ESCMID Online Lecture Library © by Author ESCMID Online Lecture Library A.M

2nd ESCMID Conference on The Impact of VACCINES on Public Health

Novel vaccines for old diseases

Flu Vaccination facing© by influenza author virus variability “to publish or not to publish?” ESCMID Online Lecture Library Albert Osterhaus DVM PhD Professor / Head Viroscience lab, Erasmus MC (NL) Professor Wildlife Virology & Virus Discovery Utrecht Univ. (NL) Chair Artemis Wildlife Health Institute (Europe) CSO Viroclinics-Biosciences BV (NL) Chair ESWI (Europe) Newly identified human respiratory viruses in last 15 years alone

- H5N1 * influenza virus 1997… - Hendra-/NipahV paramyxovirus 2000… - hMPV * paramyxovirus 2001 - SARS-CoV * coronavirus 2003 - H7N7 * influenza virus 2003 - HCoV-NL63 * coronavirus 2004 - HCoV-HKU1 coronavirus© by author 2005 - HBoV parvovirus 2005 - KI/WU-PyV polyomavirus 2007 - MelVESCMID (KamV) orthoreovirusOnline Lecture 2007 Library - H1N1v influenza virus 2009 - HPBV * picobirnavirus 2010 - HCoV-EMC* coronavirus 2012 Novel coronavirus, Saudi Arabia - June 2012 - A.M. Zaki et al., N.E.J.M. 2012

. Syncytia in LLC-MK2 cells, and CPE in Vero and LLC-MK2 cells . Negative by PCR for paramyxoviruses, enteroviruses & adenoviruses © by author . Negative by IFA for: flu A and B, PIV types 1 to 3, RSV & adenovirus ESCMID Online Lecture Library © by author ESCMID Online Lecture Library A.M. Zaki et al., N.E.J.M. 2012 Human influenza: three appearances

Seasonal influenza (A: H3N2, H1N1; B)

Avian influenza (A: H7N7, H5N1…)© by author

PandemicESCMID influenza Online Lecture Library (A: H1N1, H2N2, H3N2, H1N1…?) De Jong et al., Nature 1997 Claas & Osterhaus, Nat.Med 1998 Aquatic wild birds Fouchier et al., J Virol., 2005 Influenza A virus reservoir Munster et al., EID., 2005 Olsen et al., Science., 2006

Subtype Country Year # Cases # Deaths

H7N7 UK 1996 1 0 H5N1 Hongkong 1997 18 6 H9N2 SE-Asia 1999 >2 0 H5N1 Hongkong 2003 2? 1 H7N7 Netherlands© by author2003 89 1 H7N2 USA 2003 1 0 H7N3 Canada 2004 2 0 H5N1ESCMIDSE-Asia/M-East/ Online Lecture2003-12* >650Library>350 * Europe/W-Africa *CFR ~ 60% Avian influenza H5N1, Eastern hemisphere - H5N1 human - 2003-2011 -

Case fatality rate ~ 60 % ??

Source: www.who.int © by author ESCMID Online Lecture Library Attachment to upper or lower respiratory tract

Seasonal H3N2 Pandemic H1N1 HPAIV H5N1

van Riel et al.,Science 2006 transmission van Riel et al., Am J Pathol 2007 van Riel et al., Am J Pathol 2009 van Riel et al., Am J Pathol 2010 van Riel© et al.,byPLoS author Path. 2011 HPAIV H5N1 ESCMID Online Lecture Library Transmission set up - Ferrets -

Herfst et al., Science 2012 Fouchier et al., Science 2012 Russell et al., Science 2012 Last four pandemics

Credit: US National Museum of Health and Medicine

1918 1957 1968 2009 “Spanish Flu” “Asian Flu”© by author“Hong Kong Flu” “Mexican flu” >40 million deaths 1-4 million deaths 1-4million deaths 0.3-0.5 million deaths

A(H1N1)ESCMID OnlineA(H2N2) Lecture A(H3N2) LibraryA(H1N1) In a few weeks, the 2009 H1N1v pandemic spread around the world affecting all countries

April 2009

May 2009 START June 2009 March 2009 July 6 2009

Cumulative cases 1–10 11–50 51–500

500–5000 © by author Air traffic from Mexico >5000 ESCMID Online Lecture Library FLU pandemics: are we prepared? - medical interventions – NB: societal interventions

. Surveillance Humans: seasonal surveillance is the basis for pandemic surveillance Animals: “early warning” en “rapid response” . Antiviral therapy preventive and therapeutic…resistance© by author development ??? . Vaccination CornerstoneESCMID of prevention…pre-pandemicOnline Lecture Library vaccines ??? The first vaccination

JennerESCMID vaccinating 8Online yr-old Lecture Library James Phipps in 1796.

Note: Vacca = Cow (Greek) – vaccination – inoculation with cow material Animal model: the ferret

Clinical, Pathology & Virological Parameters Seasonal H1N1 pH1N1 2009 HPAI H5N1

Lung Weight

Munster et al., Science 2009 Del Giudice et al., Science TM 2009 © by author Chutinimitkul et al., J.Virol 2010 Temperature Virus Load Herfst et al., Vet.Pathol. 2010 Bosch et al., J.Virol. 2010 ESCMID Online Lecture LibraryKreijtz et al., J.Gen.Virol. 2010 v.d.Brand et al., JID 2010 v.d.Brand et al., J.Virol 2010 v.d.Brand et al., J.Virol 2011 Bodewes et al. ,Am J Pathol. 2011 Pandemic H1N1 (2009)-induced lung lesions as measured by CT and histopathology E.Veldhuis Kroeze et al., J.gen.Virol. 2011

“used for testing antiviral and vaccine candidates”

E.Veldhuis Kroeze et al., J.gen.Virol. 2011 Erhard van der Vries Prolonged influenza virus infection(shedding) Viral loads (Log vp/ml) ESCMID Online10 Lecture Library and developmentof resistance et al. PLoS Path.2013 © by author Prolonged shedding and rapid emergence of resistance E.vd Vries et al., PLoS Path. 2013 Immunocompetent Immunocompromised Immunocompromised + Oseltamivir Nose Throat Nose Throat Nose Throat

1 dose (trivalent): 1 chicken egg! © by author ESCMID Online Lecture Library 256 197 Canada 186 350 United States The Netherlands 186 United Kingdom 183 Germany 178 Australia 177 Spain 174 France 170 New Zealand Belgium 156 Ic eland 154163 Italy 147 HIGH RISK GROUPS Is rael 140 Rep. of Korea Ireland Austria 132135 Portugal 132 chronic cardiovascular disease Sw itzerland 118 Greece 115124 Hungary chronic airway disease Denmark 115 Rus s ia Chile 109115 Japan 101 diabetes mellitus Finland 101 Argentina 100 Brazil 97 chronic renal dysfunction Uruguay 96 Norw ay 95 Sw eden 78 immune-compromised Croatia 72 Poland 65 Latvia 59 Taiw an 58 elderly ( 60 years) Slovak Republic 51 Romania 43 © by author South Africa 38 Czech Republic 35 Lebanon 33 Hong Kong 24 Bulgaria 23 Es tonia 19 Lithuania ESCMIDCos ta Ric a 19 Online Lecture Library Tunisia 17 UA E 14 Algeria 13 Columbia 12 Mexico 10 Mor oc c o 7

0 50 100Doses 150 of 200 influenza 250 vaccine 300 350 distributed 400 / 1000 population 22 Seniors’ Health: Adding Life To Years

1980’s

1990’s

60 70 80 90 McElhaney et al., 2010 Age Online Lecture Library

Slide withheld at request© byof author author ESCMID Online Lecture Library © by author author by ©

>6 months

clinical trials with prototype vaccines limited ESCMID Online Lecture Library Library . Lecture . Online . ESCMID Production capacity !! Response time Efficacy/safety . . - Key issues - . Pandemic influenza vaccines Science 2009

Public-Private Collaboration to develop© intervention by author strategies against pdv H1N1 2009 ESCMID Online Lecture Library

Rappuoli et al. 2009, Science Pandemic influenza vaccines - Room for improvement -

Strain selection small changes; easy to incorporate

Seed-strain preparation

Production systems

larger changes; long path ©before by implementation? author New ESCMIDtargets; identify correlatesOnline of protectionLecture Library Improve efficacy; adjuvants & delivery systems Pandemic influenza vaccines - Identification of new targets, correlates of protection -

-Targeting M2; a “universal” influenza vaccine?

-Role of antibodies to NA in protection upon vaccination? Only 9 NA subtypes, versus 16 HA subtypes Less drift in NA as compared to HA? -Role of cellular immunity in protection? Identify targets (conserved internal proteins, epitopes!) Identify modes of antigen delivery (vectors, LAIV, DNA vac)

- Cross-protective immunity©between by authorvirus subtypes? ESCMID Online Lecture Library New Class of Monoclonal Antibodies against Severe Influenza: Prophylactic and Therapeutic Efficacy in Ferrets Friesen R.H. et al, PLoS One. 2010

% Affected Area of Lungs

90 No Matrix 80

20 © by author

10 0 ESCMID Online Lecture Library

Bosch B.J. et al., J.Virol. 2010 Heterosubtypic immunity in ferrets A/Brisbane/10/07 (H3N2) – A/Indonesia/5/05 (H5N1)

Not vaccinated H3N2 inoculated H3N2 vaccinated

H3N2 vaccinated H3N2 inoculated Naive © by author ESCMID Online Lecture Library

protected unprotected Bodewes et al., 2011, J. Virol. 85(6):2695-2702 (2011) Seroprevalence of antibodies against seasonal influenza A and B viruses in children in the Netherlands

Influenza A/H1N1 Influenza A/H3N2 Influenza A/H1N1 or A/H3N2

Age © by author

ProportionESCMID of Online children Lecture lack HSI Library

Bodewes et al., 2011, Clin. Vac. Immunol. 18(3):469-76 Assessment of pre-pandemic H5N1 clinical trials

Type of vaccine Compliance with EU licensing criteria

Split vaccine no adjuvant Need two doses of 90 µg Split/subunit vaccine with alum Need two doses of 30-45 µg Whole virus (egg) with alum Need two doses of 10-15 µg Subunit with MF59 adjuvant Need two doses of 7.5 µg Whole virus Vero cell culture, no© adjuvant by authorNeed two doses of 7.5 µg Split vaccine with AS adjuvant Need two doses of 3.8 µg

Data presentedESCMID at WHO meeting, Online February 2007Lecture Library (Sanofi Pasteur, 4 Companies in Jp, CSL, Microgen, Sinovac, GSK, Novartis,Baxter) The three CHMP criteria are exceeded by all the adjuvanted doses: seroconversion rates 100 3.8µg H5 7.5µg H5 15µg H5 30µg H5

75 3.8µg H5 AS 7.5µg H5 AS 15µg H5 AS 30µg H5 AS

50 CHMP criteria 40 © by author 25 ESCMIDSeroconversion rate (%) Online Lecture Library

0 Post first dose Post second dose IX International Symposium on Respiratory Viral Infections ; March 3 – 6, 2007, Hong Kong Ferrets vaccinated with AS-adjuvanted H5N1 split candidate vaccine

• 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, 105 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 15© by author 83 3.8 µg H5N1 – AS 06 100 7.5ESCMID µg H5N1 – AS Online05 Lecture Library100 15 µg H5N1 – AS 06 100

Baras et al., PLoS One 2008 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

4.0 /gr with CI95) /gr with 50 Virus titer Virus 3.0 (Log TCID 2.0 © by author1/5 0/6 0/5 0/6 0/6 1.0 ESCMID2x 15 µg 2x 15 Onlineµg 1x 3.75 µg 2x 3.75Lecture µg 1x 1.9 µg 2x 1.9Library µg 2x 1.9 µg 2x PBS

Non-adj AS03A AS03A AS03A AS03A AS03A AS03B Influenza A(H1N1)pdm09 vaccination policies and coverage in Europe

Mereckiene J et al. Euro Surveill. 2012 Jan 26;17(4). pii: 20064 Direct effectiveness of GSK’s AS03-adjuvanted pandemic H1N1 2009 vaccine

. German data:

. Persons 14 to 59 years: 96,8% . Persons ≥ 60 years: 83,3%

. Scottish data:

. At risk persons (all© ages): by 95,0%author

ESCMID. Canadian data: Online Lecture Library

. Children 36 months to < 10 years: 100% H1N1 2009 pdm vaccines as non-safe medicine in the lay press

Available at: http://www.patriotsaints.com. Last accessed 02 November 2010. Edward Jenner “father of vaccination” Public outrage!!!

• Retroviruses • Poxviruses • Adenoviruses • Adeno-associated viruses • Herpesviruses • Alphaviruses • Paramyxoviruses • VLP’s (HPV, rotavirus,© by authorparvovirus, HBV….) • Bacterial vectors • Plasmid DNA • ESCMIDDC’s and exosomesOnline Lecture Library

• NB: LAIV !!! BEVS Technology “Enabling products where speed, cost and safety matter”

Baculovirus Expression Vector System (BEVS)

n Engineer baculovirus with the n Culture expression of n Protein forms rosettes gene of interest (e.g. insect cells in a n Purify protein to > 90% Hemagglutinin) fermenter © by author into final product n Baculoviruses highly specific n Infect cells with n Formulate with PBS into to insect cells engineered virus vaccine n Powerful promoter generates n Incubate infection for ~48 ESCMIDhigh yield of protein of Online- 72 hours Lecture Library interest Flublok Approval → Validaon

41 Flublok Timeline

Inspections BLA CR Letter Submitted CR Letters and Inspection response April 2008 Response

Clinical, Tox CMC, RT and CMC Investigation FDA APPROVAL 1993 2008 2009 2010 2012 9 studies performed 16 Jan 2013 in collaboration with © by author NIAID

Initiation of ESCMIDFluBlok Online Lecture Library Clinical Studies Availability of Recombinant Pandemic Influenza Vaccines

Recombinant pandemic influenza vaccines are projected to be available much sooner than those produced with egg‐based technology.

Projected Availability of Recombinant Vaccines

Demand for Healthcare Healthcare Demand for ESCMIDServices Online Lecture Library

Adapted from R. Robinson’s presentation to FDA’s VRBPAC on February 29, 2012 Recombinant MVA generation Using two steps of homologous recombination

MVA genome

MVA‐H5 MVA‐H5

. Cynomolgus Macaques (Macaca fascicularis) (2-3 years)

Vaccines . MVA-HA-VN/04 (A/Vietnam/1194/04)1 . MVA (empty vector)1 © by author . PBS VirusesESCMID (dose: 1*108 TCID50) Online Lecture Library . Influenza virus A/Vietnam/1194/04 or A/Indonesia/5/05

1) 108.5 PFU in 1ml divided over both legs (intramuscular) Kreijtz et al JID 2009 Gross pathology

Kreijtz et al. J. Inf. Dis. 2008 CONCLUSIONS VACCINATION

• was introduced more than 200 years ago

• aided in reducing the infectious disease burden and mortality

• in a highly cost-effective way

• even allowed the eradication of two major viral diseases

• is not yet available for the majority of infectious diseases © by author • will help controlling existing and newly emerging infections • makingESCMID optimal use Online of novel technologies Lecture Library CONCLUSIONS Global pandemic preparedness :

• Societal measures

• Surveillance (animal and human)

• Use of multiple antiviral stockpiles (resistance monitoring) © by author • Rapid production and use of pandemic vaccines ESCMID(novel technologies!!!) Online Lecture Library

NB: equitable distribution? Influenza research at Erasmus MC - The team leaders -

Prof. Dr. R.A.M. Fouchier Virology Prof. Dr. T. Kuiken Pathology Prof. Dr. M. Koopmans Epidemiology Prof. Dr. C.A.B. Boucher Antiviral research Dr.A.van der Eijk / Dr.P.Fraaij© by author Clinical research Prof.Dr. G.F. Rimmelzwaan Immunology Dr. ESCMIDM. Schutten Online Lecture Diagnostics Library Dr. A. Andeweg Genomics