
  <condition_browse>
    <!-- CAUTION:  The following MeSH terms are assigned with an imperfect algorithm            -->
    <mesh_term>Celiac Disease</mesh_term>
  </condition_browse>

  <clinical_results>

    <participant_flow>
      <recruitment_details>Of 20 potential candidates, 2 could not be contacted (address changed), 1 was not interested, and 5 were unavailable (travel-2, pregnancy-2 or study-1 commitments). Twelve enrolled in September 2012. 8 committed to 3 endoscopic procedures and 2 committed to two endoscopies.</recruitment_details>
      <group_list>
        <group group_id="P1">
          <title>Necator Americanus, Gluten Challenge</title>
          <description>Single arm, vertical. Necator americanus: Subjects were inoculated with 20 3rd stage Na larvae (10 + 10 over 4-8 weeks). After hookworm colonization, a micro-dose gluten challenge of 10 mg daily for 6 weeks, followed by 50 mg daily for 6 weeks was completed. After this, a detailed assessment including histology was performed to establish it safe for the participant to proceed to a low-dose gluten challenge of 25 mg daily and 1 G (15-20 G of pasta) twice weekly for 12 weeks. After low-dose challenge, a further evaluation was undertaken before inviting participants to undertake a gluten challenge of 3 G daily over for 2 weeks (preceded by a micro-dose 2 week lead-in).</description>
        </group>
      </group_list>
      <period_list>
        <period>
          <title>Gluten Micro-challenge</title>
          <milestone_list>
            <milestone>
              <title>STARTED</title>
              <participants_list>
                <participants group_id="P1" count="12">All 12 enrolled completed hookworm inoculation and gluten micro-challenge.</participants>
              </participants_list>
            </milestone>
            <milestone>
              <title>COMPLETED</title>
              <participants_list>
                <participants group_id="P1" count="12">Two gluten intolerant participants did not proceed to the low-dose challenge.</participants>
              </participants_list>
            </milestone>
            <milestone>
              <title>NOT COMPLETED</title>
              <participants_list>
                <participants group_id="P1" count="0"/>
              </participants_list>
            </milestone>
          </milestone_list>
        </period>
        <period>
          <title>Low-dose Gluten Challenge</title>
          <milestone_list>
            <milestone>
              <title>STARTED</title>
              <participants_list>
                <participants group_id="P1" count="12">One was symptomatically intolerant to gluten &gt;25 mg. One had active CeD pre- &amp; post-micro-challenge</participants>
              </participants_list>
            </milestone>
            <milestone>
              <title>COMPLETED</title>
              <participants_list>
                <participants group_id="P1" count="10">Two had challenge interrupted for 1-2 weeks. All completed challenge.</participants>
              </participants_list>
            </milestone>
            <milestone>
              <title>NOT COMPLETED</title>
              <participants_list>
                <participants group_id="P1" count="2"/>
              </participants_list>
            </milestone>
          </milestone_list>
          <drop_withdraw_reason_list>
            <drop_withdraw_reason>
              <title>Physician Decision</title>
              <participants_list>
                <participants group_id="P1" count="2"/>
              </participants_list>
            </drop_withdraw_reason>
          </drop_withdraw_reason_list>
        </period>
        <period>
          <title>High-dose Gluten Challenge</title>
          <milestone_list>
            <milestone>
              <title>STARTED</title>
              <participants_list>
                <participants group_id="P1" count="10">2 of 10 available after post-GC-1g did not enroll for reasons unrelated to gluten.</participants>
              </participants_list>
            </milestone>
            <milestone>
              <title>COMPLETED</title>
              <participants_list>
                <participants group_id="P1" count="8"/>
              </participants_list>
            </milestone>
            <milestone>
              <title>NOT COMPLETED</title>
              <participants_list>
                <participants group_id="P1" count="2"/>
              </participants_list>
            </milestone>
          </milestone_list>
          <drop_withdraw_reason_list>
            <drop_withdraw_reason>
              <title>Withdrawal by Subject</title>
              <participants_list>
                <participants group_id="P1" count="2"/>
              </participants_list>
            </drop_withdraw_reason>
          </drop_withdraw_reason_list>
        </period>
      </period_list>
    </participant_flow>

    <baseline>
      <population>Mean age 53 years, range 39-67; females 9.</population>
      <group_list>
        <group group_id="B1">
          <title>Gluten Micro-challenge</title>
          <description>Single arm, vertical. All twelve healthy adults enrolled subjects were successfully inoculated with hookworm and there was no serious adverse response. Individual hemoglobin levels were all normal and the group mean had significantly increased unexpectedly at completion of the study. Histology was not graded until after low-dose challenge but retrospectively confirmed enrollment Marsh scores of M0-8, M1-1, M2-2 and M3a-1. All participants were complying with a gluten-free diet, were symptomatically well and had a normal anti-tTG.</description>
        </group>
      </group_list>
      <analyzed_list>
        <analyzed>
          <units>Participants</units>
          <scope>Overall</scope>
          <count_list>
            <count group_id="B1" value="12"/>
          </count_list>
        </analyzed>
      </analyzed_list>
      <measure_list>
        <measure>
          <title>Age</title>
          <units>Participants</units>
          <param>Count of Participants</param>
          <class_list>
            <class>
              <category_list>
                <category>
                  <title>&lt;=18 years</title>
                  <measurement_list>
                    <measurement group_id="B1" value="0"/>
                  </measurement_list>
                </category>
                <category>
                  <title>Between 18 and 65 years</title>
                  <measurement_list>
                    <measurement group_id="B1" value="11"/>
                  </measurement_list>
                </category>
                <category>
                  <title>&gt;=65 years</title>
                  <measurement_list>
                    <measurement group_id="B1" value="1"/>
                  </measurement_list>
                </category>
              </category_list>
            </class>
          </class_list>
        </measure>
        <measure>
          <title>Age</title>
          <units>years</units>
          <param>Mean</param>
          <dispersion>Full Range</dispersion>
          <class_list>
            <class>
              <category_list>
                <category>
                  <measurement_list>
                    <measurement group_id="B1" value="53" lower_limit="39" upper_limit="67"/>
                  </measurement_list>
                </category>
              </category_list>
            </class>
          </class_list>
        </measure>
        <measure>
          <title>Sex: Female, Male</title>
          <units>Participants</units>
          <param>Count of Participants</param>
          <class_list>
            <class>
              <category_list>
                <category>
                  <title>Female</title>
                  <measurement_list>
                    <measurement group_id="B1" value="9"/>
                  </measurement_list>
                </category>
                <category>
                  <title>Male</title>
                  <measurement_list>
                    <measurement group_id="B1" value="3"/>
                  </measurement_list>
                </category>
              </category_list>
            </class>
          </class_list>
        </measure>
      </measure_list>
    </baseline>

    <outcome_list>
      <outcome>
        <type>Primary</type>
        <title>Duodenal Villus Height:Crypt Depth</title>
        <description>Biopsies were fixed in neutral buffered formalin, processed and carefully orientated and embedded in paraffin wax. Sections (3 µm) were stained with H&amp;E. Slides from both time-points were de-identified, shuffled and graded by Dr John Croese after which results from poorly orientated slides were verified by Dr Andrew Clouston. The Vh:Cd ratios were measured on 5 randomly selected well-orientated sites. The null hypothesis is that hookworm infection will not protect against mucosal damage following 12-week exposure to gluten in celiac disease.</description>
        <time_frame>Week -24 to -36</time_frame>
        <population>All 10 of 12 participants who completed micro-challenge successfully progressed and completed low-dose challenge.</population>
        <group_list>
          <group group_id="O1">
            <title>Necator Americanus, Gluten Challenge</title>
            <description>Single arm, vertical. Necator americanus: Subjects were inoculated with 20 3rd stage Na larvae (10 + 10 over 4-8 weeks). After hookworm colonization, a micro-dose gluten challenge of 10 mg daily for 6 weeks, followed by 50 mg daily for 6 weeks was completed. After this, assessments including histology were performed to establish it safe for the participant to proceed to a low-dose gluten challenge of 25 mg daily and 1 G (15-20 G of pasta) twice weekly for 12 weeks. After low-dose challenge, a further evaluation was undertaken before inviting participants to undertake a gluten challenge of 3 G daily over for 2 weeks (preceded by a micro-dose 2 week lead-in).</description>
          </group>
        </group_list>
        <measure>
          <title>Duodenal Villus Height:Crypt Depth</title>
          <description>Biopsies were fixed in neutral buffered formalin, processed and carefully orientated and embedded in paraffin wax. Sections (3 µm) were stained with H&amp;E. Slides from both time-points were de-identified, shuffled and graded by Dr John Croese after which results from poorly orientated slides were verified by Dr Andrew Clouston. The Vh:Cd ratios were measured on 5 randomly selected well-orientated sites. The null hypothesis is that hookworm infection will not protect against mucosal damage following 12-week exposure to gluten in celiac disease.</description>
          <population>All 10 of 12 participants who completed micro-challenge successfully progressed and completed low-dose challenge.</population>
          <units>Ratio</units>
          <param>Mean</param>
          <dispersion>95% Confidence Interval</dispersion>
          <analyzed_list>
            <analyzed>
              <units>Participants</units>
              <scope>Measure</scope>
              <count_list>
                <count group_id="O1" value="10"/>
              </count_list>
            </analyzed>
          </analyzed_list>
          <class_list>
            <class>
              <title>Baseline</title>
              <category_list>
                <category>
                  <measurement_list>
                    <measurement group_id="O1" value="2.73" lower_limit="2.31" upper_limit="3.15"/>
                  </measurement_list>
                </category>
              </category_list>
            </class>
            <class>
              <title>Low-dose gluten</title>
              <category_list>
                <category>
                  <measurement_list>
                    <measurement group_id="O1" value="2.73" lower_limit="2.31" upper_limit="3.15"/>
                  </measurement_list>
                </category>
              </category_list>
            </class>
          </class_list>
        </measure>
        <analysis_list>
          <analysis>
            <group_id_list>
              <group_id>O1</group_id>
            </group_id_list>
            <non_inferiority_type>Superiority or Other</non_inferiority_type>
            <p_value>0.693</p_value>
            <method>t-test, 2 sided</method>
          </analysis>
        </analysis_list>
      </outcome>
      <outcome>
        <type>Secondary</type>
        <title>Intraepithelial Lymphocyte Count</title>
        <description>Biopsies were fixed in neutral buffered formalin, processed and carefully orientated and embedded in paraffin wax. Sections (3 µm) were stained with anti-CD3. All slides were de-identified and graded by Dr John Croese. The IEL percentages were measured on 2 or more randomly selected well-orientated villi. The null hypothesis is that hookworm infection will not protect against mucosal IEL influx following 12-week exposure to gluten in celiac disease.</description>
        <time_frame>Week-24 and -36</time_frame>
        <group_list>
          <group group_id="O1">
            <title>Necator Americanus, Gluten Challenge</title>
            <description>Single arm, vertical. Necator americanus: Subjects were inoculated with 20 3rd stage Na larvae (10 + 10 over 4-8 weeks). After hookworm colonization, a micro-dose gluten challenge of 10 mg daily for 6 weeks, followed by 50 mg daily for 6 weeks was completed. After this, a detailed assessment including histology was performed to establish it safe for the participant to proceed to a low-dose gluten challenge of 25 mg daily and 1 G (15-20 G of pasta) twice weekly for 12 weeks. After low-dose challenge, a further evaluation was undertaken before inviting participants to undertake a gluten challenge of 3 G daily over for 2 weeks (preceded by a micro-dose 2 week lead-in).</description>
          </group>
        </group_list>
        <measure>
          <title>Intraepithelial Lymphocyte Count</title>
          <description>Biopsies were fixed in neutral buffered formalin, processed and carefully orientated and embedded in paraffin wax. Sections (3 µm) were stained with anti-CD3. All slides were de-identified and graded by Dr John Croese. The IEL percentages were measured on 2 or more randomly selected well-orientated villi. The null hypothesis is that hookworm infection will not protect against mucosal IEL influx following 12-week exposure to gluten in celiac disease.</description>
          <units>Percentage of epithelial cells</units>
          <param>Mean</param>
          <dispersion>95% Confidence Interval</dispersion>
          <analyzed_list>
            <analyzed>
              <units>Participants</units>
              <scope>Measure</scope>
              <count_list>
                <count group_id="O1" value="10"/>
              </count_list>
            </analyzed>
          </analyzed_list>
          <class_list>
            <class>
              <title>Baseline</title>
              <category_list>
                <category>
                  <measurement_list>
                    <measurement group_id="O1" value="33.40" lower_limit="27.12" upper_limit="39.68"/>
                  </measurement_list>
                </category>
              </category_list>
            </class>
            <class>
              <title>Low-dose gluten</title>
              <category_list>
                <category>
                  <measurement_list>
                    <measurement group_id="O1" value="35.00" lower_limit="28.72" upper_limit="41.28"/>
                  </measurement_list>
                </category>
              </category_list>
            </class>
          </class_list>
        </measure>
        <analysis_list>
          <analysis>
            <group_id_list>
              <group_id>O1</group_id>
            </group_id_list>
            <non_inferiority_type>Superiority or Other</non_inferiority_type>
            <p_value>=0.837</p_value>
            <method>t-test, 2 sided</method>
          </analysis>
        </analysis_list>
      </outcome>
      <outcome>
        <type>Secondary</type>
        <title>Number of Participants With 2 Points Increase in Marsh Score Post GC-1g</title>
        <description>The Marsh score is a defined but qualitative assessment assigned a value to allow for comparison. The scores were evaluated by consensus between the primary (chief) investigator and the study pathologist. The Marsh score was graded 0, 1, 2, 3A (assigned-4), 3B (-5) and 3C (-6); rage 1-6 with normal=0 and severe inflammation=6. Because the scoring is vulnerable to artefact, only a 2-point shift was regarded as a significant intra-individual change. The scores were graded after week-36 on biopsies de-identified shuffled. An upward shift was interpreted to reflect a significant worsening of gluten-associated inflammation. The comparison reported evaluated changes from baseline (week-24) to post-low-dose gluten challenge (week-24; GC-1g). The objective for using the Marsh score was to identify individuals who might have experienced a severe worsening in pathology due to GC-1g that might not be reflected in the Vh:Cd group analysis.</description>
        <time_frame>Longitudinal change between week-24 and week-36</time_frame>
        <population>The outcome score was the number with a 2-point increase in Marsh 3 score post GC-1g.</population>
        <group_list>
          <group group_id="O1">
            <title>Necator Americanus, Pre-gluten Challenge</title>
            <description>Single arm, vertical. Ten of 12 participants enrolled based on symptomatic tolerance of gluten and satisfactory histology during and after micro-challenge. 2 were withdrawn pre-GC-1g, one who was symptomatically intolerant of gluten and one who had M3a after micro-challenge. Pre-GC1g scores.</description>
          </group>
        </group_list>
        <measure>
          <title>Number of Participants With 2 Points Increase in Marsh Score Post GC-1g</title>
          <description>The Marsh score is a defined but qualitative assessment assigned a value to allow for comparison. The scores were evaluated by consensus between the primary (chief) investigator and the study pathologist. The Marsh score was graded 0, 1, 2, 3A (assigned-4), 3B (-5) and 3C (-6); rage 1-6 with normal=0 and severe inflammation=6. Because the scoring is vulnerable to artefact, only a 2-point shift was regarded as a significant intra-individual change. The scores were graded after week-36 on biopsies de-identified shuffled. An upward shift was interpreted to reflect a significant worsening of gluten-associated inflammation. The comparison reported evaluated changes from baseline (week-24) to post-low-dose gluten challenge (week-24; GC-1g). The objective for using the Marsh score was to identify individuals who might have experienced a severe worsening in pathology due to GC-1g that might not be reflected in the Vh:Cd group analysis.</description>
          <population>The outcome score was the number with a 2-point increase in Marsh 3 score post GC-1g.</population>
          <units>participants</units>
          <param>Number</param>
          <analyzed_list>
            <analyzed>
              <units>Participants</units>
              <scope>Measure</scope>
              <count_list>
                <count group_id="O1" value="10"/>
              </count_list>
            </analyzed>
          </analyzed_list>
          <class_list>
            <class>
              <category_list>
                <category>
                  <measurement_list>
                    <measurement group_id="O1" value="1"/>
                  </measurement_list>
                </category>
              </category_list>
            </class>
          </class_list>
        </measure>
        <analysis_list>
          <analysis>
            <group_id_list>
              <group_id>O1</group_id>
            </group_id_list>
            <groups_desc>The null hypothesis was that irrespective of hookworm infection, GC-1g would result in a 2-point or more deterioration in the Marsh score. A binomial (yes=deterioration or no=no deterioration) distribution was applied to pre- and post-GC-1g paired biopsies.</groups_desc>
            <non_inferiority_type>Superiority or Other</non_inferiority_type>
            <p_value>=0.99</p_value>
            <method>Binomial distribution</method>
          </analysis>
        </analysis_list>
      </outcome>
      <outcome>
        <type>Secondary</type>
        <title>Serum Anti-tissue Transglutaminase Antibodies Measured as International Units/mL (IU/mL)</title>
        <description>The trial was extended with pre-trial and mid-trial anti-tTG antibody levels used to compare with the post-trial levels. Anti-tTG is a serological measure of tissue transglutaminase-2 antibodies. In active celiac disease, levels are increased. In treated disease, levels are low (normal cut-off was &lt;15 IU/mL). A significant increase compared to baseline in tTG can be expected 2 weeks after consuming 3g of gluten daily for 2 weeks in people with celiac disease who have been maintaining a gluten-free diet, but who are not taking other treatment.</description>
        <time_frame>Anti-tTG IU/mL levels pre-trial, mid-trial and after 3 gram/day gluten challenge</time_frame>
        <population>2 of 12 participants did not progress past baseline micro-challenge, 2 of 10 participants did not progress past low-dose challenge.</population>
        <group_list>
          <group group_id="O1">
            <title>Necator Americanus, Gluten Challenge</title>
            <description>Single arm, vertical. Necator americanus: Subjects were inoculated with 20 3rd stage Na larvae (10 + 10 over 4-8 weeks). After hookworm colonization, a micro-dose gluten challenge of 10 mg daily for 6 weeks, followed by 50 mg daily for 6 weeks was completed. After this, a detailed assessment including histology was performed to establish it safe for the participant to proceed to a low-dose gluten challenge of 25 mg daily and 1 G (15-20 G of pasta) twice weekly for 12 weeks. After low-dose challenge, a further evaluation was undertaken before inviting participants to undertake a gluten challenge of 3 G daily over for 2 weeks (preceded by a micro-dose 2 week lead-in).</description>
          </group>
        </group_list>
        <measure>
          <title>Serum Anti-tissue Transglutaminase Antibodies Measured as International Units/mL (IU/mL)</title>
          <description>The trial was extended with pre-trial and mid-trial anti-tTG antibody levels used to compare with the post-trial levels. Anti-tTG is a serological measure of tissue transglutaminase-2 antibodies. In active celiac disease, levels are increased. In treated disease, levels are low (normal cut-off was &lt;15 IU/mL). A significant increase compared to baseline in tTG can be expected 2 weeks after consuming 3g of gluten daily for 2 weeks in people with celiac disease who have been maintaining a gluten-free diet, but who are not taking other treatment.</description>
          <population>2 of 12 participants did not progress past baseline micro-challenge, 2 of 10 participants did not progress past low-dose challenge.</population>
          <units>International Units/mL</units>
          <param>Mean</param>
          <dispersion>95% Confidence Interval</dispersion>
          <analyzed_list>
            <analyzed>
              <units>Participants</units>
              <scope>Measure</scope>
              <count_list>
                <count group_id="O1" value="8"/>
              </count_list>
            </analyzed>
          </analyzed_list>
          <class_list>
            <class>
              <title>Baseline</title>
              <category_list>
                <category>
                  <measurement_list>
                    <measurement group_id="O1" value="4.12" lower_limit="3.12" upper_limit="5.10"/>
                  </measurement_list>
                </category>
              </category_list>
            </class>
            <class>
              <title>Low-dose gluten</title>
              <category_list>
                <category>
                  <measurement_list>
                    <measurement group_id="O1" value="2.99" lower_limit="2.00" upper_limit="3.94"/>
                  </measurement_list>
                </category>
              </category_list>
            </class>
            <class>
              <title>After 3 G gluten daily</title>
              <category_list>
                <category>
                  <measurement_list>
                    <measurement group_id="O1" value="2.11" lower_limit="1.16" upper_limit="3.07"/>
                  </measurement_list>
                </category>
              </category_list>
            </class>
          </class_list>
        </measure>
        <analysis_list>
          <analysis>
            <group_id_list>
              <group_id>O1</group_id>
            </group_id_list>
            <non_inferiority_type>Superiority or Other</non_inferiority_type>
            <p_value>=0.005</p_value>
            <method>Mixed effects model.</method>
          </analysis>
        </analysis_list>
      </outcome>
    </outcome_list>

    <reported_events>
      <group_list>
        <group group_id="E1">
          <title>Gluten Micro-challenge</title>
          <description>Single arm, longitudinal study of responses to escalating gluten doses in people with celiac disease after infection with Necator americanus, a human hookworm.</description>
        </group>
      </group_list>
      <serious_events>
        <category_list>
          <category>
            <title>Total</title>
            <event_list>
              <event>
                <sub_title>Total, serious adverse events</sub_title>
                <counts group_id="E1" subjects_affected="0" subjects_at_risk="12"/>
              </event>
            </event_list>
          </category>
        </category_list>
      </serious_events>
      <other_events>
        <frequency_threshold>0</frequency_threshold>
        <default_assessment>Systematic Assessment</default_assessment>
        <category_list>
          <category>
            <title>Total</title>
            <event_list>
              <event>
                <sub_title>Total, other adverse events</sub_title>
                <counts group_id="E1" subjects_affected="2" subjects_at_risk="12"/>
              </event>
            </event_list>
          </category>
          <category>
            <title>Gastrointestinal disorders</title>
            <event_list>
              <event>
                <sub_title>Symptomatic gluten intolerance</sub_title>
                <description>One subject experienced nausea and pain when gluten doses exceeded 25 mg/d and was advised not to continue.</description>
                <counts group_id="E1" events="1" subjects_affected="1" subjects_at_risk="12"/>
              </event>
              <event>
                <sub_title>Active CeD</sub_title>
                <assessment>Non-systematic Assessment</assessment>
                <description>One subject had Marsh 3a inflammation on biopsy collected immediately post-micro-challenge. Retrospective analysis established that this was likely present immediately pre-trial.</description>
                <counts group_id="E1" events="1" subjects_affected="1" subjects_at_risk="12"/>
              </event>
            </event_list>
          </category>
        </category_list>
      </other_events>
    </reported_events>

    <certain_agreements>
      <pi_employee>Principal Investigators are NOT employed by the organization sponsoring the study.</pi_employee>
      <restrictive_agreement>There is NOT an agreement between Principal Investigators and the Sponsor (or its agents) that restricts the PI's rights to discuss or publish trial results after the trial is completed. </restrictive_agreement>
    </certain_agreements>
    <limitations_and_caveats>Open study. Small number. Historical controls.</limitations_and_caveats>
    <point_of_contact>
      <name_or_title>Dr John Croese. The Chief Investigator</name_or_title>
      <organization>The Prince Charles Hospital</organization>
      <phone>+61733716164</phone>
      <email>jcroese@bigpond.com</email>
    </point_of_contact>
  </clinical_results>
</clinical_study>


download date: ClinicalTrials.gov processed this data on September 20, 2023
link text: Link to the current ClinicalTrials.gov record.
url: https://clinicaltrials.gov/ct2/show/NCT01661933
org study id: AU/3/BOBD012
nct id: NCT01661933
lead sponsor: 
collaborator: 
has dmc: Yes
We have established that the hookworm Necator americanus (Na) dramatically alters the local
      and systemic immune landscape of the infected human host. Consistent with the principle of
      desensitisation, diet managed celiac disease subjects previously infected by us with Na will
      be invited to receive small incremental doses of gluten as pasta (3-25 mm straw of spaghetti)
      over 16 weeks. Each participant will then be carefully re-assessed to determine if it is
      appropriate to undertake a 12-week gluten challenge.
Hypothesis The adaptive Th2/regulatory profile imposed by Na will promote gluten tolerance
      following a micro-dose desensitising programme.

      Primary Aim: To determine the safety and efficacy of Na as a tolerising agent in celiac
      subjects

      Specific Aim 1. Undertake a therapeutic pilot study comparing mucosal histopathology before
      and after a gluten challenge, to be preceded by a programmed desensitising micro-challenge
      using Na as a tolerising agent.

      Specific Aim 2. Assess systemic and mucosal immune responses to gluten micro-challenge, Na
      infection, and gluten re-challenge throughout the pilot study, to be referenced against
      hookworm-naive people with treated and untreated celiac disease.

      Specific Aim 3. Utilising blood and tissue from hookworm-naive celiac disease volunteers,
      undertake in vitro studies focusing on the effects of Na-derived excretory/secretory (ES)
      products on gluten-stimulated gut mucosal cell apoptosis, cytokine and gene profiles.
allocation: N/A
intervention model: Single Group Assignment
primary purpose: Prevention
masking: Single (Outcomes Assessor)
measure: Duodenal Villus Height:Crypt Depth
time frame: Week -24 to -36
description: Biopsies were fixed in neutral buffered formalin, processed and carefully orientated and embedded in paraffin wax. Sections (3 µm) were stained with H&E. Slides from both time-points were de-identified, shuffled and graded by Dr John Croese after which results from poorly orientated slides were verified by Dr Andrew Clouston. The Vh:Cd ratios were measured on 5 randomly selected well-orientated sites. The null hypothesis is that hookworm infection will not protect against mucosal damage following 12-week exposure to gluten in celiac disease.
measure: Intraepithelial Lymphocyte Count
time frame: Week-24 and -36
description: Biopsies were fixed in neutral buffered formalin, processed and carefully orientated and embedded in paraffin wax. Sections (3 µm) were stained with anti-CD3. All slides were de-identified and graded by Dr John Croese. The IEL percentages were measured on 2 or more randomly selected well-orientated villi. The null hypothesis is that hookworm infection will not protect against mucosal IEL influx following 12-week exposure to gluten in celiac disease.
measure: Number of Participants With 2 Points Increase in Marsh Score Post GC-1g
time frame: Longitudinal change between week-24 and week-36
description: The Marsh score is a defined but qualitative assessment assigned a value to allow for comparison. The scores were evaluated by consensus between the primary (chief) investigator and the study pathologist. The Marsh score was graded 0, 1, 2, 3A (assigned-4), 3B (-5) and 3C (-6); rage 1-6 with normal=0 and severe inflammation=6. Because the scoring is vulnerable to artefact, only a 2-point shift was regarded as a significant intra-individual change. The scores were graded after week-36 on biopsies de-identified shuffled. An upward shift was interpreted to reflect a significant worsening of gluten-associated inflammation. The comparison reported evaluated changes from baseline (week-24) to post-low-dose gluten challenge (week-24; GC-1g). The objective for using the Marsh score was to identify individuals who might have experienced a severe worsening in pathology due to GC-1g that might not be reflected in the Vh:Cd group analysis.
measure: Serum Anti-tissue Transglutaminase Antibodies Measured as International Units/mL (IU/mL)
time frame: Anti-tTG IU/mL levels pre-trial, mid-trial and after 3 gram/day gluten challenge
description: The trial was extended with pre-trial and mid-trial anti-tTG antibody levels used to compare with the post-trial levels. Anti-tTG is a serological measure of tissue transglutaminase-2 antibodies. In active celiac disease, levels are increased. In treated disease, levels are low (normal cut-off was <15 IU/mL). A significant increase compared to baseline in tTG can be expected 2 weeks after consuming 3g of gluten daily for 2 weeks in people with celiac disease who have been maintaining a gluten-free diet, but who are not taking other treatment.
arm group label: Necator americanus, gluten challenge
arm group type: Experimental
description: Single arm, vertical.
intervention type: Biological
intervention name: Necator americanus
description: Previously inoculated subjects will be further inoculated as previously undertaken with 20 3rd stage infective Na larvae (10 + 10 over 4 weeks). Four weeks after the 2nd inoculation, each participant will receive a micro-dose of gluten (10 mg daily) as pasta for 8 weeks, to be followed by a low-dose of gluten (50 mg daily) for 8 weeks. After this, a detailed assessment involving upper endoscopy and duodenal biopsy will be performed before deciding on an individual case basis that it is safe for the participant to proceed to challenge. A gluten challenge of 1 G (15-20 G of pasta or a ½ slice of standard white bread) twice weekly for 12 weeks will commence.
arm group label: Necator americanus, gluten challenge
other name: Hookworm
intervention type: Biological
intervention name: Necator americanus
description: After completion of the previously planned challenge, volunteers will be invited to extend the gluten challenge. The extension is for 4 weeks total. The gluten challenge is stepwise: gluten 10 mg daily for one week, 50 mg daily for one week and finally 3 grams daily for 2 weeks. The outcome measure is serum tissue transglutaminase to be compared before and after the intervention.
arm group label: Necator americanus, gluten challenge
other name: Hookworm
criteria: 
gender: All
minimum age: 18 Years
maximum age: N/A
healthy volunteers: No
last name: John Croese, MD
role: Study Director
affiliation: The Prince Charles Hospital, Centre for Biodiscovery and Molecular Development of Therapeutics
last name: Dianne Jones, BAppSc
role: Principal Investigator
affiliation: Logan Hospital
last name: Alexander Loukas, PhD
role: Principal Investigator
affiliation: Centre for Biodiscovery and Molecular Development of Therapeutics, James Cook University
facility: 
country: Australia
citation: Daveson AJ, Jones DM, Gaze S, McSorley H, Clouston A, Pascoe A, Cooke S, Speare R, Macdonald GA, Anderson R, McCarthy JS, Loukas A, Croese J. Effect of hookworm infection on wheat challenge in celiac disease--a randomised double-blinded placebo controlled trial. PLoS One. 2011 Mar 8;6(3):e17366. doi: 10.1371/journal.pone.0017366.
PMID: 21408161
responsible party type: Principal Investigator
investigator affiliation: The Prince Charles Hospital
investigator full name: Dr John Croese
investigator title: Chief Investigator
mesh term: Celiac Disease
participant flow: 
baseline: 
outcome list: 
reported events: 
certain agreements: 
limitations and caveats: Open study. Small number. Historical controls.
point of contact: 