Hendra, September 1994

Hendra virus infection

Advances in human therapeutics

Geoffrey Playford Director, Infection Management Services | Princess Alexandra Hospital Microbiologist, Department of Microbiology | Pathology Queensland [email protected]

Thanks to Joe McCormack

HeV infection HeV infection Human clinical manifestations Human clinical manifestations Case Date Exposure to Clinical syndrome Outcome Case Date Exposure to Clinical syndrome Outcome infected horses infected horses 4: Veterinarian Nov Performed ‘Influenza-like’ illness Recovery, no relapse 1: 40-yo Sept 1994 Respiratory ‘Influenza-like’ illness Recovery, no 2004 necropsy stable hand secretions relapse

5: 33-yo July Respiratory Acute encephalitis Died (day 31 illness) 2: 49-yo Sept 1994 Respiratory Pneumonitis, multi-organ Died (day 13 Veterinarian 2008 secretions, horse secretions failure, fatal illness) performed trainer necropsy 6: 21-yo July Respiratory Acute encephalitis Recovery, persisting 3: 36-yo Aug 1994 Assisted with Initial aseptic meningitis with Died (day 25 Veterinary 2008 secretions neurological deficits farmer necropsy recovery (Aug 1994) illness) nurse Relapsed with encephalitis 13 months later (Sept 1995) 7: 51-yo Aug Respiratory Acute encephalitis Died (day 19 illness) Veterinarian 2009 secretions

Selvey et al . Med J Aust 1995;162:642-5 Hanna et al . Med J Aust 2006;562-4 O’Sullivan et al . Lancet 1997;349:93-5 Playford et al . Emerg Infect Dis 2010;16:219-23

Neuro-radiological manifestations Neuro-histopathological findings

Case 6: day 25 (T2 FLAIR): Innumerable cortical, subcortical and midbrain hyperintense foci

Case 7: day 9 (T2 FLAIR): Extensive multifocal cerebral & brainstem hyperintensities

Wong et al. Neuropathol Appl Neurobiol. 2009;35:296-305

1 Prevention of human HeV infections Prevention of human HeV infections

• Bat-horse interface • Horse-human interface strategies: strategies: – Exclusion of horses from – Standard precautions & hand hygiene grazing beneath trees used – Additional precautions for procedures for roosting/feeding – Early recognition & consideration of – Feed/water points located away form trees/under equine HeV infection artificial cover – Minimisation of human contact with – Equine vaccination unwell/potentially infected horses

HeV epidemiology: “ Spill over” events: 1994-2010 HeV epidemiology: “ Spill over” events: 2011-

Date Location Equine cases Human cases June 2011 Beaudesert, Qld 1 0 Date Location Equine cases Human cases July 2011 Wollongbar, NSW 2 0 July 2011 Boonah, Qld 3 0 Aug 1994 Mackay, Qld 2 1 July 2011 Park Ridge, Qld 1 0 Sept 1994 Hendra, Qld 22 2 July 2011 Macksville, NSW 1 0 Jan 1999 Cairns, Qld 1 July 2011 Lismore, NSW 1 0 Oct 2004 Cairns, Qld 1 1 July 2011 Kuranda, Qld 1 0 Dec 2004 Townsville, Qld 1 July 2011 Boondall, Qld 1 0 June 2005 Peachester, Qld 1 July 2011 Logan Reserve, Qld 1 0 Oct 2006 Murwillumbah, NSW 1 July 2011 Hervey Bay, Qld 1 0 June 2007 Peachester, Qld 1 July 2011 Chinchilla, Qld 1 0 July 2007 Clifton Beach, Qld 1 July 2011 Mullumbimby, NSW 1 0 July 2008 Thornlands, Qld 5 2 Aug 2011 Mullumbimby, NSW 1 0 July 2008 Proserpine, Qld 2 Aug 2011 Ballina, NSW 1 0 Aug 2009 Cawarral, Qld 4 1 Aug 2011 South Ballina 2 0 Sept 2009 Bowen, Qld 2 Aug 2011 Gold Coast hinterland 1 0 May 2010 Tewantin, Qld 1 Aug 2011 Ballina 1 0 Oct 2011 Beachmere, Qld 1 0 Total 67 7

HeV infections: other animals HeV infections: other animals

• 2011 documentation of • Experimental infection: natural HeV infection in – Cats, pigs , guinea pigs, dog: ferrets – Asymptomatic – ?Direct transmission from infected bat or horse – ?Indirect transmission from contaminated environment

2 The importance of human HeV therapeutics

• Poor clinical outcomes • Increased frequency & geographic range of spillover events • Clinical recognition of equine infection difficult • Potential for transmission from during late incubation period • Incomplete adherence with precautions • Logistic difficulties of universal equine vaccination within at-risk areas • Potential for transmission from other animal species (e.g. dogs, feral pigs) Marsh et al. Emerg Infect Dis 2011;17:2232-8

Ribavirin/chloroquine: Animal models Hendra and Nipah virus Receptors • Ribavirin: Delayed but did not Henipavirus F & G glycoproteins – AGM/HeV model prevent death – Golden hamster/NiV model

• Chloroquine: No benefit – Ferret/NiV model Host cell

• Chloroquine +/- Delayed death by ~5 days Ribavirin: (Ribavirin) Henipavirus G glycoproteins – Golden hamster/HeV & bind to Ephrin-B2 and Ephrin-B3 NiV model: No benefit (Chloroquine or

Ribavirin+Chloroquine) Bonaparte MI, et al. (2005). PNAS 102: 10652-57. Negrete OA, et al. (2005) Nature 436: 401-405. Rockx et al. J Virol 2010 (in press); Geogres-Coubot et al. Antimicrob Agents Chemother 2006;50:1768-72; Pallister Negrete OA, et al. (2006) PLoS Pathog 2: e7. et al. J Virol 2009;83:11979-82; Freiberg et al. J Gen Virol 2010;91:765-72 Bishop KA, et al. (2007) J Virol 81: 5893-5901. Source: Chris Broder, USU

Heninpavirus therapeutics: targets Passive immunoprophylaxis Polyclonal Abs • Hamster/NiV model using polyclonal Abs pooled following F- or G- containing rVV

Bossart et al Exp Rev Anti Infect Ther. 4(1) 2006 Guillaume et al. J Virol 2004;78:834-40

3 Passive immunoprophylaxis Development of a fully human mAb to Murine mAb HeV/NiV G glycoprotein

NiV HeV • Large naive human antibody library from healthy donors • Seven Fabs (m101-7) demonstrated significant binding to HeV/NiV soluble G glycoprotein

Guillaume et al. J Virol 2006;80:1972-8 Guillaume et al. Virology 2009;387:459-65 Zhu et al. J Virol 2006;80:891-9

Development of a fully human mAb to Live virus Pharmacokinetics of m102.4 HeV/NiV G glycoprotein • Ferrets (5-25 mg/kg): • African Green Monkeys (2.5- Cell-cell fusion – Distribution t ½ = 1.5 days 11 mg/kg): – Elimination t ½ = 3.5 days – Distribution t ½ ~1 day – Serum collected at days – Elimination t ½ 10-12.5 days 1,4,8 retained neutralising NiV activity

HeV

Zhu et al. J Infect Dis 2008;197:846-53 Zhu et al. J Infect Dis 2008;197:846-53 Bossart et al. PLOS Pathogens 2009;5:e1000642

Passive immunoprophylaxis with m102.4 Passive immunoprophylaxis with m102.4 Ferret/NiV model AGM/HeV model • m102.4 (25 mg/kg) Control: – Control – #22: euthanized day 8 – 10 hrs and day 3 post-challenge – #25: euthanized day 8 – 24 hrs and day 3 post-challenge – 72 hrs and day 4 post-challenge m102.4 (50 mg/kg; 24 hours pre-challenge): – #21 (oronasal challenge): survived – #23/#24 (oronasal challenge): euthanized day 13 All developed neurological signs infection before recovery m102.4 (50 mg/kg; 10 hours post-challenge): – #26/#27 (oronasal challenge): survived – #28 (intraperitoneal challenge): survived

– Some correlation of day 3 mAb levels and protection

Bossart et al. PLOS Pathogens 2009;5:e1000642 Bossart et al. Sci Transl Res 2011;3:105ra103

4 Passive immunoprophylaxis with m102.4 Human exposure assessment Initial human experience • 2009: single patient with established HeV • Duration of contact encephalitis • Degree of direct exposure to body fluids – 100 mg (~1 mg/kg) m102.4 available • Adequacy of PPE & hand hygiene – No overt reaction/toxicity – No efficacy

• “Negligible-low” level exposures: – Counselling ± serological assessment • “Medium-high” level exposures: – Consideration for post-exposure immunoprophylaxis – Discussion between PH and ID Physicians

Production of the recombinant therapeutic anti-Hendra mAb m102.4

Cultured Mammalian Cells mAb expressing cells (CHO) Chinese Hamster Ovary Expression vector

Purified Purification Scale-up bioreactor Therapeutic mAb (filtration and (25-50L) chromatography) Shake-flask

Acknowledgements • National Biologics Facility at • AIBN Cell Line Development Group • Warren Pilbrough Passive immunoprophylaxis with m102.4 AIBN • Joe Codamo • Peter Gray (AIBN Director) • Jeff Hou Future plans • David Chin • Andrew Prowse • Matthew Smede • Marianne Gillard • NHMRC HeV UCR grant: • Collaborating partners: • Steffi Dietmair • Martina Jones • Maria Buchsteiner – Creation cGMP cell bank – USU (Bethesda, MD) • Karen Hughes • Khosrow Alibadi – Completion of – AIBN/University of • Kar Man Leung downstream/upstream Queensland (Brisbane, • Jong Wei Wooh bioprocess development Qld) • Michael Song – Formulation/stability – AAHL/CSIRO (Geelong, • Emily Chan studies Vic) • David Crawley • Edwin Huang • Future funding: – Queensland Health • Antibody Discovery Group – Bioactivity/efficacy testing – QPharm (Brisbane, Qld) • Stephen Mahler – Pre-clinical toxicology – ERA Consulting (Brisbane, • Ellen Deleon Qld) • Karin Maritz studies • Keba Lebani – Phase 1 human safety study

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