the dengue diseasethe dengue disease distribution, 2004 1 den1 den den1 den2 den2 den3 den4 den1...

The Dengue diseaseThe Dengue disease

‘Vaccinology 2008’Cartagena, ColombiaJune 4 2008June 4, 2008

Alain Bouckenooghe MD MPH DTMHsanofi pasteurClinical DevelopmentTraveler’s and Endemic diseasesSwiftwater, PA, USA

Overview of the presentation

Dengue virus and diseaseLive attenuated vaccines and second generationLive attenuated vaccines and second generationProductP li i l d tPreclinical dataGeneral overview of studiesClinical study results

Results of Ph I trials (CYD01/02)Partial results of Ph II trials (CYD04/05/06/10)Efficacy trials and further development

2

Conclusions

Dengue virusg

•Flavivirus (YF, JE)( )•Single stranded RNA genome

• 3 structural proteins• 7 non structural proteins

4 Dengue virus serotypes

Clinical diagnosis• Sub clinical infections

Cell 2002;108(5): 717-25

serotypesDen 1Den 2

• Fever• Classic Dengue • Hemorrhagic Dengue Fever

Den 3Den 4

Serological diagnosis• Primary infection• Secondary infection

g g

3

• Secondary infection

Transmission by Aedes aegypti

4

Dengue: A Global ThreatDengue Fever and Dengue Hemorrhagic Fever are a threat to more than 2.5 billion people in tropical and subtropical regions

5

Resurgence ex: reinfestation of A d ti i S th d L tiAedes aegypti in South and Latin America

1930 1970 20021930s 1970 2002

6

R12-Dengue reinfestationPAHO2002 web access January 2008 http://www.paho.org/english/ad/dpc/cdef

Serotypes distribution, 1970

DEN1DEN2

DEN1

DEN1DEN2DEN3DEN2 DEN3DEN4

7

Ref 3 :adapted from Mackenzie JS, Gubler DJ, Petersen LR. Nat Med 2004 Dec;10(12 Suppl):S98-109.

Serotypes distribution, 2004

1DEN1DEN2DEN1DEN1

DEN2DEN3DEN4 DEN1

DEN1DEN2 DEN1

DEN2DEN3DEN4

DEN1DEN2 DEN1

DEN2DEN3DEN4 DEN1

DEN2DEN3DEN4

DEN3DEN4

DEN2DEN3DEN4

DEN3DEN4

DEN4

8

Ref 3 : adapted from Mackenzie JS, Gubler DJ, Petersen LR. Nat Med 2004 Dec;10(12 Suppl):S98-109.Ref 5 :Gubler DJ. The global pandemic of dengue Ann Acad Med Singapore. 1998 Mar;27(2):227-34.

Dengue Mosquito TransmissionFlavivirus 4 serotypes4 serotypes

Pathogenesis

The disease

DSS•Target tissues include monocytes / macrophages and dendritic cells are permissive to infection with dengue virus

DHF

Dengue Fever

•Homologous (same serotype) immunity is probably lifelong

•Infection with one serotype does not provide lifelong

Undifferentiated Fever

cross-protective immunity

•Most clinically overt illness probably occurs during primary or secondary infections (ADE controversial

)

9

Asymptomatictheory, unproven in-vivo in humans)

Viremia, Fever and Antibody in Secondary Dengue Natural Infectionin Secondary Dengue Natural Infection

dire

ct I

FA

80

90100

(EIA

uni

ts)

celc

ius)

300

39.0

39.5

posi

tive

by in

d

Viremia

Fever

IgM50

60

70

ntib

ody

leve

l

re (

degr

ees

c

200

38.5

%m

osqu

ito p

IgG

20

30

40

gue

spec

ific

a

Tem

pera

tu

100

38.0

37.5

Days relative to fever resolution-3 -2 -1 0 1 2 3 4

10

0

Den

g

0 37.0

Days relative to fever resolution

10

Ref 15- adapted from CDC slide kit viremia, 2008 and Ref 7 : Vaughn, J Infect Dis; 1997, Aug 176 (2) 322-30

Comparison of clinical features of dengue fever and dengue hemorrhagic feverfever and dengue hemorrhagic fever

DF DHFFever + +Headache + +M l iMyalgias + +Rash 0/+ 0/+0/ 0/Thrombocytopenia + +++Bleeding 0/+ 0/+Plasma leakage 0 ++

11

gHepatitis + ++

DHF Haematological findings in DHF:

Low platelet count <100X10 9 /lpHaemoconcentration (rise in the packed cell volume >20% of basal level)Leucopenia early in the illnessp yAtypical lymphocytosis (>15%)Abnormal coagulation profile

Biochemical investigationsBiochemical investigationsLow albumin levelsElectrolytes disturbancesEl t d li

0.007% Asx or DF DHF DSS

Elevated liver enzymesacidosis 2.0%

1.1%

Frequency of dengue

0.18%

q y f gsyndromes among Thai children aged 1-14 yrs

12Ref 2 : Malavige GN, Postgrad Med J. 2004 Oct;80(948):592

Primary SecondaryHalstead SB, 1980

Dengue Hemorrhagic Fever : HypothesesRacial/genetic host factor

HUMANIMMUNE RESPONSE Sub-Subneutralizing antibody

Cellular immune response

C t ki

VIRUS

Cytokines

mosquitoVirus loadVirulence of some strains

13

mosquito

Management of Dengue infections

Mainly symptomatic (no specific drugs against dengue virus)

Temperature control with paracetamol and tepid sponging Light dietEarly identification of leakage phase Proper maintenance of fluid balance Monitor platelet count, packed cell volume,

l icoagulation parameters Adequate fluid administration according to severity

14Ref 2 : Malavige GN, Postgrad Med J. 2004 Oct;80(948):588-601

Dengue Vaccine developmentDengue Vaccine developmentDengue Vaccine developmentDengue Vaccine development

Important public health need for vaccinesImportant public health need for vaccines,there are no approved therapeuticsDifferent vaccine approaches

Inactivated virusInactivated virusLive attenuated virusTraditional culture techniquesTraditional culture techniques reactogenicity and stability problems

Recombinant vaccinesRecombinant vaccines

Others: DNA, proteins

15

Others: DNA, proteins

Dengue Vaccine DevelopmentsDengue Vaccine Developments

ButantanNIH licensee

Biological EBiological E.NIH licensee

PanaceaNIH liNIH licensee

FiocruzChimeric

Hawaii Biotech/NIH/WRAIR/GSK

Subunit

Inviragen/CDC/Shantha

Live attenuated DEN/DEN Chimeric

Subunit

NMRC/WRAIRDNA vaccine (monovalent)

Sanofi pasteurChimeric

Live attenuated

GSK/WRAIRLive attenuated

WRAIR/CrucellWhole virus inactivated

NIH/Univ. Of Maryland

DEN/DEN Chimeric

Phase IIIPhase IIPhase IPreclinical

PDK Mahidol / sanofi pasteur First Generation Tetravalent Dengue VaccineTetravalent Dengue Vaccine

Establishing The Dengue Tetravalent Live Attenuated Vaccine Proof of Concept in Thai Adults and Children

Live-attenuated whole virion vaccine

Proof of Concept in Thai Adults and Children

Tetravalent = Combined vaccine of the 4 polyclonal monovalents pre-MS Issued from the Thai Mahidol University

DEN 1 ( t 16007/ PDK 13)DEN 1 (parent 16007/ PDK-13),DEN 2 (parent 16681/ PDK-53), DEN 3 (parent 16562/ PGMK-30/FRhL-3)DEN 4 ( t 1036/ PDK 48)DEN 4 (parent 1036/ PDK-48)

GMP manufacture at Master,Working & Bulk levels in PDK certified cellscells

Lyophylised & stabilized clinical lots

S b t t

17

Subcutaneous route

0.5mL

GMTs GMTs of neutralizing antibody to DEN 1of neutralizing antibody to DEN 1--4 in children recipients of 4 in children recipients of dengue vaccine (Studydengue vaccine (Study 2) without Wt dengue infection (A n=74) and2) without Wt dengue infection (A n=74) anddengue vaccine (Studydengue vaccine (Study--2) without Wt dengue infection (A, n=74) and 2) without Wt dengue infection (A, n=74) and

with Wt dengue infection (B, n=8)with Wt dengue infection (B, n=8)

A B10000

Serotype1 Serotype2 Serotype3 Serotype410000


A B10000



100

1000

100

1000

100

1000

100

1000

10101010

1Do Dose Dose Dose Day of Booster Y2 Y3

1 2 2+28d of +28dbooster







Antibodies to dengue viruses of dengue vaccine recipients were well persisting. GMT values of neutralizing antibodies for den-1 and den-2 of dengue vaccine recipients with Wt dengue were significantly higher than those of vaccine recipients without Wt dengue infection and surpassed that for den-3

18

that for den-3.

Common Systemic Reactions and Rash after 1Common Systemic Reactions and Rash after 1stst, 2, 2ndnd and and Booster doseof DenguevaccineF1 and F2Booster doseof DenguevaccineF1 and F2

Fever

Booster dose of Dengue vaccine F1 and F2Booster dose of Dengue vaccine F1 and F2

Headache

Myalgia

F1(3212)(n=40, 39, 33) Dose 1

MildM dNausia

Rash

ModerateSevere

Dose 2MildModerate

Booster dose

Fever

HeadacheF2(3313)

(n=42, 40, 38)MildModerate

Myalgia

Nausia

( , , )

Rash0 10 20 30 40 50 60 70 80

Percentage

19

Percentage

Second generation: Attenuated dengue construction

17D YF genome cloned as cDNA

C prM E non-structural genes

Exchange dengue prM E prM E

envelope protein genesp p

Recombinant cDNA

C non-structural genes

Recombinant cDNA

prM E

20* Chimerivax™ technology, Acambis

Sanofi pasteur second generation

Recombinant technology dengue vaccine

replacing the genes for pre-M and E proteins of 17D YF i i ith th fvirus vaccine with those of

other flaviviruses

The resulting live attenuated viruses containing replication engine of 17D YF vaccine strain but the coatvaccine strain but the coat proteins of each dengue serotypes

CHIMERIC VIRUS

21

serotypes

Dengue Vaccine Product Profile

INDICATIONP ti f t ti d di iPrevention of symptomatic dengue disease i.e. covering the spectrum from Dengue Fever to severe Dengue cases due to serotypes 1 2 3 orsevere Dengue cases due to serotypes 1, 2, 3 or 4.

Priority: children to adults in all endemic countriesPriority: children to adults in all endemic countries (Asia, Latin America, and US Caribbean areas )

Travelers indication for children and adults fromTravelers indication for children and adults from non-endemic areas

22

Basic Preclinical data

Chimeric Tetravalent Dengue Vaccine

Genetically stable Not neurovirulent in 3-4 week old mice (IC route)Not neurovirulent in 3 4 week old mice (IC route) Less neurovirulent than YF 17D in suckling mouse and monkey

models (IC route) Does not become more neurovirulent upon extensive in vitro

passages Lower replication rate than YF 17D in liver cells Lower replication rate than YF 17D in liver cells Does not infect mosquitoes by insect’s oral route Replicates in mosquitoes by IT route similarly to the YF 17D virusReplicates in mosquitoes by IT route similarly to the YF 17D virus

and significantly lower than their WT parent viruses Protects monkeys upon a single dose vaccination against

heterologous WT challenge Induces low viremia and high neutralizing (last > 1year) response

when administered as a single SC monovalent dose to monkeys

23

when administered as a single SC monovalent dose to monkeys Lack of negative interference with YF vaccine

Completed / ongoing clinical trials with sp Dengue VaccineDengue VaccineCode Dengue Vaccine Populations Country Status

CYD01 ChimerivaxMonovalent D2

(3&5 l 10 PFU)

Adults (18-40 yo) n=56

US Completed (2002)

(3&5 log10 PFU)

CYD02 ChimerivaxTetravalent

(4 log10 TCID50/

Adults (18-40 yo) n=99

US Completed (2005)

(4 log10 TCID50/ serotype)


Adults (18-45 yo)n=66

US Completed



Adults (18-45 yo)Adolescents (12-17 yo), Children

(2 11 )

Philippines Ongoing


(2-11 yo)n=126


Adults (18-45 yo)Adolescents (12-17 yo), Children

Mexico OngoingTetravalent


Adolescents (12 17 yo), Children (2-11 yo)n=126

CYD10 Chimerivax Adults (18-40 yo)(DIV12 Trial s bjects VDV1

Australia Completed

24

Tetravalent(5 log10 TCID50/

serotype)

(DIV12 Trial subjects, VDV1, VDV2 or YF primed)

Max n=48

Ph I completed

25

Two Ph I studies

CYD01: monovalent (DEN-2) vaccine was given to 56 healthy US adultsUS adults

Good reactogenicity profile in YF naïve and YF vaccinatedG d i t 1 th d i t i d tGood immune response at 1 month, and maintained up to 12 monthsLog 5 seemed better than log 3 doseLog 5 seemed better than log 3 doseGuirakhoo et al. Hum Vaccin. 2006;2(2):60-7

CYD02: tetravalent (log 4) study with 99 healthy US adultsCYD02: tetravalent (log 4) study with 99 healthy US adultsAE rates equal to placebo and trend to lower rate compared to YFto YFInjection site reactions lowest in TV groupNo increase in AE with second dose

26

No increase in AE with second dose

CYD02 Trial : Safety profile post dose 1 and 2(% Subjects with adverse reactions)(% Subjects with adverse reactions)

100

Group ChimeriVax TV - 2 doses

Severe

Group YFV - ChimeriVax TV

15,20

34,5

0

5060708090

100

%

Severe

Moderate

Mild42,4

026,93,8

5060708090

100

%

Severe

Moderate

Mild

57,634,5

01020304050%

42,457,7

01020304050%

0ChimeriVax-Dose 1 (n=33) ChimeriVax-Dose 2 (n=29) YFV (n=33) ChimeriVax-Dose 1 (n=26)

Group Placebo - ChimeriVax TV

00

708090

100

p

Severe

Moderate

54,5

18,2

41,7

37,5

203040506070

%

Mild

27

01020

Placebo (n=33) ChimeriVax-Dose 1 (n=24)

CYD02: post dose 1 systemic reactogenicity profile

Myalgia

HeadacheChimeriVax

( 33)

P i

Fatigue

Malaise

Myalgia (n=33)

Pyrexia

Myalgia

Headache

MildYFV

Pyrexia

Fatigue

MalaiseMild

ModerateSevere

(n=33)

Malaise

Myalgia

Headache

Placebo(n=33)

Pyrexia

0 10 20 30 40 50 60 70 80

Pyrexia

Fatigue

Malaise

28

0 10 20 30 40 50 60 70 80Percentage

CYD02: Seroconversion Post-dose 1 & 2 Neutralizing antibody response (% subjects with antibody level 1:10)

90100

Serotype 1

Post-dose 1

P d 290

100

Serotype 2

Post-dose 1

4050607080

%

Pre-dose 2

Post-dose 2

40

50

60

70

80%

Post dose 1

Pre-dose 2

Post-dose 2

010203040

ChV 2 d YF V /ChV P l d ChV 1 d0

10

20

30

40

ChVx-2 doses YF-Vax/ChVx Pooled ChVx-1 dose ChVx-2 doses YF-Vax/ChVx Pooled ChVx-1 dose

90

100

Serotype 3

90100

Serotype 4

Post-dose 1

50

60

70

80

90

%Post-dose 1

Pre-dose 2

Post-dose 2

5060708090

%Pre-dose 2

Post-dose 2

0

10

20

30

40

010203040

29

0ChVx-2 doses YF-Vax/ChVx Pooled ChVx-1 dose

0ChVx-2 doses YF-Vax/ChVx Pooled ChVx-1 dose

•Ph I studies: acceptable reactogenicityPh I studies: acceptable reactogenicity profile, good safety, low viremia, good immune responsesimmune responses

Ph II studies CYD 04CYD05CYD06CYD10

30

CYD10

Three phase II observer-blind randomized controlled trialscontrolled trials

Study: USA CYD04 Philippines CYD05 Mexico CYD06

Population 66 Adults 18-40yr18 Adults 18-45yr36 Adolescents 12-17yr72 Children 2-11yr

18 Adults 18-45yr36 Adolescents 12-17yr72 Children 2-11yry y

FV Immune status at baseline**

3% 80.1 % 7.9 %baseline**

Protocol -------3 injections DV or control: Months 0, 3-4, 12------

Group 1: DV*, DV, DV DV, DV, DV DV, DV, DVpGroup 2:

, ,Placebo, DV, DV

, ,TyphimVi, DV, DV

, ,Stamaril, DV, DV

Objective To describe: safety, viremia and humoral immune responses, after each vaccine injectionj

Viremiatesting:

1) Screening of samples with a YF NS5 qRT-PCR method 2) Testing of positive samples by plaque assay, and by four RT-PCRs, specific to each dengue vaccine strain

*DV= Dengue Vaccine a log 5555doses**based on neut antibodies (dengue and JE for the Philippines)

CYD05/CYD06 Trials - Baseline Flavivirus Immune StatusAdults Ado [12-17] Child [6-11] Child [2-5] All[ ] [ ] [ ]

CYD05 Trial(dengue endemic

N=18 N=36 N=36 N=36 N=126( garea)

Flavivirus 100% 97 2% 66 6% 66 6% 80 1%Flavivirus positive(presence of neutralizing antibody against dengue

100% 97.2% 66.6% 66.6% 80.1%

and/or JE at baseline)

CYD06 Trial(non-dengue endemic area)

N=18 N=36 N=36 N=36 N=126

endemic area)

Flavivirus positive

16.6% 8.3% 8.3% 2.7% 7.9%positive(presence of neutralizing antibody against dengue at baseline)

Ph II safety

33

Post-dose 1 Reactogenicity of tetravalent dengue vaccine vs placebo, typhoid or yellow fever vaccines

60

80

100su

bjec

ts

20

40

60

% s

0Any AE Any Reaction Injection site

reactionSystemicreaction

SevereInjection site

reaction

SevereSystemicreaction

C d t l b th i t d i th FV ï l ti t

reaction reaction

USA DV USA Placebo Philippines DV Philippines TF Mexico DV Mexico YF

Compared to a placebo, there is a trend in the FV naïve population to a higher proportion of subjects experiencing systemic reactions, in terms

of asthenia, and myalgia

Compared to active control, there is no difference in the proportion of subjects experiencing systemic reactions

34Overall the majority of adverse events were mild-moderate and transient

R. Forrat, ASTM&H presentation 2007

Reactogenicity of each dose of CYD vaccine in CYD04/ CYD05/CYD06 Trials (% Subjects with adverse events)

CYD04 Trial CYD05 Trial CYD06 TrialDose 1(n=33)

Dose 2(n=30)

Dose 3(n=23)

Dose 1(n=84)

Dose 2(n=82)

Dose 1(n=84)

Dose 2(n=79)

Any Adverse event

84.8 80.0 65.2 79.8 65.9 72.6 72.2

Any 81 8 70 0 43 5 65 5 47 6 60 7 57 0Any Adverse reaction

81.8 70.0 43.5 65.5 47.6 60.7 57.0

Injection it

18.2 36.7 17.4 29.8 19.5 32.1 30.4site reactionSystemic reaction

78.8 66.7 43.5 60.7 39.0 50.0 44.3

Severe Injection site reaction

0 0 0 0 0 1.2 1.3

Severe Systemic reaction

15.2 3.3 0s 0 3.7 7.1 2.5

No increase of the incidence of AE after a 2nd or a 3rd dose in comparison to a 1st dose

and even a decrease after the 3rd dose in CYD04 trial and after the 2nd dose in CYD05 trial

Effect of age and dengue endemicity on post-dose 1 reactogenicity of dengue vaccineg y g

Philippines (endemic)80% Den/JE neut ab positive at baseline

Mexico (non-endemic)8% Den neut ab positive at baseline

80

100Adults (n=12)Adolescents (n=24)Children 6-11y (n=24)Children 2 5y (n=24)

80

100

ts

Adults (n=12)Adolescents (n=24)Children 6-11y (n=24)Children 2 5 (n 24)

40

60

% s

ubje

cts

Children 2-5y (n=24)

40

60

% s

ubje

ct Children 2-5y (n=24)

0

20

Any Head- Myalgia Malaise Asthenia Pyrexia

%

0

20

Head

Fewer systemic reactions reported for children, except fever butIncidence of Fever in DV recipients was similar to the incidence in Typhim Virecipients

Any Headache

Myalgia Malaise Asthenia PyrexiaAny Head-

acheMyalgia Malaise Asthenia Pyrexia

recipientsEpisodes were transient (1-3 days), mild/moderate (temperature <= 38.9°C)

No observed effect of baseline flavivirus immune status

Systemic adverse events frequently associated with concomitant illness (e.g. pharyngitis)


SAEs in Ph II

No vaccine related SAEs reportedSo far 12 SAEs reported (5 in CYD4 3 inSo far 12 SAEs reported (5 in CYD4, 3 in CYD5, and 4 in CYD6; none in CYD10)

E f i t l 350 bj t tExposure of approximately 350 subjects to dengue vaccine in Ph II

2 fatalities, not vaccine related (as assessed by investigator and IDMC)y g )

37

Summary of Fatal Serious Adverse EventsCYD 04 Study – Ischemic stroke

46-year-old female subject di l hi t f h ki ti l h t i imedical history of heavy smoking, essential hypertension, seizures

and alcohol abuse in the past Onset of event : 37 days after 2nd dose of ChimeriVax™ vaccine yDiagnosis: extensive right middle cerebral artery distribution ischemic stroke due to carotid artery stenosis (100% of right and 80% of left carotid artery)carotid artery)Developed cerebral edema and respiratory failureWas taken off the ventilator and subsequently died 12 days after onset q y yof the event

CYD 06 Study – Car accident 17 ld l bj t17-year-old male subject car accident on high way 5 months after receiving vaccine multiple head and abdominal contusions led to hepatic hilum and

38

multiple head and abdominal contusions led to hepatic hilum and aorta system laceration that produced internal hemorrhage. Despite life support the subject died 3 hours later

Ph II safety:mild reactogenictymild reactogenictyAE profile mild; myalgia/asthenia observed a little more thanobserved a little more than placebo but same as in controll SAE d f l t dlow SAEs and so far no related SAEs

Ph II safety biological testing

39

CYD04 Trial - Post-Dose 1 Biological Parameters(subjects with Out of normal range values among all subjects with normal value at baseline)baseline)

ChimeriVax-Dengue

Placebon=33Dengue

n=33n=33

BiochemistryBiochemistryAST 5 3ALT 3 2ALT 3 2Total Bilirubin 2 0C i i 1 0Creatinine 1 0CPK 3 4HematologyWBC 9 1

40

Neutrophils 4 0Lymphocytes 2 0

CYD04: WBC changes after dose1 and 2

pD1

pD2

41

CYD04 Trial – Biological Parameters after each dose (Out of normal range values among all subjects with normal value at baseline)ChimeriVax-Dengue

Dose 133

ChimeriVax-Dengue Dose 2

30

ChimeriVax-Dengue Dose 3

23n=33 n=30 n=23Biochemistry

AST 5 1 1AST ALT 3 0 0

Total 2 2 1Total Bilirubin

2 2 1

Creatinine 1 1 0Creatinine CPK 3 3 3

HematologyHematology

WBC 9 4 1

Neutrophils 4 2 0Neutrophils

Lymphocyte 2 0 0

42

Lymphocytes Platelet 1 0 0

CYD 05/06 Safety of dengue vaccineThese clinical trials are not closed; no vaccine-related SAE have been observed to date

Biological safety EvaluationTransient decreases of White Blood cell count were occasionally yobserved one week after dengue vaccination

They occurred more frequently in TV than after a placebo vaccine but not more than after an active control vaccinebut not more than after an active control vaccineIf noted, typically after dose 1They were of mild to moderate intensity, transient (<=1 week) and y y, ( )not part of a clinical syndromeThey were not increased in dengue endemic subjects

Biochemistry parameters were comparable between DV recipients and control vaccine recipients

43

p

Ph II i i iPh II vaccine viremia

44

CYD04/CYD05/CYD06 Trials – Viremia TestingTiming

CYD04: every two days from Day 0 to Day 20y y y yCYD05 and CYD06: 0, 7 and 14 days after vaccinationvaccination

Method (testing at GCI lab) 2 steps2 steps

1-Screening of samples with a YF-RT-PCR methodmethod2-Positive samples are then tested by a

t ifi Chi iV RT PCR d45

serotype-specific ChimeriVax RT-PCR and plaque assay

CYD04 Trial: Post-dose 1 & 2 viremia dataP t D 1&2 Vi i G 1 (YF RT PCR)Post-Dose 1&2 Viremia - Grp1 (YF-RT-PCR)

40

50Dose 1Dose 2

Viremia mainly post dose 1

20

30

% s

ubje

cts

Viremia level low

<1.4 log10 pfu/mL (LLOQ)

0

10

Day 0 Day 2 Day 4 Day 6 Day 8 Day 10 Day 12 Day 14 Day 16 Day 18 Day 20

None + by plaque assay

20

Post-Dose 1-ChimeriVax Dengue Serotype-specific RT-PCR

Viremia mainly serotype 4less 3 and rarely 2

81012141618

b su

bjec

ts

CYD4CYD3CYD2CYD1

y

After the 2nd dose, among 9 positive samples in YF-RT-PCR, only serotype 2 was identified in 2 samples

0246Nb

Day 0 Day 2 Day 4 Day 6 Day 8 Day 10 Day 12 Day 14 Day 16 Day 18 Day 20

46

identified in 2 samples

Effect of age and dengue endemicityon dengue vaccine viremiag

Philippines (endemic)80% Den/JE neut ab at baseline

Mexico (non-endemic)8% Den neut ab positive at baseline

100 100

80

100

s

80

100

Adults (n=12)Adolescents (n=24)Children 6-11y (n=24)Children 2 5y (n=24)

40

60

% S

ubje

ct

40

60Children 2-5y (n=24)

0

20

0 7 14 7 or 140

20

0 7 14 7 or 14

2 (ado group) vaccinated subjects had antigenemia levels above the LLOQ (max 2 3 log10

6 vaccinated subjects had antigenemia levels above the LLOQ (max 2 1 log10 pfu/mL)

0 7 14 7 or 14 0 7 14 7 or 14Day after injection

above the LLOQ (max 2.3 log10 pfu/mL)None were positive in Plaque assay

LLOQ (max 2.1 log10 pfu/mL)4 were positive in plaque assay (max 2.0 log10 pfu/mLAntigenemia was predominantly

47

assayAntigenemia was predominantly serotype 4, then 3

Antigenemia was predominantly serotype 4, then 3


Ph II viremia:t d dexpected and common

observationpeak day 7

more common in flavi naïvemore common in flavi-naïveviral load very low

Ph II immune response

48

CYD04 Trial – Neutralizing Antibody Results for each Serotype in Group receiving 3 doses of dengue vaccine –

CYD04-% Seropositivity-Serotype 3- Grp 1 CYD-CYD-CYD

CYD04-% Seropositivity-Serotype 1- Grp 1 CYD-CYD-CYD

80

100

10060

80

100

bjec

ts

CVD-WH0

12 1

70

100

20

40

60

% S

ubje

cts

CVD-WH0

27.3

73.3100

0

20

40

Post-Vacc 1 Post-Vacc 2 Post-Vacc 3

% S

ub

12.10


CYD04-% Seropositivity-Serotype 2- Grp 1 CYD-CYD-CYDCYD04-% Seropositivity-Serotype 4- Grp 1 CYD-CYD-CYD

93.3 10060

80

100

ubje

cts

CVD-WH0

86 7 10040

60

80

100

ubje

cts

Post-Vacc 1

Post Vacc 266.7

0

20

40


% S 63.6

86.7

0

20

40


% S

u Post-Vacc 2

Post-Vacc 3

49

CYD04 Trial – Neutralizing Antibody Results for Serotypes 1 & 2 in Group receiving 3 doses of dengue yp p g gvaccine –

% Seropositivity - Serotype 2 - Grp 1 CYD-CYD-CYD


80

100

120

s

CVD-WHO

10060

80

100

120

Subj

ects

CVD-WHO

12.1

70100

0

20

40

60

80

% S

ubje

cts

66.793.3 100

0

20

40


% S


GMT - Serotype 1 - Grp 1 CYD-CYD-CYD

1000


1000 CVD-WHO

10

100

1000

1/di

l

CVD-WHO

10

100

1/di

l

1Post-Vacc 1 Post-Vacc 2 Post-Vacc 3


50

+95% IC

CYD04 Trial – Neutralizing Antibody Results for Serotypes 3 & 4 in Group receiving 3 doses of dengue vaccine –


120

63 686.7 100

40

60

80

100

120

% S

ubje

cts

CVD-WHO% Seropositivity - Serotype 3 - Grp 1 CYD-CYD-CYD

80

100

120

ject

s

CVD-WHO

63.6

0

20

Post-Vacc 1 Post-Vacc 2 Post-Vacc 327.3

73.3100

0

20

40

60


% S

ubj


1000 CVD-WHO


1000

10

100

1/di

l

10

100

1/di

l

CVD-WHO



51

+95% IC

CYD05 - Neutralizing antibody results In endemic population – % Seropositive (Abs level >=10 1/dil) per Serotype after Two doses of TV Dengue Vaccine -

100

CYD05-% Seropositivity-Adults (n=12)

100

CYD05-% Seropositivity-Adolescents (n=24)

Adults (TV TV) Adolescents (TV TV)

60

80

100

Subj

ects

Pre-Dose 1Post-dose 2

60

80

100

Subj

ects

0

20

40

% S

Serotype 1 Serotype 2 Serotype 3 Serotype 40

20

40

% S


CYD05-% Seropositivity-Children [6-11y] (n=24) CYD05-% Seropositivity-Children [2-5y] (n=24)

Children [6-11y] (TV TV) Children [2-5y] (TV TV)

60

80

100

cts

60

80

100

cts

20

40

60

% S

ubje

c

20

40

60%

Sub

jec

52

0Serotype 1 Serotype 2 Serotype 3 Serotype 4


CYD06 - Neutralizing Antibody Results for each serotype in Children after 2 doses or 1 dose post-priming

CYD06-% Seropositivity- Grp CYD-CYD-Children [6-11y] (n=24)

100

Pre-Dose 1Post-Dose 1Pre-Dose 2Post-dose 2

CYD06-% Seropositivity- Grp YFV-CYD-Children [6-11y] (n=12)

100

Pre-Dose 1Post-Dose 1Pre-Dose 2Post-dose 2

Children [6-11y] in Grp 1 (TV TV) Children [6-11y] in Grp 2 (YF vaccine TV)

66 7 70 882,6 82,640

60

80

00

% S

ubje

cts

8070 70 70

40

60

80

% S

ubje

cts

2 CYD doses YF primed

0 0 4,2 016,7

52,266,7 70,8

9,1

47,830,4

56,561,9 65,2

0

20


%

0 0 0 08,3 8,3 16,7 8,330

10 10 10

70 70 70

0

20


%

CYD06-% Seropositivity- Grp CYD-CYD-Child [2 5 ] ( 24)

Pre-Dose 1Post-Dose 1

CYD06-% Seropositivity- Grp YFV-CYD-Child [2 5 ] ( 12)

Pre-Dose 1Post-Dose 1

Children [2-5y] in Grp 1 (TV TV) Children [2-5y] in Grp 2 (YF vaccine TV)

Children [2-5y] (n=24)

80

100

ts


Children [2-5y] (n=12)

60

80

100

cts


YF primed2 CYD doses

0 0 0 01327,3

39,152,2

5,326,3 30 35

47,4

10080 84,2

0

20

40

60

% S

ubje

ct

0 0 0 09,1 9,1 0 00 0 0 0

63,6

90,981,8

63,6

0

20

40

60

% S

ubje

c

53



CYD06 - Neutralizing Antibody Results for each serotype in Adults & Adolescents after 2 doses or 1 dose post-priming

CYD06-% Seropositivity- Grp YFV-CYD-Adults (n=6)

100

Pre-Dose 1

Post-Dose 1Pre-Dose 2

Post-dose 2

CYD06-% Seropositivity- Grp CYD-CYD-Adults (n=12)

100

Pre-Dose 1Post-Dose 1Pre-Dose 2Post-dose 22 CYD doses YF primed

Adults in Grp 1 ( TV TV) Adults in Grp 2 (YF vaccine TV)

66 7 66 740

60

80

% S

ubje

cts

Post dose 2

81,883,366 7

91,740

60

80

% S

ubje

cts

2 CYD doses YF primed

0 16,7 0 016,7 16,7 16,7 16,716,7 16,7 16,7 16,7

50 5066,7 66,7

0

20


%

0 0 0 08,3 8,3

41,7

0 16,7

41,733,3 33,3

66,7

0

20


%

CYD06-% Seropositivity- Grp CYD-CYD-Adolescents (n=24)

Pre-Dose 1

Post-Dose 1CYD06-% Seropositivity- Grp YFV-CYD-

Adolescents (n=12)Pre-Dose 1Post-Dose 1

Adolescents in Grp 1 (TV TV) Adolescents in Grp 2 (YF vaccine TV)

Adolescents (n 24)

60

80

100

cts

Pre-Dose 2

Post-dose 2

Adolescents (n 12)

60

80

100

cts


YF primed2 CYD doses

0 0 4,2 016,733,3

45,8

73,9

4,2

45,862,5

75

5066,7 75

91,7

0

20

40

60

% S

ubje

0 0 0 08,3 8,3 0 8,30 0 16,7 16,733,3

66,7 66,783,3

0

20

40

60%

Sub

je

54



CYD06 Trial – (2-45years): neutralizing antibody results for each serotype in group receiving 3 dosesresults for each serotype in group receiving 3 doses of dengue vaccine or 1 dose of YF vaccine followed by 2 doses of dengue vaccine

Neut antib response after three doses DV Dose 1Neut antib response after two doses

100

Neut antib response after three doses of dengue vaccine DV Dose 2

DV Dose 3

100

Neut antib response after two dosesof dengue vaccine in YF-primed subjects YF Dose 1

DV dose 2DV dose 3

40

60

80

opos

itive

>=

10)

40

60

80

100

ropo

sitiv

e (>

=10)

0

20

% s

er (

Serotype 1 Serotype 2 Serotype 3 Serotype 4 >=3serotypes

0

20% s

er (

Serotype 1 Serotype 2 Serotype 3 Serotype 4 >=3serotypesyp yp

55

CYD 10 resultsCYD 10 results

56

Trial Design CYD 10

Trials Design Population Status

O i j ti (1 ft i ti Ad lt 18 40 1 i j t l t d 35

CYD10

One injection (1 year after vaccination in DIV12 trial), 6 months follow-up

grp 1: monovalent VDV1 CYD TVgrp 2: monovalent VDV2 CYD TV

3 St il CYD TV

Adults 18-40y (n=36 from DIV12 trial )(n=12 FV naïve)

A t li

1 inject completed: 35 subjects

23 subjects from DIV12 trial 12 bj t FV ï10 grp 3: Stamaril CYD TV

grp 4: CYD TV

CYD TV : ~5 log10 TCID50 per serotype

Australia 12 subjects FV naïve

6 month follow-up ongoing

Objective: explore effect of pre-exposureObjective: explore effect of pre exposure

57

Sp second generation Chimeric TV Dengue Vaccine Immunogenicity after Dengue 1,2 or Yellow Fever prior exposure

CYD 10 (Australia) immunologic response after 1 dose of TV dengue

CYD10 - % Seropositivity - Den1 grp (n=7)

100

CYD10 - % Seropositivity - FV naive grp (n=12)

100

60

80

100

ects

Pre-Dose 1

Post-dose 1

60

80

100

ects

42,9

100

57,171,4 71,4

20

40% S

ubj

0 0 0 0025

58,366,7

20

40% S

ubje

0 14,3 00


CYD10 % S iti it D 2 ( 8)CYD10 - % Seropositivity - YFV grp (n=8)

0 0 0 000


CYD10 - % Seropositivity - Den2 grp (n=8)

80

100

CYD10 - % Seropositivity - YFV grp (n=8)

80

100

87,587,5100 100 100

40

60

% S

ubje

cts

7587,5

10040

60

% S

ubje

cts

58 1

0 0 00

20


0 12,5 0 025

0

20


PH II conclusions

59

Conclusions on Safety

SNo SAE related to vaccinationNo mild dengue like syndrome as previously observed

ith h l i i li tt t d d iwith whole virion live-attenuated dengue vaccineReactogenicity profile (clinical & biological) comparable t t l i t d ito control registered vaccineNo increase of reactogenicity in FV immune subjects (d YF) i i t FV i bj t(dengue or YF) in comparison to FV naive subjectsNo Increase of reactogenicity when moving to younger subjectssubjectsNo increase of reactogenicity after a 2nd or a 3rd dose

60

Conclusions on viremia

f ( OQ)Low level of viremia observed (<LLOQ)Serotype 4 the most detected then serotype 3Age effect on viremia results (less in younger children)Less viremia in dengue immune subjects compared to dengue naive subjects Decrease of viremia occurrence after a 2nd dose vs 1st dose No increase of viremia occurrence in YF primed subjects in comparison to YF naive subjects

61

Conclusions on immunogenicityIn non-endemic population,

Increase in seroconversion after the 2nd and a 3rd d f d idose of dengue vacicnePriming effect of previous YF vaccination: similar

f 1 t d i YF i d bj tresponse of a 1st dose in YF primed subjects compared to two doses in YF naive subjects

In endemic populationSubstantial Increase in seroconversion rates againstSubstantial Increase in seroconversion rates against each serotype, after two-doses of dengue vaccine

62

Moving towards efficacy trials and g yPh III

63

From the Phase II trials to Phase III Effi T i l Ph II t i lEfficacy Trials

S&IAdults-ado

S&IAdo-Adults S&I

Child

S&IAdults

S&IAdolescents

Phase II trials

du ts adoChildren

JE+/-, Den+/-Vietnam

do du tsDen+/-

SingaporeChildren

YF+, Den+/-Peru

AdultsFV naive

US

AdolescentsDen+/-

Latin Am

POC EfficacyChildren

JE+/ Den+/JE+/-, Den+/-Thailand

Phase III trials

Efficacy + Large Scale S&IChildren

Asia

Efficacy + Large Scale S&IAdolescents

Latin America

64

Challenges with the Ph III

Changing epidemiology year-by-yearDifferent epidemiology by country/sub-regionPeak incidence in different age groups for various countriesI f t t b ild f l l li i l t i l hilInfrastructure build up for large scale clinical trial, while maintaining pace of additional Ph II trialsDefinition of study endpointsDefinition of study endpointsValidation and scaling up of lab assays

65

Acknowledgements

Acambis, Cambridge, USA

M hid l U i i Th il dMahidol University, Thailand

CDC Puerto Rico, USA

Pediatric Dengue Vaccine Initiative Seoul South KoreaSeoul, South Korea

Clinical Trial Teams in Mexico, Philippines, and USA.

66

sanofi pasteur Dengue Global Team

ASADM. Boaz

Marketing C. Tricoire / J Colas

Dengue GCI Team Dengue Marketing TeamS. Hildreth

Business Development D. Julien Non Clinical Safety G Ravel

ClinicalR. Forrat / D. Crevat

G Dayan/ A BouckenooghePublic Policy J Calmet / C. Mascareñas

+Dengue Clinical Team QC Dev. P RiouDevelopment C. Navarro Dengue QC Dev Team

Dengue Development TeamQuality Assurance E. Spindler

GMA C. Luxemburger Dengue QA Team

Dengue GMA Team Regulatory L. MorganC. Rotario

L. Pollissard

Industrial Operations C MalinowskiDengue IO Team

Dengue Regulatory Team

Intellectual Property N SchaefferResearch V. Barban

B. GuyD R h T

Legal S. BauerDengue Research Team

Program Office J. Lang (PgL)

International A W th l (A i )R. Dumas (PL)El D f (PM)

67

International A Warthel (Asia)B. Zambrano (Latin America)

Elsa Defrasne (PM)

GraciasGracias

Thank youThank you

68

the dengue diseasethe dengue disease distribution, 2004 1 den1 den den1 den2 den2 den3 den4 den1...

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