clinical evaluation of pandemic live attenuated influenza vaccine (plaiv) candidate strain...

Clinical Evaluation of Pandemic Live

Attenuated Influenza Vaccine (PLAIV)

Candidate Strain A/17/CA/2009/38 (H1N1) in

Healthy Thais

Punnee Pitisuttithum - MBBS, DTM&H,FRCPT

Faculty of Tropical Medicine , Mahidol University

August 17,2011, Salaya,MU

WHO-Major approaches to increasing supplies of pandemic influenza vaccine

Develop regional and national plans for seasonal influenza vaccination programmes

Build a new production facilities in developing and/or industrialized countries

Explore formulations of influenza vaccine other than those commonly used for seasonal vaccination

3

Live Attenuated Influenza Virus Vaccine

4

5Russian Donor strain

Potential advantages of LAIVs• no down-stream processing required (harvested

vaccine is simply packaged);• high yield (20-50 doses of monovalent vaccine

per an egg);• needle-free delivery (administration is via an

intra-nasal spray), which may facilitate administration in resource-poor settings;

• induction of a broad immune response including mucosal, systemic and cell-mediated responses (in contrast parenterally administered inactivated vaccines do not induce mucasal immunity);

• induction of cross-reactive immune responses;

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History of LAIV Development in Thailand

• 2004 outbreak of H5N1 in Thailand • 2005 Indonesia stop sending flu viruses to WHO• 2006 Serious discussion on equitable sharing of benefits

from sharing viruses• 2007 WHO/HQ started supporting developing countries to

build up capacity to produce Flu vaccine in 6 countries, including Thailand

• 2008 Thailand success in producing first seasonal IIV at 2 doses per egg

• May 2009 Sublicensing agreement on LAIV with WHO based on Russian Technology from IEM, St Petersberg

• 16th July 2009 received the H1N1 (2009) pre-Master seeds from Russia, through WHO support and start MS, WS, vaccine viruses

• August 12th first PLAIV vaccine concentrate was harvested

• August 25th first PLAIV clinical lot filled and tested

10

H1N1 2009 LAIV

A/California/07/2009 (H1N1).A/Leningrad/134/17/57 (H2N2) X

A/17/California/2009/38 (H1N1) vaccine

Pre master seed

Facility for GMP production of clinical trial lot certified by WHO

Initial ObstraclesFor production

• Less yield, low dose than expected • SPF eggs-imported-German, US -not available in Thailand-Stabilizer??

PLAIV vaccine intranasal route

15

• Nasal applicator-imported• Need to be available locally

Characterization of candidate vaccines Vaccine Production-identity(genotype,

phenotype);toxicity (mice,guinea pig ferret) Potency-immune response (mice , ferret) Stability Batch release and Independent Laboratory

evaluation Standards and Reference Materials

H1N1 2009 GPO vaccine

Pre master seed from Russia

master seed

Working seed

Virus concentrates

Bulk vaccine Vaccine product

Identity- genotypic, phenotypic

Toxicities-mice,guinea pigImmuninty and attenuation in animal model

Each step required

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PRE–CLINICAL STUDY (1)

INFECTIVITY: 7.5–8.5 lg EID50/0.2 ml

IDENTITY (CONFIRMATION OF GENOME FORMULA): 6:2

GENETIC STABILITY (CONFIRMATION OF STABILITY OF MUTATIONS IN THE GENOME OF VACCINE STRAIN RESPONSIBLE FOR

THE ATTENUATION): by Faculty of Science ,MU

GMP facility for CLINICAL lot production is at Silapakorn U

PRE–CLINICAL STUDY (2)

GUENEA PIGS ( by GPO, Fac. Vet, MU) AND FERRETS STUDY (Amsterdam): for Safe & immunogenicityImmune response –at Fac.Medicine,Siriraj Hosp,MU

ATTENUATION (CONFIRMATION OF THE ts/ca/att PHENOTYPE): ts/ca (IN HENS’ EGG). att (IN MICE). TOX STUDY: SAFE FOR MICE removal of adventitious agents by Faculty of Medicine, Siriraj,MU

WILD TYPE AND COLD–ADAPTEDVIRUSES IN FERRETS

Lungs Nasal turbinates

Wild type virus Vaccine strain

lg E

ID5

0/m

L/g

r

1 2 3 4 5 6 7 8 9 100

2

4

6

8attenuated

non–attenuated

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Phase I/II Safety and Immunogenicity of

Pandemic Live Attenuated Influenza

Vaccine (PLAIV) Candidate Strain

A/17/CA/2009/38 (H1N1) in Healthy Thais

Punnee Pitisuttithum - MBBS, DTM&H,FRCPT

Faculty of Tropical Medicine , Mahidol University

Objectives 

Overall Primary objectives (Part A, Part B)• To evaluate safety and reactogenicity of PLAIV

manufactured by GPO, Thailand• To evaluate humoral immune response of the above

vaccine after intranasal application by using HAI test, micro neutralization assays

• To determine the vaccine induced local IgA response by ELISA

Secondary objectives (Part A)• To assess shedding and stability of the viral strain by

using PCR method.

Part A:• The study is a double blind randomized study

involving 24 participants with the main objective of assessing safety-tolerability and optimal immune response of the newly manufactured PLAIV candidate strain A/17/CA/2009/38 (H1N1).

• It is study of two different inoculums sizes of candidate vaccines (5.0-6.5 log10 EID50 or 6.6-7.5 log10 EID50) and given two doses 21 days apart.

Pandemic Live Attenuated Influenza Vaccine (PLAIV) Candidate Strain A/17/CA/2009/38 (H1N1) in 5% sucrose (0.5ml intranasally)

Vaccine :

Part A• 24 Volunteers• Divided into 2 groups, 12 volunteers each group• Group 1 received 5.8 log 10 EID50• Group 2 received 6.9 log 10 EID50

Group Placebo 5.0 - 6.5 log 10 EID50A/17/CA/2009/38 (H1N1)

6.6 - 7.5 log 10 EID50

A/17/CA/2009/38 (H1N1)

N

1 3 9 0 12

2 3 0 9 12

Vaccine : Placebo = 3:1

Part B:• The study is a double blind randomized study

involving 324 participants with the main objective of assessing immune responses and safety of the newly manufactured PLAIV candidate strain A/17/CA/2009/38 (H1N1).

• Using the PLAIV of 6.5-7.5 log10 EID50 and given in intranasally two doses 21 days apart.

Group >12-18 years

>18-49 years >49 years

Vaccine 81 81 81

Placebo 27 27 27

Table 1.Number of participants in 3 stratified age groups

Total =108 each arm

Activities (Part A)

Immunization D1,D21 (Two doses)

Safety follow up for 7 days after

each immunization and

D21,D42,D60

Nasal swab D2,3,5,7

Nasal wash D1,21,42,D60

Blood drawn D1,D21,D42,D60

Other systemic reactions will be assessed in 4 scales as follow:

0 - no No symptoms

1 -mild Ill-defined symptoms

2 –moderate Symptoms, affecting normal daily activity

3 -severe Symptoms markedly affecting normal daily

activity and needed medication or clinic visit or activity limit

• Data & Safety Monitoring Board-Chair-MU

(Advised by WHO regional office and TDR) • Monitoring by WHO-TDR• Audit-initial audited by WHO-TDR from

Roch• Safety monitoring team appointed by

sponsor-Chaired by Prof. Dr. Apornpirom

88 screen (14 re-screened)

24

12 12

11 12

Low dose 5.8 (EID 50) High dose 6.9 (EID 50)

High titre HAI 16/78 (20.5%)Abnormal CxR 7/88Other abnormalities

1st Immunization

2nd Immunization

Abnormal CXR (re-read)

Delayed Immunization (URI)-PCR for seasonal and pandemic flu-negative

(2)

Results

Reactogenicity –Part A

• One had fever from the high dose group(38 oc)

• Few reported cough ,scratchy throat and myalgia from both groups and also the placebos.

• Reactogenicity declined after second immunization

Immunological Measurements (Siriraj Hospital)

Specific antibodies analysis includes specific anti-influenza antibodies to the vaccine strain (HAI test, ELISA, micro-neutralization assay).

HAI assay Sera were pre-treated with receptor

destroying enzyme and were tested for hemagglutinin-inhibition (HI) antibodies using standard procedures and whole influenza A and B viruses homologous to the vaccine strains in a standard micro-titer assay

40 Samples were sent to NSBC –WHO reference lab: different in HI titre, the NSBC results in relatively higher titer.

Micro-neutralization assay

mNT was performed in MDCK cell monolayer using the local isolate, A/Thailand/104/2009(H1N1) as well as A/CA/07/2009(H1N1) as the test viruses.

sIgA in the nasal wash

- Nasal wash specimens were tested for influenza virus specific IgA antibodies using an enzyme-linked immunosorbent assay (ELISA).

• Nasal swab samples were collected on D2, 3, 5 and 7 after each vaccination.

• Viral shedding in nasal swab samples was determined by real time RT-PCR for M gene using CDC protocol for the 2009 pandemic influenza virus.

• Sensitivity of detection is limited to 10-100 copies/reaction.

• RNP was used as the house keeping gene.

Conclusion• LAIV Candidate Strain A/17/CA/2009/38 (H1N1) appeared to be safe in small number of healthy adults

• Viral shedding rate was low since it was

found only in two cases at D2 after first vaccination.

• In term of immune responses , it is difficult to

conclude since the sample size was small and there

may be other immune responses that should be

measured other than HAI and MN for LAIV vaccine for example local IgA or cell mediated immunity

• DSMB recommendation:• No safety concern• Continue as planned to children and

middle age group

Phase I/II Safety and Immunogenicity of Pandemic Live Attenuated Influenza Vaccine (PLAIV) Candidate Strain A/17/CA/2009/38

(H1N1) in Healthy Thais

Punnee Pitisuttithum MB,BS, DTM&H,FRCP(T)

Faculty of Tropical Medicine , Mahidol University

17-18 Feb 2011.Geneva

Part B

Group >12 – 18 years

>18 – 49 years

>49 years

Vaccine 81 81 81

Placebo 27 27 27

Vaccine: Placebo = 3:1 (108 each group)

Study Design It is a double blind randomized study using the

6.6-7.5 log10 EID50 dose (stabilizer is similar to Medimmune) 324 participants (243 vaccines and 81

placebos) will be enrolled

Activities

• Immunization D1,D21 vaccine using stabilizer which is similar to Med Immune LAIV vac

• Safety follow up for 7 days after each immunization,D21,42,60

• Nasal wash D1.D21,42,60 (ONLY 40 IN ADULT GROUP)

• Blood drawn D1,21,42,60

Group I (Age > 12-18)

Total Screen = 404 cases(male= 195, female= 209) ; Rescreen = 6 cases

Total enroll = 110 cases (male= 49, female= 61)

Not eligible = 294 cases (HI Titer=234, *Others = 60)

Group II (Age ≥ 18-49)

Total Screen = 267 cases(male= 101, female= 166)

Total enroll = 110 cases (male= 44, female= 66)

Not eligible = 157 cases (HI Titer=82, *Others = 75)

Screen Group II replace Group I

Total Screen = 21 cases(male= 1, female= 20); Rescreen = 10 cases

Total enroll = 10 cases (male= 0, female= 10)

Not eligible = 11 cases (HI Titer=5, *Others = 6)

Group III (Age ≥ 49)

Total Screen = 356 cases(male= 63, female= 293) ; Rescreen = 24 cases

Total enroll = 133 cases (male= 18, female= 115)

Not eligible = 223 cases (HI Titer=56, *Others = 167)

*(Others ; Abnormal CXR , Anemia, HBsAg +ve, HCV +ve, chronic disease, High AST, ALT, CPK , Abnormal urine, etc…)

GPO FLU VACCINE -01 Part B

Total Screen = 1048 casesTotal enroll = 363 casesNot eligible = 685 cases

Rescreen = 40 cases

40% reported AE suspected to be related to the vaccine and equally distributed in all three age groups

not related to treatment related to treatment related to treatment (cause permanent discontinuation

of treatment)

related to treatment (cause temporary discontinuation

of treatment)

0

10

20

30

40

50

60

70

80

90

100Total Age group

>12-18 Yr

>18-49 Yr

> 49 Yrtotal

Blinded data only those reported AEsare shown in the graph

• Common AE suspected to be related to the treatment were rhinorrhea (8%)

throat irritation (5%), nasopharyngitis (8%) cough(4%) and upper respiratory tract infection (1%)

• The majority were mild,19% reported as moderate and only 2% reported severe in intensity

• There is no serious adverse event (SAE) reported in part B

Bad Taste in Mouth

Burning Sensation

Cough Nasal Blockage

Nausea Redness of Nose

Runny Nose

Scratchy Throat

Sore Throat

Stiffness of Nose

Vomit0

5

10

15

20

25

30

First Immunization N = 310 Second Immunization N = 276

* 27.5%

Comparison of Local Reaction Post Immunization(from total volunteers) majority were mild grade

Subj

ects

, %

10%

16%

5%

19%

11%14%

6%5.8%

1%

14%

29%

13%

21%

11%

27.5%

13%

1.8%

Comparison of Maximum Grade of Local Reaction at Post Immunization separate by age group

Total Age Group

>12-18 Yr >18-49 Yr > 49 Yr0

10

20

30

40

50

60

70

80

90

100

Grade 1

Grade 2

Grade 3

Total Age Group

>12-18 Yr >18-49 Yr > 49 Yr0

10

20

30

40

50

60

70

80

90

100

Grade 1

Grade 2

Grade 3

Mild

1st immunization

Sub

ject

s, %

2nd immunization

Sub

ject

s, %

Mild

Grade 2 Grade 30

5

10

15

20

25First Immunization N = 310 Second Immunization N = 310

>37.5-38.5 >38.5

Subj

ects

, %Comparison of Fever - Post Immunization(from total volunteers)

N=6%

N=2%

N=0.6%

0

5

10

15

20

25

30

First Immunization N = 310 Second Immunization N = 310

*23%

Comparison of Systemic Reaction Post Immunization(from total volunteers)

Subj

ects

, %

6%

7%

17%

11%

7% 7%

19%

7%0

9%10%

9%

6%

13%

0.03%

Comparison of Maximum Grade of Systemic Reaction at Post Immunization separate by age group (out of those who reported)

Total Age Group

>12-18 Yr >18-49 Yr > 49 Yr0

10

20

30

40

50

60

70

80

90

100

Grade 1

Grade 2

Grade 3

Su

bje

cts,

%

Total Age Group

>12-18 Yr >18-49 Yr > 49 Yr0

10

20

30

40

50

60

70

80

90

100Grade 1

Grade 2

Grade 3

1st immunization 2nd immunization

Sub

ject

s, %

Mild

Mild

Haemagglutination inhibition test (HAI Assay)

Total Age Group

Test virus: A/17/CA/2009/38(H1N1) – GPO vaccine strain

Day Vaccination status N

Number of subjects with HI antibody titer of

No. with Ab rising in folds

<10 10 20 40 80 160 2 4

1 Pre-IMM 266 247 19 - - - - - -

21Before 2nd

IMM260 202 34 16 4 3 1

4618%

197.3%

4221 D after 2nd

IMM 258 158 49 31 14 4 291

35%47

18.2%

6039 D after 2nd

IMM 260 151 43 39 20 5 210239%

6224%

Blinded data

Since V:P 3:1

• If assume, all seroconversion by HI were due to vaccinees

• >2 folds rise D21 D42 D60

24% 47% 52%• >4 fold rise 10% 24% 31%

Conclusion

Vaccine appeared to be safeAbout 54% reported AE suspected to be related The most common ones are

nasopharyngitis,rhinorrhoea,cough which were mild in intensity

No SAE reportedOnly one reported fever>38.5 0CAbout 25% reported scratchy throat was the most

common local reaction The most common reported systemic reaction was

headache , only 5%reported as moderate and above in intensity

Immune responses

• Form blinded data,46.2% developed >2 fold rise and 24.3% developed >4 fold rise of immune responses measured by either HAI, Micro-neutralization test or sIgA from nasal wash

Licensed for Pandemic use –July12,2011 for adult

Serum Institute of India

Acknowledgement

Mahidol UniversityFaculty of ScienceFaculty of Medicine ,Siriraj HospitalFaculty of Veterinary MedicineFaculty of Tropical Medicine

• Vaccine manufactured-GPO

Sponsor by Thai Health, WHO

Dr. Suwit Wibulphonprasert ,MOPHDr. Vichai Chokviwat,MOPHDr. Marie-Paule Kieny WHODr.Larisa Rodenko, University of St Petersberg , Russia

Thank you for your attention