Efficacy and Safety of Moxidectin, Synriam, Synriam-Praziquantel versus Praziquantel against Schistosoma haematobium and S. mansoni Infections: A Randomized, Exploratory Phase 2 Trial

Background Schistosomiasis affects millions of people, yet treatment options are limited. The antimalarial Synriam (piperaquine 150 mg/arterolane 750 mg) and the anthelminthic moxidectin revealed promising antischistosomal properties in preclinical or clinical studies. Methodology We conducted two single-blind, randomized exploratory Phase 2 trials in Schistosoma mansoni and S. haematobium-infected adolescents in northern and central Côte d’Ivoire. Our primary endpoints were cure rates (CRs) and egg reduction rates (ERRs) based on geometric mean and safety. Each subject was asked to provide two stool samples (S. mansoni trial) for Kato-Katz analysis or three urine samples (S. haematobium trial) for urine filtration and one finger prick for malaria screening at baseline and follow-up. Participants were randomly assigned to either moxidectin, Synriam, Synriam plus praziquantel or praziquantel. Principal Findings 128 adolescents (age: 12–17 years) were included in each study. Against S. haematobium moxidectin and Synriam revealed low efficacy. On the other hand, Synriam plus praziquantel and praziquantel yielded CRs of 60.0% and 38.5% and ERRs of 96.0% and 93.5%, respectively. CRs observed in the treatment of S. mansoni were 13.0%, 6.7%, 27.0%, and 27.6% for moxidectin, Synriam, Synriam plus praziquantel and praziquantel, respectively. ERRs ranged from 64.9% (Synriam) to 87.5% (praziquantel). Conclusion/Significance Synriam and moxidectin show low efficacy against S. haematobium, hence an ancillary benefit is not expected when these drugs are used for treating onchocerciasis and malaria in co-endemic settings. Further studies are needed to corroborate our findings that moxidectin and Synriam show moderate ERRs against S. mansoni.


Study Rationale
Assess for the first time the safety and efficacy of oral moxidectin, Synriam® and Synriam®-praziquantel compared to praziquantel on S. mansoni and S. haematobium infection in schoolchildren

Study Objectives
The primary objective of the trial is to test the efficacy (cure rate (CR) and egg reduction rate (ERR)) of moxidectin and Synriam® (Arterolane (OZ277) and piperaquine) and a Synriam®praziquantel combination compared to praziquantel against schistosome infections.

Key inclusion / Exclusion criteria
Inclusion: Children infected with S. mansoni (study 1) and S. haematobium (study 2), absence of major systemic illnesses, written informed consent signed by parents and/or legal guardian; and oral assent by children. Exclusion: Any abnormal medical conditions or chronic disease, negative diagnostic result for schistosome infections, no written informed consent, recent anthelminthic or antimalarial treatment (past 3 months)

Primary Endpoints
Safety, CR and ERR of moxidectin and Synriam® and Synriam®/praziquantel against S. mansoni and S. haematobium

Measurements & procedures
Two stool samples (study 1), three urine samples (study 2) and one blood finger prick sample will be collected if possible on two consecutive days or otherwise within a maximum of 5 days. The medical history of the participating schoolchildren will be assessed with a standardized and previously used questionnaire, in addition to a clinical examination carried out by the study physician on the treatment day. School-aged children will also be interviewed before treatment, 2 and 24 hours after treatment about the occurrence of adverse events. The efficacy of the treatment will be determined 21 and 50/80 days post-treatment by collecting other two stool samples or three urines and one finger prick. All stool samples will be examined with duplicate Kato-Katz thick smears and Baermann method for the detection of S. stercoralis; all urine samples will be analyzed with filtration method for S. haematobium eggs and reagent strips for appraisal of microhaematuria and CCA diagnostic test. All finger pricks will be analyzed with thick and thin smear for appraisal of malaria parasitaemia and a rapid malaria diagnostic test.

Statistical Analyses
An available case analysis will be performed, including all children with primary end point data. Supplementary, a per-protocol analysis and an intention-to-treat analysis will be conducted. CRs will be calculated as the percentage of egg-positive children at baseline who become egg-negative after treatment. Geometric and arithmetic mean egg counts will be calculated for the different treatment arms before and after treatment to assess the corresponding ERRs Bootstrap resampling method with 2,000 replicates will be used to calculate 95% confidence intervals (CIs) for ERRs. Differences in ERRs will be determined under the assumption that non-overlapping CIs indicate statistical significance.

GCP statement
This study will be conducted in compliance with the protocol, the current version of the Declaration of Helsinki, ICH-GCP E6 as well as all national legal and regulatory requirements.

Key explanation for the inclusion of children
This study will be carried out in school-aged children, since infections with schistosomes occur most often in children, hence this age group is at highest risk of infections. After the study has been completed all samples will be destroyed and case report forms will be kept for a minimum of 10 years (chapter 10)

Background information
Known since ancient times, schistosomiasis (bilharzia) belongs to one of the most neglected tropical diseases, although it is affected by great morbidity with significant economic and public health consequences [1]. Schistosomiasis is caused by one of six species of schistosomes, with Schistosoma mansoni, S. japonicum, and S. haematobium being the most prevalent species [2]. It is currently estimated that approximately 230 million people are infected [2] and approximately 11,000 people die from the disease each year [1]. Millions of people suffer from severe disease manifestations including obstructive uropathy and bladder calcification (S. haematobium) and periportal hepatic fibrosis (S. mansoni and S. japonicum).
The disease gives rise to a persistent chronic disorder in endemic areas, resulting in common disabling complications such as anaemia, growth stunting, cognitive impairment, and decreased aerobic capacity [2].
Control of schistosomiasis is based on preventive chemotherapy interventions targeting the entire at-risk population. At the World Health Assembly (WHA) in 2001, resolution no. 54.19 was put forward which urged endemic countries to start seriously tackling worms, specifically schistosomiasis and soil transmitted helminthiases (STH), with a global target to treat at least 75% of all school aged children who are at risk of morbidity from schistosomiasis and STH by the year 2010 [3]. Control of all forms of schistosomiasis is currently dependent on a single drug, praziquantel. Praziquantel was developed in the early 1970s for veterinary practice, as it is true of all available anthelmintics for humans [4]. Praziquantel is active against adult schistosomes, but has little activity against the juvenile schistosomula, the young developmental stages of the parasite [4]. The high drug pressure from the widespread administration of praziquantel could lead to problematic drug resistance [5]. Should serious praziquantel resistance arise, there are no viable alternatives to this [6]. Even so, drug discovery for schistosomiasis has languished, although several antischistosomal lead compounds have been identified in recent years. Nonetheless, since no drug is currently undergoing clinical testing for schistosomiasis [7], a backup drug for praziquantel will be not available for the next decade.
The discovery of artemisinin, the active constituent of the herb Artemisia annua, was one of the most important breakthroughs in malaria chemotherapy [8]. Artemisinin is a sesquiterpene lactone that contains a peroxide bond in a unique 1,2,4-trioxane heterocycle.
The semisynthetic artemisinins also have antischistosomal properties as widely evaluated in laboratory studies and clinical trials [9]. In retrospect, it might not be so surprising that the semisynthetic artemisinins (and other peroxidic compounds) possess both antimalarial and antischistosomal activities, as both plasmodia and schistosomes digest hemoglobin. The success of the semi-synthetic artemisinins along with their pharmacologic draw-backs motivated the creation of fully synthetic derivatives in antimalarial drug discovery, the most investigated of these being the synthetic ozonides. At Swiss TPH we discovered that several ozonides also have significant antischistosomal potential. The first of these was ozonide OZ78, which, like the semisynthetic artemisinins, has high activity against the juvenile stage of S. mansoni [10]. In contrast to the lack of activity of OZ78 against adult stage S. mansoni in the mouse model, this ozonide had high efficacy against adult worms in S. mansoni-and S. japonicum-infected hamsters [11]. The mechanistic basis for the higher efficacy of OZ78 (and other peroxides) in schistosome-infected hamsters vs. mice is unclear. The first ozonide antimalarial, Synriam® (arterolane (OZ277) and piperaquine) (Ranbaxy®) has been launched a few months ago and there is a need to study its antischistosomal activities in an exploratory clinical trial [12]. The pediatric dosage is under investigation and has now entered phase III clinical trial [13], the tablet formulation used is arterolane 37.5 mg/ piperaquine 187.5 mg and the dose is adjusted according to age between 6 months and 12 years old.
Moxidectin is a macrocyclic lactone derived from the actinomycete Streptomyces cyanogriseus spp. noncyanogenus used in veterinary practice since 1985 [14]. Its main use was against lymphatic filariasis, but was demonstrated to be effective against intestinal parasites as well [15]. Studies conducted in vitro have demonstrated that moxidectin was more efficacious than ivermectin both in vivo and in vitro [16]. Considering these promising results, it has recently been adapted by human medicine as well for the treatment of onchocerciasis with good results in terms of efficacy against microfilariae and safety [17,18].
The rationale behind the research for an alternative to ivermectin in the treatment of lymphatic filariasis was to find a drug for mass treatment for onchocerciasis control with a good efficacy in interrupting the transmission of O. volvulus. The filaricidal mechanism of moxidectin is still under investigation, but studies on its kinetic have demonstrated that it influences the glutamate-gated chloride channels and the gamma-aminobutyric acid receptor complex and consequently having a paralytic effect and death of the parasite [19,20]. The bioavailability of the drug in oral formulation demonstrated in rats was moderate and the t 1/2 elim ranged between 22.9 and 44.6 hours; further studies conducted on different animals showed that the maximal concentration of oral moxidectin is reached 2 to 9 hours after administration [17]. Studies conducted on moxidectin pharmacokinetic in humans have showed that either the liquid or tablet formulation are quickly absorbed [21], extensively distributed and has a long half-life. Korth-Bradley at al. have seen an increased bioavailability of the drug by the simultaneous consumption of food [22]. CR as well as clinical parameters against Plasmodium spp infection

Type of trial
Randomized, controlled phase 2a efficacy trial.

Baseline survey
The medical history of school-aged children participating in the study will be assessed with a standardized and previously used questionnaire, in addition to a clinical examination carried out by the study clinician. Two stool samples (S. mansoni study), three urine samples (S.
haematobium study) and one blood finger prick sample will be collected from school-aged children until 120 cases of S. mansoni and S. haematobium infections have been identified (30 cases per treatment arm), regardless to concomitant infections with A. lumbricoides, T. trichiura, S. stercoralis and hookworm. The expected prevalence for schistosome positive school children was estimated to be 60% [24,25]. Hence, we anticipate enrolling approximately 200 children in each study site (to yield at least 120 S. mansoni and S. haematobium-positive children).
The standard urine filtration method (10 ml of urine) will be used for appraisal of S.
haematobium eggs [26]. The Kato-Katz technique will be used for the quantitative assessment of S. mansoni infections [27]. Baermann technique will be used for the quantitative detection of S. stercoralis larvae [28]. Each child will be invited to provide 3 urine (S. haematobium study) and 2 stool samples (S. mansoni study) within a maximum of 5 days. In addition, we will use reagent strips for appraisal of microhaematuria and the CCA (will be obtained from Govert van Dam, Leiden) [29] diagnostic tests; urine and stools samples might be preserved for possible additional diagnostic tests. In addition, one stool sample will be collected from each child in the S. haematobium study and one urine sample from each child participating in the S. mansoni study. Infection intensity (expressed as the arithmetic mean egg count per gram of stool (epg)/per 10 ml of urine will be calculated for each individual. Infections with soil-transmitted helminths, i.e. A. lumbricoides, hookworm and T. trichiura, will also be assessed and recorded for each parasite species separately.
A finger prick blood sample will be taken, thick and thin blood smears prepared on a microscope slide for subsequent appraisal of malaria parasitaemia together with dosage of haemoglobin. All the slides will be double-checked by a second laboratory technician and only considered negative if no parasites detected in 100x oil immersion field by the two independent microscopists. Additionally, a rapid malaria diagnostic test will be employed

Assessment of efficacy after treatment
At day 21 and day 50 (S. mansoni) or day 80 (S. haematobium study) after the last treatment dose has been administered we will sample again 3 urine and 2 stool specimen for analysis

Measure to minimize bias
Study participants eligible for treatment will be randomly assigned to one of the four treatment arms using a computer-generated stratified block randomization code. The random allocation sequence with varying random blocks of seven or fourteen will be provided by a statistician. The codes will be held in a locked cabinet at the Swiss Tropical and Public Health Institute. A copy of this code will be kept in a sealed envelope by one of the coinvestigators (will only be opened in emergency situations, determined by the principal investigator upon consultation with the co-investigators). Laboratory personnel will not know which child was allocated to which treatment arm and will therefore be blinded.

Duration of study and subject participation
Each trial will last three months. The screening for the baseline will start one week prior to the treatment. Follow up screening will take place 21-22 and 50 and 80 days post-treatment and last for one week. Schedules of visits are summarized in the appendix.

Recruitment
The study will be carried out in school-aged children (age: 6-14 years) of two primary schools (CNRA and Moapé) in Azaguié and Adzopé, Côte d'Ivoire, areas that are highly endemic for S. mansoni and S. haematobium, respectively [24,25].
The parents/guardians of the children will be invited to participate in an information meeting to explain the purpose and procedures of the study, including potential benefits and risks.
Parents will be encouraged to ask questions in an open discussion forum. Participants who were diagnosed with a soil-transmitted helminth or malaria infection, but who were excluded from the study due to one or several of the above-mentioned exclusion criteria, including withdrawals will be offered standard anthelminthic/antimalarial treatment (Albendazole/Praziquantel/Ivermectin and malaria treatment according to national guidelines).

Criteria for discontinuation of trial
A subject can be discontinued from the study for the following reasons: 1. Withdraws from the study (this can happen anytime as participation is voluntary and there are no further obligations once a child withdraws).

At the discretion of the Principal Investigator, if the participant is not
compliant to the requirements of the protocol.
Discontinued subjects will not be replaced. If, for any reason, a subject is discontinued from the study before the end of treatment evaluations, the safety procedures planned (adverse events monitoring) will be conducted.

Treatment of subjects
Moxidectin will be obtained by Virbac Pharma industry (Nice, France) and Synriam® will be obtained from Ranbaxy (Gurgaon, India). The formulation of Synriam® will be either the adult . The subjects will be randomized into four different groups (Table 2). All treatments will be administered in the presence of the investigator(s), and ingestion confirmed. This will be recorded with the time and date of closing. Subjects will be asked not to take any drugs other than those prescribed by the study medical team. After ingestion of the medication, the subjects will be observed for 3 hours to ensure retention of the drug.
Vomiting within 1-hour post-dosing will require re-dosing. The subjects will not allow more than one repeated dose. No re-administration will be needed for subjects vomiting after one hour.
The Principal Investigator is responsible for drug accountability at the study site. Maintaining drug accountability includes careful and systematic study drug storage, handling, dispensing and documentation of administration.

Concomitant therapy
All medications taken one month before and during the study period must be recorded with

. Safety parameters and collection and reporting of adverse events
Little adverse events have been reported following moxidectin, Synriam® and praziquantel administration. The most common adverse events were abdominal cramps, fever, nausea, headache, and vertigo [30,32]; in some subjects haematologic adverse events have been registered [17] and Mazzotti reaction in countries endemic for O. volvulus [18].
The observation time for adverse events starts when the treatment is initiated. Patients will be kept for observation for at least 3 hours following treatment for any acute adverse events.
If there is any abnormal finding, the local study physician will perform a full clinical examination and findings will be recorded. An emergency kit will be available on site to treat any medical conditions that warrant urgent medical intervention. Severely-ill subjects will be referred to the nearby health center or hospital for prompt medical care. Patients will also be interviewed 24 hours after treatment about the occurrence of adverse events.
Information on all adverse events (incidence, onset, cessation, duration, intensity, frequency, seriousness and causality) will be entered immediately in the source document, and also in the appropriate adverse event module of the case report form (CRF). For all adverse events, sufficient information will be pursued and/or obtained so as to permit i) an adequate determination of the outcome of the event (i.e. whether the event should be classified as a serious adverse event); and; ii) an assessment of the casual relationship between the adverse event and the study treatments. Intensity of adverse events will be judged by the study physician, following guidelines by the European Medicine Agency (Note for Guidance on Clinical safety Data Management).

Types of adverse events
The term "adverse event" could include any of the following events which develop or increase in severity during the course of the study: a) Any signs or symptoms whether thought to be related or unrelated to the condition under study; b) Any clinically significant laboratory abnormality; c) Any abnormality detected during physical examination.
These data will be recorded on the appropriate CRFs, regardless of whether they are thought to be associated with the study or the drug under investigation. Associated with the use of Unexpected adverse event: Any adverse event, the frequency, specificity or severity of which is unanticipated and not consistent with the available risk information described for these drugs.

Serious adverse events
A "serious" adverse event is defined as any event that suggests a significant hazard, contraindication, side effect, or precaution. A serious adverse event includes any event that: 6. is an important medical event, based upon appropriate medical judgment, that may jeopardize the patient or subject or may require medical or surgical intervention to prevent one of the other outcomes defining serious.
An unexpected event is any adverse event that is not identified in nature, severity, or frequency in the scientific literature.
A "severe" adverse event does not necessarily meet the criteria for a "serious" adverse event.
Serious adverse events that are still ongoing at the end of the study period will be followed up to determine the final outcome. Any serious adverse event that occurs after the study period and is considered to be possibly related (definitions will be used according to the WHO-UMC system; see: http://who-umc.org/Graphics/24734.pdf) to the study treatment or study participation will be recorded and reported immediately.

Serious adverse event reporting
Any study-related unanticipated problem posing risk of harm to subjects or others, and any type of serious adverse event, will be reported to the study sponsor by telephone within 24

Definition of primary endpoint
CR and ERR is the primary endpoint in our study.

Justification of number of trial subjects
The

Description of statistical methods
An available case analysis, which is sometimes erroneously referred to as an intention-totreat analysis, will be performed, including all children with primary end point data. In addition, a per-protocol analysis and an intention-to-treat analysis with a worst case and a best case scenario will be conducted. CRs will be calculated as the percentage of eggpositive children at baseline who become egg-negative after treatment. EPG will be assessed by adding up the egg counts from the duplicate Kato-Katz thick smears and multiplying this number by a factor of six. The ERR will be calculated (ERR = (1-(mean at follow-up/mean at baseline))*100). Differences among CRs will be analysed by using crude logistic regressions and adjusted logistic regressions (adjustment for age, sex, school, and height).
Geometric and arithmetic mean egg counts will be calculated for the different treatment arms before and after treatment to assess the corresponding ERRs. Bootstrap resampling method with 2,000 replicates will be used to calculate 95% confidence intervals (CIs) for ERRs.
Differences in ERRs will be determined under the assumption that non-overlapping CIs indicate statistical significance.

Description of data management
The investigators are responsible for an adequate data quality. Prior to the initiation of the study, a short investigator's meeting will be held with the investigators and their study coordinators and a member from Swiss TPH. This meeting will include a detailed discussion of the protocol, performance of study procedures, CRF completion, and specimen collection and diagnostic methods.
Screened patients will be listed in a confidential "subject screening log". Enrolled patients will be listed in a confidential "subject enrolment log" and attributed a unique study number; this document will constitute the only source to decode the pseudonymised data and will only be accessible to the local principal investigator. All data that have been hand-entered in the database will be verified by a double-key entry procedure in a validated electronic data base system and error, range and consistency checks will be programmed. Any discrepancies will be reviewed against the hard copy CRF and corrected. Electronic data files will be stored on secured network drives with restricted access for study personnel only. Data analysis will be conducted with pseudonymised data and reporting of findings will be fully anonymized.
Essential infrastructure such as lockable cabinets for safe storage of hardcopy data will be made available. Network drives with restricted access for authorized personnel only and appropriate analysis software are available.

Investigator's confirmation
This trial will be conducted in compliance with the protocol, International Conference on Harmonisation Good Clinical Practice E6 (ICH-GCP) and the current version of the Helsinki Declaration.
All protocol modifications must be documented in writing. A protocol amendment can be initiated by either the Sponsor or any Investigator. The Investigator will provide the reasons for the proposed amendment in writing and will discuss with the Sponsor and the Principal an insurance for the study participants (confirmation will be delivered).

Project management
The trial team will include the PI The investigator team is responsible for ensuring that the protocol is strictly followed. The investigator should not make any changes without the agreement of the Principal Investigator and the Co-Investigators, except when necessary to eliminate an apparent immediate hazard or danger to a study participant. The investigator will work according to the protocol and GCP. The investigator may take any steps judged necessary to protect the safety of the participants, whether specified in the protocol or not. Any such step must be documented.
During the treatment the records are maintained by the responsible medical doctor. All entries have to be made clearly readable with a pen. The investigator must be thoroughly familiar with the properties, effects and safety of the investigational pharmaceutical product.

Independent Ethics Committee (IEC)
The study will be submitted for approval by the institutional research commission of the
haematobium. All participating children remaining positive for A. lumbricoides, hookworm, T. trichiura, S. stercoralis, schistosomes and malaria will be treated with albendazole and/or praziquantel, and/or ivermectin and malaria treatment according to the national guidelines.

Subject information and consent
Parents or legal guardians of eligible children will be asked to sign a written informed consent sheet. Children will be asked orally for assent. Community meetings will be conducted to explain the purpose and procedures of the study. Participation is voluntary and children have the right to withdraw from the study at any given point in time with no further obligations.
Participation itself will not be awarded with compensation.

Subject Confidentiality
Confidentiality of information will be assured to the participants. The investigators have all been trained in GCPs. None of the investigators declare to have any conflicts of interest.
Subject's anonymity will be maintained. Subjects will be identified on the Case Report Forms by the Subject Number and Subject's Initials in addition to centre and study identification information. The investigators will keep a separate confidential enrolment log that matches identifying codes with the subjects' names and residencies.

Subjects requiring particular protection
This study will be carried out in school-aged children, since an infection with S. mansoni and S. haematobium occurs most often in children, hence this age group is at highest risk of infection. Our trial will pave the way for a safe and effective treatment of schistosomiasis in children.

Monitoring and auditing
We will work with locally based clinical monitors. They will conduct site visits to the investigational facilities for the purpose of monitoring the study. The investigator will permit them access to study documentation and the clinical supplies dispensing and storage area.
Monitoring observations and findings will be documented and communicated to appropriate study personnel and management. A corrective and preventative action plan will be requested and documented in response to any audit observations. No sponsor initiated audits are foreseen, but audits and inspections may be conducted by the local regulatory authorities or ethics committees. The Investigator agrees to allow inspectors from regulatory agencies to review records and is encouraged to assist the inspectors in their duties, if requested.

Access to data, handling of data and samples (data protection), archiving (place, duration) and destruction
Information about study subjects will be kept confidential and managed accordingly. A CRF will be completed for each subject enrolled into the clinical study. The investigators will review, approve and sign/date each completed CRF; the investigator-sponsor's signature serving as attestation of the investigator-sponsor's responsibility for ensuring that all clinical and laboratory data entered on the CRF are complete, accurate and authentic. The study CRF is the primary data collection instrument for the study. All data requested on the CRF must be recorded. All missing data must be explained. If a space on the CRF is left blank because the procedure was not done or the question was not asked "N/D" will be entered. If the item is not applicable to the individual case "N/A" will be written. All entries will be printed in black ink. All corrections must be initialed and dated.
All data on parasitology and questionnaires about adverse events and self-reported clinical signs and symptoms will be doubled entered into a database by two independent persons and cross-checked. Discrepancies between data entries will be corrected by consulting the hard copy.
The collected data will be stored at server of the Swiss Tropical and Public Health Institute and are encrypted with Secure Sockets Layer (SSL).
The results of the research study will be published, but subjects' names or identities will not be revealed. Records will remain confidential. To maintain confidentiality, the PI will keep records in locked cabinets and the results of tests will be coded to prevent association with participant's names. Data entered into the EXCEL data entry mask will be accessible only by Synriam, Synriam-praziquantel  authorized personnel directly involved with the study and will be encoded. Subject-specific information may be provided to other appropriate medical personnel only with the subject's permission.
After the study has been completed all samples will be destroyed and research data and related material will be kept for a minimum of 10 years to enable understanding of what was done, how and why, which allow the work to be assessed retrospectively and repeated if necessary.

Data entered directly in the Case Report Form (CRF)definition of source data
Source Data are the clinical findings and observations, laboratory data maintained at the study site. Source data are contained in source documents. Local authorities are allowed to access the source data.
Source Documents are the physician's subject records maintained at the study site. When applicable, information recorded on the CRF shall match the Source Data recorded on the Source Documents. All CRFs will be kept for at least 10 years.

Data and safety monitoring board (WHO) / data monitoring committee (EU/FDA)
In our study no DSMB will established, since we work with a well-known drug in a small sample size and using a single dose treatment. However, advisors will be informed regularly and the findings discussed.

Dissemination of results and publication
The final results of this study will be shared with the local laboratory staff and later published in a scientific journal and presented at scientific conferences. All results from this investigation are considered confidential and shall not be made available to any third part by any member of the investigating team before publication.