Comparison of Bovine Colostrum Versus Placebo in Treatment of Severe Alcoholic Hepatitis: A Randomized Double Blind Controlled Trial (BASH)
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|ClinicalTrials.gov Identifier: NCT02473341|
Recruitment Status : Recruiting
First Posted : June 16, 2015
Last Update Posted : April 26, 2021
|First Submitted Date ICMJE||June 8, 2015|
|First Posted Date ICMJE||June 16, 2015|
|Last Update Posted Date||April 26, 2021|
|Actual Study Start Date ICMJE||November 14, 2017|
|Estimated Primary Completion Date||July 2021 (Final data collection date for primary outcome measure)|
|Current Primary Outcome Measures ICMJE
||Survival [ Time Frame: 3 month ]
Survival at 3 month
|Original Primary Outcome Measures ICMJE
||Survival [ Time Frame: 3 month ]|
|Current Secondary Outcome Measures ICMJE
|Original Secondary Outcome Measures ICMJE
|Current Other Pre-specified Outcome Measures||Not Provided|
|Original Other Pre-specified Outcome Measures||Not Provided|
|Brief Title ICMJE||Comparison of Bovine Colostrum Versus Placebo in Treatment of Severe Alcoholic Hepatitis: A Randomized Double Blind Controlled Trial|
|Official Title ICMJE||Comparison of Bovine Colostrum Versus Placebo in Treatment of Severe Alcoholic Hepatitis: A Randomized Double Blind Controlled Trial|
Severe Alcoholic hepatitis, defined by modified Maddrey's Discriminant Function (DF) ≥32, is associated with significant morbidity and mortality.(1,2) Of the various treatment modalities evaluated for treatment of Severe Alcoholic hepatitis, corticosteroids have been the most extensively studied.(1) Five out of 13 randomized controlled trials, and four out of 5 meta-analysis have shown a survival benefit with corticosteroids, especially in patients with DF ≥32 and/ or encephalopathy.(1-4) However, the role of corticosteroids in Severe Alcoholic hepatitis still remains controversial.(5-6) Corticosteroid therapy is not considered the ideal option by most authors because their beneficial effect seems to be confined to a highly select minority group in which the inhibitory effect of corticosteroids on liver inflammation is not outweighed by side effects such as weakened defence against infections, anti-anabolic effects, and possible ulcer promoting effects.(6) Corticosteroids are usually contraindicated in those with DF > 54 or MELD >24 (7) .Also corticosteroids are contraindicated in those with renal failure, gastro-intestinal bleed, pancreatitis and active sepsis. Therefore, there have been constant efforts to evaluate new therapies for Severe Alcoholic hepatitis (SAH). In a recent trial, combination of glucocorticoids plus N-acetylcysteine was found to improve one month survival in patients with Severe Alcoholic hepatitis, compared with glucocorticoids alone. However, the 6 month survival similar in both the groups.(8) Human colostrum and bovine colostrum are rich in protein, immunoglobulin, lactoferrin and growth factors. Recent studies suggest that colostrum components, immunoglobulin and growth factor benefits physically active person as well as in the treatment of autoimmune disorders. It is used for the treatment of a wide variety of gastrointestinal conditions, including non-steroidal anti-inflammatory drug-induced gut injury, Helicobacter pylori infection, immune deficiency related diarrhea as well as infective diarrhea.(9,10,11) It has also been sucessfully used to significantly decrease the level of Endotoxemia - lower levels of Lipopolysaccharides.
We plan to compare the efficacy of bovine colostrum versus Placebo (Pasteurized milk powder) alone in treatment of severe alcoholic hepatitis. Bovine Colostrum is rich in protein, immunoglobulin, lactoferrin and growth factors. Recent studies suggest that Colostrum components, immunoglobulin and growth factor benefits physically active person and in treatment of autoimmune disorders. It is used for the treatment of a wide variety of gastrointestinal conditions, including non-steroidal anti-inflammatory drug-induced gut injury, H pylori infection, immune deficiency related diarrhea as well as infective diarrhea.(9) The guidelines by American College of Gastroenterology (10) and other authors (11) have suggested that a combination of Corticosteroids and other drugs, which have different mechanisms of action, may be more beneficial for reducing mortality in severe alcoholic hepatitis. Hence, the investigators plan to compare the efficacy of combined therapy of Corticosteroids and Bovine colostrum versus Corticosteroids alone in treatment of severe alcoholic hepatitis.
Diagnosis: The diagnosis of Alcoholic hepatitis is made by the following criteria (12)
I. Chronic active alcohol abuse - >80 grams in males and > 60 grams in females for > 5 years for developing Alcoholic Cirrhosis (13) Alcohol use will be evaluated with the AUDIT score (EASL guidelines (14) II. Duration of jaundice < 3 months III. Serum Bilirubin >5 mg/dl IV. AST/ALT > 2:1 V. AST <300 IU/L VI. Prolonged PTI/INR VII. Neutrophilicleucocytosis VIII. Liver biopsy (Percutaneous or Transjugular). [Optional]
IAssessment of Severity
Maddrey's Discriminant Function (15)
Discriminant Function Index (DFI) was originally described by Maddrey and colleagues in a placebo controlled study to assess the benefit of corticosteroids in patients with AH. The original formula was 4.6 x prothrombin time (seconds) + serum Bilirubin (mg/dl). It was observed that patients with a DFI >93 and treated with placebo had a 28 day survival of 25%, whereas those with a DFI < 93 had a 100% survival. Subsequently this score was modified in 1986 and called Modified Discriminant Function (MDF). MDF = 4.6 x (Patient's PT - Control PT) + serum bilirubin (mg/dl). Untreated patients with MDF >32 had a survival of 68%. The American College of Gastroenterology9 recommends that patients with MDF > 32 and / or Encephalopathy should be treated. The prothrombin time varies greatly depending on the sensitivity of the thromboplastin reagent used for the test. This is the drawback of the MDF.
MELD score (16)
The model for end stage liver disease (MELD) score predicts survival in patients with cirrhosis and is used to prioritize patients for liver transplantation.
MELD score = (0.957 x log serum creatinine + 0.378 x log serum bilirubin + 1.120 x log INR + 0.643) x 10. The advantage of MELD score is the use of INR in place of PT. The INR is comparable and uniform across laboratories worldwide. The American Association for Study of Liver Diseases recommends that a MELD score >20predicts SAH and should be the criterion for initiating treatment. Serial monitoring of MELD score with a change of 2 or more points over the first week on treatment has independently predicted mortality.
GAHS score (17)
Glasgow Alcoholic Hepatitis Score (GAHS) includes age, peripheral Total Leucocyte Count, serum Bilirubin (at days 1 and 6-9), blood urea nitrogen and PT. It is a better predictor of mortality at 28 days than MDF. GAHS score > 9 has an extremely poor prognosis unless treated with Corticosteroids. The drawback is lack of international validation.
LILLE'S model (18) It is not traditionally used for predicting mortality of SAH. However, it helps to predict mortality at 7 days of SAH patients on Corticosteroids .If the score is more then 0.45 then Corticosteroids should be stopped.
The diagnosis of Severe Alcoholic Hepatitis is made by the following criteria
Treatment Abstinence from alcohol This is the most important factor in predicting the outcome after surviving the acute alcoholic hepatitis (AH) episode. The incidence of recidivism after recovery from the first episode of AH varies from 10 - 70 %. Abstinence will be reinforced by giving patient oral/enteral Baclofen (GABA B receptor agonist)
Enteral nutrition is the preferred mode for supplemental nutrition. It is cheap, maintains gut mucosal integrity. This in turn decreases the risk of bacterial and endotoxin translocation resulting in less infections and endotoxemia. Pooled data from 5 RCT's of AH have demonstrated improved nutritional status compared to standard dietary intake, but without improving survival rates.19 The patient will be given 40k cal/kg diet along with 1.5gm/kg protiens, emphasizing breakfast and a night time snack with regular oral diet. Frequent interval feeding will be given to improved nitrogen balance. B complex multivitamins supplementation will be provided to all patients (EASL guidelines (14)
Pharmacotherapy of Severe Alcoholic Hepatitis
Corticosteroids are the most extensively used treatment for Severe Alcoholic Hepatitis. 6/13 Randomized Controlled Trials and 4/6 meta-analysis have supported the use of Corticosteroids in Severe Alcoholic Hepatitis. The last meta-analysis of individual patient data from 5 high quality Randomized Controlled Trials using Corticosteroids forSevere Alcoholic Hepatitis concluded that Corticosteroids confers a 50% relative survival benefit at 1 month (85% versus 65% survival amongst those treated with Corticosteroids versus untreated patients). The number of patients needed to treatedis 5 to reduce one death. Oral Prednisolone 40mg daily or parenteral methylprednisolone (for patients unable to take orally) 32 mg intravenously daily for 4 weeks is the standard therapy. A Lille score of >0.45 after 7 days of treatment with Corticosteroids is an indication of non-response, increased susceptibility to infections and diminished survival (20). The Corticosteroids should be stopped if the Lilli score is >0.45. The most recent STOPAH trial was unable to show a significant improvement in mortality of SAH patients treated with Corticosteroids. There was a trend in favour of Corticosteroids.
Pentoxifylline is a phosphodiesterase inhibitor. It is given orally in the dose of 400mg thrice a day for 28 days. In a pivotal study of 101 patients of SAH21, it was associated with survival benefit of 50%. In another study, it was found to be superior to Corticosteroids (22).
In a recent study involving 50 patients at our center (23), we found that 20% vs 40% mortality in patients treated with Pentoxifylline versus controls, after 4 weeks of treatment. Acute kidney injury was the cause of death in 20% compared to 70% patients in Pentoxifylline group versus controls. Pentoxifylline induces recovery of renal & hepatic functions with a trend towards increased survival. However, a metanalysis of 5 Randomized Controlled Trials failed to show any benefit with Pentoxifylline24.In a large recent trial Corticosteriods plus Pentoxifyllinefor 4 weeks treatment with compared with prednisolone alone, did not result in improved 6-month survival.25 The major adverse effects include vomiting, diarrhea, abdominal pain, headache and skin rash.
N-acetylcysteine could have value as an antioxidant in the treatment of acute alcoholic hepatitis,because the thiol group in N-acetylcysteine is able to reduce levels of free radicals. Administration of N-acetylcysteine might reconstitute the glutathione stocks of the hepatocytes. At present, N-acetylcysteine is used in the treatment of acetaminophen induced hepatitis. Intravenous acetylcysteine is most often used as an antidote for acetaminophen overdose due to its ability to increase levels of glutathione; however, it is also used to treat non-acetaminophen-induced acute liver failure (NAI-ALF) and severe alcoholic hepatitis and to prevent contrast-induced nephropathy (CIN). Although the i.v.and oral formulations of acetylcysteine have been evaluated for these indications, most studies have examined the i.v.form. I.V. acetylcysteine is used in the treatment of NAI-ALF to improve oxygenation to the liver. A trial to evaluate the efficacy of glucocorticoids plus N-acetylcysteine, as compared with glucocorticoids alone, in patients with severe acute alcoholic hepatitis.(26) reported improved one month survival in the combined treatment group. However the 6 month survival was not different in the two groups.
Human colostrum is the first milk produced after birth and is particularly rich in immunoglobulin, antimicrobial peptides (lactoferrin and lacto peroxidase) and other bioactive molecule, including growth factors which are important for nutrition, growth and development of newborn infants and also for passive immunity. Bovine colostrum is produced by the cows during the first one day post parturition. This "early" milk has nutrient profile and immunological composition substantially different from 'mature' milk. It contains macronutrient like proteins, carbohydrate, oligosaccharides, fats and micronutrients like vitamins and minerals, also growth factors, anti-microbial compounds and immune regulating constituents either not present in mature milk or present substantially in lower concentration.(27,28) Bovine colostrum used in the treatment of HIV-positive patients with chronic diarrhea,(29) and rotavirus diarrhea in children.(30) Available evidence suggests a beneficial effect of supplementation of bovine colostrums in improving body composition, aspects of athletic performance, diarrhea in persons with immune-deficiency syndromes, NSAID-induced gastrointestinal ulcers, and aspects of the acute phase response that occurs secondary to surgery. Specific hyperimmune bovine colostrums, produced to have high neutralizing titer activity against Cryptosporidia, H. pylori, measles, rotavirus, and Shigella sp., appear to have clinical utility in conditions associated with these infectious organisms (31) Historically colostrum has been used for various illnesses in India as well as abroad for thousands of years. Ayurvedic physicians of India have used bovine colostrum for both medicinal and spiritual purposes since cows were first domesticated. By the late 18th century, Western medicine started to take an interest in colostrum and study it for its potential health benefits. As a consequence, it was prescribed for many conditions, including immune system enhancement. Interestingly, until the development of penicillin and other artificial antibiotics in the 20th century, colostrum was commonly used for fighting bacterial infections. In the early 20th century it was noted that antibody levels in the first milk produced after birth were much higher than levels found in the milk that was produced 72 hours later.There are now over 2000 published scientific articles that document the safety and efficacy of using colostrum. This seemingly perfect food has been shown to be non-species specific (32). In 2005, it was reported that is safe and effective in repair of tissues as well as for enhancing immunity.(33) The use of bovine colostrum as dietary supplement has increased substantially over the past decades. Bovine colostrum is harvested within first few hours of calving from dairy animals. The herds of cows are kept under close supervision in good state of hygiene without exposure to antibodies, pesticides and anthelmintics. The colostrum collected within 24 hours contains maximum substances but less in amounts, colostrum collected later will be more in quantity but contain less immunoglobins.(33) Colostrum contains the growth factors that help build lean muscle, including insulin-like growth factors (IGF-I & IGF-II) and growth hormone (GH). IGF-I, which is found naturally in colostrum, is the only natural hormone capable of promoting muscle growth by itself. The IGFs in humans and cows are identical, but bovine colostrum actually contains a greater concentration of IGF-I than human colostrum. This fact makes bovine colostrum attractive to bodybuilders, athletes and others seeking to gain muscle mass. According to a study conducted in Finland, IGF-1 induces protein synthesis, which leads to an increase in lean muscle mass without a corresponding rise in adipose (fat) tissue. The growth factors in colostrum "shift fuel utilization from carbohydrate to fat. It mean that body will burn more fat, including fat made from the carbohydrate and protein that are consumed, producing fuel more efficiently.(34) Bovine has hormone factor like gastrin which plays a role as a trophic factor for mucosal growth with in stomach. GLP-2 has shown a general trophic response with in the gut.
Peptide growth factors in colostrum can influence the maintenance of mucosal mass and integrity. EGF stimulates cell proliferation and also influences crypt fission.(25) Human colostrum has higher concentration of growth factors as compared to bovine colostrum. The tables and figure below indicate how HC and BC differ in their nutrient content, immunological factors and growth factors (9,35,36)
While BC are considered a rich source of IgG, growth factors, and lactoferrin, currently no specific standards exist that define BC dietary supplements with respect to actual constituents or amounts of constituents. The following constituents are generally present in bovine colostrums: macronutrients; vitamins; minerals; Ig (IgG, IgM, and IgA - including the secretory form); cytokines including interleukin-1beta (IL-1β), interleukin- 6 (IL-6), tumor necrosis factor-alpha (TNF-α), and interferon-gamma (INF-γ); growth factors including insulin-like growth factor (IGF) I and II, transforming growth factor-beta (TGF-β), and epidermal growth factor; lactoperoxidase; and lactoferrin. Depending on the health of the cows, feeding practices followed, collection period, and the processing/concentration practices utilized by specific manufacturers, the actual range and quantities of specific macro- and micronutrients, Ig, cytokines, growth factors, and other compounds might vary considerably.(37,38,39)
BC contain relatively high amounts of Ig. Typically, Ig in general, and IgG specifically, constitutes the largest contribution to protein content in BC, with lactalbumin and casein contributing lesser amounts. Mean percentages of fat, protein, and lactose in colostrum were 6.7, 14.9, and 2.5, respectively.40 Other reports have estimated Ig concentrations from bovine mammary secretions with ranges for IgG1 (52-87 g/L), IgG2 (1.6-2.1 g/L), IgM(3.7-6.1 g/L), and IgA (3.2-6.2 g/L).41,42 As a rule, the Ig contribution will decline substantially in any BC collected more than 24 hours post-parturition and the amount of lactalbumin and casein will increase proportionately.
Detailed research plan (Materials and Methods)
Study design and setting
This will be Double blind Randomized Placebo controlled Trial. We are planning a study of 2 independent groups in the ratio of 1:1. The correct dose appears to be 60 grams and the number of patients required to be randomized should be more than 40 patients (10,11). We plan to enroll 250 patients.
We will use an uncorrected chi-squared statistic to evaluate this null hypothesis.
The study will be conducted on patients of Severe Alcoholic Hepatitis admitted in
Informed consent shall be taken from the patient/nearest relative of the patient for enrollment in the trial.
Consecutive patients diagnosed to have Severe Alcoholic Hepatitis will be randomized into two groups (group A and B). The randomization will be performed using a computer generated random sequence with permuted blocks of varying size stratified for each centre.
Masking Each center will have serially numbered identical vials containing bovine colostrum or pasteurized bovine milk arranged by a personnel who are not involved in the study according to the random sequence. The drug and the placebo will be identical in color, taste, appearance to ensure masking. All study personnel will be blinded to the treatment assignment (Bovine colostrum and placebo) for the duration of the study. The study drug will be administered by an oral route. The randomization code will be revealed only after the completion of recruitment, data collection and data analysis has been carried out.
Enrolment of patients, assessing eligibility and obtaining informed consent will be carried out by Principal Investigator (S.S. Sidhu) and other Centers Principal Investigator.
The patients will be randomized to either
Experimental arm: Bovine colostrum Enteral nutrition: Protein 1.5 gm/kg/day, energy (kcal) 30-40/day, B complex vitamins daily.
Pasteurized Bovine colostrum as a freeze dried powder (20 gm thrice a day) for 4 weeks.
+ Antibiotics + Diuretics +Terlipressin for HRS + acid suppression for prophylaxis against gastrointestinal hemorrhage + EVL for variceal bleed +drugs for HE if indicated
Placebo Comparator: Placebo Enteral nutrition: Protein 1.5 gm/kg/day, energy (kcal) 30-40/day, B complex vitamins daily.
Placebo (Pasteurised Milk Powder) 20 gms thrice a day for 4 weeks
+ Antibiotics + Diuretics + drugs for HE + Terlipressin for HRS + acid suppression for prophylaxis against gastrointestinal hemorrhage + EVL for variceal bleed + if indicated.
Study Methods Enrolment of patients, assessing eligibility and obtaining informed consent will be carried out by P.I. of each center Study Intervention
Treatment for SAH:
Liver biopsy: Transjugular liver biopsies will be obtained before start of therapy diagnosis of Alcoholic hepatitis [if possible]
Hemogram, blood glucose, liver function tests, prothrombin time, serum electrolytes, blood urea and serum creatinine will be done at baseline, and at and 7th day,14 days, 21 days , 28 days and then bimonthly for two monthsor earlier if indicated.
A diagnostic paracentesis will be done in all patients with ascites, at baseline, to diagnose Spontaneous Bacterial Peritonitis. A repeat cell count (Total and differential) shall be done on day 5 in patients diagnosed to have Spontaneous Bacterial Peritonitis. Blood culture, urine culture, cultures of aspirates from endotracheal tubes in ventilated patients for aerobic and anaerobic bacteria, and fungi shall be done on at admission. A chest radiograph shall also be done.
Endotoxin level estimation, alpha TNF,IL6& IL8 will be done at baseline and at end of treatment.
Tests for etiologic evaluation:
Etiology of cirrhosis will be taken as alcohol if there is a history of significant alcohol intake (20 gm/day for females, and 80 gm/day for males for 10 years or more). Each patient will be tested for Hepatitis B surface antigen (HBsAg) and Anti-hepatitis C (HCV) antibody using a third generation commercial ELISA. Wherever indicated, autoimmune hepatitis will be diagnosed using antinuclear antibody, anti-smooth muscle antibody and anti-LKM; and hemochromatosis using serum iron, TIBC, ferritin and transferrin saturation. Each patient shall have an abdominal ultrasonography. Upper gastrointestinal endoscopy would be done, if indicated.
Ascitic Fluid analysis:Ascitic Fluid analysis will be done on 1st day and 5th day of treatment.
Outcome measures and endpoints Primary outcome measure
Survival at 3 month
Secondary outcome measure
Monitoring for Adverse Events:
Any adverse event will be recorded specifying the time of onset, the duration, the severity and the relationship to the test medication.
Tolerability of the study drug will be assessed by comparison of full blood cell count, liver function tests and renal function tests at baseline and at end of treatment.
Follow-up All patients will be followed up to 3 months or until death. The status alive or dead will be assessed by telephoning a family member or by contacting the death registry at patients at birth place or place of residence.
Comparisons will be made with the Wilcoxon or t test for continuous variables according to the normality of distribution, and the χ2 test or Fisher exact test for qualitative variables. All results of continuous variables were expressed as means and 95% confidence intervals (CIs) for continuous variables and as the frequencies, percentages, and 95% CIs for categorical variables. The primary results will be presented for all analyses as unadjusted. The cumulative incidence of death will be estimated by the Kaplan-Meier method in each treatment group. The statistical significance of hazard ratio (HR) for treatment allocation will be tested using the Cox proportional hazards regression model. The potential heterogeneity in the treatment effect according to different study centers will tested by adding an interaction center × treatment in the Cox proportional hazards regression model. Potential risk factors will be first tested by the Cox proportional hazards regression model in univariate analysis. Prognostic variables with a significance at a level of less than 0.10 in univariate analyses will be included in a multivariable Cox proportional hazards regression model after removing variables showing a high degree of co - linearity. Factors included in a composite score will not be included in multivariable analysis to avoid bias related to the effect of co - linearity. All statistical analyses were performed in the intention- to-treat population as well as per-protocol population.
We are planning a study of 2 independent groups in the ratio of 1:1. Prior data indicates that when 40 patients undergoing gastrointestinal surgery were randomized and given 56 g daily of Bovine Colostrum for 3 days preoperatively) or placebo and the course of the plasma endotoxin levels and the endotoxin neutralization capacity (ENC) were measured daily up to the 10th postoperative day10. The results showed that the LPS-levels in the LC1-group, expressed as AUC, were significantly lower than those in the control group (p < 0.05). The difference between the two groups was apparent on the day of the operation and the day after. The fall in endotoxin neutralizing capacity (ENC) was significantly lower in the patients treated with the BCC and the return to initial values was faster than in the control group (p < 0.006).
In the second randomized study, 40 gms of Bovine Colostrum were given perioperatively to 60 open heart surgery patients without any decrease in LPS levels or fall in the ENC.(11) The correct dose appears to be 60 grams and the number of patients required to be randomized should be more than 40 patients (10,11).
Sample Size:The Survival rate of patients in standard medical treatment arm was 22% (Am J Gastroenterol 2014; 109:1417-1423). There is no contemporary Randomized controlled trial on the such type of patient (mDf >60, MELD >30). We consider a 20% increase in survival rate to clinically meaningful and sufficient to change practice. To detect a 20% increase in survival (from 22% to 42 %) in 3 month, The sample size based on survival at a fixed time point (22% vs 42% at 3 months), we require 79 per group + 10% drop outs. The total sample size required for the study is 174.
|Study Type ICMJE||Interventional|
|Study Phase ICMJE||Phase 3|
|Study Design ICMJE||Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Triple (Participant, Care Provider, Investigator)
Primary Purpose: Treatment
|Condition ICMJE||Alcoholic Hepatitis|
|Study Arms ICMJE||
* Includes publications given by the data provider as well as publications identified by ClinicalTrials.gov Identifier (NCT Number) in Medline.
|Recruitment Status ICMJE||Recruiting|
|Estimated Enrollment ICMJE
|Original Estimated Enrollment ICMJE
|Estimated Study Completion Date ICMJE||August 2021|
|Estimated Primary Completion Date||July 2021 (Final data collection date for primary outcome measure)|
|Eligibility Criteria ICMJE||
|Ages ICMJE||18 Years to 70 Years (Adult, Older Adult)|
|Accepts Healthy Volunteers ICMJE||No|
|Listed Location Countries ICMJE||India|
|Removed Location Countries|
|NCT Number ICMJE||NCT02473341|
|Other Study ID Numbers ICMJE||BASH|
|Has Data Monitoring Committee||Yes|
|U.S. FDA-regulated Product||
|IPD Sharing Statement ICMJE||Not Provided|
|Responsible Party||Prof. Sandeep S Sidhu, Dayanand Medical College and Hospital|
|Study Sponsor ICMJE||Dayanand Medical College and Hospital|
|Collaborators ICMJE||Not Provided|
|PRS Account||Dayanand Medical College and Hospital|
|Verification Date||April 2021|
ICMJE Data element required by the International Committee of Medical Journal Editors and the World Health Organization ICTRP