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Vaccines Against Influenza
Rino Rappuoli SUMMER SCHOOL ON INFLUENZA 2nd edition Siena, 16-20 July 2012
From Sclavo to Sabin exploiting innovation to solve medical needs
Achille Sclavo
1904 I.S.V.T.
Istituto Sieroterapico e Vaccinogeno Toscano
Albert Sabin
When you run out of ideas…
Influenza Type A
Matrix protein Neuraminidase (NA)
Hemagglutinin (HA)
M2 ion channel protein
Segmented RNA genome
(Influenza type B virus has a different ion channel protein)
Influenza A subtypes based on Humagglutinin – HA
Neuraminidase – NA (Subtypes H3N2, H5N1 etc )
Species Distribution of Influenza Type A Hemagglutinin
Hemagglutinin Human Swine Equine Avian H1 + + - + H2 + - - + H3 + + + + H4 - - - + H5 - - - + H6 - - - + H7 - - + +
H8-H15 - - - +
1968 Split
1976 Subunit
1958 Whole virus
New generation Vaccines against Influenza
1997 Adjuva
nted
2007 More adjuvants
VLPs High dose
Intradermal Recombinant
Pandemic Tetravalent QIV (+ B strain)
M2 (universal) M1 (universal)
Stem (universal)
2007 Cell
culture
New
Live
attenuated
World surveillance identifies antigenic variants
Epidemiologic behavior is assessed
Variants are sequenced and characterized immunologically
Specific strains for inclusion in vaccine are selected on the basis of the degree of difference from previous strains and evidence of epidemiological significance
Viruses are manipulated for high-yield growth in eggs and distributed to manufacturers
Reference reagents are generated for characterization of the vaccine product
Seed pools are expanded and inoculated into large numbers of embryonated hen’s eggs
Allantoic fluids are harvested and virions concentrated by centrifugation
Virions are chemically inactivated and disrupted with detergent, and subunit hemagglutinin and neuraminidase proteins are purified
Individual monovalent pools are blended, and content of trivalent preparation verified
Vaccine is packed, labeled, and delivered
January
February
March
April
May
June
July
August
September
October
* N Engl J Med 351: 2037-2040
(Nov 2004)
Cell culture influenza production Holly Springs facility Bulk building description
Annual bulk seasonal flu capacity of >50 M doses or 150 M doses (monovalent) within 6 months after declaration of a pandemic
Two cell culture lines (3 x 5,000L each)
Two downstream processing (purification) lines
Media preparation, buffer preparation/charging and equipment preparation
Virus seed stock production and cell culture expansion labs
Designed for BSL2+, capable to upgrade to BSL3 15
Holly Springs, United States
State of the Art Large-scale Flu Cell-culture and Adjuvant Manufacturing Facility in Holly Springs, North Carolina
Collaboration between US Department of Health and Human Services (USHHS) and Biomedical Advanced Research and Development Authority (BARDA)
Collaboration via sharing of initial capital investment and US commitment to annual pre-pandemic stockpile purchases
Site will have seasonal, pre-pandemic, and pandemic vaccine capability (150m doses within 6 month of declaration of influenza pandemic)
Construction of US-based flu cell-culture site began in 2007 • Ribbon cutting was on November 25, 2009 • Ready to respond to pandemic as early as
2011 • Full scale commercial production by 2013
Construction and 15yr operation of this facility represents financial commitment of ~USD $1.1 billion for design, construction, start-up, and validation of the facility.
Efficacy in the elderly
10-year study, 713,872 person-seasons, average age 73
27% reduction in hospitalization 48% reduction in risk of death
Impriving influenza vaccines with new adjuvants MF59: An established adjuvant
Oil-in-water emulsion adjuvant licensed for use in seasonal influenza vaccine FLUAD* since 1997 • More than 150 million commercial doses
distributed
Adjuvanted vaccine provides heterologous responses to drifted strains
>120 Clinical studies, >200,000 subjects • No safety signals in either
pharmacovigilance database or meta-analysis of clinical trial database with 6 month subject follow-up (filed with CBER)
Pediatric studies and efficacy trial in 3,000 subjects
MF59 adjuvant emulsion
SPAN 85 TWEEN 80 Antigens
160nm
*FLUAD is a registered trademark of Novartis. FLUAD is not licensed in the Unites States. FLUAD is recommended for active prophylaxis of influenza in the elderly
oil
Improving influenza vaccines with new adjuvants
1910s 1920s 1930s 1940s 1950s 1960s 1970s 1980s 1990s 2000s
Aluminium Salts MF59
Many potent vaccine adjuvants have failed, due to safety concerns
MF59 was a key innovation, first novel adjuvant in 70 years
Alum and MPL (AS04®) are the only adjuvants currently approved in US
Fluad® (influenza Fendrix ® (HBV) Cervarix® (HPV)
Prepandrix® (pandemic influenza)
MPL+Alum (ASO4) Cervarix
The Slow Pace of Adjuvant Development
Preclinical studies show that MF59 nanoparticles are the strongest adjuvant for subunit flu vaccine
0
500
1000
1500
2000
2500
3000
Seum
HI t
iters
post-1 post-2
H3N2
0
200
400
600
800
post-1 post-2
H1N1
PLGCAPCpG
MF59Alumnil
0
50
100
150
200
250
300
350
post-1 post-2
B
FCC given at 0.1 micrograms/dose
Ser
um H
I ant
ibod
y tit
ers
FLUAD Immunogenicity Meta-Analysis - All Subjects
Superior Immune Response Against Conventional Vaccines
0.0
0.5
1.0
1.5
2.0
3.0
5.0
B A/H3N2 A/H1N1
FLU
AD
/Com
para
tor Po
st-Im
mun
izat
ion
GM
T Ra
tio
1st immunisation 2st immunisation 3st immunisation
Fluad® safety meta-analysis: no severe reactions
0%
10%
20%
30%
40%
50%
Pain
Eryt
hem
a
Indu
ratio
n
Mal
aise
Hea
dach
e
Mya
lgia
Feve
r (>=
38°C
)
Pain
Eryt
hem
a
Indu
ratio
n
Mal
aise
Hea
dach
e
Mya
lgia
Feve
r (>=
38°C
)
Control SevereReaction (n= 1437)Control Mild/Mod.Reaction (n= 1437)FLUAD SevereReaction (n= 2112)FLUAD Mild/Mod.Reaction (n= 2112)
Podda, Vaccine 19: 2673-80, 2001
Enhancement of adjuvant effect in elderly with low pre-immunization titer
0%
5%
10%
15%
20%
Rel
ativ
e in
crea
se in
% w
ith 4
-fold
incr
ease
B A/H3N2 A/H1N1
Pretiter <=20 Pretiter>40
0%
5%
10%
15%
20%
Rel
ativ
e in
crea
se in
% w
ith H
I Titr
e >=
160
B A/H3N2 A/H1N1
A) Proportion of subjects with 4-fold increase or seroconversion
B) Proportion of subjects with HI Titre >= 160
** **
**
**
**
** Pretiter ≤ 20 vs Pretiter >40, P<0.01
MF59-adjuvanted vaccine in children Seroprotection rates after one and two doses
H3N2 H1N1 B
0
10
20
30
40
50
60
70
80
90
100
0
10
20
30
40
50
60
70
80
90
100
0
10
20
30
40
50
60
70
80
90
100
%%
%
DAY 1 DAY 1 DAY 1DAY 29 DAY 29 DAY 29 DAY 50DAY 50DAY 50
0
10
20
30
40
50
60
70
80
90
100
0
10
20
30
40
50
60
70
80
90
100
0
10
20
30
40
50
60
70
80
90
100
0
10
20
30
40
50
60
70
80
90
100
0
10
20
30
40
50
60
70
80
90
100
%%
%
DAY 1 DAY 1 DAY 1DAY 29 DAY 29 DAY 29 DAY 50DAY 50DAY 50
FLUAD
Vaxigrip
MF59 induces higher levels of cross-reactive antibodies against drifted strains in children
Pre Pre Pre Post Post Post
Perc
enta
ge w
ith H
I >40
to
mis
mat
ched
str
ain
a: p < 0.001 b: p < 0.05
MF59 works against drifetd viruses Fujan example
Immunogenicity (haemagglutination inhibiting antibody titers) of 3 Chiron Vaccines inactivated influenza vaccines against H3N2 homologous vaccine strain (A/Panama) and against H3N2 heterovariant strain (A/Wyoming) Agrippal™ subunit
vaccine (n = 29)
Begrivac™ split vaccine (n = 30)
Fluad™ adjuvanted subunit vaccine (n =
30) A/Panama
(H3N2) A/Wyoming@
(H3N2) A/Panama
(H3N2) A/Wyoming
(H3N2) A/Panama
(H3N2) A/Wyoming
(H3N2) Pre-
vaccination
GMT 95% CI
87.2 56.4-134.8
52 31.9-85
48.1 32.8-70.6
20.3 13.9-29.6
65.2 42.2-100.9
40.2 25.5-63.1
Seroprotection rate§
No/Total (%)
23/29 (79.3%)
19/29 (65.5%)
22/30 (73.3%)
11/30 (36.7%)
21/30 (70%)
16/30 (53.3%)
Post-
vaccination
GMT 95% CI
174 1118.3-255.9
122.3 77.3-193.6
141.2 100.4-198.5
82.2 52.6-128.5
248.7 177.5-348.5
176.9 122.6-255.3
Seroprotection rate§
No/Total (%)
28/29 (96.5%)
22/29 (75.9%)
29/30 (96.7%)
24/30 (80%)
30/30 (100%)
30/30 (100%)
§ Seroprotection rate: proportion of subjects with a protective HI titre ≥ 40 @ A/Wyoming /3/2003 is an A/Fujian/411/2002-like strain. * GMR: geometrical mean ratio (post-vaccination GMT / pre-vaccination GMT)
Efficacy in the elderly
10-year study, 713,872 person-seasons, average age 73
MF 59 can address low vaccine efficacy due to antigenic drift
The risk of subjects ≥65 years of age developing an unsolicited reaction was similar for MF59- and non-adjuvanted vaccines Green indicates statistical evidence of a decreased risk with MF59-adjuvanted vaccine;
red indicates statistical evidence of an increased risk with MF59-adjuvanted vaccine. Significance claimed if 95% CI excluded 1. * Compared to non-adjuvanted vaccine; † includes or ‡ excludes study V7P35 (ClinicalTrials.gov Identifier: NCT00481065). Risk ratio: risk of developing a disease after exposure to a vaccine. Pellegrini M. et al. Vaccine 2009; 27:6959–6965.
Relative risk of adverse events following vaccination with MF59-adjuvanted or non-adjuvanted vaccines
Pooled analysis of 38 randomized, controlled influenza trials, subjects ≥65 years of age
1.0 1.2 1.4 1.6 1.8 2.0 0.0 0.2 0.4 0.6 0.8
All unsolicited adverse events‡ Including:
Solicited local reactions
• Cardiovascular diseases‡
• New onset of chronic diseases§
• Deaths§
• Serious adverse events§
• Hospitalizations§
Solicited systemic reactions
Lower risk with MF59-adjuvanted*
Higher risk with MF59-adjuvanted*
Risk ratios
From June to December 2009 3 H1N1 vaccines were:
Developed
Tested in clinical trials
Licensed
180 million doses produced
MF59 allowed dose sparing
Priming with H5N3
Adjuvanted H5N1 vaccine prime-boost regime induces broad H5N1 coverage
1
10
100
1000
10000 Homologous H5N1 – Clade 1
Heterologous H5N1 – Clade 2.2
Heterologous H5N1 – Clade 2.3
Heterologous H5N1 – Clade 2.1
Days
Boost with H5N1 clade 1 with MF59
6-8 years
Months
Protective titer (1:40)
With MF59
w/o MF59
By day 7 post-boost most of subjects have already protective neutralizing antibody titers against all virus strains
In 2006 we vaccinated with clade 1 H5N1 vaccine those people that had been vaccinated with clade 0 H5N1 in 1999
1999 Priming Clade 0
2006 Boost Clade 1
universal vaccine for H5?
Fluad
TIV –0.6
–0.4
–0.2
0.0
0.2
0.4
0.6
0.8
1.0
Vacc
ine
effic
acy
vs. n
on-in
fluen
za c
ontr
ol
0 20 40 60 80 100 120 140 160 180 200 220
Days post-second dose
Vesikari T, et al. NEJM.
Adjuvant improves vaccine efficacy in infants
Vaccination with adjuvant: more CD4+ T cells, more antibodies....... a different game
Non-Adj-15
MF59-7.5
MF59-15
10
100
1000
1 22 130 202 223 382 43
A/VN
/111
94/0
4 M
N- G
MT
* *
*
*
*
1:40
Galli et al, Proc Natl Acad Sci USA 2009
H5-
CD
4+ (i
n 10
6 tot
CD
4)
days
*
0
250
500
750
1000
1 22 130 202 223 382 43
* *
*
CD4+ T cells
MN antibodies
0
5
10
15
20
0 22 43 202 0
5
10
15
20
0 22 43 202 0
5
10
15
20
0 22 43 202
MF59-H5N3 primed H5N3 primed Unprimed
Memory B cells are present only in those primed with adjuvanted H5N1vaccine
1.2 0.8 0.7
12
3.6 2.4
3.6 3.0 3.6 2.9
9.2
4.1
Galli et al, Proc Natl Acad Sci USA 106 (19): 7962-7967, 2009
Perc
enta
ge o
f mem
ory
B c
ells
Priming with H5N3
Memory T cells are induced first Memory B cells are more abundant following adjuvant priming
1
10
100
1000
10000 Homologous H5N1 – Clade 1
Heterologous H5N1 – Clade 2.2
Heterologous H5N1 – Clade 2.3
Heterologous H5N1 – Clade 2.1
Days
Boost with H5N1 clade 1 with MF59
6-8 years
Months
Protective titer (1:40)
With MF59
w/o MF59
0
100
200
300
400
500
Pre Post-1 Post-2
Mean IL-2+/ IFN-γ- cells (x 106)
MF59 / 15 ug
MF59 / 7.5 ug
nil / 15 ug
Mea
n T
cells
x 1
06
0
5
10
15
20
25
30p<0.05
n=17
day 22
n=6 n=7
p<0.05
plain-H5N3 primed
unprimed
MF59-H5N3 primed
MF59 mechanism of action genes modulated by adjuvants at injection site
MF59 was the most potent activator of mouse transcriptome at injection site
All adjuvants tested modulate a common set of 168 “adjuvant core response genes”
Mosca et al. PNAS 2008
MF59 is a strong inducer of cytokines & cytokine receptor genes at injection site (mouse muscle)
Mosca et al. PNAS
MF59 is a potent inducer of genes involved in leukocyte transendothelial migration at injection site
MF59 is the most potent and rapid inducer of Itgam/CD11b mRNA Suggest a more rapid recruitment of CD11b+ blood cells into the muscle compared to CpG and Alum
Mosca et al. PNAS 200
MF59 induces a rapid recruitmnent of CD11b+ blood cell injection site
Blue: Utrophin Red: PI Green: αCD11b
Mosca et al. PNAS 20
47
Herfst et al (2012). Airborne Transmission of Influenza A/H5N1 Virus Between Ferrets. Science 336: 1534-1541.