AlbertAlbert OsterhausOsterhaus HeadHead DepartmentDepartment ofof VirologyVirology CSO Viroclinics ---Biosciences BV (Erasmus MC)

NovelNovel generationgeneration influenzainfluenza :vaccines: AdjuvantsAdjuvants forfor increasingincreasing pandemicpandemic vaccinevaccine supplysupply

222ndndnd WHO Consultation on a Global Action Plan for pandemic vaccines Geneva 13 ththth July 2011 Pandemic influenza vaccines ---Key issues ---

 Response time (((currently(currently ~6 monthsmonths))))

 Production capacity (((currently(currently ~1000 million doses trivalent worldworld----widewidewide))

 EfficacyEfficacy////SafetySafety

(((human(human trials with prototype H5, H9 vaccines) NB: Regulatory issues Bodewes et al, Expert Rev Vaccines. 2010 Jan;9(1):59-72 Bodewes et al, Expert Rev Vaccines. 2010 Jan;9(1):59-72 DIAGNOSTIC READ-OUTS

Clinical & Virological Parameters

Seasonal H1N1 pH1N1 2009 HPAI H5N1

Lung Weight

Munster et al., Science 2009 Del Giudice et al., Science TM 2009 Temperature Virus Load Chutinimitkul et al., J.Virol 2010 Herfst et al., Vet.Pathol. 2010 Bosch et al., J.Virol. 2010 Kreijtz et al., J.Gen.Virol. 2010 v.d.Brand et al., JID 2010 v.d.Brand et al., J.Virol 2010 Pandemic influenza vaccines - Room for improvement -

Strain selection “““small ””” changes; easy to incorporate

Seed-strain preparation

Production systems

New targets; identify correlates of protection

ImproveImprove efficacy; efficacy: adjuvantsadjuvants & delivery & delivery systems systems

largerlarger changes;changes; longlong pathpath beforebefore implementation?implementation? Adjuvants and antigen presentation systems for viral vaccines tested in humans (1/2) (an arbritary selection)

Adjuvant Viral antigen

Mineral salts Aluminium salts numerous Alum + MPL HBsAg, HSV (gD)

Emulsions MF 59 / ASOx Flu HBV (rPreS2-S) HSV2 (rgB + rgD) HIV1 (gp 120) CMV (rgB) HPV MF59 + MTP-PE Flu (split) HIV1 QS21 HIV1 (gp120) Incomplete Freund (IFA) HIV1 (gp120 depleted) Montamide ISA51 HIV1 (Tat ) Adjuvants and antigen presentation systems for viral vaccines tested in humans (2/2) (an arbritary selection)

Emulsions (cont.) QS21 HIV1 (gp120) Incomplete Freund (IFA) HIV1 (gp120 depleted) Montamide ISA51 HIV1 (Tat toxoid)

Bacterial products MPL (like) numerous Holotoxins (CT, PT, LT) Flu

Immunoadjuvants Cytokines numerous

Particulate formulations Liposomes Flu Virosomes Flu, HAV ISCOMS numerous Pandemic influenza vaccines - Improve efficacy; adjuvants & delivery systems -

- Adjuvants & antigen delivery systems Aluminum salts MF59 ASO3 Virosomes ISCOMs -Variety of presentations Others…. Subunits Split vaccines Whole inactivated virus Live-attenuated virus Virus-like particles Recombinant proteins DNA vaccines Others…. New adjuvanted influenza vaccines / candidates (an arbritary selection)

 Approved:  MF59 ((squalenesqualene emulsion) seasonal / pandemic  AS03 ((squalene/tocopherolsqualene/tocopherol emulsion) pandemic  Alum pandemic  Virosomes (((liposomes (liposomesliposomes))))seasonal  Polyoxidonium (poly(poly- ---electrolyte)electrolyte) seasonal  Clinical studies (phase 1, 2)  Iscom / Iscom Matrix )  AF3 (((squalene (squalene o/w emulsions)  SE (((squalene (squalene o/w emulsions)  GLA (TLR 4 agonist)  Covaccine (TLR 4 agonist)  Flagellin (TLR 5 agonist)  IC31 (((dI:dC (dI:dC ––– TLR9 agonist)  Inulin (complement activator)  JVRSJVRS----100100 (cationic liposome) FormalinFormalin inactivatedinactivated alumalum adjuvantedadjuvanted vaccines:vaccines: an additional risk?

• FormalinFormalin----inactivatedinactivated paramyxovirus vaccines adjuvanted with alum can predispose to hypersensitivity responses (sixties!!!)

• Similar pathology seen for FIFI----RSV,RSV, FIFI----MV,MV, FIFI----hMPVhMPVhMPV,, SARSSARS----CoVCoV

• HowHow aboutabout formalinformalin inactivatedinactivated FluFlu alumalum vaccines?vaccines? Immunopathology study in monkey: General conclusion about safety

 Protection against homologous challenge  NoNoNoNoNoNo pneumoniapneumonia exacerbationexacerbation observed when monkeys vaccinated with an inactivated split-virion influenza A/H5N1 adjuvanted with aluminum hydroxide were challenged with a parental wild type strain

Ruat et al ., J.VirolJ.Virol.,., 2008 Protective immunity (Rimmelzwaan et al., Vaccine 1998)

A/NL/18/94 iscoms SIV-iscoms controls 6 6 6

4 4 4 LLF 2 2 2

0 ND ND 0 ND ND 0 ND ND /ml /ml /ml

50 4 50 4 50 4 PS 2 2 2

log TCID log 0 TCID log 0 TCID log 0

4 4 4 NS 2 2 2

0 0 0 0 1 2 3 4 6 811 0 1 2 3 4 6 811 0 1 2 3 4 6 811 days post challenge days post challenge infection days post challenge infection A/NL/18/94 glycoprotein A/NL/18/94 glycoprotein primary infection preparation I preparation II with A/NL/18/94 6 6 6

4 4 4 LLF 2 2 2

0 ND ND 0 ND ND 0 ND ND /ml /ml /ml

50 4 50 4 50 4 Nature 308:457308:457----460, 1984 PS 2 2 2

log TCID log 0 TCID log 0 TCID log 0

4 4 4 NS 2 2 2

0 0 0 0 1 2 3 4 6 811 0 1 2 3 4 6 811 0 1 2 3 4 6 811 days post challenge infection days post challenge infection days post challenge infection

Lung damage: HPAI H5N1 virus challenge in ferrets ---response to NA important ---

Bosch B.J. et al., J.VirolJ.Virol....2010 AssessmentAssessment ofof prepre ----pandemicpandemic H5N1H5N1 clinicalclinical trialstrials

Type of vaccine Compliance with EU licensing criteria

Split vaccine no adjuvant Need two doses of 90 µµµµgggg Split/ with alum Need two doses of 3030----4545 µµµgµggg Whole virus (egg) with alum Need two doses of 1010----1515 µµµgµggg Subunit with MF59 adjuvant Need two doses of 7.5 µµµµgggg Whole virus Vero cell culture, no adjuvant Need two doses of 7.5 µµµµgggg Split vaccine with AS adjuvant Need two doses of 3.8 µµµµgggg

Data presented at WHO meeting, February 2007 ( Pasteur, 4 Companies in Jp, CSL, Microgen, Sinovac, GSK, Novartis,BaxterNovartis,Baxter) ))) (Courtesy: John Wood) The three CHMP criteria are exceeded by all the adjuvanted doses: seroconversionseroconversion ratesrates

100 3.8 µg H5 7.5 µg H5 15 µg H5 30 µg H5

757575 3.8 µg H5 AS 7.5 µg H5 AS 15 g H5 AS rate (%) (%) rate rate rate (%) (%) rate rate µ 30 µg H5 AS 505050 CHMP criteria 404040

252525 Seroconversion Seroconversion Seroconversion Seroconversion

000 Post first dose Post second dose IX International Symposium on Respiratory Viral ; March 3 – 6, 2007, Hong Kong Reactogenicity data are consistent with results

obtained in H5N1/AS03 A pandemic vaccine: general adverse events

100

90

80

70

60

50

% subjects % 40

30

20

10

0

Arthralgia Fatigue Fever Headache Myalgia Shivering Sweating

H1N1 (5.25µg) + AS03 A H1N1 (21µg) All grades Grade 3

H5N1 (3.75µg) + AS03 A*

Devaster JM. et al. Immunogenicity and safety of an A/H1N1v AS03A-adjuvanted pandemic candidate: Preliminary results from a randomized, controlled trial in adults. Vaccine Congress 2009, Singapore. H5N1/AS03 A pandemic vaccine has shown a broad and persistent immune response

Two immunisations at day 1 and day 21 with H5N1 A/Vietnam/1194/04 split virus, AS03 A

A/Indonesia/5/05 A/turkey/Turkey/1/05 A/Anhui/1/05 Clade 2.1 Clade 2.2 Clade 2.3 100 Day 21 Day 42 80 Day 180

60

40

Seroconversion rate (%) 20

0 3.8 µg 3.8 µg + AS03 A 3.8 µg 3.8 µg + AS03 A 3.8 µg 3.8 µg + AS03 A

20 subjects per group

Leroux-Roels et al. Broad clade 2 cross-reactive immunity induced by an adjuvanted clade 1 rH5N1 pandemic influenza vaccine. PLoS ONE 2008; 3 (2): e1665. MF59-ADJUVANTED H5N1-VIETNAM VACCINE GENERATED BROADER ANTIBODY PROFILE COMPARED TO UNADJUVANTED VACCINE (phage-display library) STUDY-1: NIAID (HAI-80)

Correlates of broad H1-98% protection?

H2O H O H2O 2 H2O H2O

H2O H2O OIL H2O H2O

H2O H2O H O H2O 2 H2O H2O Composition MF59: 0.5% Polysorbate 80 (water(water----solublesoluble surfactant) 0.5% Sorbitan Triolate (oil(oil----solublesoluble surfactant) 4.3% Squalene ---oil -oiloiloil

19 Water for injection 10 nMnMnMNaNaNa- Na ---citratecitrate buffer Khurana S, et al.(2010) Science Transl Med 20 2010 2:15ra5

The response in adults

Y Y Y

HA1 HA2

1 Y

Y Y Y Y Y

2

Y YYYY

Y

Y Y

Y Y Y Y Y 3 Y YY Y Y Y Y Y

Khurana et al, Science Transl Med 2011

InIn adults,adults, alreadyalready primedprimed byby naturalnatural infectioninfection (( 1 ),), vaccinationvaccination withwith plainplain influenzainfluenza vaccinevaccine essentiallyessentially expandsexpands pre-existingpre-existing memorymemory BB cellscells directeddirected againstagainst thethe HA2HA2 region,region, withwith littlelittle effecteffect onon primiprimingng naivenaive BB cellscells againstagainst thethe HA1HA1 regionregion (( 2 ).). VaccinationVaccination withwith MF59-adjuvantedMF59-adjuvanted vvaccine,accine, dramaticallydramatically primesprimes 20 | Briefing Dutch Health Council | June 29, 2011 | Response to Questions on (Pre)pandemic Influenza Vaccines | naivenaiveConfidential BB cellscells thatthat nownow produceproduce antibodiesantibodies againstagainst tthehe HA1HA1 regionregion ( ( 3 )) FerretsFerrets vaccinatedvaccinated withwith ASASASASASAS ------adjuvantedadjuvanted H5N1H5N1 splitsplit candidatecandidate vaccinevaccine

• 2 immunisations of ferrets at D0 and D21 (H5N1 A/Vietnam/1194/04 split virus / AS) • Heterologous challenge (wild-type virus A/Indonesia/5/05 , 10 5 TCID50) at D49 • Post challenge results at D5

Dead Alive % Survival Pooled controls 12 0 0 (15 µg Antigen only or AS only) 1.7 µg H5N1 – AS 1 5 83 3.8 µg H5N1 – AS 0 6 100 7.5 µg H5N1 – AS 0 5 100 15 µg H5N1 – AS 0 6 100

Baras et al., PLoS One 2008 virus 2009 - New H1N1 -

New pandemic - First animal models testing vaccines testing antivirals studying pathogenesis - First genetic and antigenic data - Clinical network Key publications: antiviral therapy J. v.d. Brand et al, EID 2011 (IV / ICU / ECMO) J. v.d. Brand et al, JID 2010 S. Herfst et al J.Virol. 2010 antiviral resistance F. Wildschut et al. Plos One 2010 G. Del Giudice et al. Science TM 2009 S. Herfst et al, Vet Pathol. 2009. J. Van den Brand et al, EID 2009. V. Munster et al, Science. 2009 16-10-2001 A. Meijer et al, J Clin Virol. 2009 Neutralization assay (Challenge strain)

Anti-The Netherlands/602/09 neutralizing titers Day 0 Day 21 Responders: neutralizing titers > 40 Day 42 5/5 2500 Day 48 6/6 2000 1500 6/6 1000 6/6 800

600 3/5 400 4/6 (GMT with (GMT 95%CI) 200

Neutralizing antibody titers antibody Neutralizing 0/6 0/6 0 15 µg 15 µg 3.75 µg 3.75 µg 1.9 µg 1.9 µg 1.9 µg PBS no adj + AS03 A + AS03 A + AS03 A + AS03 A + AS03 A + AS03 B (2x) (2x) (1x) (2x) (1x) (2x) (2x) (2x)

Neutralizing antibodies observed in all groups immunized with AS03-split H1N1 vaccines  88% response rate (100% with two doses, 64% with a single dose). 23 Viral load in the lungs by culture

Day 4 post-challenge (A/The Netherlands/602/09) 7.0 6/6 6/6 6.0 2/6

5.0

/gr with /gr CI95) 4.0 50 Virus titer Virus 3.0 (LogTCID 2.0 1/5 0/6 0/5 0/6 0/6 1.0 2x 15 µg 2x 15 µg 1x 3.75 µg 2x 3.75 µg 1x 1.9 µg 2x 1.9 µg 2x 1.9 µg 2x PBS

Non-adj AS03 A AS03 A AS03 A AS03 A AS03 A AS03 B

Lower virus load observed in animals immunized with AS03-adjuvanted vaccines compared to ferrets receiving the non-adjuvanted vaccine (or PBS). No virus detected with two doses of AS03-adjuvanted vaccine, virus detected in 27% (3/11 ferrets) ferrets receiving a single dose. 24 Seasonal vaccine provides priming against A/H1N1 pandemic influenza

Vaccines - = PBS A = seasonal H1N1 F = seasonal H1N1 + MF59 C = pdmpdmpdmH1N1 C+ = pdmpdmpdmH1N1 + MF59

Del Guidice et al. Science TM 2009 v.d.Brand et al J.Virol. 2010 Preliminary immunogenicity results post-dose one exceed the regulatory threshold

GMT SPR SCR

1000 100 100 90 90 80 80 70 70 100 60 60 50 50 40

% subjects % 40 10 subjects % 30 30 20 20 10 10 1 0 0 D0 D21 D0 D21 D0 D21 D0 D21 D21 D21

H1N1 (5.25µg) H1N1 (21µg) H1N1 (5.25µg) H1N1 (21µg) H1N1 (5.25µg) H1N1 (21µg) + + +

AS03 A AS03 A AS03 A

Prior to receipt of official regents vaccines were formulated using an alternative assay for HA content. HA potencies were then retested by SRD once calibrated reagents were available.

Devaster JM. et al. Immunogenicity and safety of an A/H1N1v AS03A-adjuvanted pandemic influenza vaccine candidate: Preliminary results from a randomized, controlled trial in adults. Vaccine Congress 2009, Singapore. VaccinationVaccination effectiveneseffectivenes studiesstudies """"""SwineSwine fluflufluflufluflu 2009"2009"

TheThe ScottishScottish VIPERVIPER studystudy andand aa GermanGerman studystudy

 was effective 97% in 1515----6565 age group 83% in > 65 age group  vaccination reduced risk of Influenza  vaccination reduced risk of and hospitalisation  vaccination reduced mortality In the lay press pandemic vaccines 2009 were said to be unsafe

Available at: http://http://www.patriotsaints.comwww.patriotsaints.comwww.patriotsaints.com.. Last accessed 02 November 2010.2010. Europe: Experience with pandemic vaccines in mass vaccination programs

Conclusion stated by EMA

“The CHMP re-assessed the benefit-risk profile of Celvapan [Baxter ], Focetria [Novartis ] and [GSK ]. Taking into account the comprehensive information available on the clinical safety and efficacy of these vaccines, the CHMP concluded that

the benefit-risk profile of these vaccines continues to be positive.

Consequently, the CHMP recommended the further use of the vaccines within the EU in the authorised indication even after the pandemic was declared over. ”

European Medicines Agency. Twenty-second pandemic pharmacovigilance update. Available at http://www.ema.europa.eu/docs/en_GB/document_library/Report/2010/08/WC500095870.pdf. European Medicines Agency updates on the review of Pandemrix and reports of narcolepsy (23 September 2010 )

 “As per 17 September 2010, there are 81 reports from healthcare professionals suggestive of narcolepsy , all collected through spontaneous reporting systems.”

 “The European Medicines Agency’s (EMA) Committee for Medicinal Products for Human Use (CHMP) agreed that at present the benefit-risk balance for Pandemrix continues to be positive, and that while the review is still ongoing there was no need for Europe-wide restrictions on use.”

 “Available evidence does not confirm a link; more research needed .”

European Medicines Agency. Press release 23 September 2010. Available at: http://www.ema.europa.eu/docs/en_GB/document_library/Press_release/2010/09/WC500096998.pdf. AdjuvantsAdjuvants forfor pandemicpandemic influenzainfluenza vaccinesvaccines

POINTSPOINTS TOTO CONSIDER:CONSIDER:

 effectiveness (Ag sparing, breadth/longevity response...)  nananaïna ïïïveve versus primed individuals  also effective and safe for seasonal vaccine usage?  correlates of protection (HAI/VN antibody, T cells...? regulatoryregulator y issues!)  safety issues (also upon challenge; autoauto----immune,immune, e.g. GBS, narcolepsy.. )  availability, IP rights, cost...  ease to manufacture  ease to formulate  separate storage possible (emulsions!!)  … AcknowledgementsAcknowledgements

Virology, Erasmus MC Vincent Munster Viroclinics Biosciences BV Emmie de Wit James Simon Debby van Riel Koert Stittelaar Theo Bestebroer Judith v.d. Brand GSK Geert van Amerongen Robert Dias d’Ullois Novartis Martin Schutten Jan de Jong Guus Rimmelzwaan Bart Haagmans Solvay Thijs Kuiken Ron Fouchier Isconova … …